Smallest worthwhile effect of land-based and water-based pulmonary rehabilitation for COPD

Using the benefit-harm trade-off method to determine the smallest worthwhile effect of intensive motor training on strength for people with spinal cord injury

STUDY DESIGN

Interviews using the benefit-harm trade-off method and an online survey.

OBJECTIVES

To determine the smallest worthwhile effect (SWE) of motor training on strength for people with spinal cord injury (SCI).

SETTING

SCI units, Australia.

METHODS

Forty people with recent SCI who had participated in motor training as part of their rehabilitation program (patient participants) and 37 physiotherapists (physiotherapist participants) working in SCI were recruited. The patient participants underwent an iterative process using the benefit-harm trade-off method to determine the SWE of motor training on strength. The physiotherapist participants were given an online survey to determine the SWE for five different scenarios. Both groups considered the SWE of a physiotherapy intervention involving an additional 12 h of motor training for 10 weeks on top of usual care. They were required to estimate the smallest improvement in strength (points on the Total Motor Score of the International Standards for Neurological Classification of SCI) to justify the effort and associated costs, risks or inconveniences of the motor training.

RESULTS

The median (interquartile range) smallest improvement in strength that patient and physiotherapist participants deemed worth the effort and associated costs, risks or inconveniences of the motor training was 3 (1-5) points, and 9 (7-13) points, respectively.

CONCLUSIONS

People with recent SCI are willing to devote 12 h a week for 10 weeks to motor training in addition to their usual care to gain small changes in strength. Physiotherapists wanted to see greater improvements to justify the intervention.

Estimating the smallest worthwhile difference of antidepressants: a cross-sectional survey

BACKGROUND

Approximately 30% of patients experience substantial improvement in depression after 2 months without treatment, and 45% with antidepressants. The smallest worthwhile difference (SWD) refers to an intervention's smallest beneficial effect over a comparison patients deem worthwhile given treatment burdens (harms, expenses and inconveniences), but is undetermined for antidepressants.

OBJECTIVE

Estimating the SWD of commonly prescribed antidepressants for depression compared to no treatment.

METHODS

The SWD was estimated as a patient-required difference in response rates between antidepressants and no treatment after 2 months. An online cross-sectional survey using Prolific, MQ Mental Health and Amazon Mechanical Turk crowdsourcing services in the UK and USA between October 2022 and January 2023 garnered participants (N=935) that were a mean age of 44.1 (SD=13.9) and 66% women (n=617).

FINDINGS

Of 935 participants, 124 reported moderate-to-severe depressive symptoms but were not in treatment, 390 were in treatment and 495 reported absent-to-mild symptoms with or without treatment experiences. The median SWD was a 20% (IQR=10-30%) difference in response rates for people with moderate-to-severe depressive symptoms, not in treatment, and willing to consider antidepressants, and 25% (IQR=10-35%) for the full sample.

CONCLUSIONS

Our observed SWDs mean that the current 15% antidepressant benefit over no treatment was sufficient for one in three people to accept antidepressants given the burdens, but two in three expected greater treatment benefits.

IMPLICATIONS

While a minority may be satisfied with the best currently available antidepressants, more effective and/or less burdensome medications are needed, with more attention given to patient perspectives.

The smallest worthwhile effect on pain intensity of nonsteroidal anti-inflammatory drugs and exercise therapy for acute and chronic low back pain: a benefit-harm trade-off study

QUESTION

What are the smallest worthwhile effects of nonsteroidal anti-inflammatory drugs (NSAIDs) for people with acute and chronic low back pain (LBP)? What is the smallest worthwhile effect of individualised exercise for people with chronic LBP compared with no intervention?

DESIGN

Benefit-harm trade-off study.

PARTICIPANTS

Participants were recruited by advertisement on social media and included if they were English-speaking adults in Australia who had non-specific LBP.

OUTCOME MEASURE

Pain intensity.

RESULTS

A total of 116 people with acute LBP and 230 people with chronic LBP were recruited. For acute LBP, the smallest worthwhile effect of NSAIDs additional to no intervention was a 30% (IQR 10 to 40%) reduction in pain intensity. For chronic LBP, the smallest worthwhile effect of NSAIDs additional to no intervention was a 27.5% (IQR 10 to 50%) reduction in pain intensity. For chronic LBP, the smallest worthwhile effect of exercise additional to no intervention was a 20% (IQR 10 to 40%) reduction in pain intensity. There were small associations between baseline pain, duration of pain and level of exercise and the smallest worthwhile effect of NSAIDs for acute LBP. There were no other clear associations.

