1
|
Swärd EM, Beckman J, Tabaroj F, Wilcke MK. Efficacy of denervation for osteoarthritis in the proximal interphalangeal joint (DOP): protocol of a randomized controlled trial. Trials 2024; 25:553. [PMID: 39169395 DOI: 10.1186/s13063-024-08399-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 08/12/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND Osteoarthritis (OA) contributes increasingly to disability worldwide. There is ample high-quality research on the treatment of knee and hip OA, whereas research on surgical and non-surgical treatment in hand OA is sparse. Limited evidence suggests that education and exercise may improve pain, function, stiffness, and grip strength in hand OA. The established surgical options in hand OA have disadvantages. Prostheses preserve motion but have a high complication rate, whereas fusions decrease function due to limited movement. There is an unmet need for high-quality research on treatment options for hand OA and a need for the development of effective and safe movement-sparing therapies. This study aims to compare the effects of a motion-preserving surgical treatment (denervation of the proximal interphalangeal (PIP) joint) with a patient education and exercise program on patient-reported outcomes and objective function in painful PIP OA. METHODS In this parallel-group, two-armed, randomized, controlled superiority trial (RCT), 90 participants are assigned to surgical PIP joint denervation or education and exercise. Pain on load 1 year after intervention is the primary outcome measure. Secondary outcome measures include pain at rest, Patient-Rated Wrist and Hand Evaluation (PRWHE), HQ8 score, EQ5D-5L, objective physical function, complications, two-point discrimination, Mini Sollerman, consumption of analgesics, and the need for further surgery. Assessments are performed at baseline, 3 and 6 months, and 1 year after intervention. DISCUSSION There are no previous RCTs comparing surgical and non-surgical treatment in PIP OA. If patient education plus exercise or PIP denervation improve function, these treatments could be implemented as first-line treatment options in PIP OA. However, if denervation does not achieve better results than non-surgical treatment, it is not justified to use in PIP OA. TRIAL REGISTRATION Prospectively registered in ClinicalTrials.gov (NCT05980793) on 8 August 2023. URL https://classic. CLINICALTRIALS gov/ct2/show/NCT05980793 .
Collapse
Affiliation(s)
- Elin M Swärd
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, Stockholm, 11883, Sweden.
- Department for Hand Surgery, Södersjukhuset, Stockholm, Sweden.
- Handkirurgiska kliniken Södersjukhuset, Sjukhusbacken 10, Stockholm, 11883, Sweden.
| | - Jonas Beckman
- Department for Hand Surgery, Södersjukhuset, Stockholm, Sweden
| | | | - Maria K Wilcke
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, Stockholm, 11883, Sweden
- Department for Hand Surgery, Södersjukhuset, Stockholm, Sweden
| |
Collapse
|
2
|
Freitas JP, Corrêa LA, Bittencourt JV, Armstrong KM, Meziat-Filho N, Nogueira LAC. One spinal manipulation session reduces local pain sensitivity but does not affect postural stability in individuals with chronic low back pain: a randomised, placebo-controlled trial. Chiropr Man Therap 2024; 32:20. [PMID: 38822395 PMCID: PMC11143588 DOI: 10.1186/s12998-024-00541-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 05/07/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Clinical practice guidelines recommend spinal manipulation for patients with low back pain. However, the effects of spinal manipulation have contradictory findings compared to placebo intervention. Therefore, this study investigated the immediate effects of lumbar spinal manipulation on pressure pain threshold (PPT) and postural stability in people with chronic low back pain (cLBP). Second, we investigated the immediate effect of lumbar spinal manipulation on pain intensity and the interference of the participant beliefs about which treatment was received in the PPT, postural stability, and pain intensity. METHODS A two-arm, randomised, placebo-controlled, double-blind trial was performed. Eighty participants with nonspecific cLPB and a minimum score of 3 on the Numeric Pain Rating Scale received one session of lumbar spinal manipulation (n = 40) or simulated lumbar spinal manipulation (n = 40). Primary outcomes were local and remote PPTs and postural stability. Secondary outcomes were pain intensity and participant's perceived treatment allocation. Between-group mean differences and their 95% confidence intervals (CIs) estimated the treatment effect. One-way analysis of covariance (ANCOVA) was performed to assess whether beliefs about which treatment was received influenced the outcomes. RESULTS Participants had a mean (SD) age of 34.9 (10.5) years, and 50 (62.5%) were women. Right L5 [between-group mean difference = 0.55 (95%CI 0.19 to 0.90)], left L5 [between-group mean difference = 0.45 (95%CI 0.13 to 0.76)], right L1 [between-group mean difference = 0.41 (95%CI 0.05 to 0.78)], left L1 [between-group mean difference = 0.57 (95%CI 0.15 to 0.99)], left DT [between-group mean difference = 0.35 (95%CI 0.04 to 0.65)], and right LE [between-group mean difference = 0.34 (95%CI 0.08 to 0.60)] showed superior treatment effect in the spinal manipulation group than sham. Neither intervention altered postural stability. Self-reported pain intensity showed clinically significant decreases in both groups after the intervention. A higher proportion of participants in the spinal manipulation group achieved more than two points of pain relief (spinal manipulation = 90%; sham = 60%). The participants' perceived treatment allocation did not affect the outcomes. CONCLUSION One spinal manipulation session reduces lumbar pain sensitivity but does not affect postural stability compared to a sham session in individuals with cLPB. Self-reported pain intensity lowered in both groups and a higher proportion of participants in the spinal manipulation group reached clinically significant pain relief. The participant's belief in receiving the manipulation did not appear to have influenced the outcomes since the adjusted model revealed similar findings.
Collapse
Affiliation(s)
- João Paulo Freitas
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Avenida Paris, 84, Bonsucesso, Rio de Janeiro, RJ, CEP 21041-020, Brasil
- Physiotherapy Department, Northern Parana State University (UENP), Paraná, Brazil
| | - Leticia Amaral Corrêa
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Avenida Paris, 84, Bonsucesso, Rio de Janeiro, RJ, CEP 21041-020, Brasil
| | - Juliana Valentim Bittencourt
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Avenida Paris, 84, Bonsucesso, Rio de Janeiro, RJ, CEP 21041-020, Brasil
| | | | - Ney Meziat-Filho
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Avenida Paris, 84, Bonsucesso, Rio de Janeiro, RJ, CEP 21041-020, Brasil
| | - Leandro Alberto Calazans Nogueira
- Rehabilitation Science Postgraduation Program, Augusto Motta University Centre (UNISUAM), Avenida Paris, 84, Bonsucesso, Rio de Janeiro, RJ, CEP 21041-020, Brasil.
- Physiotherapy Department, Federal Institute of Rio de Janeiro (IFRJ), Rio de Janeiro, Brazil.
| |
Collapse
|
3
|
Äärimaa V, Kohtala K, Rantalaiho I, Ekman E, Mäkelä K, Taskinen HS, Ryösä A, Kostensalo J, Meronen S, Laaksonen I. A Comprehensive Approach to PROMs in Elective Orthopedic Surgery: Comparing Effect Sizes across Patient Subgroups. J Clin Med 2024; 13:3073. [PMID: 38892784 PMCID: PMC11173138 DOI: 10.3390/jcm13113073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/10/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Background: There is limited knowledge regarding the comparative patient-reported outcomes (PROMs) and effect sizes (ESs) across orthopedic elective surgery. Methods: All patient data between January 2020 and December 2022 were collected, and treatment outcomes assessed as a PROM difference between baseline and one-year follow-up. The cohort was divided into subgroups (hand, elbow, shoulder, spine, hip, knee, and foot/ankle). The PROM ESs were calculated for each patient separately, and patients with ES > 0.5 were considered responders. Results: In total, 7695 patients were operated on. The mean ES across all patient groups was 1.81 (SD 1.41), and the largest ES was observed in shoulder patients and the smallest in hand patients. Overall, shoulder, hip, and knee patients had a larger ES compared to hand, spine, and foot/ankle patients (p < 0.0001). The proportion of positive responders ranged between 91-94% in the knee, shoulder, and hip, and 69-70% in the hand, spine, and foot/ankle subgroups. Conclusions: The ESs are generally high throughout elective orthopedic surgery. However, based on our institutional observations, shoulder, hip, and knee patients experience larger treatment effects compared to hand, spine, and foot/ankle patients, among whom there are also more non-responders. The expected treatment outcomes should be clearly communicated to patients when considering elective surgery. Because of the study limitations, the results should be approached with some caution.
