Between 1999 and 2007 I was commissioned by the New Zealand Accident Compensation Commission (ACC) to conduct number of research projects. My colleague Bruce Arroll was also assisted in this research and is co-author on a number of the publications. Some of the later work involved other co-authors. Reports were produced for ACC for each commissioned work and the findings were also published in peer-reviewed journals.
Rehabilitation after arthroscopic meniscectomy
In 1999 – 2000 I conducted a systematic review on rehabilitation after arthroscopic meniscectomy:
Rehabilitation after arthroscopic meniscectomy a critical review of the clinical trials
Goodyear-Smith FA & Arroll B. International Orthopaedics,24 (6): 350-353, 2001.
We reviewed the literature on patient management following arthroscopic meniscal surgery. A critical appraisal of the literature produced 8 randomized controlled trials evaluating the use of non-steroidal anti-inflammatory drugs or various forms of physiotherapy and pain control. Different treatments and outcome measures precluded meta-analysis. The limited evidence suggests that this is a relatively pain-free procedure with rapid recovery, and that in most cases simple analgesia in the first 1-2 days following surgery and a well-planned home-based exercise program should be sufficient. It is possible that routine daily non-steroidal anti-inflammatory drugs post-operatively for 3-6 weeks may enhance recovery rates. One study found that physiotherapy was beneficial for regaining muscle strength and on pain assessment but this did not translate into functional improvement. Descriptive studies are required to ascertain the types and duration of treatments being offered to patients after arthroscopic meniscectomy. Further research is needed to perform well-designed studies of current treatments that take into account predisposing factors and their impact on outcome, including use of prerandomization and real-life functional outcome measures
Literature review on rehabilitation after arthroscopic knee surgery for meniscal damage. Final Report to the Accident Rehabilitation and Compensation Insurance Corporation
Goodyear-Smith F & Arroll B 46pp Oct 1999.
Imaging and referrals with respect to acute and chronic low back pain
In 2001 I conducted a literature review and research to provide recommendations to ACC regarding imaging and referrals with respect to acute and chronic low back pain:
Recommendations for GPs regarding imaging with respect to low back pain: a Delphi and evidence-based study
Goodyear-Smith F, Arroll B New Zealand Family Physician, 29 (2): 97-101, 2002
Introduction: Despite evidence-based guidelines, plain x-rays are used more extensively than recommended in low back pain, do not help diagnose simple back pain or nerve root problems and carry high false-positive risk.
Aim: To review the literature regarding GPs’ use of plain x-ray and determine expert opinion regarding use of these investigations.
Method: A literature review and modified two-round Delphi consultation was conducted with a panel of GPs and other relevant practitioners.
Results: There was consensus that most low back pain resolves, and spondylosis and disc degeneration findings are common in both symptomatic and non-symptomatic patients, hence in absence of trauma or other ‘red flags’ lumbar spine x-rays should be avoided for 4-6 weeks. X-rays are recommended where serious pathology is suspected. Opinion was mixed regarding MRI as first-line investigation. Lumbar x-rays require 30-40 times the dose of chest x-ray radiation.
Conclusion: Where there is consensus on the literature GPs should adhere to recommendations. Lack of consensus justifies GP clinical flexibility. A greater awareness by doctors and patients of radiation levels involved may diminish ordering lumbar x-rays when serious pathology is unlikely.
Imaging for back pain full text
GP management and referral of low back pain: a Delphi and evidence-based study
Goodyear-Smith F, Arroll B. New Zealand Family Physician, 29 (2): 102-107, 2002
Background: Numerous evidence-based guidelines on low back pain management have been produced but specific conditions for General Practitioner (GP) referral are not always specified.
Aim: Literature review and expert consultation to determine best management circumstances and timing of referral to other health practitioners.
Method: Multi-disciplinary panel underwent two-round Delphi consultation assessing their opinions and degree of agreement to evidence-based statements.
Results: Conservative treatment should include information about low back pain; reinforcement of positive expectations; education about self-management and self-responsibility, pain management and control and increase in exercise tolerance. NSAIDs, muscle relaxants and manipulation should be considered if there is no radicular pain. Referral for steroid epidural injections, TENS, acupuncture, traction and lumbar support should be avoided. Clinically severe nerve impingement requires referral to orthopedic surgeons. There was consensus that referral should occur if no improvement after 6 weeks and certainly after 12 weeks. To whom GPs should refer is not clear.
