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Ooghe A, Liu X, Robbins S, Eyles JP, Deveza LA, Branders S, Clermont F, Pereira A, Hunter DJ. Report of similar placebo response in one internet versus onsite randomised controlled trials from the literature. OSTEOARTHRITIS AND CARTILAGE OPEN 2024; 6:100474. [PMID: 38737983 PMCID: PMC11088186 DOI: 10.1016/j.ocarto.2024.100474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 04/23/2024] [Indexed: 05/14/2024] Open
Abstract
Objective The aim of this study was to compare the magnitude and the predictors of the placebo response in an internet versus onsite randomised controlled trials (RCTs) in people with hand osteoarthritis (HOA). Method This study is a post-hoc analysis based on one internet RCT (RADIANT) and previously published onsite RCTs for HOA identified through a rigorous searching and selection strategy. The magnitude of the placebo response in the two different types of RCTs were compared using heterogeneity statistics and forest plots visualisation. Classic placebo predictors as well as a combined model, defined with data from onsite RCTs, were tested to predict the placebo response. Results We analysed the dataset from RADIANT and fourteen previously published onsite RCTs. None of the analyses showed a significant difference between the placebo response for the internet versus onsite RCTs. The "classic" placebo predictors combined in a multivariate predictive model correlated significantly with the placebo response measured in RADIANT study. Conclusion Despite the absence of face-to-face interactions with the study personnel, there is no evidence that either the magnitude or the predictors of the placebo response of this internet RCT differ from those of onsite RCTs. This analysis is considered as a first step towards evaluating the difference between these designs and strengthens the argument that internet RCTs remain an acceptable alternative way to assess the efficacy of an active treatment in comparison to a placebo.
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Affiliation(s)
- Arthur Ooghe
- Cognivia, 11 rue Granbonpré, Bte 9 - 1435 Mont-Saint-Guibert, Belgium
| | - Xiaoqian Liu
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia
- Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Australia
| | - Sarah Robbins
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia
- Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Australia
| | - Jillian P. Eyles
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia
- Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Australia
| | - Leticia A. Deveza
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia
- Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Australia
| | - Samuel Branders
- Cognivia, 11 rue Granbonpré, Bte 9 - 1435 Mont-Saint-Guibert, Belgium
| | - Frédéric Clermont
- Cognivia, 11 rue Granbonpré, Bte 9 - 1435 Mont-Saint-Guibert, Belgium
| | - Alvaro Pereira
- Cognivia, 11 rue Granbonpré, Bte 9 - 1435 Mont-Saint-Guibert, Belgium
| | - David J. Hunter
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Australia
- Sydney Musculoskeletal Health, Kolling Institute, The University of Sydney, Australia
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2
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Saueressig T, Owen PJ, Pedder H, Tagliaferri S, Kaczorowski S, Altrichter A, Richard A, Miller CT, Donath L, Belavy DL. The importance of context (placebo effects) in conservative interventions for musculoskeletal pain: A systematic review and meta-analysis of randomized controlled trials. Eur J Pain 2024; 28:675-704. [PMID: 38116995 DOI: 10.1002/ejp.2222] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 10/04/2023] [Accepted: 11/25/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND AND OBJECTIVE Contextual effects (e.g. patient expectations) may play a role in treatment effectiveness. This study aimed to estimate the magnitude of contextual effects for conservative, non-pharmacological interventions for musculoskeletal pain conditions. A systematic review and meta-analysis of randomized controlled trials (RCTs) that compared placebo conservative non-pharmacological interventions to no treatment for musculoskeletal pain. The outcomes assessed included pain intensity, physical functioning, health-related quality of life, global rating of change, depression, anxiety and sleep at immediate, short-, medium- and/or long-term follow-up. DATABASES AND DATA TREATMENT MEDLINE, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL and SPORTDiscus were searched from inception to September 2021. Trial registry searches, backward and forward citation tracking and searches for prior systematic reviews were completed. The Cochrane risk of bias 2 tool was implemented. RESULTS The study included 64 RCTs (N = 4314) out of 8898 records. For pain intensity, a mean difference of (MD: -5.32, 95% confidence interval (CI): -7.20, -3.44, N = 57 studies with 74 outcomes, GRADE: very low) was estimated for placebo interventions. A small effect in favour of the placebo interventions for physical function was estimated (SMD: -0.22, 95% CI: -0.35, -0.09; N = 37 with 48 outcomes, GRADE: very low). Similar results were found for a broad range of patient-reported outcomes. Meta-regression analyses did not explain heterogeneity among analyses. CONCLUSION The study found that the contextual effect of non-pharmacological conservative interventions for musculoskeletal conditions is likely to be small. However, given the known effect sizes of recommended evidence-based treatments for musculoskeletal conditions, it may still contribute an important component. SIGNIFICANCE Contextual effects of non-pharmacological conservative interventions for musculoskeletal conditions are likely to be small for a broad range of patient-reported outcomes (pain intensity, physical function, quality of life, global rating of change and depression). Contextual effects are unlikely, in isolation, to offer much clinical care. But these factors do have relevance in an overall treatment context as they provide almost 30% of the minimally clinically important difference.
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Affiliation(s)
| | - Patrick J Owen
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition (IPAN), Deakin University, Geelong, Victoria, Australia
| | - Hugo Pedder
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Scott Tagliaferri
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition (IPAN), Deakin University, Geelong, Victoria, Australia
| | - Svenja Kaczorowski
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Bochum, Germany
| | - Adina Altrichter
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Bochum, Germany
| | - Antonia Richard
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Bochum, Germany
| | - Clint T Miller
- School of Exercise and Nutrition Sciences, Institute for Physical Activity and Nutrition (IPAN), Deakin University, Geelong, Victoria, Australia
| | - Lars Donath
- Department of Intervention Research in Exercise Training, German Sport University Cologne, Cologne, Germany
| | - Daniel L Belavy
- Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Bochum, Germany
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Coté GA, Elmunzer BJ, Nitchie H, Kwon RS, Willingham FF, Wani S, Kushnir V, Chak A, Singh V, Papachristou G, Slivka A, Freeman M, Gaddam S, Jamidar P, Tarnasky P, Varadarajulu S, Foster LD, Cotton PB. Sphincterotomy for Biliary Sphincter of Oddi Disorder and idiopathic Acute Recurrent Pancreatitis: THE RESPOND LONGITUDINAL COHORT. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.18.24305985. [PMID: 38699351 PMCID: PMC11065013 DOI: 10.1101/2024.04.18.24305985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Objective Sphincter of Oddi Disorders (SOD) are contentious conditions in patients whose abdominal pain, idiopathic acute pancreatitis (iAP) might arise from pressurization at the sphincter of Oddi. The present study aimed to measure the benefit of sphincterotomy for suspected SOD. Design Prospective cohort conducted at 14 U.S. centers with 12 months follow-up. Patients undergoing first-time ERCP with sphincterotomy for suspected SOD were eligible: pancreatobiliary-type pain with or without iAP. The primary outcome was defined as the composite of improvement by Patient Global Impression of Change (PGIC), no new or increased opioids, and no repeat intervention. Missing data were addressed by hierarchal, multiple imputation scheme. Results Of 316 screened, 213 were enrolled with 190 (89.2%) of these having a dilated bile duct, abnormal labs, iAP, or some combination. By imputation, an average of 122/213 (57.4% [95%CI 50.4-64.4]) improved; response rate was similar for those with complete follow-up (99/161, 61.5%, [54.0-69.0]); of these, 118 (73.3%) improved by PGIC alone. Duct size, elevated labs, and patient characteristics were not associated with response. AP occurred in 37/213 (17.4%) at a median of 6 months post-ERCP and was more likely in those with a history of AP (30.9 vs. 2.9%, p<0.0001). Conclusion Nearly 60% of patients undergoing ERCP for suspected SOD improve, although the contribution of a placebo response is unknown. Contrary to prevailing belief, duct size and labs are poor response predictors. AP recurrence was common and like observations from prior non-intervention cohorts, suggesting no benefit of sphincterotomy in mitigating future AP episodes.Key Messages: WHAT IS ALREADY KNOWN ON THIS TOPIC: It is not clear if the sphincter of Oddi can cause abdominal pain (Functional Biliary Sphincter of Oddi Disorder) and idiopathic acute pancreatitis (Functional Pancreatic Sphincter of Oddi Disorder), and whether ERCP with sphincterotomy can ameliorate abdominal pain or pancreatitis.WHAT THIS STUDY ADDS: Using multiple patient-reported outcome measures, most patients with suspected sphincter of Oddi disorder improve after ERCP with sphincterotomy.Duct size, elevated pancreatobiliary labs, and baseline patient characteristics are not independently associated with response.There is a high rate of recurrent acute pancreatitis within 12 months of sphincterotomy in those with a history of idiopathic acute pancreatitis.HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY: Since a discrete population with a high (> 80-90%) response rate to sphincterotomy for suspected pancreatobiliary pain could not be identified, there is a need for additional observational and interventional studies that include phenotyping of patients using novel imaging or biochemical biomarkers.There remains a pressing need for quantitative nociceptive biomarkers to distinguish pancreatobiliary pain from other causes of abdominal pain or central sensitization.Discovery of blood-, bile-, or imaging-based biomarkers for occult microlithiasis and pancreatitis may be helpful in predicting who is likely to benefit from sphincterotomy.
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Tepper SJ, Cirillo J, Kim E, L'Italien G, Tweedie JM, Lodaya K, Riley D, Pathan F, Antaki N, Nathanson BH, McAllister P. The temporal trend of placebo response in migraine prevention from 1990 to 2021: a systematic literature review and meta-analysis with regression. J Headache Pain 2023; 24:54. [PMID: 37193973 DOI: 10.1186/s10194-023-01587-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/26/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Migraine affects 1.1 billion people globally and is the second leading cause of disability worldwide. In clinical trials, treatment efficacy is evaluated by comparing the differential responses in the treatment and placebo arms. Although placebo response in preventive migraine trials has been studied, there is limited research examining temporal trends. This study evaluates the trend of placebo response over thirty years in migraine prevention trials and investigates the association of potential confounders, such as patient, treatment, and study characteristics on placebo response using meta-analysis with regression. METHODS We conducted literature searches from January 1990 to August 2021 in bibliographical databases (PubMed, Cochrane Library, and EMBASE). Studies were selected according to PICOS criteria and included randomized, double-blind, placebo-controlled trials evaluating preventive migraine treatments in adult patients diagnosed with episodic or chronic migraine, with or without aura. The protocol was registered with PROSPERO (CRD42021271732). Migraine efficacy outcomes included were either continuous (e.g., monthly migraine days) or dichotomous (e.g., ≥ 50% responder rate (yes/no)). We assessed the correlation of the change in outcome from baseline in the placebo arm, with the year of publication. The relationship between placebo response and year of publication was also assessed after accounting to confounders. RESULTS A total of 907 studies were identified, and 83 were found eligible. For the continuous outcomes, the change from baseline in mean placebo response showed an increase over the years (rho = 0.32, p = 0.006). The multivariable regression analysis also showed an overall increase in placebo response over the years. The correlation analysis of dichotomous responses showed no significant linear trend between publication year and mean placebo response (rho = 0.08, p = 0.596). Placebo response also varied by route of administration. CONCLUSION Placebo response increased over the past 30 years in migraine preventive trials. This phenomenon should be considered when designing clinical trials and conducting meta-analyses.