Collapse
Affiliation(s)
- Ville Äärimaa
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
- The Faculty of Medicine, University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Karita Kohtala
- The Faculty of Medicine, University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Ida Rantalaiho
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
| | - Elina Ekman
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
| | - Keijo Mäkelä
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
- The Faculty of Medicine, University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Hanna-Stiina Taskinen
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
| | - Anssi Ryösä
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
- The Faculty of Medicine, University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| | - Joel Kostensalo
- Natural Resources Institute Finland, Yliopistokatu 6B, 80100 Joensuu, Finland;
| | - Saara Meronen
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
| | - Inari Laaksonen
- Department of Orthopedics and Traumatology, Turku University Hospital, Luolavuorenkatu 2, 20720 Turku, Finland; (V.Ä.); (I.R.); (E.E.); (K.M.); (H.-S.T.); (A.R.); (S.M.); (I.L.)
- The Faculty of Medicine, University of Turku, Kiinamyllynkatu 4-8, 20521 Turku, Finland
| |
Collapse
|
4
|
Natarajan P, Menounos S, Harris L, Monuja M, Gorelik A, Karjalainen T, Buchbinder R, Harris IA, Naylor JM, Adie S. Participant recruitment and attrition in surgical randomised trials with placebo controls versus non-operative controls: a meta-epidemiological study and meta-analysis. BMJ Open 2024; 14:e080258. [PMID: 38637129 PMCID: PMC11029374 DOI: 10.1136/bmjopen-2023-080258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/22/2024] [Indexed: 04/20/2024] Open
Abstract
OBJECTIVE To compare differences in recruitment and attrition between placebo control randomised trials of surgery, and trials of the same surgical interventions and conditions that used non-operative (non-placebo) controls. DESIGN Meta-epidemiological study. DATA SOURCES Randomised controlled trials were identified from an electronic search of MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from their inception date to 21 November 2018. STUDY SELECTION Placebo control trials evaluating efficacy of any surgical intervention and non-operative control trials of the same surgical intervention were included in this study. 25 730 records were retrieved from our systemic search, identifying 61 placebo control and 38 non-operative control trials for inclusion in analysis. OUTCOME MEASURES Primary outcome measures were recruitment and attrition. These were assessed in terms of recruitment rate (number of participants enrolled, as a proportion of those eligible) and overall attrition rate (composite of dropout, loss to follow-up and cross-overs, expressed as proportion of total sample size). Secondary outcome measures included participant cross-over rate, dropout and loss to follow-up. RESULTS Unadjusted pooled recruitment and attrition rates were similar between placebo and non-operative control trials. Study characteristics were not significantly different apart from time to primary timepoint which was shorter in studies with placebo controls (365 vs 274 days, p=0.006). After adjusting for covariates (follow-up duration and number of timepoints), the attrition rate of placebo control trials was almost twice as high compared with non-operative controlled-trials (incident rate ratio (IRR) (95% CI) 1.8 (1.1 to 3.0), p=0.032). The incorporation of one additional follow-up timepoint (regardless of follow-up duration) was associated with reduced attrition in placebo control surgical trials (IRR (95% CI) 0.64 (0.52 to 0.79), p<0.001). CONCLUSIONS Placebo control trials of surgery have similar recruitment issues but higher attrition compared with non-operative (non-placebo) control trials. Study design should incorporate strategies such as increased timepoints for given follow-up duration to mitigate losses to follow-up and dropout. PROSPERO REGISTRATION NUMBER CRD42019117364.
