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Ho EKY, Mobbs RJ, van Gelder JM, Harris IA, Davis G, Stanford R, Beard DJ, Maher CG, Prior J, Knox M, Anderson DB, Buchbinder R, Ferreira ML. Challenges of conducting a randomised placebo-controlled trial of spinal surgery: the SUcceSS trial of lumbar spine decompression. Trials 2023; 24:794. [PMID: 38057932 PMCID: PMC10698887 DOI: 10.1186/s13063-023-07772-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/01/2023] [Indexed: 12/08/2023] Open
Abstract
Although placebo-controlled trials are considered the gold standard for evaluating the efficacy of healthcare interventions, they can be perceived to be controversial and challenging to conduct for surgical treatments. The SUcceSS trial is the first placebo-controlled trial of lumbar decompression surgery for symptomatic lumbar canal stenosis. The SUcceSS trial has experienced common issues affecting the implementation of randomised placebo-controlled surgery trials, accentuated by the COVID-19 pandemic. Using the SUcceSS trial as an example, we discuss key challenges and mitigation strategies specific to the conduct of a randomised placebo-controlled surgical trial. Overall, the key lessons learned were (i) involving key stakeholders early and throughout the trial design phase may increase clinician and patient willingness to participate in a placebo-controlled trial of surgical interventions, (ii) additional resources (e.g. budget, staff time) are likely required to successfully operationalise trials of this nature, (iii) the level of placebo fidelity, timing of randomisation relative to intervention delivery, and nuances of the surgical procedure under investigation should be considered carefully. Findings are based on one example of a placebo-controlled surgical trial; however, researchers may benefit from employing or building from the strategies described and lessons learned when designing or implementing future trials of this nature.
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Affiliation(s)
- Emma Kwan-Yee Ho
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, Sydney, NSW, 2050, Australia.
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - Ralph Jasper Mobbs
- NeuroSpine Surgery Reserach Group (NSURG), Sydney, NSW, 2031, Australia
- Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
- School of Medicine, University of New South Wales, Sydney, Australia
| | - James Montague van Gelder
- Department of Neurosurgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Sydney Spine Institute, Burwood, NSW, 2134, Australia
| | - Ian Andrew Harris
- South West Sydney Clinical Campuses, School of Clinical Medicine, UNSW Medicine & Health, University of New South Wales, Sydney, NSW, 2170, Australia
| | - Gavin Davis
- Neurosurgery, Cabrini & Austin Hospitals; and School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3800, Australia
| | - Ralph Stanford
- Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
| | - David John Beard
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, Sydney, NSW, 2050, Australia
- NHMRC CTC, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | - Joanna Prior
- The University of Sydney, School of Health Sciences, Faculty of Medicine and Health, Sydney, NSW, 2050, Australia
| | - Michael Knox
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
| | - David Barrett Anderson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3800, Australia
| | - Rachelle Buchbinder
- Musculoskeletal Health and Wiser Health Care Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Manuela Loureiro Ferreira
- The University of Sydney, Sydney Musculoskeletal Health and the Kolling Institute, Faculty of Medicine and Health, School of Health Sciences, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
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Campbell MK, Beard DJ, Blazeby JM, Cousins S. Further considerations for placebo controls in surgical trials. Trials 2023; 24:391. [PMID: 37301819 PMCID: PMC10257825 DOI: 10.1186/s13063-023-07417-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 05/25/2023] [Indexed: 06/12/2023] Open
Abstract
The use of invasive placebo controls in surgical trials can be challenging. The ASPIRE guidance, published in the Lancet in 2020, provided advice for the design and conduct of surgical trials with an invasive placebo control. Based on a more recent international expert workshop in June 2022, we now provide further insights into this topic. These include the purpose and design of invasive placebo controls, patient information provision and how findings from these trials may be used to inform decision-making.
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Affiliation(s)
- Marion K Campbell
- Royal College of Surgeons of England (RCSEng) Aberdeen Surgical Trials Centre; Health Services Research Unit, Health Sciences Building, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences; RCSEng Surgical Intervention Trials Unit; National Institute for Health and Care Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Headington, Oxford, UK
| | - Jane M Blazeby
- NIHR Bristol Biomedical Research Centre; RCSEng Bristol Surgical Trials Centre, Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, BS8 2PS, Bristol, UK
| | - Sian Cousins
- NIHR Bristol Biomedical Research Centre; RCSEng Bristol Surgical Trials Centre, Bristol Centre for Surgical Research, Population Health Sciences, University of Bristol, BS8 2PS, Bristol, UK.
