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Case:
Give brief ANONYMISED details of the case you saw in practice which involved a clinical dilemma for which you used a systematic review to answer your clincial question.
John is a 46 year old man who has been diagnosed with osteoarthritis of the right hip.
He is on a waiting list to be seen by the orthopaedic surgeon and has an appointment in one year. Pain is limiting his activities and John is getting frustrated about the waiting time.
I wondered if exercise is useful in helping to reduce the pain associated with hip osteoarthritis.
He has no other significant medical history and is on simple analgesia.
PICO
Formulate a PICO for your case, and clarify your clinical question
P Population
Middle-aged men with osteoarthritis of the hip
I Intervention
Exercise
C Comparison
No exercise
O Outcome
Reduction in pain score
CCQ
Clinical Question
In middle-aged men with osteoarthritis of the hip who are otherwise well, does exercise reduce pain?
Searching for the Evidence
SOURCES AND SEARCHES
Detail the source and search results which you carried out to find the evidence to answer your clinical question
Source Summaries Search terms used and results found Articles/ entries
UpToDate ‘Osteoarthritis’ -> ‘Non-pharmacologic therapy of osteoarthritis’ -> ‘Exercise’
Mostly related to OA knee, little mention of hip OA specifically.
• ‘Aquatic exercises are of particular benefit for those with severe arthritis and/or marked deconditioning’
• Specifically designed Tai Chi exercise can reduce pain in OA 5 refs
DynaMed ‘Osteoarthritis’ – ‘Degenerative joint disease of the hip’, 2011 - reference conflicting systematic reviews –
‘Exercise may have no long term benefits for knee or hip osteoarthritis’
‘Therapeutic exercise associated with pain reduction in hip osteoarthritis’
‘Land-based exercise may reduce pain but may not reduce function in hip osteoarthritis’
1
Source
Cochrane Library ‘Hip AND arthritis’
‘Exercise for osteoarthritis of the hip’, 2014
Conclusion: More research needed..
117 results
Third on list is the reference chosen below
PubMed Osteoarthritis AND hip AND exercise
Clinical Queries filter: systematic reviews
731
94
(Article chosen is number 3)
Guidelines
(derived from Dynamed, UpToDate, Library EBM webpage) American College of Rheumatology; Orthopaedic Section of the American Physical Therapy Association; Dutch Medical Association, NICE Guidelines ‘The care and management of osteoarthritis in adults’
From these searches, choose a systematic review of randomised controlled trials appropriate to your clinical question to critically appraise.
Title Exercise for osteoarthritis of the hip (Review)
Lead Author M Fransen
Journal The Cochrane Collaboration
Fransen M, McConnell S, Hernandez-Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews 2009, Issue 3.
PDF of paper Link
Critical Appraisal: Validity
Are the results of the study valid?
Did the review address a sensible clinical question?
Yes. This is a practical question which is frequently asked in practice. Many doctors recommend exercise to patients with osteoarthritis, so it is reasonable of the Cochrane Collaboration to carry out this review.
Were the methods clearly stated? Briefly explain
Yes – details regarding methodology of the review were described including the types of studies included, types of participants, types of interventions and outcome measures used. Details of search methods data collection and analysis were also given.
Was the search for relevant searches detailed and exhaustive? Please explain.
Yes. A thorough search was carried out using five databases: Medline; Embase (Ovid); The Cochrane Library; CINAHL; and PEDro (physiotherapy evidence database).
Details are given in the appendices of the study regarding the search strategies, which appear exhaustive.
Were the primary studies (i.e the studies found by the reviewers) of high methodologic quality?
Ten studies met the inclusion criteria.
75% of the study participants who were enrolled in the studies included in this review only had hip osteoarthritis. The previous version of this review had many more participants who had, for instance, hip AND knee OA. Five of the ten studies included recruited patients with ONLY hip OA.
There was significant variability between the amount and type of exercise between studies and between the participants recruited in the study.
Was biased selection and reporting of the primary studies unlikely?
The risk of selection bias was assessed for each study included in the review, using methods recommended by the Cochrane Collaboration, and an overall assessment of risk was then assigned to each study . ‘Most of the RCTs included in this systematic review were considered by our criteria to have a ‘low risk of bias’.
Were selection and assessments of studies reproducible?
The studies were screened independently for inclusion by four reviewers , and if agreement was not reached, consensus was reached between the four.
Results
What are the overall results of this study?
Exercise reduced pain and improved physical function immediately after treatment.
Only three studies looked at the effect of exercise on quality of life in these patients, and the quality of this evidence was low, with no benefit shown.
A couple of patients in five studies experienced increased pain which was reported as an adverse event.
Were the results similar from study to study?
No, there was marked heterogeneity between the studies, meaning that comparison was difficult. This reduces the validity of the systematic review.
How precise were the results? Were confidence intervals provided? If so, what are they? Please comment on their precision.
95% confidence intervals were presented and the results were significant at that level. The review concludes that there is evidence that land-based exercise will reduce hip pain and improve physical function in patients with hip osteoarthritis.
Applicability
How can I apply the results to care of my patient?
Were all patient-important outcomes considered?
The outcomes measured were pain and physical function. Other outcome measures which may be important to patients would include: time to surgical intervention; overall wellbeing scores; effect on mood. However the outcomes considered are probably the most important. The quality of evidence relating to quality of life was disappointing, and one would expect that this may be an important research direction in the future.
What is the overall quality of the evidence? If this is not defined in the study, please comment on whether you think the evidence is convincing/good or not.
The evidence is better than the previous systematic review – the review published by the same authors in 2009 included only 5 primary papers, whereas this one could include 10.
However , given that OA of the hip is a common condition, one would expect that there should be plenty of trials carried out on this group of patients, so it may be that the inclusion criteria are too narrow (or that the exclusion criteria are too broad..)
Are the benefits worth the costs and potential risks?
It seems that the benefits are worth the potential risks – a small number of patients experienced an increase in pain, but there was a statistically significant improvement in pain scores and physical function overall, so I expect that the risk is worth it.
Conclusion
What are MY conclusions regarding this article?
Validity:
For a very common condition, there were only ten studies included in this review. Reasonably small numbers of patients were involved. This does not seem to be sufficient. The exercise programmes varied hugely from study to study, which makes it difficult to propose a standardised exercise programme for patients.