Collapse
Affiliation(s)
- Pragadesh Natarajan
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Spiro Menounos
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Laura Harris
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
| | - Masiath Monuja
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
| | - Alexandra Gorelik
- Department of Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Teemu Karjalainen
- Department of Musculoskeletal Diseases, Tampere University Hospital, Tampere, Finland
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ian A Harris
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Justine M Naylor
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
| | - Sam Adie
- St George and Sutherland Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- St George and Sutherland Centre for Clinical Orthopaedic Research Limited, (SCORe), Kogarah, New South Wales, Australia
| |
Collapse
|
5
|
Ring D, Adams J, Samora J, Kamal R. AOA Critical Issues: A Culture of Safety Across All Orthopaedic Professional Endeavors. J Bone Joint Surg Am 2024; 106:654-658. [PMID: 38194597 DOI: 10.2106/jbjs.23.00784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
ABSTRACT Medical professionals strive for a culture of safety in which error is anticipated, systems are designed to catch an error before it causes harm, and each event is an opportunity for specific clinicians and the system they work in to improve. A culture of safety is based on behavioral ethics, which recognizes that the automatic functions of the human mind can lead good people to misstep, and it incorporates tools such as checklists that embody critical thinking in order to help limit missteps and associated harm. Although the discussion surrounding a culture of safety often focuses on patient care, the social contract between physicians and society involves expectations that physicians will use their expertise to promote the public good in all of their professional endeavors. For example, lapses in professional conduct in the management of conflicts of interest and in ethical marketing have led to restrictions in physician self-regulation. Orthopaedic surgeons can cultivate a culture of safety and a growth mindset across all aspects of the profession, including media coverage of musculoskeletal illness, surgeon participation in informational media (e.g., podcasts and blogs), the marketing of oneself or one's practice, practice patterns and variations, academic discourse, expert legal testimony, the development and implementation of policy and law, and commercial ventures. Systems that anticipate the human potential for missteps; create tools, tactics, and structures to limit missteps and associated harm; and support surgeons and their teams in all professional endeavors can contribute to the effective and fulfilling promotion of the public good.
Collapse
Affiliation(s)
- David Ring
- Dell Medical School, The University of Texas, Austin, Texas
| | - Julie Adams
- Chattanooga Orthopedic Institute, Chattanooga, Tennessee
| | | | | |
Collapse
|
6
|
Hohenschurz-Schmidt D, Phalip J, Chan J, Gauhe G, Soliman N, Vollert J, Lunde SJ, Vase L. Placebo analgesia in physical and psychological interventions: Systematic review and meta-analysis of three-armed trials. Eur J Pain 2024; 28:513-531. [PMID: 37985188 DOI: 10.1002/ejp.2205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/18/2023] [Accepted: 11/03/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The magnitude of placebo effects from physical and psychological 'sham' is unknown but could impact efficacy trials and treatment understanding. To quantify placebo effects, this systematic review of three-armed randomised controlled trials (RCTs) of physical and psychological interventions for pain compared outcomes in 'sham' control intervention and non-exposure arms. METHODS RCTs with treatment, 'sham' control intervention, and non-exposure groups were included, enrolling adults with any pain. A protocol was pre-registered (PROSPERO: CRD42023413324), and twelve databases searched from 2008 to July 2023. Trial methods and blinding were analysed descriptively and risk of bias assessed. Meta-analysis of pain measures at short-, medium- and long-term was performed with random-effects models of standardised mean differences (SMD).Studies were sub-grouped according to control intervention type. RESULTS Seventeen RCTs were included. The average short-term placebo effect was small (0.21 SMD, 0.1-0.33 95% CI, p = 0.0002, 1440 participants). It showed no heterogeneity (Tau2 = 0.1, I2 = 11%, p = 0.3), preventing meta-regression analyses of effect modifiers. However, sub-group analyses revealed larger placebo effects in manual control interventions compared to disabled devices and miscellaneous control interventions. Overall, placebo analgesia accounted for 39% of treatments' short-term effectiveness. No placebo effects were found at medium-term (7 RCTs, 381 participants) or long-term follow-up (3 RCTs, 173 participants). CONCLUSIONS The observed placebo analgesia has mechanistic and methodological implications, though its clinical importance may be limited. Control intervention design affects placebo effects, highlighting the importance of considering methodology in RCT interpretation. Review limitations include a small number of long-term studies and sample heterogeneity. SIGNIFICANCE This systematic review directly quantifies placebo effects from physical and psychological 'sham' control interventions and compares them to treatments' overall effectiveness. By doing so, the review enhances our understanding of placebo effects, their relative contribution in clinical trials, and their susceptibly to trial design. It poses further questions regarding the influence of blinding, participant expectations, and features of the therapeutic context. Overall, the insights provided by this review carry methodological significance and are important for the interpretation and synthesis of efficacy trials in this field.
