details of the case you used a systematic review of randomised controlled trials to answer your clinical question.

52 year-old- woman at menupose attended the clinc for the regular check up and vaccination.

She also asked to renew her prescription for her regular meds and one of them was the HRT ‘estrogen’ , she asked to change the form from the oral pills to the patches that she used to use before as the pills were not much helpful in terms of treating the hot flashes especially at night

She mentiond that the HRT “estrogen “ patches were better that she rarely had any symptoms with them . So I wondered are the HRT patches more effective than the oral pills when used to treat menopause symptoums in women ?

To answer you have to refer to the answered example to see how to answer fill the template with the answer and the referanses

the research question is ( Are the HRT patches more effective than the oral pills when used to treat menupose symptoums in women ?)

please find the attached template and see the format on the sample answer

provide the answer in the format

no copying or plagirism as everything withh be detected in the university softwate

Copying and pasting is also considered plagiarism and will result in zero marks.
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
Search terms used and results found
Articles/
Summaries
entries
UpToDate
‘Osteoarthritis’ -> ‘Non-pharmacologic therapy of
5 refs
osteoarthritis’ -> ‘Exercise’
Mostly related to OA knee, little mention of hip
OA specifically.
• ‘Aquatic exercises are of particular benefit
1
DynaMed
Source
Cochrane Library
for those with severe arthritis and/or
marked deconditioning’
• Specifically designed Tai Chi exercise can
reduce pain in OA
‘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’
‘Hip AND arthritis’
‘Exercise for osteoarthritis of the hip’, 2014
Conclusion: More research needed..
PubMed
Osteoarthritis AND hip AND exercise
Clinical Queries filter: systematic reviews
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’
1
117 results
Third on list
is the
reference
chosen
below
731
94
(Article
chosen is
number 3)
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
2
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.
3
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..)
4
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.
Results:
The primary evidence included in the review showed significant between-study
heterogeneity, and had small patient numbers, both of which reduce the validity of
the findings.
Applicability:
The results are applicable to my patient, but as the exercise details were not
standardised, it is difficult to tell whether these options are available to my patient.
Ideally, the forms of exercise studied would be suitable for home rather than
hospital implementation, as this would reduce the cost of delivering the exercise
programme.
Summary:
I think that I would advise my patient to as I could inform him that there is some
evidence of benefit to both pain scores and physical function.
I would keep an eye out for further updates of this systematic review, addressing
this common and useful topic.
5
Please familiarise yourself with the Irish Medical Council ‘Guidelines for medical
schools on ethical standards and behaviour appropriate for medical students’,
including:
‘Adhere to the rules and regulations, policies and procedures governing plagiarism
and falsification of data in any academic and clinical activities’.
Copying and pasting is also considered plagiarism and will result in zero marks.
Case
Give brief ANONYMISED details of the case you saw in practice which involved a clinical
dilemma for which you used a systematic review of randomised controlled trials to answer your
clinical question.
PICO
Formulate a PICO for your case, and clarify your clinical question
P
Population
I
Intervention
C
Comparison
O
Outcome
CCQ
Clinical Question
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
DynaMed
Source
Cochrane Library
PubMed
Guidelines
(derived from Dynamed,
UpToDate, Library EBM
webpage)
From these searches, choose a systematic review of randomized controlled trials appropriate to
your clinical question to critically appraise.
Title
Lead Author
Journal
PDF of paper
Critical Appraisal: Validity
Are the results of the study valid?
Did the review address a sensible clinical question?
Were the methods clearly stated? Briefly explain
Was the search for relevant studies detailed and exhaustive? Please explain.
Were the primary studies (i.e. the studies found by the reviewers) of high methodologic quality?
Was biased selection and reporting of the primary studies unlikely?
Were selection and assessments of studies reproducible?
Results
What are the overall results of this study?
Were the results similar from study to study?
How precise were the results? Were confidence intervals provided? If so, what are they? Please
comment on their precision.
Applicability
How can I apply the results to care of MY patient?
Were all patient-important outcomes considered?
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.
Are the benefits worth the costs and potential risks?
Conclusions
What are MY conclusions regarding this article?
Validity
Results
Applicability
Summary
Copying and pasting is also considered plagiarism and will result in zero marks.
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
Search terms used and results found
Articles/
Summaries
entries
UpToDate
‘Osteoarthritis’ -> ‘Non-pharmacologic therapy of
5 refs
osteoarthritis’ -> ‘Exercise’
Mostly related to OA knee, little mention of hip
OA specifically.
• ‘Aquatic exercises are of particular benefit
1
DynaMed
Source
Cochrane Library
for those with severe arthritis and/or
marked deconditioning’
• Specifically designed Tai Chi exercise can
reduce pain in OA
‘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’
‘Hip AND arthritis’
