Translating evidence to clinical practice: how long is too long?

By Rebecca Blyth

A ground-breaking study in 2002 suggested that arthroscopic debridement or lavage of the knee joint was no better than placebo surgery[1], yet this is a still a surgical option today.  It’s confirmed that the benefits from arthroscopic knee surgery in degenerative knee disease are absent at one to two years follow-up and the surgery has risks[2]. Surgical decompression for subacromial pain faces similar scrutiny. A well-designed study showed that there was no clinically significant improvement in those with subacromial impingement symptoms with arthroscopic decompression when compared to no treatment[3]. As a clinician it can be extremely frustrating to have patients who are unhappy with their post-op outcomes after being under the impression that surgery will ‘fix’ their issue and pain. We as clinicians know that pain is complex and that fixing or removing a structure may have little to no influence on the phenomenon of pain. Now, I’m not here to suggest that there is no place for arthroscopic surgery (having had an arthroscopic ACL reconstruction myself and a positive outcome), but, are we using it far more than the evidence suggests we should and in cases were evidence suggests we should not?

Beliefs are shifting

I have raised two surgical examples but there are many other treatment techniques still being used in sports medicine despite evidence suggesting limited or no effect.  This raises the question, how long is too long before we start implementing evidence into our practice? It comes down to health professionals and patients trusting the evidence more than they trust their own opinions and previous experiences. Cognitive dissonance comes into play as ‘new’ evidence contradicts practitioners’ beliefs.  An orthopaedic surgeon who has performed knee arthroscopies for degenerative menisci for the past 20 years may find it hard to balance this experience with the current evidence suggesting no benefit.  There is certainly a shift within sports medicine and I do believe that practitioners are on board with these findings and starting to re-think their practices.  A recent blog by a sports doctor discussed why surgery was not the best option for his patients medial meniscus tear, despite her being told following MRI that an arthroscopy would be the best treatment[4]. This is an excellent example of translating evidence into clinical practice, however, we as a sports medicine profession are still offering treatment techniques that are potentially no better than a conservative management plan.  Are we not educating our patients well enough about the available options and how these weigh up to one another?  Or are our patients not willing to be educated about this and are after the so called ‘quick fix’ that an arthroscopy will offer?  In my opinion it is a combination of the two, humans have an innate desire for the quickest and easiest option available and clinicians are influenced by this and giving patients what they want.  How do we change this attitude to achieve the best long-term outcomes?

Driving change: stop using non-evidence-based treatments!

It’s no surprise to anyone that it is difficult to create an attitude and culture change.  As clinicians we advise the pros and cons of treatments to patients, but if the patient has a preconceived idea of what treatment they need, this information is not processed.  I don’t believe we should be waiting until the day funding bodies and insurers pull funding for arthroscopic surgeries for degenerative knees and certain subacromial conditions.  I believe that we as sports medicine practitioners have already synthesised and understand the growing evidence base.  Using this knowledge, we should be able to drive the change and reduce the use of non-evidence-based treatments.  I still don’t know the answer to my question on how long is too long, but 16 years after the first ground-breaking study in 2002 does seem too long to me.

Rebecca Blyth, Physiotherapist.  Currently working towards Masters of Sports Physiotherapy at the University of Otago, New Zealand.  Special interest sports medicine, particularly football, working in private practice in Auckland, New Zealand. Email: rebeccablyth8@gmail.com

Competing interests

None declared

References

  1. Moseley, J. B., O’Malley, K., Petersen, N. J., Menke, T. J., Brody, B. A., Kuykendall, D. H., Wray, N. P. (2002). A controlled trial of arthroscopic surgery for osteoarthritis of the knee. The New England Journal of Medicine, 347(2), 81-88. doi:10.1056/NEJMoa013259
  2. Thorlund, J. B., Juhl, C. B., Roos, E. M., & Lohmander, L. (2015). Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. British Journal of Sports Medicine, 49(19), 1229. doi:10.1136/bjsports-2015-h2747rep
  3. Beard, D. J., Rees, J. L., Cook, J. A., Rombach, I., Cooper, C., Merritt, N., . . . Carr, A. J. (2018). Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet, 391(10118), 329-338. doi:10.1016/S0140-6736(17)32457-1
  4. Fulcher, M. L. (2018). Surgery for my medial meniscus tear? Retrieved from https://www.axissportsmedicine.co.nz/blog/archive/surgery-for-my-medial-meniscal-tear/.Retrieved on 15 September 2018.

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