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JUNIOR HOSPITAL DOCTORS
27
subcentre has been established with resident paramedics. There are plans to do the same elsewhere: the success of subcentres is crucial to the project, since the proximity of medical facilities is the main factor determining how, or whether, the villagers will use them. This applies par-
ticularly
to women,
whose
mobility
is still very
res-
tricted. Another important aspect of the work is houseto-house visiting by small teams of paramedics. They do vaccinations (mainly smallpox so far), distribute contra-
ceptive pills, advise on nutrition and hygiene, and generally encourage people to make use of the services offered. As to the tubectomy programme, after great success locally it has been extended to Jamalpur and Sherpur-towns 120 miles
to
the north. Teams of 7 or 8, in-
cluding 1 doctor, travel there on request, staying three or four days. Finally, the project has expanded into nonmedical territory-notably, agriculture and vocational training for women. Although these activities have met with only limited success, they are seen as essential to a project which seeks to involve the local population at all levels. Gonoshasthaya Kendra deserves close attention in years to
come.
INJECTING THE PAINFUL SHOULDER INTRA-ARTICULAR corticosteroid injections are undoubtedly valuable in rheumatoid arthritis and similar inflammatory arthropathies. What is not clearcut is the value, if any, of local corticosteroid injections in the treatment of the painful shoulder without inflammatory arthritis. Shoulder pain is a common cause of disability,’1 but like back pain it receives less than its fair share of attention in rheumatology textbooks. A useful method of examination of the shoulder is that practised by Cyriax2 though not everyone agrees with his classification of disorders or his treatment. Classification of shoulder pain is difficult largely because the pain may arise from one or more structures, including the glenohumeral joint, the acromioclavicular joint, the joint capsule, the subacromial bursa, and the tendons of supraspinatus, infraspinatus, teres minor, and subscapularis muscles-the rotator cuff. Pain may also be referred from the cervical spine and diaphragm. Capsulitis, rotator-cuff syndrome, subacromial bursitis, supraspinatus tendinitis, periarthritis, and frozen shoulder are diagnoses which mean different things to different doctors, though many use the terms in a synonymous and inconstant way. This terminological confusion muddles many of the clinical trials comparing methods of treatment. One multicentre trial’ has compared local steroid injections (prednisolone acetate 25 mg/ml) in a group of patients with rotator cuff/capsulitis lesions with physiological-saline injections in a similar group. The shoulder was injected at first attendance and at two weeks: on each occasion 1 ml of injection fluid was given into the subdeltoid bursa and 1 ml into the glenohumeral joint by the posterior route. Six weeks after the initial injection there
statistically significant improvement in passive shoulder movement in the steroid-injected group compared with the saline-injected group. There was no significant difference between the groups for subjective pain, night pain, or pain on resisted movement. was a
1. Richardson, A. T. Proc. R. Soc. Med. 1975, 68, 731 2. Cyriax, J. Br. J. Hosp. Med. 1975, 13, 185. 3. Hazleman, B. L. Rheum. phys. Med. 1972, 11, 413. 4. Sheldon, P. J. H. ibid. p. 422.
retrospective studies34 comparing physiotherapy with local hydrocortisone injections or with manipulation under anaesthesia there seems little to choose between treatments, the stiff painful shoulder tending to improve over a period of months. A trial in periarthritis of the shoulder’ compared heat and exercises, hydrocortisone to the shoulder-joint and exercises, hydrocortisone around the biceps tendon in the bicipital groove and exercises, and a fourth group taking analgesics only. After six weeks the analgesic group fared worst but there was no significant difference between the three treatment groups. A more recent investigation6 compared local steroid injection with local anaesthetic injection in a group of patients with supraspinatus tears (confirmed in most cases by arthrography). The local steroid injection gave pain relief initially but after a From
month there was little difference between the two groups. The message is not that local steroid injections have no part to play-in some patients the effect may be startling-but that unprecise diagnostic labels hamper attempts at prognosis. Intra-articular and peri-articular injections, even performed as recommended by Steinbrocker and Neustadt,7 carry a risk of infection, and repeated injections of a corticosteroid into the same site may lead to joint destruction.8 The hypothalamic/pituitary/adrenal axis is affected: 48 hours after an injection of 80 mg methylprednisolone acetate into one knee9 the response to insulin hypoglycaemia was suppressed, and plasma-cortisol was suppressed for three to six days. These systemic effects decrease the attraction of intra-articular corticosteroids for treating a condition as common as the painful shoulder. We should be doing more to find out the pathogenesis and the most effective treatment of a condition which can keep a man off physical work for weeks or months.
