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Background: Sciatica has a substantial impact on individuals and society. Stratified care has been shown to lead to better outcomes among patients with non-specific low back pain, but it has not been tested for sciatica. We aimed to investigate the clinical and cost-effectiveness of stratified care versus non-stratified usual care for patients presenting with sciatica in primary care., Methods: We did a two-parallel arm, pragmatic, randomised controlled trial across three centres in the UK (North Staffordshire, North Shropshire/Wales, and Cheshire). Eligible patients were aged 18 years or older, had a clinical diagnosis of sciatica, access to a mobile phone or landline number, were not pregnant, were not currently receiving treatment for the same problem, and had no previous spinal surgery. Patients were recruited from general practices and randomly assigned (1:1) by a remote web-based service to stratified care or usual care, stratified by centre and stratification group allocation. In the stratified care arm, a combination of prognostic and clinical criteria associated with referral to spinal specialist services were used to allocate patients to one of three groups for matched care pathways. Group 1 was offered brief advice and support in up to two physiotherapy sessions; group 2 was offered up to six physiotherapy sessions; and group 3 was fast-tracked to MRI and spinal specialist assessment within 4 weeks of randomisation. The primary outcome was self-reported time to first resolution of sciatica symptoms, defined as "completely recovered" or "much better" on a 6-point ordinal scale, collected via text messages or telephone calls. Analyses were by intention to treat. Health-care costs and cost-effectiveness were also assessed. This trial is registered on the ISRCTN registry, ISRCTN75449581., Findings: Between May 28, 2015, and July 18, 2017, 476 patients from 42 general practices around three UK centres were randomly assigned to stratified care or usual care (238 in each arm). For the primary outcome, the overall response rate was 89% (9467 of 10 601 text messages sent; 4688 [88%] of 5310 in the stratified care arm and 4779 [90%] of 5291 in the usual care arm). Median time to symptom resolution was 10 weeks (95% CI 6·4-13·6) in the stratified care arm and 12 weeks (9·4-14·6) in the usual care arm, with the survival analysis showing no significant difference between the arms (hazard ratio 1·14 [95% CI 0·89-1·46]). Stratified care was not cost-effective compared to usual care., Interpretation: The stratified care model for patients with sciatica consulting in primary care was not better than usual care for either clinical or health economic outcomes. These results do not support a transition to this stratified care model for patients with sciatica., Funding: National Institute for Health Research., (© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.)

Background: Low back pain (LBP) and sciatica place significant burden on individuals and healthcare systems, with societal costs alone likely to be in excess of £15 billion. Two recent systematic reviews for LBP and sciatica identified a shortage of modelling studies in both conditions., Objectives: The aim of this systematic review was to document existing model-based economic evaluations for the treatment and management of both conditions; critically appraise current modelling techniques, analytical methods, data inputs, and structure, using narrative synthesis; and identify unresolved methodological problems and gaps in the literature., Methods: A systematic literature review was conducted whereby 6512 records were extracted from 11 databases, with no date limits imposed. Studies were abstracted according to a predesigned protocol, whereby they must be economic evaluations that employed an economic decision model and considered any management approach for LBP and sciatica. Study abstraction was initially performed by one reviewer who removed duplicates and screened titles to remove irrelevant studies. Overall, 133 potential studies for inclusion were then screened independently by other reviewers. Consensus was reached between reviewers regarding final inclusion., Results: Twenty-one publications of 20 unique models were included in the review, five of which were modelling studies in LBP and 16 in sciatica. Results revealed a poor standard of modelling in both conditions, particularly regarding modelling techniques, analytical methods, and data quality. Specific issues relate to inappropriate representation of both conditions in terms of health states, insufficient time horizons, and use of inappropriate utility values., Conclusion: High-quality modelling studies, which reflect modelling best practice, as well as contemporary clinical understandings of both conditions, are required to enhance the economic evidence for treatments for both conditions.