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Affiliation(s)
- Stewart J Tepper
- Geisel School of Medicine at Dartmouth, Dartmouth Headache Clinic, Hanover, NH, USA.
| | | | - Edward Kim
- Biohaven Pharmaceuticals, New Haven, CT, USA
| | | | | | - Kunal Lodaya
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | - Dushon Riley
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | - Farah Pathan
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | - Nicholas Antaki
- Boston Strategic Partners Inc, 4 Wellington St., Suite 3, Boston, MA, USA
| | | | - Peter McAllister
- New England Institute for Neurology and Headache, Stamford, CT, USA
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5
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Mihalko SL, Messier SP. From weight loss to weight gain: utilizing the full spectrum of weight management for behavioral intervention. Osteoarthritis Cartilage 2023; 31:295-297. [PMID: 36473674 DOI: 10.1016/j.joca.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 11/26/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Affiliation(s)
- S L Mihalko
- Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA; Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - S P Messier
- J.B. Snow Biomechanics Laboratory, Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA; Department of Rheumatology and Immunology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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6
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Ahmadzad-Asl M, Davoudi F, Mohamadi S, Hadi F, Nejadghaderi SA, Mirbehbahani SH, Jabbarinejad R, Saneh S, Arshadi M, Naserbakht M, Sinyor M, Kabir A, Shamshiri A. Systematic review and meta-analysis of the placebo effect in panic disorder: Implications for research and clinical practice. Aust N Z J Psychiatry 2022; 56:1130-1141. [PMID: 34996304 DOI: 10.1177/00048674211068793] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This review aimed to measure the degree of placebo response in panic disorder. DATA SOURCES We searched major databases up to 31 January 2021, for randomized pharmacotherapy trials published in English. STUDY SELECTION A total of 43 studies met inclusion criteria to be in the analysis (with 174 separate outcome measurements). DATA EXTRACTION Changes in outcome measures from baseline in the placebo group were used to estimate modified Cohen's d effect size. RESULTS A total of 43 trials (2392 subjects, 174 outcomes using 27 rating scales) were included in the meta-analysis. Overall placebo effect size was 0.57 (95% confidence interval = [0.50, 0.64]), heterogeneity (I2: 96.3%). Higher placebo effect size was observed among clinician-rated scales compared to patient reports (0.75 vs 0.35) and among general symptom and anxiety scales compared to panic symptoms and depression scales (0.92 and 0.64 vs 0.56 and 0.54, respectively). There was an upward trend in effect size over the publication period (r = 0.02, p = 0.002) that was only significant among clinician-rated scales (r = 0.02, p = 0.011). There was no significant publication bias, Egger's test (p = 0.08). CONCLUSION We observed a substantial placebo effect size in panic disorder. This effect was more prominent for some aspects of panic disorder psychopathology than for others and was correlated with the source of the assessment and publication year. This finding has implications both for research design, to address the heterogeneity and diversity in placebo responses, and for clinical practice to ensure optimal quality of care. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO, CRD42019125979.
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Affiliation(s)
- Masoud Ahmadzad-Asl
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Farnoush Davoudi
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Department of Community and Family Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Safoura Mohamadi
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Hadi
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Roxana Jabbarinejad
- Cognitive Neuroscience Laboratory, Brain Injury Research, Think+Speak Lab, Shirley Ryan Ability Lab, Northwestern University, Chicago, IL, USA
| | - Sadaf Saneh
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Arshadi
- Department of Psychiatry & Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Morteza Naserbakht
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mark Sinyor
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Ali Kabir
- Education Development Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmadreza Shamshiri
- Department of Epidemiology, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
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Oo WM, Hunter DJ. Repurposed and investigational disease-modifying drugs in osteoarthritis (DMOADs). Ther Adv Musculoskelet Dis 2022; 14:1759720X221090297. [PMID: 35619876 PMCID: PMC9128067 DOI: 10.1177/1759720x221090297] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/10/2022] [Indexed: 12/12/2022] Open
Abstract
In spite of a major public health burden with increasing prevalence, current osteoarthritis (OA) management is largely palliative with an unmet need for effective treatment. Both industry and academic researchers have invested a vast amount of time and financial expense to discover the first diseasing-modifying osteoarthritis drugs (DMOADs), with no regulatory success so far. In this narrative review, we discuss repurposed drugs as well as investigational agents which have progressed into phase II and III clinical trials based on three principal endotypes: bone-driven, synovitis-driven and cartilage-driven. Then, we will briefly describe the recent failures and lessons learned, promising findings from predefined post hoc analyses and insights gained, novel methodologies to enhance future success and steps underway to overcome regulatory hurdles.
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Affiliation(s)
- Win Min Oo
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Physical Medicine and Rehabilitation, Mandalay General Hospital, University of Medicine, Mandalay, Mandalay, Myanmar
| | - David J. Hunter
- Rheumatology Department, Royal North Shore Hospital, and Institute of Bone and Joint Research, Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2065, Australia
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8
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Perry TA, Segal NA. An open-label, single-arm trial of cryoneurolysis for improvements in pain, Activities of Daily Living and Quality of Life in patients with symptomatic ankle osteoarthritis. OSTEOARTHRITIS AND CARTILAGE OPEN 2022; 4:100272. [DOI: 10.1016/j.ocarto.2022.100272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/13/2022] [Accepted: 05/08/2022] [Indexed: 10/18/2022] Open
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9
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Block JA, Cherny D. Management of Knee Osteoarthritis: What Internists Need to Know. Rheum Dis Clin North Am 2022; 48:549-567. [PMID: 35400378 DOI: 10.1016/j.rdc.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Knee osteoarthritis (OA) is a common and morbid condition. No disease-modifying therapies exist; hence the goals of current treatment are to palliate pain and to retain function. OA pain is significantly influenced by the placebo effect. Nonpharmacologic interventions are essential and have been shown to improve outcomes. Canes, unloading braces, and therapeutic heating/cooling may be valuable. Pharmacotherapy options include topical and oral nonsteroidal anti-inflammatory drugs, duloxetine, and periodic intra-articular glucocorticoids and hyaluronans. Opioids, intra-articular stem cells, and platelet-rich plasma are not recommended. Novel targets such as nerve growth factor are under investigation and may be approved soon for OA pain.
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Affiliation(s)
- Joel A Block
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA.
| | - Dmitriy Cherny
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA
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10
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Kloppenburg M, Rannou F, Berenbaum F. What evidence is needed to demonstrate the beneficial effects of exercise for osteoarthritis? Ann Rheum Dis 2022; 81:451-453. [PMID: 35135833 DOI: 10.1136/annrheumdis-2021-221685] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/22/2022] [Indexed: 11/04/2022]
Affiliation(s)
| | - François Rannou
- Rehabilitation, Institute of Rheumatology, Cochin Hospital, AP-HP, INSERM U1124, University of Paris, Paris, France
| | - Francis Berenbaum
- Rheumatology, Saint-Antoine Hospital, AP-HP, INSERM CSRA, Sorbonne Université, Paris, France
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11
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Choi JW. Genicular Artery Embolization: Beyond the Placebo Effect, and Planning for the Long Road Ahead. J Vasc Interv Radiol 2022; 33:11-13. [PMID: 34980449 DOI: 10.1016/j.jvir.2021.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/18/2021] [Accepted: 09/25/2021] [Indexed: 01/22/2023] Open
Affiliation(s)
- Jin Woo Choi
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea.
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12
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Reito A, Harris IA, Karjalainen T. Arthroscopic partial meniscectomy: did it ever work? Acta Orthop 2021; 93:1-10. [PMID: 34605736 PMCID: PMC8815409 DOI: 10.1080/17453674.2021.1979793] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/17/2021] [Indexed: 02/08/2023] Open
Abstract
Arthroscopic partial meniscectomy (APM) is one the most common orthopedic surgical procedures. The most common indication for APM is a degenerative meniscal tear (DMT). High-quality evidence suggests that APM does not provide meaningful benefits in patients with DMTs and may even be harmful in the longer term. This narrative review focuses on a fundamental question: considering the history and large number of these surgeries, has APM ever actually worked in patients with DMT? A truly effective treatment needs a valid disease model that would biologically and plausibly explain the perceived treatment benefits. In the case of DMT, effectiveness requires a credible framework for the pain-generating process, which should be influenced by APM. Basic research, pathoanatomy, and clinical evidence gives no support to these frameworks. Moreover, treatment of DMT with an APM does not align with the traditional practice of medicine since DMT is not a reliable diagnosis for knee pain and no evidence-based indication exists that would influence patient prognosis from APM. A plausible and robust explanation supported by both basic research and clinical evidence is that DMTs are part of an osteoarthritic disease process and do not contribute to the symptoms independently or in isolation and that symptoms are not treatable with APM. This is further supported by the fact that APM as an intervention is paradoxical because the extent of procedure and severity of disease are both inversely associated with outcome. We argue that arthroscopic treatment of DMT is largely based on a logical fallacy: post hoc ergo propter hoc.
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Affiliation(s)
- Aleksi Reito
- Department of Orthopaedics and Traumatology, Tampere University Hospital, and Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Sydney, Australia
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13
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Rodriguez-García SC, Castellanos-Moreira R, Uson J, Naredo E, O'Neill TW, Doherty M, Boesen M, Pandit H, Möller Parera I, Vardanyan V, Terslev L, Kampen WU, D'Agostino MA, Berenbaum F, Nikiphorou E, Pitsillidou I, de la Torre-Aboki J, Carmona L. Efficacy and safety of intra-articular therapies in rheumatic and musculoskeletal diseases: an overview of systematic reviews. RMD Open 2021; 7:rmdopen-2021-001658. [PMID: 34103406 PMCID: PMC8186751 DOI: 10.1136/rmdopen-2021-001658] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Objective To summarise the evidence on intra-articular therapies (IAT) to inform the 2020 EULAR recommendations. Methods An overview of systematic reviews (SR) including randomised-controlled trials (RCTs) of IAT in adults with arthropathies was performed up to July 2020. Pain, function, and frequency of adverse events were the main efficacy and safety outcomes, respectively. Quality was assessed with the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool. Results Of 184 references identified, 16 met the inclusion criteria, and a search of their reference lists identified 16 additional SRs. After quality assessment, 29 were finally included. Of these, 18 focused on knee osteoarthritis (KOA), 6 on hip osteoarthritis (HOA), 3 on shoulder capsulitis (SC), and 3 on rheumatoid arthritis. Overall, hyaluronic acid showed a small effect on pain and function in KOA but not in HOA or shoulder capsulitis. Intra-articular glucocorticoids showed a small effect in pain and function in KOA and function in HOA and SC. Platelet-rich plasma showed benefit in pain and function in KOA but not in HOA. Mesenchymal stem cells behaved similarly. Most SR results were of moderate quality and RCTs included often presented a high risk of bias, mainly due to inadequate blinding and heterogeneous results. All interventions were well tolerated with no clear safety differences. Conclusions This overview underlines that most IAT currently used in KOA, HOA, and SC exert small effects and are well tolerated. However, no firm conclusions can be drawn for inflammatory arthritis due to the limited data found.