JUNIOR HOSPITAL DOCTORS AFTER a meeting of the Hospital Junior Staffs Committee on Dec. 23 hopes were high for an early return to normal work by those junior doctors who had been imposing sanctions for the previous four weeks. By 38 votes to 9 the committee decided to recommend acceptance of the proposals for new contracts and suspension ("for the present") of industrial action; but it would be left to regions to decide whether or not to return to normal working. The juniors’ negotiators believed that outstanding difficulties had been overcome and that the new audit 10 of overtime payments would disclose that much more than the Government’s figure of 12 million would be available for distribution without breaking the pay restraints which the Government had imposed. Though normal services were resumed over Christmas in some casualty departments, other hospitals were still unable to call on the wholehearted support of their junior staff. 5. Lee, P. N., Lee, M., Haq, A. M. M. M., Longton, E. B., Wright, V. Ann. rheum Dis. 1974, 33, 116. 6. Coomes, E. N., Darlington, L. G. Paper read to the Heberden Society, London, Nov. 28, 1975. 7. Steinbrocker, O., Neustadt, D. H. Aspiration and Injection Therapy in Arthritis and Musculo-skeletal Disorders. Maryland, 1972. 8. Bentley, G., Goodfellow, J. W. J. Bone Ji Surg. 1969, 51B, 498. 9. Koehler, B. E., Urowitz, M. B., Killinger, D. W. J. Rheumatol. 1974, 1, 117. 10. See Lancet,
Dec. 20, 1975, p. 1249.
subcentre has been established with resident paramedics. There are plans to do the same elsewhere: the success of subcentres is crucial to the project, since the proximity of medical facilities is the main factor determining how, or whether, the villagers will use them. This applies par-
ticularly
to women,
whose
mobility
is still very
res-
tricted. Another important aspect of the work is houseto-house visiting by small teams of paramedics. They do vaccinations (mainly smallpox so far), distribute contra-
ceptive pills, advise on nutrition and hygiene, and generally encourage people to make use of the services offered. As to the tubectomy programme, after great success locally it has been extended to Jamalpur and Sherpur-towns 120 miles
to
the north. Teams of 7 or 8, in-
cluding 1 doctor, travel there on request, staying three or four days. Finally, the project has expanded into nonmedical territory-notably, agriculture and vocational training for women. Although these activities have met with only limited success, they are seen as essential to a project which seeks to involve the local population at all levels. Gonoshasthaya Kendra deserves close attention in years to
come.
