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Why participants in The United Kingdom Rotator Cuff Tear (UKUFF) trial did not remain in their allocated treatment arm: a qualitative study

  • Catherine J. Minns Lowe
    Correspondence
    Corresponding author.
    Affiliations
    Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Windmill Road, Headington, Oxford OX3 7HE, United Kingdom
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  • Jane Moser
    Affiliations
    Oxford University Hospitals NHS Foundation Trust, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7HE, United Kingdom

    Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7HE, United Kingdom
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  • Karen L. Barker
    Affiliations
    Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Windmill Road, Headington, Oxford OX3 7HE, United Kingdom

    Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7HE, United Kingdom
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Published:September 21, 2017DOI:https://doi.org/10.1016/j.physio.2017.09.002

      Abstract

      Objective

      The UKUFF trial was a three-way parallel group randomised trial comparing surgical and non-surgical treatments for people with rotator cuff tears of their shoulder.
      High crossover between arms in the UKUFF led to the original trial design being reconfigured; ‘Rest then Exercise’ was halted. This study explored why participants recruited did not remain within allocated treatment arms and explored crossover and surgical decision making.

      Design

      A qualitative phenomenological approach.

      Participants

      Purposive sampling (n = 18) included participants randomised to ‘Rest then Exercise’ arm considered least likely to proceed to surgery but who had surgery, plus participants from all arms not having surgery.

      Methods

      In-depth, semi-structured interviews were recorded and transcribed. Field-notes, memos, member-checking and a reflexive diary were used.

      Data analyses

      In accordance with Interpretative Phenomenological Analysis. Peer review, code-recode audits and constant comparison occurred throughout.

      Results

      1. Impact of symptoms and diagnosis: these influenced crossover; long durations of severe pain and failed conservative treatment increased eagerness for surgery. 2. Perceptions and expectations of treatment: surgery provided hope for participants, especially when “Rest then Exercise” was perceived as having previously failed. Surgeons were perceived to believe “tears need repairing”. 3. Professionals know best: autonomy and communication: patients deciding not to have surgery had to actively leave the surgical waiting list. Increasing age, carer role, self-employment, co-morbidity and improving symptoms were reasons described for declining surgery.

      Conclusions

      Most participants had failed conservative treatment before trial entry and described strong preferences regarding treatment. Trials should demonstrate patient and clinician equipoise but participants’ rarely described equipoise. If conservative treatments are usually provided sequentially in clinical practice, it may be inappropriate to include them as comparators in surgical trials.
      This is a qualitative study and not eligible for trial registration since it was carried out independently of the UKUFF trial (UKUFF ISRCTN97804283 Date assigned 29/06/2007).

      Keywords

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