Conclusion: Where there is good evidence there is usually a consensus regarding management and referral for back pain, for example no or limited referral for acute pain. Where there is no or equivocal evidence then clinical judgement for individuals is needed. More randomised controlled trials are required to elucidate the best persons to whom GPs should refer patients with subacute or chronic back pain.
Management of back pain full text
Recommendations regarding imaging and referrals with respect to acute and chronic low back pain. Report to the Accident Rehabilitation and Compensation Insurance Corporation
Goodyear-Smith F, Arroll B 57pp, Mar 2001
Management of carpal tunnel syndrome
In 2002-2003 I conducted a literature review on the evidence for management of carpal tunnel syndrome.
What can family physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of non-surgical management
Goodyear-Smith F, Arroll B. Annals of Family Medicine, 2 (3): 267-273, 2004
Background: We undertook a literature review to produce evidence-based recommendations for nonsurgical family physician management of carpal tunnel syndrome (CTS).
Methods: Study design was systematic review of randomized controlled trials (RCTs) on CTS treatment. Data sources were English publications from all relevant databases, hand searches, and guidelines. Outcomes measured were nonsurgical management options for CTS.
Results: We assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using historical controls. A considerable percentage of CTS resolves spontaneously. There is strong evidence that local corticosteroid injections, and to a lesser extent oral corticosteroids, give short-term relief for CTS sufferers. There is limited evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic ultrasound may be effective in the short to medium term (up to 6 months). The evidence for nerve and tendon gliding exercises is even more tentative. The evidence does not support the use of nonsteroidal anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic treatment, or magnet treatment.
Conclusions: For those who are not able to get surgery or for those who do not want surgery, there are some conservative modalities that can be tried. These modalities include ones for which there is good evidence. It would be reasonable to try some of the techniques with less evidence if the better ones are not successful. Reconsideration of surgery must always be kept in mind to avoid permanent nerve damage.
Recommendations on the diagnosis and management of carpal tunnel syndrome: Report to the Accident Rehabilitation and Compensation Insurance Corporation
Goodyear-Smith F & Arroll B Auckland, 48pp, Mar 2002
Effectiveness of corticosteroid injections into shoulder, knee and ankle joints in relation to injury-related conditions
In 2002-2003 I conducted systematic literature reviews and meta-analysis for ACC on the effectiveness of corticosteroid injections into shoulder, knee and ankle joints in relation to injury-related conditions.
Corticosteroid injections for osteoarthritis of the knee: a meta-analysis
Arroll B, Goodyear-Smith F British Medical Journal, 328:869, 23 March 2004 doi:10.1136/bmj.38039.573970.7C
OBJECTIVES: To determine the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee and to identify numbers needed to treat. DATA SOURCES: Cochrane controlled trials register, Medline (1966 to 2003), Embase (1980 to 2003), hand searches, and contact with authors.
INCLUSION CRITERIA: Randomised controlled trial in which the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee could be ascertained.
RESULTS: In high quality studies, the pooled relative risk for improvement in symptoms of osteoarthritis of the knee at 16-24 weeks after intra-articular corticosteroid injections was 2.09 (95% confidence interval 1.2 to 3.7) and the number needed to treat was 4.4. The pooled relative risk for improvement up to two weeks after injections was 1.66 (1.37 to 2.0). The numbers needed to treat to get one improvement in the statistically significant studies was 1.3 to 3.5 patients.
CONCLUSION: Evidence supports short term (up to two weeks) improvement in symptoms of osteoarthritis of the knee after intra-articular corticosteroid injection. Significant improvement was also shown in the only methodologically sound studies addressing longer term response (16-24 weeks). A dose equivalent to 50 mg of prednisone may be needed to show benefit at 16-24 weeks.
Corticosteroid injection for the knee
Corticosteroid injections for painful shoulder: a meta-analysis
Arroll B, Goodyear-Smith F. British Journal of General Practice, 55: 224-228, 2005
Objectives: To determine the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee and to identify numbers needed to treat.
Data sources: Cochrane controlled trials register, Medline (1966 to 2003), Embase (1980 to 2003), hand searches, and contact with authors.
Inclusion criteria: Randomised controlled trial in which the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee could be ascertained.
Results: In high quality studies, the pooled relative risk for improvement in symptoms of osteoarthritis of the knee at 16-24 weeks after intra-articular corticosteroid injections was 2.09 (95% confidence interval 1.2 to 3.7) and the number needed to treat was 4.4. The pooled relative risk for improvement up to two weeks after injections was 1.66 (1.37 to 2.0). The numbers needed to treat to get one improvement in the statistically significant studies was 1.3 to 3.5 patients.