INJECTING THE PAINFUL SHOULDER INTRA-ARTICULAR corticosteroid injections are undoubtedly valuable in rheumatoid arthritis and similar inflammatory arthropathies. What is not clearcut is the value, if any, of local corticosteroid injections in the treatment of the painful shoulder without inflammatory arthritis. Shoulder pain is a common cause of disability,’1 but like back pain it receives less than its fair share of attention in rheumatology textbooks. A useful method of examination of the shoulder is that practised by Cyriax2 though not everyone agrees with his classification of disorders or his treatment. Classification of shoulder pain is difficult largely because the pain may arise from one or more structures, including the glenohumeral joint, the acromioclavicular joint, the joint capsule, the subacromial bursa, and the tendons of supraspinatus, infraspinatus, teres minor, and subscapularis muscles-the rotator cuff. Pain may also be referred from the cervical spine and diaphragm. Capsulitis, rotator-cuff syndrome, subacromial bursitis, supraspinatus tendinitis, periarthritis, and frozen shoulder are diagnoses which mean different things to different doctors, though many use the terms in a synonymous and inconstant way. This terminological confusion muddles many of the clinical trials comparing methods of treatment. One multicentre trial’ has compared local steroid injections (prednisolone acetate 25 mg/ml) in a group of patients with rotator cuff/capsulitis lesions with physiological-saline injections in a similar group. The shoulder was injected at first attendance and at two weeks: on each occasion 1 ml of injection fluid was given into the subdeltoid bursa and 1 ml into the glenohumeral joint by the posterior route. Six weeks after the initial injection there
statistically significant improvement in passive shoulder movement in the steroid-injected group compared with the saline-injected group. There was no significant difference between the groups for subjective pain, night pain, or pain on resisted movement. was a
1. Richardson, A. T. Proc. R. Soc. Med. 1975, 68, 731 2. Cyriax, J. Br. J. Hosp. Med. 1975, 13, 185. 3. Hazleman, B. L. Rheum. phys. Med. 1972, 11, 413. 4. Sheldon, P. J. H. ibid. p. 422.
retrospective studies34 comparing physiotherapy with local hydrocortisone injections or with manipulation under anaesthesia there seems little to choose between treatments, the stiff painful shoulder tending to improve over a period of months. A trial in periarthritis of the shoulder’ compared heat and exercises, hydrocortisone to the shoulder-joint and exercises, hydrocortisone around the biceps tendon in the bicipital groove and exercises, and a fourth group taking analgesics only. After six weeks the analgesic group fared worst but there was no significant difference between the three treatment groups. A more recent investigation6 compared local steroid injection with local anaesthetic injection in a group of patients with supraspinatus tears (confirmed in most cases by arthrography). The local steroid injection gave pain relief initially but after a From
month there was little difference between the two groups. The message is not that local steroid injections have no part to play-in some patients the effect may be startling-but that unprecise diagnostic labels hamper attempts at prognosis. Intra-articular and peri-articular injections, even performed as recommended by Steinbrocker and Neustadt,7 carry a risk of infection, and repeated injections of a corticosteroid into the same site may lead to joint destruction.8 The hypothalamic/pituitary/adrenal axis is affected: 48 hours after an injection of 80 mg methylprednisolone acetate into one knee9 the response to insulin hypoglycaemia was suppressed, and plasma-cortisol was suppressed for three to six days. These systemic effects decrease the attraction of intra-articular corticosteroids for treating a condition as common as the painful shoulder. We should be doing more to find out the pathogenesis and the most effective treatment of a condition which can keep a man off physical work for weeks or months.
JUNIOR HOSPITAL DOCTORS AFTER a meeting of the Hospital Junior Staffs Committee on Dec. 23 hopes were high for an early return to normal work by those junior doctors who had been imposing sanctions for the previous four weeks. By 38 votes to 9 the committee decided to recommend acceptance of the proposals for new contracts and suspension ("for the present") of industrial action; but it would be left to regions to decide whether or not to return to normal working. The juniors’ negotiators believed that outstanding difficulties had been overcome and that the new audit 10 of overtime payments would disclose that much more than the Government’s figure of 12 million would be available for distribution without breaking the pay restraints which the Government had imposed. Though normal services were resumed over Christmas in some casualty departments, other hospitals were still unable to call on the wholehearted support of their junior staff. 5. Lee, P. N., Lee, M., Haq, A. M. M. M., Longton, E. B., Wright, V. Ann. rheum Dis. 1974, 33, 116. 6. Coomes, E. N., Darlington, L. G. Paper read to the Heberden Society, London, Nov. 28, 1975. 7. Steinbrocker, O., Neustadt, D. H. Aspiration and Injection Therapy in Arthritis and Musculo-skeletal Disorders. Maryland, 1972. 8. Bentley, G., Goodfellow, J. W. J. Bone Ji Surg. 1969, 51B, 498. 9. Koehler, B. E., Urowitz, M. B., Killinger, D. W. J. Rheumatol. 1974, 1, 117. 10. See Lancet,
Dec. 20, 1975, p. 1249.