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Affiliation(s)
| | | | - Jacqueline Uson
- Rheumatology, Hospital Universitario de Mostoles, Madrid, Spain.,Medicine, Universidad Rey Juan Carlos, Madrid, Spain
| | - Esperanza Naredo
- Rheumatology, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain.,Rheumatology - Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Terence W O'Neill
- Rheumatology, Centre for Epidemiology Versus Arthritis, University of Manchester & NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Mikael Boesen
- Radiology, Copenhagen University Hospital Bispebjerg- Frederiksberg, Copenhagen, Denmark
| | | | - Ingrid Möller Parera
- Facultad de Medicina y Ciencias de La Salud, Universidad de Barcelona, Barcelona, Spain.,Rheumatology, Instituto POAL de Reumatología, Barcelona, Spain
| | - Valentina Vardanyan
- Rheumatology, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
| | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | | | - Maria Antonieta D'Agostino
- Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Francis Berenbaum
- Rheumatology, AP-HP Saint-Antoine hospital, Paris, France.,Sorbonne University - INSERM CRSA, Paris, France
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK.,Rheumatology Department, King's College Hospital, London, UK
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14
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Miller CT, Owen PJ, Than CA, Ball J, Sadler K, Piedimonte A, Benedetti F, Belavy DL. Attempting to Separate Placebo Effects from Exercise in Chronic Pain: A Systematic Review and Meta-analysis. Sports Med 2021; 52:789-816. [PMID: 34453277 DOI: 10.1007/s40279-021-01526-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pain is the most disabling characteristic of musculoskeletal disorders, and while exercise is promoted as an important treatment modality for chronic musculoskeletal conditions, the relative contribution of the specific effects of exercise training, placebo effects and non-specific effects such as natural history are not clear. The aim of this systematic review and meta-analysis was to determine the relative contribution of these factors to better understand the true effect of exercise training for reducing pain in chronic primary musculoskeletal pain conditions. DESIGN Systematic review with meta-analysis DATA SOURCES: MEDLINE, CINAHL, SPORTDiscus, EMBASE and CENTRAL from inception to February 2021. Reference lists of prior systematic reviews. ELIGIBILITY CRITERIA Randomised controlled trials of interventions that used exercise training compared to placebo, true control or usual care in adults with chronic primary musculoskeletal pain. The review was registered prospectively with PROSPERO (CRD42019141096). RESULTS We identified 79 eligible trials for quantitative analysis. Pairwise meta-analysis showed very low-quality evidence (GRADE criteria) that exercise training was not more effective than placebo (g [95% CI]: 0.94 [- 0.17, 2.06], P = 0.098, I2 = 92.46%, studies: n = 4). Exercise training was more effective than true, no intervention controls (g [95% CI]: 0.99 [0.66, 1.32], P < 0.001, I2 = 92.43%, studies: n = 42), usual care controls (g [95% CI]: 0.64 [0.44, 0.83], P < 0.001, I2 = 76.52%, studies: n = 33), and when all controls combined (g [95% CI]: 0.84 [0.64, 1.04], P < 0.001, I2 = 90.02%, studies: n = 79). CONCLUSIONS There is very low-quality evidence that exercise training is not more effective than non-exercise placebo treatments in chronic pain. Exercise training and the associated clinical encounter are more effective than true control or standard medical care for reductions in pain for adults with chronic musculoskeletal pain, with very low quality of evidence based on GRADE criteria.
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Affiliation(s)
- Clint T Miller
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia.
| | - Patrick J Owen
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Christian A Than
- School of Biomedical Sciences, The University of Queensland, St. Lucia, Brisbane, Australia
| | - Jake Ball
- School of Medicine and Public Health, University of Newcastle, Callaghan, Newcastle, Australia
| | - Kate Sadler
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia
| | - Alessandro Piedimonte
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Fabrizio Benedetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy.,Medicine and Physiology of Hypoxia, Plateau Rosà, Zermatt, Switzerland
| | - Daniel L Belavy
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Geelong, VIC, Australia.,Department of Applied Health Sciences, Division of Physiotherapy, Hochschule für Gesundheit (University of Applied Sciences), Bochum, Germany
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15
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Liu X, Robbins S, Eyles J, Fedorova T, Virk S, Deveza LA, McLachlan AJ, Hunter DJ. Efficacy and safety of a supplement combination on hand pain among people with symptomatic hand osteoarthritis an internet-based, randomised clinical trial the RADIANT study. Osteoarthritis Cartilage 2021; 29:667-677. [PMID: 33617972 DOI: 10.1016/j.joca.2021.01.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/10/2020] [Accepted: 01/08/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The RADIANT study aimed to investigate the efficacy and safety of a complementary medicine supplement combination in people with hand osteoarthritis (HOA). METHOD This was an internet-based, double-blind, randomised, placebo-controlled trial. Participants aged over 40 years with symptomatic HOA with radiographic confirmation (Kellgren Lawrence grade ≥ 2) throughout Australia were recruited and randomly assigned (1:1) to receive either a supplement combination composed of Boswellia serrata extract 250 mg/day, pine bark extract 100 mg/day, methylsulfonylmethane 1,500 mg/day and curcumin 168 mg/day or placebo for 12 weeks. The primary outcome was change in hand pain assessed using a visual analogue scale (VAS 0-100) from baseline to week 12. A range of secondary outcomes and additional measures were recorded. Adverse events were monitored weekly. RESULTS One hundred and six participants were included with mean age 65.6 years and 81% were women. 45% of the participants were graded as KLG 4, 40% KLG three and 39 (37%) had erosive OA. There was no significant difference in pain VAS reduction between groups. The adjusted between group difference in means (95%CI) was 5.34 (-2.39 to 13.07). Five participants (10%) in the supplement combination group discontinued study treatment due to AE vs four participants (7%) in the placebo group. CONCLUSION There were no significant differences in symptomatic relief between the two groups over 12 weeks. These findings do not support the use of the supplement combination for treating hand pain in people with HOA. REGISTRATION Prospectively registered (Australian New Zealand Clinical Trials Registry ACTRN12619000835145, 31/05/2019).
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Affiliation(s)
- X Liu
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney, Australia.
| | - S Robbins
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney, Australia.
| | - J Eyles
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney, Australia.
| | - T Fedorova
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney, Australia.
| | - S Virk
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney, Australia.
| | - L A Deveza
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney, Australia.
| | - A J McLachlan
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Australia.
| | - D J Hunter
- Rheumatology Department, Royal North Shore Hospital, Northern Clinical School, Faculty of Medicine and Health, The University of Sydney Institute of Bone and Joint Research, Kolling Institute of Medical Research, The University of Sydney, Australia; Clinical Research Centre, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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16
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Verma N, Mudge JD, Kasole M, Chen RC, Blanz SL, Trevathan JK, Lovett EG, Williams JC, Ludwig KA. Auricular Vagus Neuromodulation-A Systematic Review on Quality of Evidence and Clinical Effects. Front Neurosci 2021; 15:664740. [PMID: 33994937 PMCID: PMC8120162 DOI: 10.3389/fnins.2021.664740] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 03/25/2021] [Indexed: 12/13/2022] Open
Abstract
Background: The auricular branch of the vagus nerve runs superficially, which makes it a favorable target for non-invasive stimulation techniques to modulate vagal activity. For this reason, there have been many early-stage clinical trials on a diverse range of conditions. These trials often report conflicting results for the same indication. Methods: Using the Cochrane Risk of Bias tool we conducted a systematic review of auricular vagus nerve stimulation (aVNS) randomized controlled trials (RCTs) to identify the factors that led to these conflicting results. The majority of aVNS studies were assessed as having "some" or "high" risk of bias, which makes it difficult to interpret their results in a broader context. Results: There is evidence of a modest decrease in heart rate during higher stimulation dosages, sometimes at above the level of sensory discomfort. Findings on heart rate variability conflict between studies and are hindered by trial design, including inappropriate washout periods, and multiple methods used to quantify heart rate variability. There is early-stage evidence to suggest aVNS may reduce circulating levels and endotoxin-induced levels of inflammatory markers. Studies on epilepsy reached primary endpoints similar to previous RCTs testing implantable vagus nerve stimulation therapy. Preliminary evidence shows that aVNS ameliorated pathological pain but not evoked pain. Discussion: Based on results of the Cochrane analysis we list common improvements for the reporting of results, which can be implemented immediately to improve the quality of evidence. In the long term, existing data from aVNS studies and salient lessons from drug development highlight the need for direct measures of local neural target engagement. Direct measures of neural activity around the electrode will provide data for the optimization of electrode design, placement, and stimulation waveform parameters to improve on-target engagement and minimize off-target activation. Furthermore, direct measures of target engagement, along with consistent evaluation of blinding success, must be used to improve the design of controls-a major source of concern identified in the Cochrane analysis. The need for direct measures of neural target engagement and consistent evaluation of blinding success is applicable to the development of other paresthesia-inducing neuromodulation therapies and their control designs.
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Affiliation(s)
- Nishant Verma
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
| | - Jonah D. Mudge
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
| | - Maïsha Kasole
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
| | - Rex C. Chen
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
| | - Stephan L. Blanz
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
| | - James K. Trevathan
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
| | | | - Justin C. Williams
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
- Department of Neurosurgery, University of Wisconsin – Madison, Madison, WI, United States
| | - Kip A. Ludwig
- Department of Biomedical Engineering, University of Wisconsin – Madison, Madison, WI, United States
- Wisconsin Institute for Translational Neuroengineering (WITNe) – Madison, Madison, WI, United States
- Department of Neurosurgery, University of Wisconsin – Madison, Madison, WI, United States
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17
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Exploring patient views of empathic optimistic communication for osteoarthritis in primary care: a qualitative interview study using vignettes. BJGP Open 2021; 5:BJGPO.2021.0014. [PMID: 33712500 PMCID: PMC8278506 DOI: 10.3399/bjgpo.2021.0014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/10/2021] [Indexed: 12/30/2022] Open
Abstract
Background Osteoarthritis (OA) causes pain and disability. An empathic optimistic consultation approach can improve patient quality of life, satisfaction with care, and reduce pain. However, expressing empathic optimism may be overlooked in busy primary care consultations and there is limited understanding of patients’ views about this approach. Aim To explore patients’ perspectives on clinician communication of empathy and optimism in primary care OA consultations. Design & setting Vignette study with qualitative semi-structured interviews. Purposefully sampled patients (n = 33) aged >45 years with hip or knee OA from GP practices in Wessex (Hampshire, Dorest, Wiltshire, and Somerset). Method Fifteen participants watched two filmed OA consultations with a GP, and 18 participants read two case vignettes. In both formats, one GP depicted an empathic optimistic approach and one GP had a ‘neutral’ approach. Semi-structured interviews were conducted with all participants and analysed using thematic analysis. Results Patients recognised that empathic communication enhanced interactions, helping to engender a sense of trust in their clinician. They felt it was acceptable for GPs to convey optimism only if it was realistic, personalised, and embedded within an empathic consultation. Discussing patients’ experiences and views with them, and conveying an accurate understanding of these experiences improves the credibility of optimistic messages. Conclusion Patients value communication with empathy and optimism, but it requires a fine balance to ensure messages remain realistic and trustworthy. Increased use of a realistic optimistic approach within an empathic consultation could enhance consultations for OA and other chronic conditions, and improve patient outcomes. Digital training to help GPs implement these findings is being developed.
