Thread by @MarinusWinters

*NEW* *LIVING* STUDY:

WHICH TREATMENT IS MOST EFFECTIVE FOR ACHILLES TENDINOPATHY?

@BJSM_BMJ

bjsm.bmj.com/content/early/…

Thread*
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Prepared for the Dutch multidisciplinary guideline on Achilles tendinopathy, supported by @sportmedisch & @de_specialisten

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In this thread, we will explain why & how we have done this study, and what makes this study so different to previous SRs on AT

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Achilles tendinopathy is very common in the general population & sports communities. Two types of tendinopathy can be differentiated:

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Achilles tendinopathy severely impacts on daily life and sports participation.

journals.plos.org/plosone/articl…

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There are many ways to treat this condition.

As a patient you may wonder “do I need exercise, shockwave, an insole, an injection or maybe surgery for my painful Achilles?”

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Clinicians trying to answer this question will need to review >100 systematic reviews on separate comparisons, e.g.

bjsm.bmj.com/content/52/24/…
bjsm.bmj.com/content/53/17/…

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This is a huge challenge, and probably leaves us with the questions “but which of all those treatments investigated is most effective?”

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Network meta-analysis can overcome this challenge by testing the comparative effectiveness of all available treatments in one single model

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What is a network meta-analysis?
An introduction: ncbi.nlm.nih.gov/pmc/articles/P…

#NMA #HealthTechnologyAssessment

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To reduce research resources, avoiding waste of research and efforts, we plan updating this document in the years to come #living #NoMoreReviews?

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Ok – are you still here?

Codeword is *SEMRules* 😇

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What did we do? We used a comprehensive conventional and grey literature search, and we searched trial registers.

Why? --> bjsm.bmj.com/content/51/6/4…
Our full protocol: repub.eur.nl/pub/116534/

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We appraised the risk of bias using ROB 2.
Please see why and how to do this here:

bjsm.bmj.com/content/early/…

bjsm.bmj.com/content/early/…

ROB 2 Tool here: bmj.com/content/366/bm…

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We used a Bayesian network meta-analysis to compare available treatments, and categorized these treatments (e.g. exercise category)

We used treatment and treatment category (a.k.a. class) models to compare treatments

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We included 29 trials investigating 42 treatments; 76% of trial outcomes were at high risk of bias

(please don't shoot the messengers)

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Any treatment appears superior to wait-and-see for midportion Achilles tendinopathy at 3 months.

#DontWaitAndSee! #DisclaimerLowCertainty

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At 12 months, exercise, exercise + injection, exercise + night splints all seem comparable to one another.

#DisclaimerLowCertainty

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No NMA for insertional Achilles tendinopathy could be performed #NoEvidence

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Calf exercises seem the most logical treatment; they’re cheap & have no serious negative effects.

(you may want to instruct & check how they do it 😂)

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Additional treatments do not show superior effect to exercise alone

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Does the type of calf exercise matter?

It appears not to matter whether eccentric ex. or heavy slow resistance exercises are prescribed

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What else? The quality of studies in the field of Achilles tendinopathy should be improved!

8 RECOMMENDATIONS for research practice:

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RECOMMENDATION 1:

Upgrade reporting: follow reporting guidelines, i.e. CONSORT statement consort-statement.org

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RECOMMENDATION 2:

Study the ROB 2 tool PRIOR TO STARTING AN RCT.
bmj.com/content/366/bm…

Teach yourself how to prevent systematic errors in your research.

#WorkWithAnEpidemiologist!

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RECOMMENDATION 3:

Register your study previous to starting your RCT! E.g. on clinicaltrials.gov

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RECOMMENDATION 4:

Do not do an RCT for the sake of doing an RCT – if you start an RCT – make it big! We already have small studies.

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RECOMMENDATION 5:

Adequately describe the study population and specifically how the diagnosis of Achilles tendinopathy was established.

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bjsm.bmj.com/content/54/11/…

RECOMMENDATION 6:

Trials should use exercise as a standalone comparator

#ConnectWithTheNetwork

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RECOMMENDATION 7:

INCLUDE VALIDATED OUTCOME MEARURES FROM THE CORE DOMAINS FOR TENDINOPATHY

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bjsm.bmj.com/content/54/8/4…

RECOMMENDATION 8:

Follow outcomes for at least 12 months

#LongstandingCondition #achilles #tendinopathy

END