Top POEMs of 2015 Consistent with the Principles of the Choosing Wisely Campaign: Musculoskeletal Disease

Top 20 POEMs of 2015 Consistent with the Principles of the Choosing Wisely Campaign

Arthroscopy Not Beneficial in Degenerative Knee Pain

Clinical question
In older patients with knee pain and degenerative disease, is arthroscopic surgery effective?

Bottom line
In middle-aged or older patients with knee pain, arthroscopic meniscectomy and/or debridement is no more effective than sham surgery or exercise to reduce pain and improve physical functioning. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ 2015;350:h2747.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis
To complete this meta-analysis, these Danish researchers searched 5 databases, including CENTRAL, and identified 9 randomized controlled trials assessing the benefits of knee surgery in 1279 middle-aged and older patients with knee pain and degenerative knee disease (but without evidence of cruciate ligament damage). Some of the trials, but not all, enrolled patients with radiographic evidence of osteoarthritis. Interventions included meniscectomy, debridement, or both, compared with placebo surgery (!) or exercise. Two researchers independently selected studies for inclusion and assessed risk of bias, which was fairly high in most studies since most were not blinded. Individually, only a single study found a benefit on pain scores; taken together, there was a small effect on pain, which translated to a 2.4-mm difference in pain scores on a 0-mm to 100-mm visual analog scale (95% CI 0.4 - 4.3). Pain scores were better in the first 6 months following the intervention, which could be related to the placebo effect. By 2 years there was no difference in pain scores. There was no benefit on physical function at any time during follow-up. A Cochrane Review has shown a similar lack of benefit with debridement.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

No Long-Term Benefit of Arthroscopic Surgery for Meniscal Tears in Middle-Aged Persons

Clinical question
Does arthroscopic surgery improve outcomes for patients with a degenerative meniscal tear and little or no osteoarthritis?

Bottom line
Arthroscopic repair of degenerative meniscal tears in middle-aged adults does not significantly improve long-term pain or function. Patients should do physical therapy and try to avoid surgery if possible. (LOE = 1a-)(www.essentialevidenceplus.com)

Reference
Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014;186(14):1057-1064.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Synopsis
The authors of this systematic review identified randomized controlled trials that compared arthroscopic meniscal debridement with conservative management for patients with degenerative (nontraumatic) meniscal tears and little or no osteoarthritis. They found a total of 7 studies (including 5 published in 2013) with a total of 805 patients, mostly from Europe. Overall study quality was not impressive. Conservative management generally included a standardized exercise program, though one study used an intraarticular steroid injection and one used sham surgery. Studies employed a variety of outcome measures, so the authors combined them using standardized mean differences for the effect sizes. The mean age of the patients was 53 years to 59 years in the 7 included studies. Risk of bias was high or uncertain for 6 of the 7 studies, largely due to failure to mask and uncertainty regarding allocation concealment and randomization. In the short term (< 6 months) there was a statistically significant improvement in functional outcomes with surgery (standardized mean difference 0.25; 95% CI 0.02 - 0.48). However, this improvement was not seen for longer-term outcomes (6 months to 2 years) and did not exceed the threshold for a minimally important difference. Surgery did not improve pain either in the short term or in the long term.

Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA

Pregabalin = Placebo in Neurogenic Claudication from Spinal Stenosis

Clinical question
Does pregabalin relieve neurogenic claudication (walking-induced pain) in patients with spinal stenosis?

Bottom line
Ten days of pregabalin is no more effective than active placebo (low-dose diphenhydramine) in increasing exercise tolerance or decreasing pain in patients with neurogenic claudication due to lumbar spinal stenosis. Whether longer duration treatment has any benefit is not knowable from this study. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Markman JD, Frazer ME, Rast SA, et al. Double-blind, randomized, controlled, crossover trial of pregabalin for neurogenic claudication. Neurology 2015;84(3):265-272.