CONCLUSIONS

For people with LBP, the smallest worthwhile effect of exercise and NSAIDs additional to no intervention is approximately a 20 to 30% reduction in pain. These results can inform the interpretation of the effects of NSAIDs and exercise in randomised trials and meta-analyses, incorporating consumers' perspectives. Further research on comparisons between different interventions and on other core LBP outcomes may inform decision-making.

REGISTRATION

OSF osf.io/3erjx/.

The minimal important change for measures of balance and postural control in older adults: a systematic review

The minimal important change and analogous terms (MIC) can provide a measure of change in health outcome variables that is associated with a level of importance for participant/patient. This review explores the availability of the MIC for different balance measures used with older adults in research and clinical settings. PubMed, ProQuest and Web of Science search engines were used and based on the inclusion and exclusion criteria, 11 studies were deemed suitable for data extraction and analysis. The results demonstrated that MIC is available for the following balance-associated tests: Berg Balance Scale, Timed Up and Go, Short Physical Performance Battery, BESTest and the Tinetti test. A range of MIC values were shown, reflective of different older adult health conditions, calculation methods and anchors used. It was also evident that the responsiveness of the test was not always available or appropriately determined, questioning the validity of the MIC value published. Greater research is needed to establish MIC for balance measurements for use with older adults with different health conditions, preferably using objective measures such as falls. The calculation of such statistics will improve the evaluation of intervention effectiveness.

The smallest worthwhile effect is superior to the MCID for estimating acceptable benefits of knee arthroplasty

BACKGROUND AND OBJECTIVES

Traditionally, the minimal clinically important difference (MCID) is used to judge the meaningfulness of outcomes in total knee arthroplasty (TKA). However, MCID estimates do not consider patient costs, potential side effects, and inconveniences. MCIDs vary substantially across TKA studies and have several conceptual and psychometric problems. A more scientifically sound alternative for estimating benefits patients expect TKA is the smallest worthwhile effect (SWE), measured with the benefit-harm trade-off method.

METHODS

We recruited 121 participants and followed them for 6 months after surgery. All participants completed Knee Injury and Osteoarthritis Score (KOOS) Pain and Function, and underwent an interview using the benefit-harm trade-off method.

RESULTS

The absolute SWE at the 50th percentile (approximating the average patient) was 31 points KOOS Pain improvement and 28 points for KOOS Function, daily living. Construct validity was supported with strong associations between meeting SWE (yes or no) and satisfaction with 6-month outcome (yes or no) using Pearson Chi Square (24.5, P < 0.001).

CONCLUSION

Current MCID-based methods for interpreting KOOS change scores have flaws while the SWE method is conceptually superior. We determined the SWE of TKA that would justify the costs, risks, and inconveniences of surgery. SWE estimates suggest that patients expect a substantially greater change in KOOS scores than would be expected using MCID estimates. Clinicians can use SWE estimates when discussing likely outcomes and potential TKA benefits and risks with their patients.

Effects of water-based Liuzijue exercise on peak exercise capacity, functional exercise capacity, and quality of life in people with COPD

OBJECTIVES

This study was conducted to investigate the effect of water-based Liuzijue exercise on peak exercise capacity, functional exercise capacity, and quality of life in people with COPD.

METHODS

The study included 50 participants randomly divided into three groups: a control group (CG = 17), a land-based Liuzijue exercise group (LG = 17), and a water-based Liuzijue exercise group (WG = 16). The LG and WG performed Liuzijue exercise in different environments, and the CG had no exercise intervention. All participants received prescribed medical treatment. Liuzijue exercise was performed according to the description of Health Qigong Liuzijue compiled by Chinese Health Qigong Association for 60 minutes, two times per week, for 12 weeks.

RESULTS

After intervention, peak oxygen uptake and peak working rate were significantly improved in WG (P = .02). The results of the 6 minutes walking test (6MWT) and 30 seconds sit-to-stand test were significantly improved in both WG and LG (P < .05), and significant difference was found between WG and CG in 6MWT (P = .03). The St. George's Respiratory Questionnaire (SGRQ) activity score increased significantly in the CG (P = .03), while all domains of SGRQ significantly decreased in both training groups (P < .01). All SGRQ scores showed a significant difference between LG and CG (P < .05) and, except for the activity score, between WG and CG (P < .05).

CONCLUSIONS

Water-based Liuzijue exercise can effectively improve peak exercise capacity, functional exercise capacity, and quality of life in people with COPD, especially with respect to increasing peak VO₂ and 6MWD.