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Systematic reviews cannot inform clinical practice. An example using a critical appraisal of a systematic review of shockwave therapy
Manual Therapy 25 (2016) e57ee169
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Abstracts from IFOMPT 2016 conference, 4-8 July 2016, Glasgow, UK Poster Papers Advanced assessment/practice and managing complex patients PO1-AP-005 SYSTEMATIC REVIEWS CANNOT INFORM CLINICAL PRACTICE. AN EXAMPLE USING A CRITICAL APPRAISAL OF A SYSTEMATIC REVIEW OF SHOCKWAVE THERAPY
Advanced assessment/practice and managing complex patients PO1-CS-011 THE EFFECT OF ISOMETRIC INTERNAL AND EXTERNAL ROTATION ON THE ACROMIOHUMERAL DISTANCE IN SUBJECTS WITH SUBACROMIAL PAIN SYNDROME
V. Korakakis 1,2, *, R. Whiteley 1, A. Tzavara 2. 1 Orthopaedic and sports medicine hospital, Aspetar, Doha, Qatar; 2 HOMTD, Hellenic Orthopaedic Manipulative Therapy Diploma, Athens, Greece
D. Tailor*, S. Deleany, M. Field, A. Kuncewicz, D. Critchley. Division of Health and Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
* Corresponding author.
Background: Physiotherapists have been recommended to use systematic reviews as a guide for evidence based clinical practice. There is growing evidence for the effectiveness of shock wave therapy and increasing popularity in use as a therapeutic intervention. Purpose: The aim of the present critical appraisal was to evaluate methodology, external validity, and bias of a systematic review assessing the effectiveness of shock wave therapy in common lower limb pathologies including: Achilles tendinopathy, patellar tendinopathy, proximal hamstring tendinopathy, medial tibial stress syndrome, and greater trochanteric pain syndrome. Methods: From a critical viewpoint two assessors evaluated: the quality assessment tools used for randomised and non-controlled trials, the inclusion criteria used in studies defining the included condition, the validity of clinical tests used, biases (funding, publication, reporting), and clinical applicability of protocols used and reported. Results: Several important shortcomings were identified in terms of: quality assessment, sub-grouping of patients, publication bias, external validity, level of evidence, applicability of results in clinical practice and minimal reporting. Conclusion: The systematic review was unable to generalize findings to the clinical population due to insufficient homogeneity of sub-groups analysed. This was seen to be largely due to a lack of valid clinical tests capable of sub-grouping. Currently methods for the assessment of the quality of trials do not adequately document clinical homogeneity, validity and reliability of the clinical tests employed, or account for inappropriate clustering of different treatment modalities, and publication bias. Each of these shortcomings severely limit the generalizability of the findings of systematic reviews, and considered together render them bordering on clinically useless. Implications: Clinicians should interpret with caution the results provided by systematic reviews, at least for the example of shock wave therapy in lower limb pathologies. We posit that these findings may generalize to other conditions and interventions commonly encountered clinically. Funding Acknowledgements: None Ethics Approval: Not applicable Disclosure of Interest: None Declared Keywords: Critical appraisal, Extracorporeal shock wave therapy, Systematic review
* Corresponding author.
Background: Sub-acromial pain syndrome (SAPS) is one of the commonest disorders of the shoulder. SAPS may result from reduction of the sub-acromial space causing compression of its contents. Resisted external (ER) and internal rotation (IR) exercises are commonly prescribed in the management of SAPS and are suggested to increase the sub-acromial space. Their effect on the sub-acromial space in symptomatic subjects with SAPS is unknown. Purpose: To determine the effect of isometric IR and ER contractions on the acromiohumeral distance (AHD), a measure of the sub-acromial space, in symptomatic subjects with SAPS. Methods: 33 participants with SAPS (6 with bilateral SAPS) were recruited from 3 private musculoskeletal physiotherapy clinics and faculty of King's College London. Ultrasound measures of AHD at rest, and during isometric IR and ER contractions were taken with the shoulder positioned in neutral and 45 degrees abduction, at 50% and 100% of one-repetition maximal voluntary isometric contractions (MVIC). Results: There was no significant difference in AHD between any of the test conditions tested in neutral. Mean (95% CI) AHD: Rest 11.7(11.1-12.47) mm; IR at 100% MVIC 11.4(10.63-12.22)mm, 50% MVIC 11.5(10.76-12.43) mm; ER contractions at 100% MVIC 11.2(10.5-12.02), 50% MVIC 11.3(10.6612.01)mm. There was no significant difference in AHD between any of the test conditions tested in 45 degrees of abduction. Median (95% CI) AHD: Rest 10.5(9.8-12.4)mm; IR at 100% MVIC 12.4(11.1-13.1)mm, 50% MVIC 11.1(10.2-12.8)mm; ER contractions at 100% MVIC 10.8(9.6-11.5)mm, 50% MVIC 10.7(9.8-11.7)mm. Conclusion: AHD does not change during resisted IR and ER contractions compared to rest. Ultrasound measurement of AHD has excellent intrarater reliability. Other mechanisms, such as loading tendons or reducing the threat response of the central nervous system, may explain the demonstrated benefits of IR and ER exercises. Findings were instantaneous, the longer-term effects of exercise programmes on the subacromial space should be evaluated. AHD, a two-dimensional linear measure, may not fully represent change in the three-dimensional sub-acromial space; further research using 3D imaging is suggested. There were large individual variations in findings; investigating sub-classification of SAPS patients may improve understanding of this condition. Implications: The clinical benefits of IR and ER exercises appear to be unrelated to changes in acromiohumeral distance. Funding Acknowledgements: Unfunded Ethics Approval: King’s College London Research Ethics Committee (Ref: BDM/13/14-81)
Contents lists available at ScienceDirect
Manual Therapy journal homepage: www.elsevier.com/math
Abstracts from IFOMPT 2016 conference, 4-8 July 2016, Glasgow, UK Poster Papers Advanced assessment/practice and managing complex patients PO1-AP-005 SYSTEMATIC REVIEWS CANNOT INFORM CLINICAL PRACTICE. AN EXAMPLE USING A CRITICAL APPRAISAL OF A SYSTEMATIC REVIEW OF SHOCKWAVE THERAPY
Advanced assessment/practice and managing complex patients PO1-CS-011 THE EFFECT OF ISOMETRIC INTERNAL AND EXTERNAL ROTATION ON THE ACROMIOHUMERAL DISTANCE IN SUBJECTS WITH SUBACROMIAL PAIN SYNDROME
V. Korakakis 1,2, *, R. Whiteley 1, A. Tzavara 2. 1 Orthopaedic and sports medicine hospital, Aspetar, Doha, Qatar; 2 HOMTD, Hellenic Orthopaedic Manipulative Therapy Diploma, Athens, Greece
D. Tailor*, S. Deleany, M. Field, A. Kuncewicz, D. Critchley. Division of Health and Social Care Research, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
* Corresponding author.