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18
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Ahmed O, Block J, Mautner K, Plancher K, Anitescu M, Isaacson A, Filippiadis DK, Epelboym Y, Bercu Z, Mitchell JW, Cristescu M, White SB, Prologo JD. Percutaneous Management of Osteoarthritis in the Knee: Proceedings from the Society of Interventional Radiology Research Consensus Panel. J Vasc Interv Radiol 2021; 32:919.e1-919.e6. [PMID: 33689834 DOI: 10.1016/j.jvir.2021.03.409] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 01/21/2023] Open
Affiliation(s)
- Osman Ahmed
- Department of Radiology, Section of Interventional Radiology, University of Chicago, Chicago, Illinois.
| | - Joel Block
- Division of Rheumatology, Rush Medical College, Chicago, Illinois
| | - Kenneth Mautner
- Department of Rehabilitation Medicine and Department of Orthopedics, Emory University, Atlanta, Georgia
| | - Kevin Plancher
- Department of Orthopedics, Albert Einstein College of Medicine, Bronx, New York; Department of Orthopedics, Weill Cornell Medical College, Cornell University, Ithaca, New York
| | - Magdalena Anitescu
- Department of Anesthesia and Critical Care, Section of Anesthesia and Pain Medicine, University of Chicago, Chicago, Illinois
| | - Ari Isaacson
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Yan Epelboym
- Department of Radiology, Harvard University, Cambridge, Massachusetts, and Brigham & Women's Hospital, Boston, Massachusetts
| | - Zachary Bercu
- Department of Radiology, Division of Interventional Radiology and Image-Guided Medicine, Emory University, Atlanta, Georgia
| | - Jason W Mitchell
- Department of Radiology, Capital Regional Medical Center, Tallahassee, Florida
| | - Mircea Cristescu
- Department of Radiology and Imaging Services, Emory University, Atlanta, Georgia
| | - Sarah B White
- Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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19
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Cashin AG, McAuley JH, Lamb SE, Lee H. Disentangling contextual effects from musculoskeletal treatments. Osteoarthritis Cartilage 2021; 29:297-299. [PMID: 33429055 DOI: 10.1016/j.joca.2020.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 11/26/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Affiliation(s)
- A G Cashin
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia; Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - J H McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia; School of Medical Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - S E Lamb
- Institute of Health Research, University of Exeter Medical School, Exeter, UK; Centre for Statistics in Medicine, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.
| | - H Lee
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
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20
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Abstract
Knee osteoarthritis (OA) is a common and morbid condition. No disease-modifying therapies exist; hence the goals of current treatment are to palliate pain and to retain function. OA is significantly influenced by the placebo effect. Nonpharmacologic interventions are essential and have been shown to improve outcomes. Canes, unloading braces, and therapeutic heating/cooling may be valuable. Pharmacotherapy options include topical and oral nonsteroidal anti-inflammatory drugs, duloxetine, and periodic intra-articular glucocorticoids and hyaluronans. Opioids, intra-articular stem cells, and platelet-rich plasma are not recommended. Novel targets such as nerve growth factor are under investigation and may be approved soon for OA pain.
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Affiliation(s)
- Joel A Block
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA.
| | - Dmitriy Cherny
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA
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21
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Hunter DJ, Harris RE. Acupuncture and Knee Osteoarthritis: Does Dose Matter? Arthritis Rheumatol 2020; 73:371-373. [PMID: 33169542 DOI: 10.1002/art.41583] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/03/2020] [Indexed: 11/05/2022]
Affiliation(s)
- David J Hunter
- Royal North Shore Hospital, St. Leonards, New South Wales, Australia, and the Institute of Bone and Joint Research, Kolling Institute of Medical Research, and The University of Sydney, Sydney, New South Wales, Australia, and Zhujiang Hospital and Southern Medical University, Guangzhou, China
| | - Richard E Harris
- Chronic Pain and Fatigue Research Center, University of Michigan, Ann Arbor
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22
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Shen Z, Xu Q, Jin L. Structured procedures promote placebo effects. JOURNAL OF EXPERIMENTAL SOCIAL PSYCHOLOGY 2020. [DOI: 10.1016/j.jesp.2020.104029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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23
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Huang K, Giddins G, Wu LD. Platelet-Rich Plasma Versus Corticosteroid Injections in the Management of Elbow Epicondylitis and Plantar Fasciitis: An Updated Systematic Review and Meta-analysis. Am J Sports Med 2020; 48:2572-2585. [PMID: 31821010 DOI: 10.1177/0363546519888450] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP), as a promising alternative to traditional corticosteroid (CS), is now increasingly used in the treatment of elbow epicondylitis (EE) and plantar fasciitis (PF). To date, however, the synthesis of information on the clinical efficacy of PRP versus CS is limited with divergent conclusions. PURPOSE To compare the clinical efficacy of PRP and CS injections in reducing pain and improving function in EE and PF. STUDY DESIGN Systematic review and meta-analysis. METHODS Online databases were searched from inception to October 2018 for prospective studies evaluating PRP versus CS injections for EE or PF. Independent reviewers undertook searches, screening, and risk-of-bias appraisals. The primary outcomes of interest were pain and function in both the short term (1-3 months) and the long term (≥6 months). RESULTS Twenty trials with 1268 participants were included. For EE, PRP provides a statistically and clinically meaningful long-term improvement in pain, with a very large effect size of -1.3 (95% CI, -1.9 to -0.7) when compared with CS, but the evidence level was low. For EE, there was moderate evidence that CS provides a statistically meaningful improvement in pain in the short term, with a medium effect size of 0.56 (95% CI, 0.08-1.03) as compared with PRP; this improvement might not be clinically significant. For PF, there was low evidence that PRP provides a statistically and clinically meaningful long-term improvement in function (American Orthopedic Foot & Ankle Society score), with a very large effect size of 1.94 (95% CI, 0.61-3.28). There were no significant differences between the groups in improvement in function in EE and pain and short-term function in PF, but the quality of the evidence was low. CONCLUSION The use of PRP yields statistically and clinically better improvement in long-term pain than does CS in the treatment of EE. The use of PRP yields statistically and clinically better long-term functional improvement than that of CS in the treatment of PF.
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Affiliation(s)
- Kai Huang
- Department of Orthopaedic Surgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Grey Giddins
- Department of Orthopaedic Surgery, Royal United Hospital Bath, Bath, UK
| | - Li-Dong Wu
- Department of Orthopaedic Surgery, The Second Hospital of Medical College, Zhejiang University, Hangzhou, China
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24
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Core and adjunctive interventions for osteoarthritis: efficacy and models for implementation. Nat Rev Rheumatol 2020; 16:434-447. [DOI: 10.1038/s41584-020-0447-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 12/13/2022]
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25
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Sun N, Wang LQ, Shao JK, Zhang N, Zhou P, Fang SN, Chen W, Yang JW, Liu CZ. An expert consensus to standardize acupuncture treatment for knee osteoarthritis. Acupunct Med 2020; 38:327-334. [PMID: 32309995 DOI: 10.1177/0964528419900789] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acupuncture has been advocated for as a potentially effective therapy for patients with knee osteoarthritis (KOA) in systematic reviews and guidelines. However, there is still a lack of agreement on the optimal therapeutic protocol for acupuncture. This aim of this study was to develop an expert consensus regarding the therapeutic protocol of acupuncture to guide doctors in clinical practice. METHODS An initial list of items was based on an overview of research evidence from four databases and clinical problem investigation with a multidisciplinary panel. A two-step process was used to optimize the list, including semi-structured interviews with three acupuncture clinical experts and a three-round Delphi consensus survey with the voting panel. A nine-point Likert-type scale (1 = strongly disagree, 9 = strongly agree) was used to measure agreement. RESULTS In total, 52 professionals (response rate: 52%) confirmed their participation in the voting panel. The initial list including 28 items was evaluated. Following a three-round Delphi survey, a consensus was achieved including 37 items that can be broadly categorized into six domains: (1) main treatment principles, (2) acupuncture treatment, (3) dose of acupuncture intervention, (4) primary outcomes, (5) adverse events and (6) others. CONCLUSION This expert consensus could be used to guide doctors in clinical practice and help patients with KOA gain access to appropriate and coordinated acupuncture treatment.
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Affiliation(s)
- Ning Sun
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Li-Qiong Wang
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Jia-Kai Shao
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Na Zhang
- School of Acupuncture, Moxibustion and Tuina, Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Ping Zhou
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Sai-Nan Fang
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Wei Chen
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Jing-Wen Yang
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Cun-Zhi Liu
- Acupuncture Research Center, School of Acupuncture, Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
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26
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Faig-Martí J, Martínez-Catassús A. Measuring the placebo effect in carpal tunnel syndrome. J Orthop Traumatol 2020; 21:1. [PMID: 31993783 PMCID: PMC6987286 DOI: 10.1186/s10195-019-0540-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 12/19/2019] [Indexed: 12/31/2022] Open
Abstract
Background The placebo effect can account for part of the improvement seen in patients undergoing any type of treatment, be it surgical or pharmacological. The objective of this study is to quantify the placebo effect in carpal tunnel syndrome treatment. Materials and methods A double-blinded randomized trial was performed with 68 patients suffering from mild to moderate carpal tunnel syndrome, divided into two groups with no statistically significant differences regarding age, weight, or degree of nerve compression. The patients were evaluated clinically and electromyographically before and after 2 months of treatment with either palmitoylethanolamide (PEA) or placebo. Results The results, comparing the two groups, showed an improvement in both groups on a visual analogue scale (VAS) and Levine’s questionnaire, which have been reported to show statistical differences in only a few items. In the placebo group, the mean age was 53.32 years (±13.43) and the BMI was 28.85 kg/m2 (±4.84). Before treatment, the average symptom severity score (SSS) on the Levine questionnaire was 2.57 (±0.74) and the functional status score (FSS) was 2.24 (±0.66). After treatment, these decreased to 2.11 (±0.81) and 1.96 (±0.77), being statistically nonsignificant for SSS (p = 0.0865) but significant for FSS (p = 0.0028). VAS showed a statistically nonsignificant decrease from 4.06 to 3.25 (p = 0.3407). After placebo treatment, SSS, FSS, and VAS improved by 0.46, 0.28, and 0.81 points or 17.89%, 12.5%, and 19.95%, respectively. Conclusions These results show an improvement in the studied parameters by up to 20%, but when compared with those published in literature, these show great variability due to the wide variety of factors involved in the placebo effect. Several factors that affect the placebo effect are discussed, and the present work tries to quantify it in carpal tunnel syndrome. Level of Evidence Level 2 of evidence according to “The Oxford 2011 Level of Evidence.”
