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Programmes not preventing fractures
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Falls prevention programmes are ineffective in preventing fractures, study finds
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TWO “screen and treat” programmes to prevent older people falling do not reduce fractures, an NIHR-funded trial has revealed.
As part of the largest clinical trial of its kind in the UK, researchers from the University of Warwick and University of Exeter examined two approaches to preventing falls in older people to find out if they also resulted in fewer fractures. Their results, published in the New England Journal of Medicine, showed that these programmes are ineffective, when using a population screening approach, in reducing fractures in older people.
The study examined two programmes: multi-factorial fall prevention (MFFP), and exercise for people at increased falls risk. People living in the community (not in care homes) were screened for falls risk and invited to attend the programmes. Both interventions are widely used in health services internationally and prescribed regularly for older people. TALKBACK l WINTER 2020
Multi-factorial fall prevention involved a one-hour assessment with a trained health professional for eight risk factors for falls. Following this, participants would either be given specific advice, see their GP for a detailed medication review, or be referred for physiotherapy-led exercise. The exercise programme ran for six months during which they were seen by a physiotherapist and exercised at home.
Staying mobile
Lead author Professor Sallie Lamb of the University of Exeter, who began the research while working at the University of Warwick, said: “While this is a disappointing result, it shows that we must continue to invest in research and development to reduce fractures in older people. We need to think about the broader causes of fractures, and understand more about what happens to cause falls.”
Co-author Professor Julie Bruce from Warwick Clinical Trials Unit at the University of Warwick said: “We saw benefits to the general health of people doing exercise and a short-term reduction in the number of falls after exercise. People completing the six-month exercise programme became stronger and their balance improved – but that did not translate into a reduction in fractures in the long term. The take home message is that we would encourage older people to do physical activity and keep mobile because of the health benefits.”
Each year, up to one in 20 older people with a history of falling sustains a fracture, with some being admitted to hospital, or needing to move to a care home. One in three people with a hip fracture dies within one year. Hip fractures alone cost the UK more than £2 billion a year. www.nihr.ac.uk www.nejm.org
PATIENTS with suspected early inflammatory arthritis are waiting too long to see a specialist, says a new report.
The National Early Inflammatory Arthritis Audit, conducted by the British Society for Rheumatology (BSR), reveals that only 41% of patients met the three-day standard for referral from their GP and only 38% referred to a rheumatology unit were seen within the three-week guidelines. The average wait for the first appointment was 28 days.
A prompt diagnosis of early inflammatory arthritis can make the difference between developing life-long disabilities or actually going into remission.
Shortages of rheumatology staff was identified as a key factor for the delays. The audit data also shows considerable variation
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Prompt diagnosis can be life changing across England and Wales and identifies 51 trusts or health boards performing less well than the rest. These “outliers” are being encouraged to use their data to lobby for additional resources as well as to look at how processes can be improved.
Ali Rivett, Chief Executive of the BSR, said: “Our audit plays a vital role in identifying where the problems are. It’s not just about resources but also units making better use of the resources they have. Reconfiguring services and sharing learning among units can make a real difference.”
The audit helps to show the impact of early inflammatory arthritis on people’s lives and the importance of prompt treatment; patients who accessed appropriate treatment within three months were much more likely to get back to work and less likely to be depressed and anxious.
It shows good examples across England and Wales where units are performing well, and regional champions have been set up to help others learn from their good practice. www.rheumatology.org.uk/neia-audit
Keyhole surgery no better than other therapies for frozen shoulder
KEYHOLE surgery is no better at treating frozen shoulder than less invasive therapies, an NIHRfunded trial published in The Lancet has found.
Frozen shoulder is a common and painful condition in which movements in the shoulder become restricted. It affects 10% of women and 8% of men of working age and can last years.
A common surgical treatment is arthroscopic capsular release (ACR), a keyhole procedure under general anaesthetic where a probe is inserted into the shoulder, along with a camera and the joint capsule is released, stretched and manipulated to regain a range of movement.
However, NIHR researchers, led by a team at South Tees Hospitals NHS Foundation Trust and University of York Trials Unit, have found that ACR was no more effective than two other less costly and invasive treatments using a patient-reported questionnaire about shoulder pain and function.
One treatment was manipulation under anaesthesia (MUA) – a minimally invasive procedure where surgeons move the shoulder joint to a full range of motion. The other was early structured physiotherapy (ESP) with a steroid injection – a treatment specially designed for the trial that doesn’t require a general anaesthetic.
Chief Investigator Professor Amar Rangan, Consultant Orthopaedic Surgeon at South Tees NHSFT, said: “Frozen shoulder is a common condition for which thousands of people each year need hospital treatment because of the pain they are in and struggle with daily activities, sleep and work.
“Our trial has shown that an expensive keyhole surgery is no better than two alternative therapies. This could provide more choice for patients – especially those with conditions like diabetes who have to manage a chronic disease and who may not want the additional inconvenience and risk of surgery under anaesthetic.”
The randomised controlled trial was carried out in 35 UK hospitals, where 503 patients were randomised, with 203 receiving ACR and 201 MUA. The remaining 99 underwent ESP.
All three treatments led to significant improvements in patient reported shoulder pain and function over one year, but none of the treatments was superior.
Overall, MUA was found to be the most costeffective option that provided the NHS with the best value for money spent in terms of health gains for the patient. www.nihr.ac.uk
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