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3
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Hinwood M, Wall L, Lang D, Balogh ZJ, Smith A, Dowsey M, Clarke P, Choong P, Bunzli S, Paolucci F. Patient and clinician characteristics and preferences for increasing participation in placebo surgery trials: a scoping review of attributes to inform a discrete choice experiment. Trials 2022; 23:296. [PMID: 35413876 PMCID: PMC9006556 DOI: 10.1186/s13063-022-06277-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Orthopaedic surgeries include some of the highest volume surgical interventions globally; however, studies have shown that a significant proportion of patients report no clinically meaningful improvement in pain or function after certain procedures. As a result, there is increasing interest in conducting randomised placebo-controlled trials in orthopaedic surgery. However, these frequently fail to reach recruitment targets suggesting a need to improve trial design to encourage participation. The objective of this study was to systematically scope the available evidence on patient and clinician values and preferences which may influence the decision to participate in placebo surgery trial. Methods A systematic review was conducted via a literature search in the MEDLINE, Embase, PsycInfo, CINAHL, and EconLit databases as of 19 July 2021, for studies of any design (except commentaries or opinion pieces) based on two key concepts: patient and clinician characteristics, values and preferences, and placebo surgery trials. Results Of 3424 initial articles, we retained 18 eligible studies. Characteristics, preferences, values, and attitudes of patients (including levels of pain/function, risk/benefit perception, and altruism) and of clinicians (including concerns regarding patient deception associated with placebo, and experience/training in research) influenced their decisions to participate in placebo-controlled trials. Furthermore, some aspects of trial design, including randomisation procedures, availability of the procedure outside of the trial, and the information and consent procedures used, also influenced decisions to participate. Conclusion Participant recruitment is a significant challenge in placebo surgery trials, and individual decisions to participate appear to be sensitive to preferences around treatment. Understanding and quantifying the role patient and clinician preferences may play in surgical trials may contribute to the optimisation of the design and implementation of clinical trials in surgery. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06277-x.
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Affiliation(s)
- Madeleine Hinwood
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia. .,Hunter Medical Research Institute, New Lambton Heights, Australia.
| | - Laura Wall
- Newcastle Business School, University of Newcastle, Newcastle, Australia
| | - Danielle Lang
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, New Lambton Heights, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and the University of Newcastle, Newcastle, Australia
| | - Angela Smith
- Hunter New England Local Health District, Newcastle, Australia
| | - Michelle Dowsey
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Phillip Clarke
- School of Population and Global Health, University of Melbourne, Australia, Parkville, Australia.,Health Economics Research Centre, University of Oxford, Oxford, England
| | - Peter Choong
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Samantha Bunzli
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Australia, Fitzroy, Australia
| | - Francesco Paolucci
- Newcastle Business School, University of Newcastle, Newcastle, Australia
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Anderson DB, Beard DJ, Sabet T, Eyles JP, Harris IA, Adie S, Buchbinder R, Maher CG, Ferreira ML. Evaluation of placebo fidelity and trial design methodology in placebo-controlled surgical trials of musculoskeletal conditions: a systematic review. Pain 2022; 163:637-651. [PMID: 34382608 DOI: 10.1097/j.pain.0000000000002432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/26/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT The number of placebo surgical trials on musculoskeletal conditions is increasing, but little is known about the quality of their design and methods. This review aimed to (1) assess the level of placebo fidelity (ie, degree to which the placebo control mimicked the index procedure) in placebo trials of musculoskeletal surgery, (2) describe the trials' methodological features using the adapted Applying Surgical Placebo in Randomised Evaluations (ASPIRE) checklist, and (3) describe each trial's characteristics. We searched 4 electronic databases from inception until February 18, 2021, for randomised trials of surgery that included a placebo control for any musculoskeletal condition. Protocols and full text were used to assess placebo fidelity (categorised as minimal, low, or high fidelity). The adapted 26-item ASPIRE checklist was also completed on each trial. PROSPERO registration number: CRD42021202131. A total of 30,697 studies were identified in the search, and 22 placebo-controlled surgical trials of 2045 patients included. Thirteen trials (59%) included a high-fidelity placebo control, 7 (32%) used low fidelity, and 2 (9%) minimal fidelity. According to the ASPIRE checklist, included trials had good reporting of the "rationale and ethics" (68% overall) and "design" sections (42%), but few provided enough information on the "conduct" (13%) and "interpretation and translation" (11%) of the placebo trials. Most trials sufficiently reported their rationale and ethics, but interpretation and translation are areas for improvement, including greater stakeholder involvement. Most trials used a high-fidelity placebo procedure suggesting an emphasis on blinding and controlling for nonspecific effects.