Conclusion: Evidence supports short term (up to two weeks) improvement in symptoms of osteoarthritis of the knee after intra-articular corticosteroid injection. Significant improvement was also shown in the only methodologically sound studies addressing longer term response (16-24 weeks). A dose equivalent to 50 mg of prednisone may be needed to show benefit at 16-24 weeks.
Review: Intra-articular corticosteroid injections are better than placebo for improving symptoms of knee osteoarthritis
Arroll B. Goodyear-Smith F. Shoor S. Evidence Based Medicine. 10 (1):23, 2005 doi:10.1136/ebm.10.1.23
Commentary: Stanford Shoor, MD Kaiser Permanente Medical Center? Santa Clara, California, USA
The biological mechanism of corticosteroids suggests that they should be effective in joint disease with significant inflammation—a fact established in the treatment of rheumatoid arthritis. However, how beneficial are corticosteroids in such conditions as OA? The meta-analysis by Arroll et al provides the best answers to date: (1) Intra-articular steroids are modestly better than saline for short term relief of pain. Patients who receive intra-articular corticosteroids are 1.6 times more likely to improve at 2 weeks than those who receive placebo injections (number needed to treat [NNT]?=?4). This conclusion is robust, given the results of previous studies,1 the tendency of OA to worsen over time, and the consistency of the findings of this review (7 of 10 trials showed improvement). (2) Corticosteroids appear to have slight benefit at 16–24 weeks (NNT?=?5). However, this conclusion was based on only 2 trials, is less consistent with the clinical experience of rheumatologists, and may be dose dependent.
The review by Arroll et al also raises several questions: which group of OA patients are likely to respond to corticosteroids (ie, those with less severe disease or those with clinical evidence of inflammation such as an effusion)? To what degree is the apparent success of intra-articular steroids affected by how the procedure is performed? For example, how much fluid is withdrawn if lavage is used rather than saline instillation? At what point in the treatment regimen should intra-articular corticosteroids be used (ie, after or before NSAID or physical therapy)? What is the effective and safe interval for repeat injections?
Unless or until further studies address these issues, clinicians should be reassured that with prudent use, intra-articular corticosteroids remain a valuable option for short term management of OA of the knee.
1 Wise C. The rational use of steroid injections in arthritis and nonarticular musculoskeletal pain syndromes. Bull Rheum Dis 2003;52:1–4
Recommendations regarding effectiveness of corticosteroid injections into shoulder, knee and ankle joints in relation to injury-related conditions: Report to the Accident Rehabilitation and Compensation Insurance Corporation
Goodyear-Smith F & Arroll B 82pp, Mar 2003
Sexual abuse counselling treatment rates by professional group
In 2004-2005 I was commissioned by ACC to conduct an analysis of data provided by ACC on the sexual abuse counselling: treatment rates provided by psychiatrists, psychologists and counsellors under ACC funding. My co-authors were Dr Brenda Lobb (Department of Psychology, University of Auckland) and James Mansell, Senior Analyst, Child Youth and Family, Wellington.
ACC pays for treatment for sexual abuse if there is evidence of a diagnosable mental injury and that this mental injury was caused by sexual abuse events. Mental injury is defined as a clinically significant behavioural, cognitive or psychological dysfunction (such as acute stress disorder, post-traumatic stress disorder, anxiety disorder, depression, dissociative identity disorder) that is more than an immediate reaction to the event and requires treatment. The sexual abuse act must be one of the criminal acts described in Schedule 3 of the Injury Prevention, Rehabilitation and Compensation Act 2001 (sexual violation or other sexual offence). We noted that counsellors could see claimants for up to 52 hours before a Diagnostic and Treatment Assessment (DATA) according to DSM IV was required by a qualified professional. In our discussion we wrote that this “raised potential concerns about accuracy of the initial diagnosis (mental injury), appropriateness of the treatment selected and best use of available funds”. In our recommendations we noted that “Given the serious nature of the mental injuries treated by ACC-funded providers, it may be appropriate for the initial and final assessments at the least to be conducted by a professional qualified to perform a DATA according to DSM IV criteria – i.e. a psychiatrist or clinical psychologist.”
Sexual abuse counselling: treatment rates provided by psychiatrists, psychologists and counsellors under ACC funding
Goodyear-Smith F, Lobb B, Mansell J. New Zealand Family Physician, 32 (6): 389-393, 2005
Objective: To compare treatment rates provided to Accident Compensation Corporation (ACC) sexual abuse claimants by professional provider categories of psychiatrist, psychologist and counsellor.