Background: Physiotherapists have been recommended to use systematic reviews as a guide for evidence based clinical practice. There is growing evidence for the effectiveness of shock wave therapy and increasing popularity in use as a therapeutic intervention. Purpose: The aim of the present critical appraisal was to evaluate methodology, external validity, and bias of a systematic review assessing the effectiveness of shock wave therapy in common lower limb pathologies including: Achilles tendinopathy, patellar tendinopathy, proximal hamstring tendinopathy, medial tibial stress syndrome, and greater trochanteric pain syndrome. Methods: From a critical viewpoint two assessors evaluated: the quality assessment tools used for randomised and non-controlled trials, the inclusion criteria used in studies defining the included condition, the validity of clinical tests used, biases (funding, publication, reporting), and clinical applicability of protocols used and reported. Results: Several important shortcomings were identified in terms of: quality assessment, sub-grouping of patients, publication bias, external validity, level of evidence, applicability of results in clinical practice and minimal reporting. Conclusion: The systematic review was unable to generalize findings to the clinical population due to insufficient homogeneity of sub-groups analysed. This was seen to be largely due to a lack of valid clinical tests capable of sub-grouping. Currently methods for the assessment of the quality of trials do not adequately document clinical homogeneity, validity and reliability of the clinical tests employed, or account for inappropriate clustering of different treatment modalities, and publication bias. Each of these shortcomings severely limit the generalizability of the findings of systematic reviews, and considered together render them bordering on clinically useless. Implications: Clinicians should interpret with caution the results provided by systematic reviews, at least for the example of shock wave therapy in lower limb pathologies. We posit that these findings may generalize to other conditions and interventions commonly encountered clinically. Funding Acknowledgements: None Ethics Approval: Not applicable Disclosure of Interest: None Declared Keywords: Critical appraisal, Extracorporeal shock wave therapy, Systematic review
* Corresponding author.
Background: Sub-acromial pain syndrome (SAPS) is one of the commonest disorders of the shoulder. SAPS may result from reduction of the sub-acromial space causing compression of its contents. Resisted external (ER) and internal rotation (IR) exercises are commonly prescribed in the management of SAPS and are suggested to increase the sub-acromial space. Their effect on the sub-acromial space in symptomatic subjects with SAPS is unknown. Purpose: To determine the effect of isometric IR and ER contractions on the acromiohumeral distance (AHD), a measure of the sub-acromial space, in symptomatic subjects with SAPS. Methods: 33 participants with SAPS (6 with bilateral SAPS) were recruited from 3 private musculoskeletal physiotherapy clinics and faculty of King's College London. Ultrasound measures of AHD at rest, and during isometric IR and ER contractions were taken with the shoulder positioned in neutral and 45 degrees abduction, at 50% and 100% of one-repetition maximal voluntary isometric contractions (MVIC). Results: There was no significant difference in AHD between any of the test conditions tested in neutral. Mean (95% CI) AHD: Rest 11.7(11.1-12.47) mm; IR at 100% MVIC 11.4(10.63-12.22)mm, 50% MVIC 11.5(10.76-12.43) mm; ER contractions at 100% MVIC 11.2(10.5-12.02), 50% MVIC 11.3(10.6612.01)mm. There was no significant difference in AHD between any of the test conditions tested in 45 degrees of abduction. Median (95% CI) AHD: Rest 10.5(9.8-12.4)mm; IR at 100% MVIC 12.4(11.1-13.1)mm, 50% MVIC 11.1(10.2-12.8)mm; ER contractions at 100% MVIC 10.8(9.6-11.5)mm, 50% MVIC 10.7(9.8-11.7)mm. Conclusion: AHD does not change during resisted IR and ER contractions compared to rest. Ultrasound measurement of AHD has excellent intrarater reliability. Other mechanisms, such as loading tendons or reducing the threat response of the central nervous system, may explain the demonstrated benefits of IR and ER exercises. Findings were instantaneous, the longer-term effects of exercise programmes on the subacromial space should be evaluated. AHD, a two-dimensional linear measure, may not fully represent change in the three-dimensional sub-acromial space; further research using 3D imaging is suggested. There were large individual variations in findings; investigating sub-classification of SAPS patients may improve understanding of this condition. Implications: The clinical benefits of IR and ER exercises appear to be unrelated to changes in acromiohumeral distance. Funding Acknowledgements: Unfunded Ethics Approval: King’s College London Research Ethics Committee (Ref: BDM/13/14-81)