Collapse
Affiliation(s)
- David Hohenschurz-Schmidt
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, UK
- Research Department, University College of Osteopathy, London, UK
| | - Jules Phalip
- Institut ANALGESIA, Faculté de Médecine, Université Clermont Auvergne, Clermont-Ferrand, France
- CHU Clermont-Ferrand, Inserm 1107 Neuro-Dol, Service de pharmacologie médicale, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Jessica Chan
- Faculty of Medicine, Imperial College London, London, UK
| | - Greta Gauhe
- Centre for Dance Research, Coventry University, Coventry, UK
| | - Nadia Soliman
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Imperial College London, London, UK
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Münster, Germany
- Neurophysiology, Mannheim Center of Translational Neuroscience (MCTN), Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Sigrid Juhl Lunde
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| | - Lene Vase
- Department of Psychology and Behavioural Sciences, School of Business and Social Sciences, Aarhus University, Aarhus, Denmark
| |
Collapse
|
7
|
Lusa V, Karjalainen TV, Pääkkönen M, Rajamäki TJ, Jaatinen K. Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database Syst Rev 2024; 1:CD001552. [PMID: 38189479 PMCID: PMC10772978 DOI: 10.1002/14651858.cd001552.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a compression neuropathy of the median nerve at the wrist. Surgery is considered when symptoms persist despite the use of non-surgical treatments. It is unclear whether surgery produces a better outcome than non-surgical therapy. This is an update of a Cochrane review published in 2008. OBJECTIVES To assess the evidence regarding the benefits and harms of carpal tunnel release compared with non-surgical treatment in the short (< 3 months) and long (> 3 months) term. SEARCH METHODS In this update, we included studies from the previous version of this review and searched the Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, ClinicalTrials.gov and WHO ICTRP until 18 November 2022. We also checked the reference lists of included studies and relevant systematic reviews for studies. SELECTION CRITERIA We included randomised controlled trials comparing any surgical technique with any non-surgical therapies for CTS. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS The 14 included studies randomised 1231 participants (1293 wrists). Eighty-four per cent of participants were women. The mean age ranged from 32 to 53 years, and the mean duration of symptoms from 31 weeks to 3.5 years. Trial sizes varied from 22 to 176 participants. The studies compared surgery with: splinting, corticosteroid injection, splinting and corticosteroid injection, platelet-rich plasma injection, manual therapy, multimodal non-operative treatment, unspecified medical treatment and hand support, and surgery and corticosteroid injection with corticosteroid injection alone. Since surgery is generally used for its long-term effects, this abstract presents only long-term results for surgery versus splinting and surgery versus corticosteroid injection. 1) Surgery compared to splinting in the long term (> 3 months) Surgery probably results in a higher rate of clinical improvement (risk ratio (RR) 2.10, 95% confidence interval (CI) 1.04 to 4.24; 3 studies, 210 participants; moderate-certainty evidence). Surgery probably does not provide clinically important benefit in symptoms or hand function compared with splinting (moderate-certainty evidence). The mean Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (scale 1 to 5; higher is worse; minimal clinically important difference (MCID) = 1) was 1.54 with splint and 0.26 points better with surgery (95% CI 0.52 better to 0.01 worse; 2 studies, 195 participants). The mean BCTQ Functional Status Scale (scale 1 to 5; higher is worse; MCID 0.7) was 1.75 with splint and 0.36 points better with surgery (95% CI 0.62 better to 0.09 better; 2 studies, 195 participants). None of the studies reported pain. Surgery may not provide better health-related quality of life compared with splinting (low-certainty evidence). The mean EQ-5D index (scale 0 to 1; higher is better; MCID 0.074) was 0.81 with splinting and 0.04 points better with surgery (95% CI 0.0 to 0.08 better; 1 study, 167 participants). We are uncertain about the risk of adverse effects (very low-certainty evidence). Adverse effects were reported amongst 60 of 98 participants (61%) in the surgery group and 46 of 112 participants (41%) in the splinting group (RR 2.11, 95% CI 0.37 to 12.12; 2 studies, 210 participants). Surgery probably reduces the risk of further surgery; 41 of 93 participants (44%) were referred to surgery in the splinting group and 0 of 83 participants (0%) repeated surgery in the surgery group (RR 0.03, 95% CI 0.00 to 0.21; 2 studies, 176 participants). This corresponds to a number needed to treat for an additional beneficial outcome (NNTB) of 2 (95% CI 1 to 9). 