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Affiliation(s)
- David B Anderson
- Faculty of Medicine and Health, School of Health Sciences, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Headington, Oxford, United Kingdom
| | - Tamer Sabet
- Department of Health Professionals, Faculty of Medicine, Health and Human Sciences, Macquarie University, New South Wales, Australia
| | - Jillian P Eyles
- Faculty of Medicine and Health, School of Medicine, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
| | - Ian A Harris
- South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, UNSW Sydney, New South Wales, Australia Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney New South Wales, Australia
- St. George and Sutherland Clinical School, UNSW Sydney, New South Wales, Australia
| | - Sam Adie
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Rachelle Buchbinder
- Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology, Cabrini Health, Malvern, Vic, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher G Maher
- St. George and Sutherland Clinical School, UNSW Sydney, New South Wales, Australia
| | - Manuela L Ferreira
- Faculty of Medicine and Health, School of Health Sciences, Institute of Bone and Joint Research, the Kolling Institute, The University of Sydney, New South Wales, Australia
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Ammendolia C, Hofkirchner C, Plener J, Bussières A, Schneider MJ, Young JJ, Furlan AD, Stuber K, Ahmed A, Cancelliere C, Adeboyejo A, Ornelas J. Non-operative treatment for lumbar spinal stenosis with neurogenic claudication: an updated systematic review. BMJ Open 2022; 12:e057724. [PMID: 35046008 PMCID: PMC8772406 DOI: 10.1136/bmjopen-2021-057724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Neurogenic claudication due to lumbar spinal stenosis (LSS) is a growing health problem in older adults. We updated our previous Cochrane review (2013) to determine the effectiveness of non-operative treatment of LSS with neurogenic claudication. DESIGN A systematic review. DATA SOURCES CENTRAL, MEDLINE, EMBASE, CINAHL and Index to Chiropractic Literature databases were searched and updated up to 22 July 2020. ELIGIBILITY CRITERIA We only included randomised controlled trials published in English where at least one arm provided data on non-operative treatment and included participants diagnosed with neurogenic claudication with imaging confirmed LSS. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed risk of bias using the Cochrane Risk of Bias Tool 1. Grading of Recommendations Assessment, Development and Evaluation was used for evidence synthesis. RESULTS Of 15 200 citations screened, 156 were assessed and 23 new trials were identified. There is moderate-quality evidence from three trials that: Manual therapy and exercise provides superior and clinically important short-term improvement in symptoms and function compared with medical care or community-based group exercise; manual therapy, education and exercise delivered using a cognitive-behavioural approach demonstrates superior and clinically important improvements in walking distance in the immediate to long term compared with self-directed home exercises and glucocorticoid plus lidocaine injection is more effective than lidocaine alone in improving statistical, but not clinically important improvements in pain and function in the short term. The remaining 20 new trials demonstrated low-quality or very low-quality evidence for all comparisons and outcomes, like the findings of our original review. CONCLUSIONS There is moderate-quality evidence that a multimodal approach which includes manual therapy and exercise, with or without education, is an effective treatment and that epidural steroids are not effective for the management of LSS with neurogenic claudication. All other non-operative interventions provided insufficient quality evidence to make conclusions on their effectiveness. PROSPERO REGISTRATION NUMBER CRD42020191860.
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Affiliation(s)
- Carlo Ammendolia
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | - Corey Hofkirchner
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Joshua Plener
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - André Bussières
- School of Physical and Occupational Therapy, Faculy of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Département Chiropratique, Université du Québec à Trois-Rivières, boulevard des Forges, Trois-Rivières Québec, Canada
| | | | - James J Young
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
- Sports Medicine and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Andrea D Furlan
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Institute for Work & Health, Toronto, Ontario, Canada
| | - Kent Stuber
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Aksa Ahmed
- Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | - Carol Cancelliere
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Aleisha Adeboyejo
- Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada
| | - Joseph Ornelas
- Health Systems Management, Rush University, Chicago, Illinois, USA
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Mobbs RJ, Mobbs RR, Choy WJ. Proposed objective scoring algorithm for assessment and intervention recovery following surgery for lumbar spinal stenosis based on relevant gait metrics from wearable devices: the Gait Posture index (GPi). JOURNAL OF SPINE SURGERY 2019; 5:300-309. [PMID: 31663040 DOI: 10.21037/jss.2019.09.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Lumbar spinal stenosis (LSS) results in significant pain and disability. As spine healthcare providers, monitoring patient's outcomes is of the highest importance, and guides everything we do. However, a large amount of our data has been based solely on subjective, single time-point outcome tools limited by their subjective nature. Methods We herein propose a novel, simple objective scoring system, the Gait Posture index (GPi). Four key objective health metrics, which can be measured using wearable devices have been identified to correlate with health status: (I) step count; (II) gait velocity; (III) step length; (IV) posture. An algorithm combining the above metrics was established to 'score' patient's ambulation from 0 (bed bound)-100 (excellent mobility and gait function). Thirteen surgical patients were assigned to the GPi scoring algorithm and compared with traditional subjective scoring systems Oswestry Disability Index (ODI) and Patient Satisfaction Index (PSI) as a proof of concept and confirmation of validity. Results At 3 months, 11 out of 13 patients following decompression for LSS had an improvement with their GPi 20.79±17.44, P=0.001. In addition, Pearson correlation revealed positive correlation between change in GPi with change in ODI (r=0.682, n=13, P=0.01) and negative correlation between change in GPi with PSI (r=-0.618, n=13, P=0.024). Conclusions The GPi algorithm correlates accurately with preoperative and post-operative mobility which are comparable to traditional subjective scoring systems. GPi affords the health care provider with a relevant measure of patient outcome, and real-time recovery dynamics following decompression for LSS.
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Affiliation(s)
- Ralph J Mobbs
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - Wen Jie Choy
- NeuroSpine Surgery Research Group (NSURG), Sydney, Australia.,Neurospine Clinic, Prince of Wales Private Hospital, Randwick, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
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