Method: Data on total numbers of claims per provider and claimant visits to each provider were analysed for all ACC-funded providers of sexual abuse counselling services in 2003. Visits per claim for provider were estimated as total number of treatment visits divided by total number of new claimants seen within 2003. Providers were classified as psychiatrists, psychologists or counsellors. These data were analysed using nonparametric Kruskal-Wallace and Mann-Whitney U tests to determine any significant differences between professional categories in visits per claim.
Results: Sexual abuse counselling services were provided by 647 professionals to 8676 claimants over 107,685 visits during 2003. Most services were provided by counsellors (89.4%) rather than more highly qualified professionals. On average counsellors had 12.87 visits per claim, registered psychologists 9.11 and psychiatrists 8.89. Counsellors had significantly more visits per claim than psychiatrists and psychologists (?²=33.53, df=2, p<.000) with no significant difference between psychiatrists and registered psychologists.
Conclusions: To determine whether psychiatrists and registered psychologists work more effectively than counsellors, we recommend that additional following data should be collated and analysed including duration between reported traumatic event and onset of counselling, nature of sexual crime suffered; diagnosis at onset of treatment (mental injury resulting from sexual crime); treatment modalities provided; frequency and duration of sessions; whether provider or claimant concluded treatment. Counsellors see claimants for up to 52 hours before a Diagnostic and Treatment Assessment (DATA) is provided by a qualified professional (psychiatrist or clinical psychologist). We recommend that initial and final DATA assessments are performed by qualified professionals. Although they have higher fee structures, their use may be cost-effective if assessment assures correct diagnosis is made and optimum treatment provided from the outset.
Sexual abuse counselling full text
Treatment rates of sexual abuse counselling provided by psychiatrists, psychologists and counsellors under ACC finding: Report to the Accident Rehabilitation and Compensation Insurance Corporation
Goodyear-Smith F, Lobb B, Mansell J. 21 pp, Mar 2005.
Efficacy of anticonvulsant drugs for neuropathic pain management
In 2006-2007 I conducted systematic literature reviews regarding the efficacy of anticonvulsant drugs for neuropathic pain management.
Anticonvulsants for neuropathic pain: gaps in the evidence
Goodyear-Smith FA, Halliwell J. Clinical Journal of Pain, 25 (6):528-536, 2009. doi: 10.1097/AJP.0b013e318197d4cc
OBJECTIVE: To summarize the available evidence on the use of anticonvulsant drugs for the treatment of various conditions of neuropathic pain.
METHODS: This is a systematic review on quantity and quality of evidence for using anticonvulsants in the management of neuropathic pain. Medical Subject Heading terms searched were “anticonvulsants” and “pain.” Data sources used were the Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, Medline 1966 to May 2006, Embase 1980 to May 2006, and CINAHL 1982 to May 2006. Additional studies were identified by hand searching the reference lists of retrieved papers and by autoalerts subsequent to May 2006. Randomized controlled trials, systematic reviews, and meta-analyses included. Non-English papers excluded. Evidence and evidence gaps with regard to specific conditions and drugs identified.
RESULTS: Concise summary of all existing evidence or lack thereof was produced. A succinct table is presented of the efficacy of specific drugs for specific conditions and the nature and quality of evidence. The paper outlines the incidence of specific neuropathic pain conditions within various population groups and assesses the quantity of available evidence in regard to the frequency that those conditions are likely to occur.
DISCUSSION: Gaps in the evidence are striking. Recommendations directly supported by the evidence by drug and by condition are made
Recommendations regarding efficacy of anticonvulsant drugs for neuropathic pain management: Report to the Accident Compensation Corporation
Goodyear-Smith F, Halliwell J Auckland, 245 pp, April 2007
Recommendations regarding efficacy of anticonvulsant drugs (excluding gabapentin and pregabalin) for neuropathic pain management, Report to the Accident Compensation Corporation
Goodyear-Smith F, Halliwell J Auckland, 141pp, Nov 2006
These findings resulted in a Considered Judgement Form Anticonvulsants for neuropathic pain published by ACC in August 2007.
Interventional Pain Management
From 2002 to 2005 I was the RNZCGP Representative as a member of a large multi-disciplinary team on the ACC Interventional Pain Management Guideline Group. We systematically reviewed a large volume of literature pertaining to interventional pain management for a variety of injury-related conditions, and published a guidance for best practice.