2) Surgery compared to corticosteroid injection in the long term (> 3 months) We are uncertain if clinical improvement or symptom relief differs between surgery and corticosteroid injection (very low-certainty evidence). The RR for clinical improvement was 1.23 (95% CI 0.73 to 2.06; 3 studies, 187 participants). For symptoms, the standardised mean difference (SMD) was -0.60 (95% CI -1.88 to 0.69; 2 studies, 118 participants). This translates to 0.4 points better (95% CI from 1.3 better to 0.5 worse) on the BCTQ Symptom Severity Scale. Hand function or pain probably do not differ between surgery and corticosteroid injection (moderate-certainty evidence). For function, the SMD was -0.12 (95% CI -0.80 to 0.56; 2 studies, 191 participants) translating to 0.10 points better (95% CI 0.66 better to 0.46 worse) on the BCTQ Functional Status Scale with surgery. Pain (0 to 100 scale) was 8 points with corticosteroid injection and 6 points better (95% CI 10.45 better to 1.55 better; 1 study, 123 participants) with surgery. We found no data to estimate the difference in health-related quality of life (very low-certainty evidence). We are uncertain about the risk of adverse effects and further surgery (very low-certainty evidence). Adverse effects were reported amongst 3 of 45 participants (7%) in the surgery group and 2 of 45 participants (4%) in the corticosteroid injection group (RR 1.49, 95% CI 0.25 to 8.70; 2 studies, 90 participants). In one study, 12 of 83 participants (15%) needed surgery in the corticosteroid group, and 7 of 80 participants (9%) needed repeated surgery in the surgery group (RR 0.61, 95% CI 0.25 to 1.46; 1 study, 163 participants). AUTHORS' CONCLUSIONS Currently, the efficacy of surgery in people with CTS is unclear. It is also unclear if the results can be applied to people who are not satisfied after trying various non-surgical options. Future studies should preferably blind participants from treatment allocation and randomise people who are dissatisfied after being treated non-surgically. The decision for a patient to opt for surgery should balance the small benefits and potential risks of surgery. Patients with severe symptoms, a high preference for clinical improvement and reluctance to adhere to non-surgical options, and who do not consider potential surgical risks and morbidity a burden, may choose surgery. On the other hand, those who have tolerable symptoms, who have not tried non-surgical options and who want to avoid surgery-related morbidity can start with non-surgical options and have surgery only if necessary. We are uncertain if the risk of adverse effects differs between surgery and non-surgical treatments. The severity of adverse effects may also be different.
Collapse
Affiliation(s)
- Vieda Lusa
- Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Teemu V Karjalainen
- Department of Surgery, Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Melbourne, Australia
| | - Markus Pääkkönen
- Turku University Hospital, Wellbeing Services County of Southwest Finland, Turku, Finland
| | - Tuomas Jaakko Rajamäki
- Department of Hand Surgery, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Kati Jaatinen
- Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland
| |
Collapse
|
8
|
Ibezim CF, Reichel LM, Ring D. Measurement of Upper Extremity-Specific Comfort and Capability. J Am Acad Orthop Surg 2023; 31:e876-e882. [PMID: 37332222 DOI: 10.5435/jaaos-d-23-00109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/05/2023] [Indexed: 06/20/2023] Open
Abstract
Patient-reported outcome measures (PROMs) quantify symptom intensity and magnitude of capability. Upper extremity PROMs were developed shortly after the advent of general health PROMs. PROMs are still primarily research tools, and their use with individual patients is still evolving. When PROMs were developed, the initial and intuitive expectation was a strong correlation of comfort and capability with pathophysiology severity. In other words, people with greater radiographic arthritis or larger degenerative tendon defects were expected to feel worse and do less. After more than 20 years of research using PROMs, it is clear that mindset and circumstances account for more of the variation in PROMs than pathophysiology severity. Mounting research establishes upper extremity PROMs and PROMs in general as useful tools for anchoring and developing comprehensive, biopsychosocial approaches to care.