Study design: Cross-over trial (randomized)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
These researchers evaluated 29 adults older than 50 years who had at least 3 months of neurogenic claudication associated with radiographically confirmed lumbar spinal stenosis. The patients randomly received pregabalin (75 mg twice daily for 3 days, followed by 150 mg twice daily for 7 days, then 75 mg twice daily for 3 days) or an active placebo (diphenhydramine 6.25 mg twice daily, followed by 12.5 mg twice daily, then 6.25 mg twice daily). There was a 7-day washout period between treatment periods. The patients had to have an intensity of pain of 4 out of 10 induced within 15 minutes of walking on a treadmill. The authors excluded patients with prior pregabalin treatment, lumbar surgery within 2 years of enrollment, or lumbar epidural steroid injection in the previous 3 months. This was a crossover study, which means that each patient received both treatment and placebo. The beauty of the crossover design is that each patient serves as his or her own control, so fewer patients are needed. The drawbacks are that the analysis can become complicated, and because relatively few patients are needed the results are less applicable to a wider population. Three patients withdrew during the initial treatment period but none withdrew during the second treatment period. The main outcomes in this study included walking time before onset of pain, pain intensity, and so forth. Overall, during the time the patients were treated with pregabalin they experienced no improvement in any of the outcomes studied compared with the intervals in which active placebo was used. Nearly two thirds of the patients experienced adverse effects during their pregabalin treatment compared with approximately one third while taking placebo. The most common side effect – dizziness – occured in slightly fewer than half the patients.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Gabapentin = Epidural Steroid for Radicular Pain

Clinical question
Is an epidural steroid injection or gabapentin more effective for pain relief in patients with lumbosacral radicular pain due to a herniated disc or spinal stenosis?

Bottom line
After controlling for the placebo effect that may accompany an epidural steroid injection, treatment with gabapentin is as effective as the injection in reducing radicular leg pain in the short term (3 months). A placebo bump in response, if present, is likely to be transient. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Cohen SP, Hanling S, Bicket MC, et al. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ 2015;350:h1748. doi: 10.1136/bmj.h1748

Study design: Randomized controlled trial (double-blinded)

Funding source: Foundation

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
Patients enrolled in this study were recruited from 8 hospitals in different areas of the United States and from a U.S. military facility in Europe. The 145 patients (74% men) had lumbosacral radicular pain due to a herniated disc or spinal stenosis for less than 4 years in duration and the leg pain was as severe or more severe than back pain. The patients were randomly assigned, using concealed allocation to receive either gabapentin (titrated to between 1800 and 3600 mg per day in 3 doses for 3 months) or to receive a single epidural injection of depomethylprednisolone 60 mg with a local anesthetic. To mask patients to their treatment, thereby minimizing the placebo effect of the procedure or the daily medication use, all patients took daily medicine and all patients received an injection, with the patients in the gabapentin group receiving a saline injection. After 1 month, pain scores had decreased similarly in both groups. Patients receiving steroid had a slightly better response to a reduction in their "worst leg pain" scores (a decrease of 3 points vs 2 points; P = .04) and were more likely to report a positive successful outcome (number needed to treat = 5). By 3 months, though, improvement was similar in both groups.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Spinal Stenosis: Physical Therapy Before Surgery

Clinical question
Is surgery more effective than physical therapy in patients referred for surgery for spinal stenosis?

Bottom line
Assigning patients to 6 weeks of physical therapy is as effective as initially sending them for decompression surgery, with fewer complications, even in patients who have a strong preference for surgery. A trial of 6 weeks of physical therapy makes sense for many patients with confirmed spinal stenosis before getting out the scalpel. (LOE = 1b-)(www.essentialevidenceplus.com)