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Affiliation(s)
- Jordi Faig-Martí
- Hospital Sant Rafael, Pg. Vall d'Hebron 107-117, 08035, Barcelona, Catalonia, Spain.
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Takamura J, Seo T, Strand V. A Single Intra-Articular Injection of Gel-200 for Treatment of Symptomatic Osteoarthritis of the Knee Is More Effective than Phosphate Buffered Saline at 6 Months: A Subgroup Analysis of a Multicenter, Randomized Controlled Trial. Cartilage 2019; 10:417-422. [PMID: 29644875 PMCID: PMC6755876 DOI: 10.1177/1947603518768015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Many clinical trials of viscosupplementation have been conducted, although only the Gel-200 (primary) trial included a different patient population. A subgroup analysis of a multicenter, randomized controlled trial comparing the efficacy of single intra-articular injections of Gel-200 with phosphate buffered saline (PBS) was performed to demonstrate its benefit as treatment of osteoarthritis of the knee in a population similar to those of other reported trials of viscosupplementation. DESIGN The subgroup population was defined as patients in the intention-to-treat (ITT) population who met the specified criteria. Changes from baseline in Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores following treatment with Gel-200 or PBS were derived from a longitudinal model and treatment differences compared between groups at weeks 12 and 26, and over 26 weeks. RESULTS The subgroup included 311 subjects (152 Gel-200; 159 PBS). Mean improvements from baseline in WOMAC pain subscores in the Gel-200 over PBS groups were statistically significant at week 12 (P = 0.031) and week 26 (P = 0.019). Treatment group differences in WOMAC stiffness and total scores were statistically significant at week 26 (P = 0.023 and P = 0.036, respectively). CONCLUSIONS The efficacy of Gel-200 following a single injection for knee osteoarthritis was demonstrated in WOMAC pain, stiffness, and total scores as well as clinically important improvements in pain at 26 weeks in this subset of patients with comparable characteristics to populations evaluated in other viscosupplementation treatment trials.
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Affiliation(s)
- Junko Takamura
- R&D Planning Department, Research & Development Division, Seikagaku Corporation, Chiyoda-ku, Tokyo, Japan
| | - Takayuki Seo
- Clinical Development Department, Research & Development Division, Seikagaku Corporation, Chiyoda-ku, Tokyo, Japan
| | - Vibeke Strand
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
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Van Ginckel A, Hinman RS, Wrigley TV, Hunter DJ, Marshall CJ, Duryea J, Melo L, Simic M, Kasza J, Robbins SR, Wallis JA, Bennell KL. Effect of cane use on bone marrow lesion volume in people with medial tibiofemoral knee osteoarthritis: randomized clinical trial. Osteoarthritis Cartilage 2019; 27:1324-1338. [PMID: 31121294 DOI: 10.1016/j.joca.2019.05.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 04/17/2019] [Accepted: 05/03/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate effects of daily cane use for 3 months on medial tibiofemoral bone marrow lesion (BML) volumes in people with medial tibiofemoral osteoarthritis (OA). DESIGN In this randomized controlled trial (RCT), 79 participants with medial tibiofemoral OA were randomized to either a cane group (using a cane whenever walking) or control group (not using any gait aid) for 3 months. The cane group received a single training session by a physiotherapist, using a biofeedback cane to teach optimal technique and body weight support and motor learning principles to facilitate retention of learning. The primary outcome was change in total medial tibiofemoral BML volume (per unit bone volume) measured from magnetic resonance imaging (MRI) at 3 months. Secondary outcomes were BML volumes (per unit bone volume) of the medial tibia and femur, and patient-reported outcomes of overall knee pain, knee pain on walking, physical function, perceived global symptom changes and health-related quality of life. MRI analyses were performed by a blinded assessor. RESULTS Seventy-eight participants (99%) completed the primary outcome. Mean (standard deviation) daily cane use was 2.3 (1.7) hours over 3 months. No evidence of between-group differences was found for change in total medial tibiofemoral BML volume (mean difference: -0.0010 (95% confidence intervals: -0.0022, 0.0003)). Most secondary outcomes showed minimal differences between groups. CONCLUSION Daily use of a cane during walking for 3 months aiming to reduce knee joint loading did not change medial tibiofemoral BML volumes compared to no use of gait aids. CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trial Registry (ACTRN12614000909628).
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Affiliation(s)
- A Van Ginckel
- Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium; Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Parkville, Australia.
| | - R S Hinman
- Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Parkville, Australia.
| | - T V Wrigley
- Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Parkville, Australia.
| | - D J Hunter
- Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Parkville, Australia.
| | - C J Marshall
- Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Parkville, Australia.
| | - J Duryea
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
| | - L Melo
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, Australia; Department of Rheumatology, Royal North Shore Hospital, St Leonards, Australia.
| | - M Simic
- Discipline of Physiotherapy, Musculoskeletal Research Group, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
| | - J Kasza
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - S R Robbins
- Institute of Bone and Joint Research, Kolling Institute, The University of Sydney, Sydney, Australia; Department of Rheumatology, Royal North Shore Hospital, St Leonards, Australia.
| | - J A Wallis
- Department of Physical Therapy, Eastern Health. Department of Physical Therapy, La Trobe University, Melbourne, Australia.
| | - K L Bennell
- Centre for Health, Exercise and Sports Medicine, The University of Melbourne, Parkville, Australia.
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Richardson C, Plaas A, Block JA. Intra-articular Hyaluronan Therapy for Symptomatic Knee Osteoarthritis. Rheum Dis Clin North Am 2019; 45:439-451. [DOI: 10.1016/j.rdc.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
Objective To evaluate contextual effects in the form of placebo responses (PRs) for patient-reported pain and function and objectively measured function in osteoarthritis (OA) clinical trials. Methods Two authors independently searched major electronic databases from inception to 20 May 2019. Included studies were randomized, placebo-controlled OA trials of pharmacological agents reporting both patient-reported and objectively measured outcomes. PRs for each type of outcome measure were compared by standardized mean differences (SMDs). The placebo response ratio (PRR) assessed the placebo to treatment effect size. The effect sizes of PRs and PRRs were pooled using a random effects model. Results Twenty-one trials met the inclusion criteria; 20 were double-blinded with one not reporting on blinding status. Compared with patients’ self-reported outcome (PRO) pain, PRs were significantly lower for PRO function (SMD − 0.16 [95% CI = − 0.28, − 0.05], p = 0.006), objectively measured muscle strength (SMD − 0.34 [95% CI − 0.58, − 0.10], p = 0.006), and range of motion (SMD = − 0.31 [95% CI = − 0.54, − 0.08], p = 0.008) function. Generally, PRs for function outcomes (patient-reported and objectively measured) were similar. The overall PRR for different measures ranged from the smallest (most favorable) for walking time/distance (0.30, 95% CI 0.16 to 0.43) to the largest for PRO pain (0.44, 95% CI 0.23 to 0.65). Conclusion Function measures both subjective and objective had less contextual effects than pain measures in OA trials. Our results support the OMERACT-OARSI recommendations to include measures of physical function in all clinical trials of hip and knee OA and suggest that a greater use of function measures might enhance the success rates of pharmacological OA trials. Increasing the availability of mobile health apps should facilitate the acquisition of measured function data. Electronic supplementary material The online version of this article (10.1186/s13075-019-1951-6) contains supplementary material, which is available to authorized users.