Collapse
Affiliation(s)
- Chizitam F Ibezim
- From the Dell Medical School, the University of Texas at Austin, Austin, TX
| | | | | |
Collapse
|
9
|
Jütte R. Involving Voters and Consumers in Decision-Making about the Health Care System - The Swiss Case: A Review. Complement Med Res 2023; 31:78-83. [PMID: 37748443 DOI: 10.1159/000534268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Behind the principle of involving users and voters directly in decision-making about the health care system are ideas relating to empowerment. This implies a challenge to the traditional view that scientific knowledge is generally believed to be of higher value than empirical knowledge, as it is the case with CAM. The objectives of this review are (a) to show that this assumption disregards the fact that CAM is as scientific as conventional medicine but has different basic assumptions what the world is being made of and consequently uses different/adapted scientific methods; (b) to demonstrate how a perspective of the history of medicine and science as well as direct democracy mechanisms such as stipulated in the Swiss constitution can be used to achieve the acceptance of CAM in a modern medical health care system. A public health care system financed by levies from the population should also reflect the widely documented desire in the population for medical pluralism (provided that therapeutical alternatives are not risky). Otherwise, the problem of social inequality arises because only people with a good financial background can afford this medicine. SUMMARY From the perspective of scientific theory and the history of science, the answer to the question of whether complementary medicine and conventional medical procedures must provide proof of efficacy according to a uniform scientific is quite controversial according to epistemologically oriented studies on this issue. KEY MESSAGES This review found strong evidence for involving voters and consumers directly in decision-making about the provision of CAM in the health care system. It also seems necessary to step back in the debate on evidence-based medicine, taking a history of medicine and science perspective, as the role which the proper method occupies and plays in medicine is defined by the scientific nature of the world view. Hinter dem Grundsatz, Nutzer und Wähler direkt in die Entscheidungsfindung über das Gesundheitssystem einzubeziehen, stehen Vorstellungen von Empowerment. Dies impliziert eine Infragestellung der traditionellen Ansicht, dass wissenschaftliches Wissen im Allgemeinen als wertvoller angesehen wird als empirisches Wissen und erprobte Erfahrung, wie es bei der Komplementärmedizin der Fall ist. Die Ziele dieser Übersichtsarbeit sind: (a) zu zeigen, dass diese Annahme die Tatsache außer Acht lässt, dass die Komplementärmedizin ebenso wissenschaftlich ist wie die Schulmedizin, aber von anderen Grundannahmen ausgeht, wie die Welt beschaffen ist, und folglich andere/angepasste wissenschaftliche Methoden anwendet; (b) aufzuzeigen, wie eine medizin- und wissenschaftsgeschichtliche Perspektive sowie Mechanismen der direkten Demokratie, wie sie in der Schweizer Verfassung vorgesehen sind, genutzt werden können, um die Akzeptanz der Komplementärmedizin in einem modernen medizinischen Gesundheitssystem zu erreichen. Ein öffentliches, durch Abgaben der Bevölkerung finanziertes Gesundheitssystem sollte auch dem vielfach dokumentierten Wunsch der Bevölkerung nach medizinischem Pluralismus Rechnung tragen (sofern die therapeutischen Alternativen nicht riskant sind). Andernfalls stellt sich das Problem der sozialen Ungleichheit, weil sich nur Menschen mit einem guten finanziellen Hintergrund diese Medizin leisten können.
Collapse
Affiliation(s)
- Robert Jütte
- Institute for the History of Medicine of the Robert Bosch Foundation, Stuttgart, Germany
| |
Collapse
|
10
|
Stanhope J, Salter A, Weinstein P. "A wolf in sheep's clothing": when so-called placebo interventions are not what they seem. Med J Aust 2023; 218:244-246. [PMID: 36893725 DOI: 10.5694/mja2.51881] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/23/2023] [Accepted: 02/06/2023] [Indexed: 03/11/2023]
|