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Clinical lead, Dr David Hamilton
Evidence for interventions – one size fits all?

Evidence based practice is central to good patient care. A sentiment that’s easy to agree with but harder to put into practice; mainly through limitations in said evidence.  This is a huge challenge across medicine, but orthopaedics should be recognised for daring to ask some fundamental questions around the efficacy of its interventions. This has been possible through large volume datasets and an ever growing enthusiasm for randomised trials. We have seen, for example, challenges to the use of arthroscopy for treating osteoarthritis of the knee1 and to surgical management for treating closed, displaced, intra-articular fractures of the calcaneus.2 Of course the author’s conclusions are challengeable, and there will be situations where these operations are beneficial, but these papers are good examples of research that may change general clinical practice. Debate has been sparked, and we move forwards as a result.

The associated musculoskeletal specialties must follow this lead. Physiotherapy, to take another example, is typically offered for conditions such as osteoarthritis of the hip. Although the evidence is limited it’s surely worth a try? Interestingly, a recent study suggests perhaps not. Bennell et al3 report a well conducted study; a placebo controlled, double-blind, randomised trial of patients with modest to severe hip osteoarthritis. Twelve weeks of exercises and manual therapy was found to be no more effective than a sham ultrasound treatment. No differences were found in outcome parameters, and the therapy arm reported frequent (though mild) adverse effects. These results clearly question the benefit of physiotherapy in this population. Interestingly though, both groups did get better. The therapy intervention reduced the patient’s pain and enhanced their function – but only as much as the pretend intervention. Evidence then, for visiting a therapist but not for the efficacy of the treatment.

This poses an interesting problem. If the evidence suggests failure of a treatment to outperform a placebo in blinded randomised trials then we are in the realms of homeopathy and should really think twice before recommending it to patients. On the other hand, the patients did get better by seeing the physiotherapist, and that may well be of value in the overall management of a long-term condition. This study in isolation shouldn’t change practice, but it should spark debate. Perhaps physiotherapy is more beneficial in the earlier stages of degenerative joint disease, and finite resources should be focused here?

We need to be open to the idea that some currently employed interventions are not helpful to all patients at all times, but should be targeted to cases where there is evidence for efficacy.  As ever, more high quality trials and data are needed to tease out such situations, but our evidence base is now growing at a rate that we can realistically aim to achieve this.

Dr David Hamilton, Research Fellow, Department of Orthopaedics,  University of Edinburgh, UK
August 2014

References

1. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2008;359:1097-1107.
2. Griffin D, Parsons N, Shaw E, et al. Operative versus non-operative treatment for closed, displaced, intra-articular fractures of the calcaneus: randomised controlled trial. BMJ 2014;349:g4483.
3. Bennell K, Egerton T, Martin J, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis; a randomized clinical trial. JAMA 2014;311:1987-1997. 


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