ACC Clinical Reference Group
From 2007 to 2008 I was an Appointed Member of Accident Compensation Corporation’s Clinical Reference Group. I resigned this position (and many other roles) when I took on the editorship of the RNZCGP Peer-reviewed Journal and became the founding editor of the Journal of Primary Health Care in 2009.
Response to allegations in the Sunday Star-Times article August 2010
The article Conflicting interests? alleged that I was responsible for the 2009 ACC sexual abuse clinical pathway.
In 2009 ACC made some changes to funding for counsellors providing counselling for sexual abuse. In their new clinical pathway they introduced a requirement that before they could access ACC counselling claimants had to be diagnosed formally with a mental injury as defined by the American Diagnostic and Statistical Manual (DSM-IV).
This change was introduced by their medical director at that time, Dr Peter Jansen. Dr Jansen introduced this requirement based on the legal requirement that a sexual abuse ‘Sensitive claim’ could only be made ‘when a mental injury is caused by ‘certain criminal acts’ specified in sections of the Crimes Act 1961 and listed in Schedule 3 of the Accident Compensation (AC) Act 2001 and ‘Mental injuries (as defined in Section 27 of the AC Act) must meet the criteria outlined in ‘The Diagnostic and Statistical Manual (DSM-IV™) of the American Psychiatric Association’ in order to be eligible for ACC cover.’
When asked subsequently Dr Jansen said that to the best of his knowledge he had never read the paper written by myself, Brenda Lobb and James Mansell and he had never discussed these ACC changes with me. I had no knowledge that these changes had occurred until 2010. I did know Dr Jansen and we had previously both served on ACC’s Interventional Pain Management Guideline Group 2002 to 2005.
The NZ psychotherapy and counselling community were very upset by these changes, which meant they could no longer claim for counselling for anyone alleging sexual abuse without their client undergoing an assessment as to whether there was evidence of resulting mental injury. Prior to this they could claim for up to one year of weekly counselling with the option to renew for additional sessions without any diagnostic assessment of their clients. For many counsellors this was their sole or main source of income, so they were seriously affected by these changes, and apparently by 2010 ACC was paying millions of dollars less for sexual abuse counselling.
Unbeknown to me, the counselling network thought that I was the architect of this new clinical pathway, and this message had been widely disseminated, including on blogs and websites. They dubbed the pathway the “rapists’ charter”.
In August 2010 I denied any involvement when approached by the media. This led to an article in a Sunday paper “Academic with link to sex abusers silent on role in drafting ACC rules.”
Denise Cosgrove, the General Manager, claims Management ACC wrote the following Letter to the Editor saying that the article
was misleading in some important respects. The article suggests that Dr Felicity Goodyear-Smith was involved with the development of the ACC clinical pathway for sexual abuse claims. She was not. Goodyear-Smith had no role in the development of the pathway. The report she and two other researchers produced five years ago was an inconclusive study which compared treatment rates provided to ACC sexual abuse clients by psychologists, psychiatrists and counsellors. So it was not relevant to the development of the pathway.
Yes, one of their recommendations was that there should be diagnosis before treatment, using an assessment tool called DSM-IV. Yes, that is what we’ve been doing. But we didn’t do so because it was in their report. Far from it. We did it because it was internationally seen as best practice, because the courts in NZ had endorsed DSM-IV as an appropriate method and because no suitable alternative options have been put forward. Goodyear-Smith had no part in any of that.
However this was followed by a long article about me in the Sunday-Star Times by Tim Hume examining “allegations of Goodyear-Smith’s influence in ACC’s recent drastic cut in support for victims of sex crimes.”
On 5 September 2010 Tim Hume published a further article in response to talking with Dr David Rankin, who had been the Medical Director of ACC when I conducted my research in 2005: Sex-abuse cuts ‘all about costs’ by Tim Hume Sunday Star-Times 5 Sep 2010
Included in this is the statement that:
Rankin said Goodyear-Smith’s research had set out to determine whether psychologists provided more effective treatment than less-qualified counsellors. He had been “stunned” when her research had not borne out their expectation that they would. He said he had been aware of Goodyear-Smith’s links to sex offenders and strong views, and for that reason stipulated “that I personally read what she said before we published it”. He blocked a number of her recommendations. “We acknowledged the agenda and protected both herself and us against it.
This is untrue. My contracts with ACC included the clause that I was entitled to publish my findings without interference from the funder. ACC did not publish my findings although they did receive my report and may have put this on their website – my results were published in the NZ Family Physician.