Reference
Delitto A, Piva SR, Moore CG, et al. Surgery versus nonsurgical treatment of lumbar spinal stenosis. A randomized trial. Ann Intern Med 2015;162(7):465-473.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
The investigators enrolled 169 patients (average age: 66-69 years) with image-confirmed lumbar stenosis who consented to surgery. This approach to enrollment eliminated many patients, presumably those with milder symptoms. The patients were randomly assigned (allocation concealed) to surgery or physical therapy. The decompression surgery was the typical procedure used in research and practice. Physical therapy, administered twice weekly for 6 weeks, consisted of lumbar flexion exercises and conditioning to identify the issues of strength and flexibility identified at enrollment. Analysis was by intention to treat, meaning that patients assigned to physical therapy were analyzed as being in that group even if they eventually received surgery, which 57% of them did over the 2 years of follow-up (most of them within the first 10 weeks of the study). Approximately 20% in each group sought additional physical therapy. Two years after identification, general quality of life (as measured by the Short Form-36 Health Survey, a typical measure of quality of life) improved equally in both groups, to an average score of 48-50 from a baseline of 26-28 of a possible 100. Analyzing by actual treatment rather than by intention to treat yielded similar results though the study may not have had enough power to find a difference if one existed. Pain, disability, and neurogenic symptoms improved similarly in both groups. Complications were common in the back surgery group, including the need for re-operation. Many patients were not returned to "normal" but continued to visit either a back surgeon or primary care physician for back pain 2 years after the intervention.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Platelet-Rich Plasma Injections Are Not Superior to Hyaluronic Acid for Knee Degenerative Joint Disease

Clinical question
Are platelet-rich plasma injections more effective than viscosupplementation to alleviate pain and improve function in patients with symptomatic knee degenerative joint disease?

Bottom line
Platelet-rich plasma (PRP) injections into the knees of patients with degenerative joint disease (DJD) are not superior to viscosupplementation. Since the benefits of viscosupplementation have been minimal-to-nonexistent, we have relatively few ways of helping our patients: exercises, analgesics, orthotics. (LOE = 1a)(www.essentialevidenceplus.com)

Reference
Filardo G, Di Matteo B, Di Martino A, et al. Platelet-rich plasma intra-articular knee injections show no superiority versus viscosupplementation: a randomized controlled trial. Am J Sports Med 2015;43(7):1575-1582.

Study design: Randomized controlled trial (double-blinded)

Funding source: Unknown/not stated

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
This Italian study took 4 years to complete. The researchers' hypothesis was that PRP injections in the knees of patients with symptomatic DJD would be more effective than viscosupplementation with hyaluronic acid (HA). They randomly assigned patients to 3 weekly injections of PRP (n = 96) or 3 weekly injections of HA (n = 96). To further conceal the treatment group, each patient underwent blood harvesting to obtain PRP. The researchers, masked to original treatment, evaluated each patient at baseline, then 2, 6, and 12 months after the last injection. Patients receiving PRP reported no adverse events, while 2 patients treated with HA reported pain and swelling after the injections. Nonetheless, both treatments improved symptoms and function scores to a comparable degree. A 2006 systematic Cochrane Review concluded that viscosupplementation was effective in improving symptoms, but a more recent systematic review (Rutjes AW, et al. Ann Intern Med 2012;157(30):180‐191) concluded that viscosupplementation is associated with "a small and clinically irrelevant benefit and an increased risk for serious adverse events" in patients with symptomatic osteoarthritis of the knee. This raises the question as to whether the effects seen in this study, regardless of selected intervention, are merely placebo or nocebo.

Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI

Steroid Injection Does Not Improve Response to Exercise Therapy for Knee Osteoarthritis

Clinical question
Does a steroid injection before the start of exercise therapy improve the response in patients with knee osteoarthritis?

Bottom line
Unlike other study results, in this study a steroid injection given 2 weeks before the start of supervised exercise was no more effective than a placebo injection at improving pain scores 2 weeks later in patients with knee osteoarthritis. It also did not cause a greater improvement after 3 months of exercise. (LOE = 1b)(www.essentialevidenceplus.com)

Reference
Henriksen M, Christensen R, Klokker L, et al. Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee: A randomized clinical trial. JAMA Intern Med 2015;175(6):923-930.

Study design: Randomized controlled trial (double-blinded)

Funding source: Foundation

Allocation: Concealed

Setting: Outpatient (specialty)

Synopsis
The Danish researchers enrolled 100 patients with knee osteoarthritis (confirmed by radiography) and knee pain while walking who were not morbidly obese. The patients were randomized, using concealed allocation, to receive an injection of methylprednisolone 40 mg or saline (both with lidocaine). Two weeks later all participants started a 12-week supervised exercise program. At the 2-week visit (before starting exercise), pain scores had improved slightly in both groups. By the end of 3 months of exercise therapy, scores had improved significantly and similarly in both groups.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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