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Verhoef LM, van den Bemt BJF, van der Maas A, Vriezekolk JE, Hulscher ME, van den Hoogen FHJ, Jacobs WCH, van Herwaarden N, den Broeder AA. Down-titration and discontinuation strategies of tumour necrosis factor-blocking agents for rheumatoid arthritis in patients with low disease activity. Cochrane Database Syst Rev 2019; 5:CD010455. [PMID: 31125448 PMCID: PMC6534285 DOI: 10.1002/14651858.cd010455.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anti-tumour necrosis factor (TNF) agents are effective in treating people with rheumatoid arthritis (RA), but are associated with (dose-dependent) adverse effects and high costs. To prevent overtreatment, several trials have assessed the effectiveness of down-titration compared with continuation of the standard dose. This is an update of a Cochrane Review published in 2014. OBJECTIVES To evaluate the benefits and harms of down-titration (dose reduction, discontinuation, or disease activity-guided dose tapering) of anti-TNF agents on disease activity, functioning, costs, safety, and radiographic damage compared with usual care in people with RA and low disease activity. SEARCH METHODS We searched MEDLINE, Embase, Web of Science and CENTRAL (29 March 2018) and four trial registries (11 April 2018) together with reference checking, citation searching, and contact with study authors to identify additional studies. We screened conference proceedings (American College of Rheumatology and European League Against Rheumatism 2005-2017). SELECTION CRITERIA Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing down-titration (dose reduction, discontinuation, disease activity-guided dose tapering) of anti-TNF agents (adalimumab, certolizumab pegol, etanercept, golimumab, infliximab) to usual care/no down-titration in people with RA and low disease activity. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology. MAIN RESULTS One previously included trial was excluded retrospectively in this update because it was not an RCT/CCT. We included eight additional trials, for a total of 14 studies (13 RCTs and one CCT, 3315 participants in total) reporting anti-TNF down-titration. Six studies (1148 participants) reported anti-TNF dose reduction compared with anti-TNF continuation. Eight studies (2111 participants) reported anti-TNF discontinuation compared with anti-TNF continuation (three studies assessed both anti-TNF discontinuation and dose reduction), and three studies assessed disease activity-guided anti-TNF dose tapering (365 participants). These studies included data on all anti-TNF agents, but primarily adalimumab and etanercept. Thirteen studies were available in full text, one was available as abstract. We assessed the included studies generally at low to moderate risk of bias; our main concerns were bias due to open-label treatment and unblinded outcome assessment. Clinical heterogeneity between the trials was high. The included studies were performed at clinical centres around the world and included people with early as well as established RA, the majority of whom were female with mean ages between 47 and 60. Study durations ranged from 6 months to 3.5 years.We found that anti-TNF dose reduction leads to little or no difference in mean disease activity score (DAS28) after 26 to 52 weeks (high-certainty evidence, mean difference (MD) 0.06, 95% confidence interval (CI) -0.11 to 0.24, absolute risk difference (ARD) 1%) compared with continuation. Also, anti-TNF dose reduction does not result in an important deterioration in function after 26 to 52 weeks (Health Assessment Questionnaire Disability Index (HAQ-DI)) (high-certainty evidence, MD 0.09, 95% CI 0.00 to 0.19, ARD 3%). Next to this, anti-TNF dose reduction may slightly reduce the proportion of participants switched to another biologic (low-certainty evidence), but probably slightly increases the proportion of participants with minimal radiographic progression after 52 weeks (moderate-certainty evidence, risk ratio (RR) 1.22, 95% CI 0.76 to 1.95, ARD 2% higher). Anti-TNF dose reduction may cause little or no difference in serious adverse events, withdrawals due to adverse events and proportion of participants with persistent remission (low-certainty evidence).Results show that anti-TNF discontinuation probably slightly increases the mean disease activity score (DAS28) after 28 to 52 weeks (moderate-certainty evidence, MD 0.96, 95% CI 0.67 to 1.25, ARD 14%), and that the RR of persistent remission lies between 0.16 and 0.77 (low-certainty evidence). Anti-TNF discontinuation increases the proportion participants with minimal radiographic progression after 52 weeks (high-certainty evidence, RR 1.69, 95% CI 1.10 to 2.59, ARD 7%) and may lead to a slight deterioration in function (HAQ-DI) (low-certainty evidence). It is uncertain whether anti-TNF discontinuation influences the number of serious adverse events (due to very low-certainty evidence) and the number of withdrawals due to adverse events after 28 to 52 weeks probably increases slightly (moderate-certainty evidence, RR 1.46, 95% CI 0.75 to 2.84, ARD 1% higher).Anti-TNF disease activity-guided dose tapering may result in little or no difference in mean disease activity score (DAS28) after 72 to 78 weeks (low-certainty evidence). Furthermore, anti-TNF disease activity-guided dose tapering results in little or no difference in the proportion of participants with persistent remission after 18 months (high-certainty evidence, RR 0.89, 95% CI 0.75 to 1.06, ARD -9%) and may result in little or no difference in switching to another biologic (low-certainty evidence). Anti-TNF disease activity-guided dose tapering may slightly increase proportion of participants with minimal radiographic progression (low-certainty evidence) and probably leads to a slight deterioration of function after 18 months (moderate-certainty evidence, MD 0.2 higher, 0.02 lower to 0.42 higher, ARD 7% higher), It is uncertain whether anti-TNF disease activity-guided dose tapering influences the number of serious adverse events due to very low-certainty evidence. AUTHORS' CONCLUSIONS We found that fixed-dose reduction of anti-TNF, after at least three to 12 months of low disease activity, is comparable to continuation of the standard dose regarding disease activity and function, and may be comparable with regards to the proportion of participants with persistent remission. Discontinuation (also without disease activity-guided adaptation) of anti-TNF is probably inferior to continuation of treatment with respect to disease activity, the proportion of participants with persistent remission, function, and minimal radiographic damage. Disease activity-guided dose tapering of anti-TNF is comparable to continuation of treatment with respect to the proportion of participants with persistent remission and may be comparable regarding disease activity.Caveats of this review are that available data are mainly limited to etanercept and adalimumab, the heterogeneity between studies, and the use of superiority instead of non-inferiority designs.Future research should focus on the anti-TNF agents infliximab and golimumab; assessment of disease activity, function, and radiographic outcomes after longer follow-up; and assessment of long-term safety, cost-effectiveness, and predictors for successful down-titration. Also, use of a validated flare criterion, non-inferiority designs, and disease activity-guided tapering instead of fixed-dose reduction or discontinuation would allow researchers to better interpret study findings and generalise to clinical practice.
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Affiliation(s)
- Lise M Verhoef
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Bart JF van den Bemt
- Sint MaartenskliniekDepartment of PharmacyHengstdal 3NijmegenGelderlandNetherlands6522JV
- Radboud University Medical CenterDepartment of PharmacyNijmegenNetherlands
| | - Aatke van der Maas
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Johanna E Vriezekolk
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Marlies E Hulscher
- Radboud Institute for Health Sciences, Radboud University Medical CenterIQ healthcarePO Box 9101117 KWAZONijmegenNetherlands6500 HB
| | - Frank HJ van den Hoogen
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
- Radboud University Medical CenterDepartment of RheumatologyNijmegenNetherlands
| | - Wilco CH Jacobs
- The Health ScientistFraeylemastraat 13The HagueNetherlands2532 TX
| | - Noortje van Herwaarden
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
| | - Alfons A den Broeder
- Sint MaartenskliniekDepartment of RheumatologyHengstdal 3NijmegenGelderlandNetherlands6574 NA
- Radboud University Medical CenterDepartment of RheumatologyNijmegenNetherlands
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Smits RM, Veldhuijzen DS, Wulffraat NM, Evers AWM. The role of placebo effects in immune-related conditions: mechanisms and clinical considerations. Expert Rev Clin Immunol 2018; 14:761-770. [DOI: 10.1080/1744666x.2018.1516144] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Rosanne M. Smits
- Faculty of Social and Behavioural Sciences, Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Department Pediatric Rheumatology and Immunolgy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Dieuwke S. Veldhuijzen
- Faculty of Social and Behavioural Sciences, Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Nico M. Wulffraat
- Department Pediatric Rheumatology and Immunolgy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Andrea W. M. Evers
- Faculty of Social and Behavioural Sciences, Institute of Psychology, Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
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Wartolowska K, Beard D, Carr A. Blinding in trials of interventional procedures is possible and worthwhile. F1000Res 2018; 6:1663. [PMID: 29259763 DOI: 10.12688/f1000research.12528.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 12/31/2022] Open
Abstract
In this paper, we use evidence from our earlier review of surgical randomised controlled trials with a placebo arm to show that blinding in trials of interventional procedures is feasible. We give examples of ingenious strategies that have been used to simulate the active procedure and to make the placebo control indistinguishable from the active treatment. We discuss why it is important to blind of patients, assessors, and caregivers and what types of bias that may occur in interventional trials. Finally, we describe the benefits of blinding, from the obvious ones such as avoiding bias, as well as less evident benefits such as avoiding patient drop out in the control arm.
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Affiliation(s)
- Karolina Wartolowska
- Nuffield Department of Primary Care Health Sciences (NDPCHS), Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - David Beard
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - Andrew Carr
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
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34
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Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord 2018; 19:27. [PMID: 29357856 PMCID: PMC5778801 DOI: 10.1186/s12891-018-1943-8] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 01/15/2018] [Indexed: 12/18/2022] Open
Abstract
Placebo and nocebo effects are embodied psycho-neurobiological responses capable of modulating pain and producing changes at different neurobiological, body at perceptual and cognitive levels. These modifications are triggered by different contextual factors (CFs) presented in the therapeutic encounter between patient and healthcare providers, such as healing rituals and signs. The CFs directly impact on the quality of the therapeutic outcome: a positive context, that is a context characterized by the presence of positive CFs, can reduce pain by producing placebo effects, while a negative context, characterized by the presence of negative CFs, can aggravate pain by creating nocebo effects. Despite the increasing interest about this topic; the detailed study of CFs as triggers of placebo and nocebo effects is still lacked in the management of musculoskeletal pain. Increasing evidence suggest a relevant role of CFs in musculoskeletal pain management. CFs are a complex sets of internal, external or relational elements encompassing: patient’s expectation, history, baseline characteristics; clinician’s behavior, belief, verbal suggestions and therapeutic touch; positive therapeutic encounter, patient-centered approach and social learning; overt therapy, posology of intervention, modality of treatment administration; marketing features of treatment and health care setting. Different explanatory models such as classical conditioning and expectancy can explain how CFs trigger placebo and nocebo effects. CFs act through specific neural networks and neurotransmitters that were described as mediators of placebo and nocebo effects. Available findings suggest a relevant clinical role and impact of CFs. They should be integrated in the clinical reasoning to increase the number of treatment solutions, boosts their efficacy and improve the quality of the decision-making. From a clinical perspective, the mindful manipulation of CFs represents a useful opportunity to enrich a well-established therapy in therapeutic setting within the ethical border. From a translational perspective, there is a strong need of research studies on CFs close to routine and real-world clinical practice in order to underline the uncertainty of therapy action and help clinicians to implement knowledge in daily practice.
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Affiliation(s)
- Giacomo Rossettini
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona. Via Magliotto, 2, 17100, Savona, Italy
| | - Elisa Carlino
- Department of Neuroscience, University of Turin Medical School, Turin, Italy
| | - Marco Testa
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Campus of Savona. Via Magliotto, 2, 17100, Savona, Italy.
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Wartolowska K, Beard D, Carr A. Blinding in trials of interventional procedures is possible and worthwhile. F1000Res 2017; 6:1663. [PMID: 29259763 PMCID: PMC5717470 DOI: 10.12688/f1000research.12528.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2018] [Indexed: 12/27/2022] Open
Abstract
In this paper, we use evidence from our earlier review of surgical randomised controlled trials with a placebo arm to show that blinding in trials of interventional procedures is feasible. We give examples of ingenious strategies that have been used to simulate the active procedure and to make the placebo control indistinguishable from the active treatment. We discuss why it is important to blind of patients, assessors, and caregivers and what types of bias that may occur in interventional trials. Finally, we describe the benefits of blinding, from the obvious ones such as avoiding bias, as well as less evident benefits such as avoiding patient drop out in the control arm.
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Affiliation(s)
- Karolina Wartolowska
- Nuffield Department of Primary Care Health Sciences (NDPCHS), Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - David Beard
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
| | - Andrew Carr
- Botnar Research Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (NDORMS), Windmill Road, Oxford, OX3 7LD, UK
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Saltzman BM, Leroux T, Meyer MA, Basques BA, Chahal J, Bach BR, Yanke AB, Cole BJ. The Therapeutic Effect of Intra-articular Normal Saline Injections for Knee Osteoarthritis: A Meta-analysis of Evidence Level 1 Studies. Am J Sports Med 2017; 45:2647-2653. [PMID: 28027657 DOI: 10.1177/0363546516680607] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intra-articular normal saline (IA-NS) injections have been utilized as a placebo in a number of randomized controlled trials pertaining to the management of knee osteoarthritis (OA); however, it is believed that these "placebo" injections may have a therapeutic effect that has not been quantified in the literature. PURPOSE To (1) quantify the effect of IA-NS injections on patient-reported outcomes (PROs) and (2) compare postinjection PROs to established minimal clinically important difference (MCID) criteria to demonstrate a potential therapeutic effect. STUDY DESIGN Meta-analysis. METHODS A review was conducted to identify all randomized, placebo-controlled trials on injection therapy for knee OA between 2006 and 2016. Patient demographics and PROs before the injection and at 3 and 6 months after the injection were collected for patients in the IA-NS injection group in each study. A random-effects model was used to compare preinjection scores and scores at each postinjection time point in a pairwise fashion. RESULTS In total, there were 14 placebo cohorts in 13 studies that were analyzed after meeting inclusion criteria for this meta-analysis. This included 1076 patients (Kellgren-Lawrence grade 1-4), with a weighted mean age of 62.53 years and mean body mass index of 28.67 kg/m2. There was only sufficient information to perform analyses of visual analog scale (VAS) pain and Western Ontario and McMaster Universities Arthritis Index (WOMAC) total scores. At 3 months after the IA-NS placebo injection, there was a significant improvement in VAS pain scores (mean difference [MD], 12.10 [95% CI, 3.27 to 20.93]; P = .007), whereas improvement in the WOMAC total scores approached but did not reach statistical significance (MD, 19.75 [95% CI, -0.50 to 40.09]; P = .06). At 6 months, both VAS pain scores (MD, 16.62 [95% CI, 12.13-21.10]; P < .00001) and WOMAC total scores (MD, 11.34 [95% CI, 7.03-15.65]; P < .00001) were significantly improved in comparison to preinjection values. Furthermore, improvements in both the VAS pain and WOMAC total scores at 6 months were clinically significant (MCID, 1.37 and 9, respectively). CONCLUSION The administration of an IA-NS placebo injection yields a statistically and clinically meaningful improvement in PROs up to 6 months after the injection in patients with knee OA. This observation supports the notion that the so-called placebo effect for IA-NS injections achieves a clinically meaningful response in patients with OA when provided during comparison studies to an active treatment group (ie, hyaluronic acid).