Musculoskeletal conditions are a major cause of ill health and disability. Inadequate health literacy may partly explain why musculoskeletal self-management programs are not effective for some patients. This study prospectively evaluated the impact of patients' health literacy level on their musculoskeletal pain and physical function (PF) following usual primary care. Primary care patients ( N = 4,720) who had consulted for musculoskeletal pain were mailed a baseline questionnaire; responders were sent a 6-month follow-up questionnaire. The measure of health literacy used was the single-item Literary Screener at baseline, and the outcomes were PF and pain intensity at the 6-months follow-up. Analysis was conducted by linear regression. The number of patients who responded was 1,890 (40%); 17.3% (95% CI [15.6%-19%]) of them had inadequate health literacy. Inadequate health literacy was associated with older age ( p < .05), lower education, mental health, and comorbidities (all p < .001), but not by gender ( p = .642). At the 6-month follow-up stage, patients with inadequate health literacy had lower PF (mean difference -12.2; 95% CI [-16.7, -7.6]) and higher pain intensity (mean difference 1; 95% CI [0.6, 1.4]), which was adjusted for age, gender, education, mental health, and comorbidities. Differences in PF and particularly pain scores between patients with inadequate and adequate health literacy increased over 6 months. Future studies should develop interventions that better support patients who have musculoskeletal pain with inadequate health literacy to successfully manage their pain. [ HLRP: Health Literacy Research and Practice . 2018;2(4):e214-e220.] .

Objective: To investigate the cost-effectiveness (cost-utility) of introducing general practitioner screening for anxiety and depression in patients consulting for osteoarthritis (OA)., Methods: A cluster-randomized trial-based economic evaluation to assess general practitioners screening for anxiety and depression symptoms in patients consulting for OA compared to usual care (screening for pain intensity) was undertaken over a 12-month period from a UK National Health Service and societal perspective. Patient-level mean costs and mean quality-adjusted life years (QALYs) were estimated, and cost-effectiveness acceptability curves controlling for cluster-level data were constructed. The base-case analysis used the net benefit regressions approach. The 2-stage nonparametric sampling technique was explored in a sensitivity analysis., Results: The base-case analysis demonstrated that the intervention was as costly as, and less effective than, the control (QALY differential -0.029 [95% confidence interval -0.062, 0.003]). In the base-case analyses, general practitioner screening for anxiety and depression was unlikely to be a cost-effective option (probability <5% at £20,000/QALY). Similar results were observed in all sensitivity analyses., Conclusion: Prompting general practitioners to routinely screen and manage comorbid anxiety and depression in patients presenting with OA is unlikely to be cost-effective. Further research is needed to explore clinically effective and cost-effective models of managing anxiety and depression in patients presenting with clinical OA., (© 2018 The Authors. Arthritis Care & Research published by Wiley Periodicals, Inc. on behalf of American College of Rheumatology.)

Background: Patients with inflammatory rheumatic conditions such as rheumatoid arthritis, polymyalgia rheumatica and ankylosing spondylitis are at increased risk of common comorbidities such as cardiovascular disease, osteoporosis and anxiety and depression which lead to increased morbidity and mortality. These associated morbidities are often un-recognized and under-treated. While patients with other long-term conditions such as diabetes are invited for routine reviews in primary care, which may include identification and management of co-morbidities, at present this does not occur for patients with inflammatory conditions, and thus, opportunities to diagnose and optimally manage these comorbidities are missed., Objective: To evaluate the feasibility and acceptability of a nurse-led integrated care review (the INtegrating and improving Care for patients with infLammatory rheUmatological DisordErs in the community (INCLUDE) review) for people with inflammatory rheumatological conditions in primary care., Design: A pilot cluster randomized controlled trial will be undertaken to test the feasibility and acceptability of a nurse-led integrated primary care review for identification, assessment and initial management of common comorbidities including cardiovascular disease, osteoporosis and anxiety and depression. A process evaluation will be undertaken using a mixed methods approach including participant self-reported questionnaires, a medical record review, an INCLUDE EMIS template, intervention fidelity checking using audio-recordings of the INCLUDE review consultation and qualitative interviews with patient participants, study nurses and study general practitioners (GPs)., Discussion: Success of the pilot study will be measured against the engagement, recruitment and study retention rates of both general practices and participants. Acceptability of the INCLUDE review to patients and practitioners and treatment fidelity will be explored using a parallel process evaluation., Trial Registration: ISRCTN12765345., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Low back pain (LBP) and pelvic girdle pain (PGP) during pregnancy are common and often accepted as a 'normal' part of pregnancy. Many women receive little in the way of treatment, and yet pain interferes with sleep, daily activities and work and leads to increasing requests for induction of labour or elective caesarean section. The aim of this study was to assess the feasibility of a full RCT evaluating the benefit of acupuncture for pregnancy-related back pain., Methods: This study is a single-centre, three-arm pilot RCT in one large maternity unit and associated antenatal and physiotherapy clinics. Women were eligible if they had pregnancy-related LBP with or without PGP. Exclusions included a history of miscarriage, high risk of early labour or pre-eclampsia, PGP only and previous acupuncture. Interventions were standard care (SC): a self-management booklet with physiotherapy if needed. SC+TA: the booklet and physiotherapy comprising true (penetrating) acupuncture, advice and exercise. SC+NPA: the booklet and physiotherapy comprising non-penetrating acupuncture, advice and exercise. Remote telephone randomisation used a 1:1:1 allocation ratio stratified by gestational weeks. Three measures of pain/function were compared to inform the primary outcome measure in a full RCT: the Pelvic Girdle Questionnaire (PGQ), Oswestry Disability Index (ODI) and 11-point 0-10 numerical rating scale for pain. Analysis focused on process evaluation of recruitment, retention, descriptive information on outcomes, adherence to treatment, occurrence of adverse events and impact of physiotherapist training., Results: One hundred twenty-five women were randomised (45% of those eligible) between April and October 2013; 73% ( n  = 91) provided 8-week follow-up data. Three of six recruitment methods accounted for 82% of total uptake: screening questionnaire at the 20-week scan, community midwives issuing study cards, and self-referral following local awareness initiatives. Physiotherapists' self-confidence on managing pregnancy-related LBP improved post training. The PGQ is suitable as the primary outcome in a full trial. The average number of treatment sessions in both SC+TA and SC+NPA was six (in line with treatment protocols). No serious adverse events attributable to the trial treatments were reported., Conclusions: A full RCT is feasible and would provide evidence about the effectiveness of acupuncture and inform treatment choices for women with pregnancy-related LBP., Trial Registration: ISRCTN49955124.

