Lecture 1C
08.30-10.30 |
Do RCT’S Provide the Answer? The Current State of Play for Musculoskeletal Conditions and what is on the Horizon?
Common musculoskeletal problems such as low back pain, neck, knee and shoulder pain are leading causes of disability and activity limitation. Their primary prevention has proven difficult and thus intervention approaches focus on minimising symptoms of pain and disability. The randomised controlled trial (RCT) is the most appropriate tool to obtain unbiased estimates of the effects of interventions. Key features of high quality RCTs include recruitment of a sample representative of the patient group, randomisation of individuals, an appropriate control or comparison treatment, concealment of the intervention from both patients and practitioners, and an intention-to-treat analysis. There is a clear trend towards high quality RCTs showing only small to moderate benefits from non-pharmacological interventions for patients with musculoskeletal problems and either no differences or very small differences between the effectiveness of different approaches. In the field of low back alone, trials show only small differences in improvements of disability, of questionable clinical significance, between various treatment approaches.
These findings are strongly at odds with the experiences of practitioners who see individual patients improve, often dramatically, leading practitioners to believe in the effectiveness of specific interventions. Possible explanations for this include the natural history of common musculoskeletal problems, the heterogeneity of patients within trials making it difficult to capture true treatment effects and/or inadequate identification of important patient subgroups leading to insufficient targeting or individualisation of treatments. There may be overestimation of the specific effects of interventions on individual patients and underestimation of the contribution of the non-specific effects of the interventions. In addition, despite many trials now using a core set of recommended outcome measures, they may still fail to capture what is really important to patients. Drawing on available literature and consensus from a national Clinical Trials Thinktank, this presentation will address:
• What can be learned from previous randomised clinical trials?
• What recommendations can be made to improve future trials of interventions for musculoskeletal pain?
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