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Affiliation(s)
- Bryan M Saltzman
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Leroux
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Maximilian A Meyer
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Bryce A Basques
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jaskarndip Chahal
- Division of Sports Medicine, Department of Orthopedic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Bernard R Bach
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Adam B Yanke
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Sandal LF, Thorlund JB, Moore AJ, Ulrich RS, Dieppe PA, Roos EM. Room for improvement: a randomised controlled trial with nested qualitative interviews on space, place and treatment delivery. Br J Sports Med 2017; 53:359-367. [PMID: 28768617 DOI: 10.1136/bjsports-2016-097448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Healthcare-oriented design in hospitals can promote better clinical outcomes. Creating optimal facilities may increase treatment effects. We investigated the influence of the treatment room on effects of exercise therapy. METHODS In a mixed-method randomised controlled double-blind trial, middle-aged individuals reporting knee or hip pain performed 8 weeks of exercise therapy in (1) a newly built physically enhanced environment, (2) a standard environment or (3) were waitlisted, receiving no intervention. Participants and therapists were blind to study aim. Primary outcome was participants' Global Perceived Effect (GPE; seven-point Likert scale). Six nested focus group interviews with participants (n=25) and individual interviews with therapists (n=2) explored experiences of the environments. RESULTS 42 people exercised in the physically enhanced environment, 40 in the standard environment, 21 were waitlisted. Contrary to our hypothesis, the treatment response seemed greater in the standard environment for GPE (0.98, 95% CI0.5 to 1.4) than for the physically enhanced environment (0.37, 95% CI -0.2 to 0.9), between-group difference (0.61, 95% CI -0.1 to 1.3) did not reach statistical significance (p=0.07). Waitlist group reported no improvement (-0.05 95% CI -0.5 to 0.4). In interviews, participants from the standard environment expressed greater social cohesion and feeling at home. Qualitative themes identified; reflection, sense of fellowship and transition. Secondary patient-reported outcomes and qualitative findings supported the primary finding, while improvements in muscle strength and aerobic capacity did not differ between exercise groups. CONCLUSION Results suggest that the physical environment contributes to treatment response. Matching patients' preferences to treatment rooms may improve patient-reported outcomes. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier: NCT02043613.
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Affiliation(s)
- Louise F Sandal
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Jonas B Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Andrew J Moore
- School of Clinical Science, University of Bristol, Bristol, UK
| | - Roger S Ulrich
- Department of Architecture, Chalmers University of Technology, Gothenburg, Sweden
| | | | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
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Lozada CJ, del Rio E, Reitberg DP, Smith RA, Kahn CB, Moskowitz RW. A double-blind, randomized, saline-controlled study of the efficacy and safety of co-administered intra-articular injections of Tr14 and Ze14 for treatment of painful osteoarthritis of the knee: The MOZArT trial. Eur J Integr Med 2017. [DOI: 10.1016/j.eujim.2017.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Efficacy paradox and proportional contextual effect (PCE). Clin Immunol 2017; 186:82-86. [PMID: 28736278 DOI: 10.1016/j.clim.2017.07.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/23/2022]
Abstract
The "efficacy paradox" is when the effect of a treatment tested in an RCT, or evidence-based guideline advice, differs markedly from treatment benefits observed in clinical practice. This arises because in RCT reporting and guideline development treatment efficacy is judged by the separation of the treatment group from the placebo group (the specific treatment effect) whereas in clinical practice it is the overall treatment effect, which includes both specific and contextual responses, that patients experience. This paradox causes a disconnect between guidelines and clinical practice and ignores the importance of contextual response in clinical care. This article fully explains and discusses these issues and presents a possible way to reduce the paradox through an alteration in RCT reporting that shifts the focus to overall treatment benefit and the proportion ("proportional contextual effect") that is explained by placebo and contextual effects.
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Green J, Wright H. From Bench to Bedside: Converting Placebo Research into Belief Activation. J Altern Complement Med 2017; 23:575-580. [PMID: 28719223 DOI: 10.1089/acm.2016.0375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Research on the placebo effect contains important elements that can be harnessed to improve clinical care. This paper proposes a new term, "Belief Activation," to describe the deliberate use of placebo effect tools by both patients and clinicians to catalyze healing. Belief Activation includes, but is not limited to, maximizing patient and practitioner expectations, classical and social conditioning, spirituality and prayer/intention, therapeutic relationship, healing environments, and minimizing the nocebo effect. This paper demonstrates ways in which Belief Activation is a form of evidence-based medicine and seeks to translate knowledge from placebo research into medical practice.
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Affiliation(s)
- Jen Green
- 1 Emcura Integrative Clinic , Bloomfield Township, MI
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Bishop FL, Coghlan B, Geraghty AWA, Everitt H, Little P, Holmes MM, Seretis D, Lewith G. What techniques might be used to harness placebo effects in non-malignant pain? A literature review and survey to develop a taxonomy. BMJ Open 2017; 7:e015516. [PMID: 28667217 PMCID: PMC5734496 DOI: 10.1136/bmjopen-2016-015516] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Placebo effects can be clinically meaningful but are seldom fully exploited in clinical practice. This review aimed to facilitate translational research by producing a taxonomy of techniques that could augment placebo analgesia in clinical practice. DESIGN Literature review and survey. METHODS We systematically analysed methods which could plausibly be used to elicit placebo effects in 169 clinical and laboratory-based studies involving non-malignant pain, drawn from seven systematic reviews. In a validation exercise, we surveyed 33 leading placebo researchers (mean 12 years’ research experience, SD 9.8), who were asked to comment on and add to the draft taxonomy derived from the literature. RESULTS The final taxonomy defines 30 procedures that may contribute to placebo effects in clinical and experimental research, proposes 60 possible clinical applications and classifies procedures into five domains: the patient’s characteristics and belief (5 procedures and 11 clinical applications), the practitioner’s characteristics and beliefs (2 procedures and 4 clinical applications), the healthcare setting (8 procedures and 13 clinical applications), treatment characteristics (8 procedures and 14 clinical applications) and the patientâ€"practitioner interaction (7 procedures and 18 clinical applications). CONCLUSION The taxonomy provides a preliminary and novel tool with potential to guide translational research aiming to harness placebo effects for patient benefit in practice.
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Affiliation(s)
- Felicity L Bishop
- Department of Psychology, Faculty of Social Human and Mathematical Sciences, University of Southampton, Southampton, UK
| | - Beverly Coghlan
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Adam WA Geraghty
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Hazel Everitt
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Paul Little
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Michelle M Holmes
- Department of Psychology, Faculty of Social Human and Mathematical Sciences, University of Southampton, Southampton, UK
| | - Dionysis Seretis
- Department of Psychology, Faculty of Social Human and Mathematical Sciences, University of Southampton, Southampton, UK
| | - George Lewith
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
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Coste J, Montel S. Placebo-related effects: a meta-narrative review of conceptualization, mechanisms and their relevance in rheumatology. Rheumatology (Oxford) 2017; 56:334-343. [PMID: 27477808 DOI: 10.1093/rheumatology/kew274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Indexed: 12/19/2022] Open
Abstract
For decades in medicine, the placebo effect has been conceptualized as a subjective psychological effect associated with an inert substance and considered to be a nuisance noise in the assessment of therapeutic effects in clinical trials. However, research on placebo has undergone substantial developments since the mid-1980s in several fields of knowledge (including methodology, psychology and neurosciences) that challenge this traditional view. Using a meta-narrative approach, this review of conceptualizations, determinants, mechanisms and models of placebo effects shows that placebo effects are genuine biopsychosocial phenomena strongly affected by context and factors surrounding the patient and treatments. Psychological experiments and neurobiological and neuroimaging studies have identified various types of placebo responses, driven by different mechanisms (especially but not only expectation and conditioning) and associated with different chemical, structural and functional features. Insights into the mechanisms involved in placebo responses have led to opportunities for ethical enhancements of these mechanisms in clinical practice, notably by improving the patient-doctor interaction and refining the therapeutic ritual. These developments should be carefully considered in rheumatology settings, in which placebo effects are both prevalent and significant, with the potential to improve patient care.
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Affiliation(s)
- Joël Coste
- APEMAC, EA 4360, Paris Descartes University, University of Lorraine.,Biostatistics and Epidemiology Unit, Hôtel Dieu, Assistance Publique, Hôpitaux de Paris
| | - Sébastien Montel
- APEMAC, EA 4360, Paris Descartes University, University of Lorraine.,Department of Psychology, University Paris Saint Denis, Paris, France
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Wehling P, Evans C, Wehling J, Maixner W. Effectiveness of intra-articular therapies in osteoarthritis: a literature review. Ther Adv Musculoskelet Dis 2017; 9:183-196. [PMID: 28835778 DOI: 10.1177/1759720x17712695] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 04/25/2017] [Indexed: 12/11/2022] Open
Abstract
Osteoarthritis is a painful, chronic disease with widespread burden on patients, communities, health and social care systems. Conservative therapies, such as nonpharmacological interventions, systemic drug treatment and intra-articular therapies are used before resorting to surgery; nonetheless, disease control often remains inadequate. Recent advances in osteoarthritis management have aimed to provide greater variety of treatment options. Here, we summarize a targeted literature review evaluating efficacy and safety of intra-articular therapies for osteoarthritis. Injections of intra-articular therapies directly into the joint avoid conventional barriers to joint entry, increase bioavailability and lower systemic toxicity. Intra-articular corticosteroids and hyaluronic acid are established United States Food and Drug Administration (US FDA)/European Medicines Agency (EMA)-approved treatments; however, concerns exist regarding effect duration, safety, effectiveness across populations and heterogeneity. Newer therapies, such as autologous blood products and mesenchymal stem cells, are in development. Benefits of autologous blood products (e.g. platelet-rich plasma, autologous conditioned serum) include an expected improved safety profile and direct targeting of osteoarthritis-related pathophysiology. Autologous conditioned serum is cell-free and manufactured by a standardized process, whereas platelet-rich plasma composition and characteristics can vary. Currently, only limited efficacy comparisons between these biological treatments can be drawn; long-term clinical and safety studies are needed to increase the efficacy evidence base and earn consideration in treatment frameworks.