Introduction: The choice of the most appropriate approach to valuing productivity loss has received much debate in the literature. The friction cost approach has been proposed as a more appropriate alternative to the human capital approach when valuing productivity loss, although its application remains limited. This study reviews application of the friction cost approach in health economic studies and examines how its use varies in practice across different country settings., Methods: A systematic review was performed to identify economic evaluation studies that have estimated productivity costs using the friction cost approach and published in English from 1996 to 2013. A standard template was developed and used to extract information from studies meeting the inclusion criteria., Results: The search yielded 46 studies from 12 countries. Of these, 28 were from the Netherlands. Thirty-five studies reported the length of friction period used, with only 16 stating explicitly the source of the friction period. Nine studies reported the elasticity correction factor used. The reported friction cost approach methods used to derive productivity costs varied in quality across studies from different countries., Conclusions: Few health economic studies have estimated productivity costs using the friction cost approach. The estimation and reporting of productivity costs using this method appears to differ in quality by country. The review reveals gaps and lack of clarity in reporting of methods for friction cost evaluation. Generating reporting guidelines and country-specific parameters for the friction cost approach is recommended if increased application and accuracy of the method is to be realized.

Objective: To determine the clinical effectiveness and cost-effectiveness of nurse-led care (NLC) for people with rheumatoid arthritis (RA)., Methods: In a multicentre pragmatic randomised controlled trial, the assessment of clinical effects followed a non-inferiority design, while patient satisfaction and cost assessments followed a superiority design. Participants were 181 adults with RA randomly assigned to either NLC or rheumatologist-led care (RLC), both arms carrying out their normal practice. The primary outcome was the disease activity score (DAS28) assessed at baseline, weeks 13, 26, 39 and 52; the non-inferiority margin being DAS28 change of 0.6. Mean differences between the groups were estimated controlling for covariates following per-protocol (PP) and intention-to-treat (ITT) strategies. The economic evaluation (NHS and healthcare perspectives) estimated cost relative to change in DAS28 and quality-adjusted life-years (QALY) derived from EQ5D., Results: Demographics and baseline characteristics of patients under NLC (n=91) were comparable to those under RLC (n=90). Overall baseline-adjusted difference in DAS28 mean change (95% CI) for RLC minus NLC was -0.31 (-0.63 to 0.02) for PP and -0.15 (-0.45 to 0.14) for ITT analyses. Mean difference in healthcare cost (RLC minus NLC) was £710 (-£352, £1773) and -£128 (-£1263, £1006) for PP and ITT analyses, respectively. NLC was more cost-effective with respect to cost and DAS28, but not in relation to QALY utility scores. In all secondary outcomes, significance was met for non-inferiority of NLC. NLC had higher 'general satisfaction' scores than RLC in week 26., Conclusions: The results provide robust evidence to support non-inferiority of NLC in the management of RA., Trial Registration: ISRCTN29803766., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To investigate the association between shoulder region pain presenting in primary care and cervical spine magnetic resonance imaging (MRI) abnormalities., Methods: A matched case-control study of 48 pairs of participants. Patients had presented to primary care with a new episode of shoulder pain. Controls had no history of pain in the shoulder region and were individually matched with cases by age, gender and referring clinician. All participants underwent a structured clinical assessment and cervical spine MRI. Scans were scored by experienced musculoskeletal radiologists blinded to case-control status., Results: Median age of participants was 51 years (range 