Thread by @MarinusWinters

*NEW*🔓*LIVING* STUDY:

COMPARATIVE EFFECTIVENESS OF TREATMENTS FOR PATELLOFEMORAL PAIN: A LIVING SYSTEMATIC REVIEW WITH NETWORK META-ANALYSIS

@BJSM_BMJ

bjsm.bmj.com/content/early/…

Thread*

Please RT
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PFP is a persistent condition; up to 40% of patients continue to have pain 2 years after starting treatment

journals.sagepub.com/doi/abs/10.117…

bjsm.bmj.com/content/50/14/…

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PFP impacts on daily living, sporting activities and makes it hard for people to stay active

e.g.
bmjopen.bmj.com/content/bmjope…

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Patients wonder how to manage their #PFP most effectively; “should I do exercises, use orthotics, taping or should I just wait and rest as my GP suggests?”

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Clinicians try to answer this question but will need to review +/- 100 systematic reviews (!) on separate comparisons in pubmed such as:

pubmed.ncbi.nlm.nih.gov/29392329/

pubmed.ncbi.nlm.nih.gov/26175019/

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

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Check out this thread on a living network meta-analysis of treatments for Achilles tendinopathy to find out why network meta-analysis can overcome this challenge.

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https://twitter.com/MarinusWinters/status/1270946274599206912?s=20

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

Our full protocol: bmjopen.bmj.com/content/8/11/e…

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We included RCTs that assessed patient-reported outcomes after at least 6 weeks, i.e.
- global rating of change scales,
- worst pain in the previous week, and
- patient-rated pain during specific activities (ADL/Sports).

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We appraised the risk of bias using ROB 2  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. different exercise types combined to make an overarching ‘exercise category’

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We included 22 trials investigating 21 different treatments; 75% of these included exercise.

79% of trial outcomes were at high risk of bias.⬇️⬇️

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For global perceived effect: any treatment investigated appears superior to wait-and-see at 3 months

#DONTWAITANDSEE! #DISCLAIMERLowQualityEvidence
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Education plus exercise plus patellar taping/mobilisations, with or without orthosis, were superior to education alone at 3 months

Neither exercise (prescribed on its own) nor orthosis + education were superior to education alone at 3 months

#DISCLAIMERLowQualityEvidence

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No specific type of exercise was superior to another type of exercise at 3 months

#DISCLAIMERLowQualityEvidence

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At 12 months, no differences were found between education, education + exercise + patellar taping/mobilisations, education + orthosis or education + exercise + patellar taping/mobilisations + orthosis

#DISCLAIMERLowQualityEvidence

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None of the trials investigated the outcomes of wait-and-see (or natural history) at 12months

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For worst pain, none of the treatments investigated were superior to any other treatment or to wait-and-see at 3 months

#DISCLAIMERLowQualityEvidence

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At 12 months, education plus exercise + patellar taping/mobilisations appears superior to education alone.

#DISCLAIMERLowQualityEvidence

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Education + exercise + patellar taping/mobilisations + orthosis appears better than education alone but was not found to be superior to education + exercise + patellar taping/mobilisations

#DISCLAIMERLowQualityEvidence

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For pain while descending stairs, hip, knee and trunk exercises combined were superior to hip and knee exercises alone and to a program including ‘minimal’ hip/knee exercises at 3 months.

#DISCLAIMERLowQualityEvidence

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No difference was found between minimal hip/knee exercises and usual hip/knee exercises

#DISCLAIMERLowQualityEvidence

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At 12 months hip, knee and trunk exercises combined were superior to a combination of hip/knee exercises and arthroscopy, and also superior to hip/knee exercises alone.

#DISCLAIMERLowQualityEvidence

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No difference was found between hip/knee exercises plus arthroscopy or hip/knee exercises alone.

#DISCLAIMERLowQualityEvidence

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IN SUMMARY ⬇️⬇️

#DISCLAIMERLowQualityEvidence

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We plan to update this document in the years to come to keep you up to date with the latest evidence on treatments for patellofemoral pain, please see:

almenmedicin.aau.dk/forskning/fors…

[Soon online!! Keep an eye out!]

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RECOMMENDATIONS FOR RESEARCH:

We need larger trials, preferably >100 subjects per study arm

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RCTs should include patient reported outcomes (measures) and include at least a 12-month follow-up.

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A core outcome set for trials on patellofemoral pain is needed to aid evidence-synthesis in the future.

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As a minimum, trials should include the global rating of change scale, and worst pain in the past week to connect to the networks

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Use a comparator treatment arm that connects to the existing network, e.g. education or education + exercise + patellar taping/mobilisations

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Trials comparing their treatment to a true wait-and-see arm (natural history) in the long term are desirable.

Treatments seem superior to careful waiting in the short term – but are they superior to doing nothing in the long term?

32/END