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Affiliation(s)
- Peter Wehling
- Orthogen AG, Ernst-Schneider-Platz 1, 40212 Düsseldorf, Germany
| | - Christopher Evans
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, MN, USA
| | - Jana Wehling
- Center for Molecular Orthopaedics and Regenerative Medicine, Stadttor 1, Düsseldorf, Germany
| | - William Maixner
- Center for Translational Pain Medicine, Duke University School of Medicine, Durham, NC, USA
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Thorlund JB. Deconstructing a popular myth: why knee arthroscopy is no better than placebo surgery for degenerative meniscal tears. Br J Sports Med 2017; 51:1630-1631. [PMID: 28615215 DOI: 10.1136/bjsports-2017-097877] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2017] [Indexed: 11/04/2022]
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Sardana V, Burzynski J, Zalzal P. Safety and efficacy of topical ketoprofen in transfersome gel in knee osteoarthritis: A systematic review. Musculoskeletal Care 2017; 15:114-121. [PMID: 27778435 DOI: 10.1002/msc.1163] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE Topical ketoprofen in Transfersome gel has been used for the alleviation of symptoms in osteoarthritis. Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with various side effects. Topical NSAIDs are known to have a lower side-effect profile when compared with systemic administration. The present systematic review aimed to determine the safety and efficacy of topical ketoprofen in Transfersome gel in knee osteoarthritis (OA). METHODS A systematic literature review was performed. The electronic databases EMBASE, MEDLINE, HealthStar and PubMed were searched from 1946 to June 2016. A screen of the reference sections of the included studies was also performed. Two blinded reviewers searched, screened, abstracted and evaluated the data quality using the Jadad scale. Studies were included if they contained: at least 50% of participants with knee OA, topical ketoprofen, human subjects and participants from North America or Europe. Study outcomes had to include patient-reported functional outcome scores. RESULTS Five studies were included, with a total of 3619 participants, and a mean Jadad score of 3.4/5. Western Ontario McMaster Universities (WOMAC) Osteoarthritis Index was the only outcome measure consistent across all of the randomized controlled trials included in the present review (four of the five included studies). All topical ketoprofen in Transfersome gel groups (25 mg, 50 mg and 100 mg) had improvements in pain that were superior to all other treatment arms, and the 50 mg topical ketoprofen in Transfersome gel group had functional gains that were superior to all other treatment arms. The majority of the adverse events were non-serious and related to skin and subcutaneous tissue disorders, with erythema being the most common. The average of all adverse events and gastrointestinal (GI) adverse events was highest in the oral celecoxib group (47.1% and 15.1%, respectively). The average frequency of GI adverse events in the topical ketoprofen groups was comparable with that in the topical placebo treatment arm. A meta-analysis was not feasible due to the heterogeneity among the studies. CONCLUSIONS Topical ketoprofen in Transfersome gel is an effective means of treating symptoms of knee OA, and is superior to oral celecoxib, oral placebo and topical placebo. The most commonly reported adverse events associated with the use of topical ketoprofen in Transfersome gel were non-severe skin and subcutaneous tissue disorders. Furthermore, as topical ketoprofen in Transfersome gel was associated with fewer adverse events when compared with oral celecoxib, and had rates of GI adverse events comparable with those of topical placebo, it may be ideal for those who are unable to take oral NSAIDs.
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Affiliation(s)
- Vandit Sardana
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Joanna Burzynski
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Paul Zalzal
- Division of Orthopedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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46
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Dabare C, Le Marshall K, Leung A, Page CJ, Choong PF, Lim KK. Differences in presentation, progression and rates of arthroplasty between hip and knee osteoarthritis: Observations from an osteoarthritis cohort study-a clear role for conservative management. Int J Rheum Dis 2017; 20:1350-1360. [PMID: 28493422 PMCID: PMC5655735 DOI: 10.1111/1756-185x.13083] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aim To describe the natural progression and the rates of arthroplasty of a cohort of hip and knee osteoarthritis (OA) patients. Methods An observational study of 247 consecutive patients who attended an OA clinic between May 2008 and August 2009. Follow‐up survey was conducted from July 2014 to December 2014, with the primary end point being joint replacement surgery. Results One hundred and sixty‐seven patients had knee OA and 80 patients had hip OA. When adjusted for other variables (age, gender, body mass index, Kellgren‐Lawrence stage, symptom duration, presence of OA elsewhere and pain score), patients with hip OA demonstrated 86% increased hazard of surgery compared to knee OA patients (95% CI increase of 19% to 193%). At 6 years after initial consultation, 67% of patients with knee OA did not require a knee replacement surgery, while 40% (30, 51) of hip OA patients did not undergo surgery (95% CI: 59–74%). Overall at 6 years, 58% of patients (95% CI: 51–64%) did not undergo joint replacement surgery. Conclusion Knee and hip OA patients appear to behave differently, with hip OA patients more likely to undergo arthroplasty. There is a significant number of both hip OA and knee OA patients who did not require arthroplasty at the end of 6 years, suggesting a major role for conservative therapy.
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Affiliation(s)
- Chamila Dabare
- Rheumatology Unit, Western Health, Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kim Le Marshall
- Rheumatology Unit, Western Health, Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia
| | - Albert Leung
- Rheumatology Unit, Western Health, Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Orthopaedics, The University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Carolyn J Page
- Department of Physiotherapy, The University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Peter F Choong
- Department of Orthopaedics, The University of Melbourne and Western Health, Melbourne, Victoria, Australia.,Department of Surgery, St. Vincent's Hospital, The University of Melbourne and Western Health, Melbourne, Victoria, Australia
| | - Keith K Lim
- Rheumatology Unit, Western Health, Department of Medicine, Melbourne Medical School - Western Precinct, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Orthopaedics, The University of Melbourne and Western Health, Melbourne, Victoria, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western Health, Melbourne, Victoria, Australia
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Hummel M, Whiteside GT. Measuring and realizing the translational significance of preclinical in vivo studies of painful osteoarthritis. Osteoarthritis Cartilage 2017; 25:376-384. [PMID: 27592040 DOI: 10.1016/j.joca.2016.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 02/02/2023]
Abstract
In this communication, we discuss some key issues surrounding the translation of preclinical efficacy studies in models of painful osteoarthritis (OA) to the clinical arena. We highlight potential pitfalls which could negatively impact successful translation. These include lack of alignment between a model + endpoint and the intended clinical population, employing testing strategies in animals that are not appropriate for the targeted human population such as pre-emptive treatment and lastly, underestimating the magnitude of the efficacy signal in animals that may be needed to see an effect in the clinical population. Through careful analysis, we highlight the importance of each pitfall by providing relevant examples that will hopefully improve future chances of optimizing translation in the area of OA pain research. We advocate advancing publications directed at comparing methods, outcomes and conclusions between preclinical and clinical studies, regardless of whether the findings are positive or negative, are important for improving the potential for a desired successful translation from the bench to bedside.
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Affiliation(s)
- M Hummel
- Discovery Research, Purdue Pharma L.P., 6 Cedar Brook Drive, Cranbury, NJ 08512, USA
| | - G T Whiteside
- Discovery Research, Purdue Pharma L.P., 6 Cedar Brook Drive, Cranbury, NJ 08512, USA.
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The temporal effect of platelet-rich plasma on pain and physical function in the treatment of knee osteoarthritis: systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 2017; 12:16. [PMID: 28115016 PMCID: PMC5260061 DOI: 10.1186/s13018-017-0521-3] [Citation(s) in RCA: 187] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 01/03/2017] [Indexed: 12/16/2022] Open
Abstract
Background Quite a few randomized controlled trials (RCTs) investigating the efficacy of platelet-rich plasma (PRP) for treatment of knee osteoarthritis (OA) have been recently published. Therefore, an updated systematic review was performed to evaluate the temporal effect of PRP on knee pain and physical function. Methods Pubmed, Embase, Cochrane library, and Scopus were searched for human RCTs comparing the efficacy and/or safety of PRP infiltration with other intra-articular injections. A descriptive summary and quality assessment were performed for all the studies finally included for analysis. For studies reporting outcomes concerning Western Ontario and McMaster Universities Arthritis Index (WOMAC) or adverse events, a random-effects model was used for data synthesis. Results Fourteen RCTs comprising 1423 participants were included. The control included saline placebo, HA, ozone, and corticosteroids. The follow-up ranged from 12 weeks to 12 months. Risk of bias assessment showed that 4 studies were considered as moderate risk of bias and 10 as high risk of bias. Compared with control, PRP injections significantly reduced WOMAC pain subscores at 3, 6, and 12 months follow-up (p = 0.02, 0.004, <0.001, respectively); PRP significantly improved WOMAC physical function subscores at 3, 6, and 12 months (p = 0.002, 0.01, <0.001, respectively); PRP also significantly improved total WOMAC scores at 3, 6 and 12 months (all p < 0.001); nonetheless, PRP did not significantly increased the risk of post-injection adverse events (RR, 1.40 [95% CI, 0.80 to 2.45], I2 = 59%, p = 0.24). Conclusions Intra-articular PRP injections probably are more efficacious in the treatment of knee OA in terms of pain relief and self-reported function improvement at 3, 6 and 12 months follow-up, compared with other injections, including saline placebo, HA, ozone, and corticosteroids. Review registration PROSPERO CRD42016045410. Registered 8 August 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13018-017-0521-3) contains supplementary material, which is available to authorized users.
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Roman‐Blas JA, Castañeda S, Sánchez‐Pernaute O, Largo R, Herrero‐Beaumont G, Blanco FJ, Gómez RB, Burlato MC, González CG, Vázquez JLG, Martín‐Mola E, Brancós AIM, Navarro Blasco FJ, Román Ivorra JA, Rosas Gómez de Salazar JC. Combined Treatment With Chondroitin Sulfate and Glucosamine Sulfate Shows No Superiority Over Placebo for Reduction of Joint Pain and Functional Impairment in Patients With Knee Osteoarthritis: A Six‐Month Multicenter, Randomized, Double‐Blind, Placebo‐Controlled Clinical Trial. Arthritis Rheumatol 2016; 69:77-85. [DOI: 10.1002/art.39819] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 07/14/2016] [Indexed: 01/21/2023]
Affiliation(s)
| | - Santos Castañeda
- Hospital de La Princesa, Madrid, Spain. Members of the CS/GS Combined Therapy Study Group are shown in Appendix A
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Affiliation(s)
- Giuseppe Filardo
- Biomechanics Laboratory - II Clinic, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136, Bologna, Italy.
| | - Elizaveta Kon
- Biomechanics Laboratory - II Clinic, Rizzoli Orthopaedic Institute, Via di Barbiano 1/10, 40136, Bologna, Italy
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