19-79) and 21 (44%) were female. "Neck pain in the past week" was reported by 25 (52%) cases and seven (15%) controls (odds ratio, OR, 10.0; 95% confidence interval, CI, 2.4, 88.2). Cervical spine MRI from C3/4 to C6/7 revealed: 18 (38%) of both cases and controls had disc height loss >/=50% at any level; 10 (21%) cases and eight (17%) controls had disc disease with neural compromise; 11 (23%) cases and 16 (33%) controls had foraminal stenosis; nine (19%) of both cases and controls had canal narrowing. At least one of the above findings was present in 24 (50%) cases and 23 (48%) controls (OR 1.1; 95% CI 0.4, 3.4)., Conclusions: Cervical spine MRI abnormalities were similar in both cases and controls, despite significantly more self-reported neck pain in cases with shoulder pain. Other possible mechanisms, such as muscular strain or postural problems, may explain the observed clinical association between shoulder region pain and neck associated symptoms.

Aim: To investigate the impact of piecework on musculoskeletal pain and general health, and the influence of perceived workplace psychosocial factors on any such associations, in a general UK population., Methods: A questionnaire was mailed to an age-stratified random sample of 10 000 adults aged 18-75 in North Staffordshire, UK. Respondents reporting a current main job were asked if this job was paid by a piecework system. Health measures were (i) number of pain areas according to a body manikin and (ii) general health (SF-12v2). Other measures included questions on occupational history and psychosocial aspects of the work environment., Results: The adjusted response was 54%. A total of 1193 respondents reported a current main job, of whom 201 (17%) reported piecework. Pieceworkers were more likely to be older (P < 0.05), male (P < 0.001) and in lower socioeconomic groups (P < 0.001) than non-pieceworkers. Piecework was associated with perceptions of a poor psychosocial working environment, more pain areas (P < 0.05), more elbow (P < 0.01), forearm (P < 0.001) and hand pain (P < 0.05), and a lower physical health score (SF-12v2; P < 0.01), but no difference in mental health score (P = 0.60), compared with non-pieceworkers. After controlling for psychosocial factors, and socioeconomic group, the associations between piecework and pain areas, or physical health, were no longer statistically significant., Conclusions: These results show that piecework was associated with poorer self-reported general physical health and more areas of pain, which may be attributed to low socioeconomic group, and workplace perceptions of little job control, high physical demand and little supervisor support.

Objective: To investigate whether the International Classification of Functioning Disability and Health (ICF) Core Sets for low back pain encompass the key functional problems of patients., Design: Cross-sectional evaluation of patient-centred problems with low back pain., Subjects: A total of 402 patients living in the UK recruited into a randomized clinical trial., Methods: Patients with acute or subacute low back pain were asked to identify: (i) the one thing they find most difficult to do, and (ii) something they usually enjoyed but were unable to do because of their back pain. Two raters classified responses according to the ICF. Inter-rater agreement was measured using the kappa statistic. The response categories were examined for inclusion within the Core Sets., Results: For question (i) above, agreement between raters was 323/397 (81%), kappa (95% confidence interval (95% CI)) = 0.78 (0.73-0.82). A total of 329 (83%) fell within the ICF Brief Core Set; all except 3 were contained within the Comprehensive Core Set. For question (ii) agreement was 290/312 (93%), kappa (95% CI) = 0.91 (0.87-0.95). Only 54 (17%) of these fell within the Brief Core Set; the 2 most chosen categories (recreation and leisure: d920; caring for household objects: d650) accounted for 70% of responses, and were not included. All except 2 responses were encompassed by the Comprehensive Core Set., Conclusion: Addition of codes d920 and d650 to the low back pain Brief Core Set would significantly increase the inclusion rate in this cohort.