The hip injection trial (HIT) nested qualitative study: experiences of living with hip Osteoarthritis and receiving trial treatments.

Holden, M.A.; Hawarden, A.; Paskins, Z.; Roddy, E.; Mallen, C.; Jinks, C.; Trial Team, The HIT.

Abstract

Purpose: Evidence about the effectiveness of intra-articular corticosteroid injection for hip osteoarthritis (OA) is limited. The HIT trial compared ultrasound-guided intra-articular hip injection (USGI) of triamcinolone acetonide and 1% lidocaine hydrochloride combined with best current treatment (BCT) with (i) BCT alone and (ii) an USGI of 1% lidocaine only combined with BCT (EudraCT: 2014-003412-37). BCT included verbal and written advice on exercise, weight loss and pain management. This nested qualitative study explored participants’ experiences of living with hip OA and of and of the treatment they received.

Methods: Semi-structured interviews were completed with purposefully sampled trial participants from each arm after return of their 2-month follow-up questionnaire. Interviewers knew whether participants had received an injection within the trial, but not which injection (to minimise patients becoming un-blinded to treatment allocation). Interviews were recorded, transcribed and analysed thematically. Analysis was undertaken blind to the clinical trial Results to facilitate an interpretive and inductive approach. Sampling ceased on inductive thematic saturation.

Results: 34 trial participants were interviewed across all arms (USGI of triamcinolone acetonide and lidocaine plus BCT = 13, BCT alone = 8, USGI of lidocaine plus BCT = 11). Both males and females aged between 53 and 83 years old, with varying levels of pain intensity, functional ability, and pain self-efficacy participated in an interview. Participants described how hip OA impacted on many aspects of their life. It caused pain and physical limitations, restrictions in being able to undertake valued activities, difficulties at work, and lowered mood. It also commonly disrupted sleep. Participants who received BCT alone reported receiving an examination, information/explanation and exercises. Despite this, most felt that they had not received ‘treatment’ per se (e.g. “I don’t feel like I’ve had treatment because I was already doing the exercise anyway and I was taking something to help the pain” #10282), and many reported limited exercise adherence. Participants described little or no benefit from BCT, and thoughts about the future tended to focus on inevitable decline. In contrast, experiences of having an injection were positive overall and participants in both injection groups experienced marked improvements in pain, function and other aspects of life, including sleep. Participants described “getting their life back” and having “a new lease of life”. Perceived benefit appeared greater among those randomised to USGI of triamcinolone acetonide and lidocaine plus BCT, however length of benefit varied in both injection groups. Despite uncertainty about the longer-term benefits of injection and the possibility of having repeated injections, there was more hope and optimism about the future among participants who had received an injection in comparison to those who had received BCT alone.

Conclusions: Hip OA is burdensome, affecting many different aspects of life. Participants perceived little or no benefit from BCT alone, but reported marked improvements when combined with an USGI of triamcinolone and lidocaine or lidocaine alone. This complements the clinical trial Results which demonstrated superiority of USGI of triamcinolone and lidocaine plus BCT over 6 months compared with BCT alone, but no significant difference in hip pain intensity between the injection groups. Together these findings raise the possibility of a degree of placebo effect. As participants in BCT reported receiving advice and education but did not feel they had treatment, novel ways to effectively implement self-management may be required. Varying duration of response to injection between individuals, and reported uncertainty regarding effectiveness and safety of future injections, suggest these areas as important for future research.

• Journal Article Type: Conference Paper
• Conference Name: 2020 OARSI World Congress on Osteoarthritis; 30 April-3 May 2020
• Conference Location: Messe Wien Exhibition & Congress Center, Vienna, Austria
• Online Publication Date: Apr 20, 2020
• Publication Date: 2020-04
• Deposit Date: Jun 28, 2023
• Journal: Osteoarthritis and Cartilage
• Print ISSN: 1063-4584
• Publisher: Elsevier
• Peer Reviewed: Peer Reviewed
• Volume: 28
• Pages: S499
• DOI: https://doi.org/10.1016/j.joca.2020.02.782
• Keywords: Orthopedics and Sports Medicine; Biomedical Engineering; Rheumatology