‘Exercise for osteoarthritis of the hip’, 2014
Conclusion: More research needed..
PubMed
Osteoarthritis AND hip AND exercise
Clinical Queries filter: systematic reviews
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’
1
117 results
Third on list
is the
reference
chosen
below
731
94
(Article
chosen is
number 3)
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
2
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.
3
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..)
4
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.
Results:
The primary evidence included in the review showed significant between-study
heterogeneity, and had small patient numbers, both of which reduce the validity of
the findings.
Applicability:
The results are applicable to my patient, but as the exercise details were not
standardised, it is difficult to tell whether these options are available to my patient.
Ideally, the forms of exercise studied would be suitable for home rather than
hospital implementation, as this would reduce the cost of delivering the exercise
programme.
Summary:
I think that I would advise my patient to as I could inform him that there is some
evidence of benefit to both pain scores and physical function.
I would keep an eye out for further updates of this systematic review, addressing
this common and useful topic.
5
‘Adhere to the rules and regulations, policies and procedures governing plagiarism
and falsification of data in any academic and clinical activities’.
Copying and pasting is also considered plagiarism and will result in zero marks.
Case
Give brief ANONYMISED details of the case you saw in practice which involved a clinical
dilemma for which you used a systematic review of randomised controlled trials to answer your
clinical question.
PICO
Formulate a PICO for your case, and clarify your clinical question
P
Population
I
Intervention
C
Comparison
O
Outcome
CCQ
Clinical Question
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
DynaMed
Source
Cochrane Library
PubMed
Guidelines
(derived from Dynamed,
UpToDate, Library EBM
webpage)
From these searches, choose a systematic review of randomized controlled trials appropriate to
your clinical question to critically appraise.
Title
Lead Author
Journal
PDF of paper
Critical Appraisal: Validity
Are the results of the study valid?
Did the review address a sensible clinical question?
Were the methods clearly stated? Briefly explain
Was the search for relevant studies detailed and exhaustive? Please explain.
Were the primary studies (i.e. the studies found by the reviewers) of high methodologic quality?
Was biased selection and reporting of the primary studies unlikely?
Were selection and assessments of studies reproducible?
Results
What are the overall results of this study?
Were the results similar from study to study?
How precise were the results? Were confidence intervals provided? If so, what are they? Please
comment on their precision.
Applicability
How can I apply the results to care of MY patient?
Were all patient-important outcomes considered?
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.
Are the benefits worth the costs and potential risks?
Conclusions
What are MY conclusions regarding this article?
Validity
Results
Applicability
Summary
Copying and pasting is also considered plagiarism and will result in zero marks.
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
Search terms used and results found
Articles/
Summaries
entries
UpToDate
‘Osteoarthritis’ -> ‘Non-pharmacologic therapy of
5 refs
osteoarthritis’ -> ‘Exercise’
Mostly related to OA knee, little mention of hip
OA specifically.
• ‘Aquatic exercises are of particular benefit
1
DynaMed
Source
Cochrane Library
for those with severe arthritis and/or
marked deconditioning’
• Specifically designed Tai Chi exercise can
reduce pain in OA
‘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’
‘Hip AND arthritis’
‘Exercise for osteoarthritis of the hip’, 2014
Conclusion: More research needed..
PubMed
Osteoarthritis AND hip AND exercise
Clinical Queries filter: systematic reviews
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’
1
117 results
Third on list
is the
reference
chosen
below
731
94
(Article
chosen is
number 3)
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
2
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.
3
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..)
4
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.
Results:
The primary evidence included in the review showed significant between-study
heterogeneity, and had small patient numbers, both of which reduce the validity of
the findings.
Applicability:
The results are applicable to my patient, but as the exercise details were not
standardised, it is difficult to tell whether these options are available to my patient.
Ideally, the forms of exercise studied would be suitable for home rather than
hospital implementation, as this would reduce the cost of delivering the exercise
programme.
Summary:
I think that I would advise my patient to as I could inform him that there is some
evidence of benefit to both pain scores and physical function.
I would keep an eye out for further updates of this systematic review, addressing
this common and useful topic.
5
Copying and pasting is also considered plagiarism and will result in zero marks.
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
Search terms used and results found
Articles/
Summaries
entries
UpToDate
‘Osteoarthritis’ -> ‘Non-pharmacologic therapy of
5 refs
osteoarthritis’ -> ‘Exercise’
Mostly related to OA knee, little mention of hip
OA specifically.
• ‘Aquatic exercises are of particular benefit
1
DynaMed
Source
Cochrane Library
for those with severe arthritis and/or
marked deconditioning’
• Specifically designed Tai Chi exercise can
reduce pain in OA
‘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’
‘Hip AND arthritis’
‘Exercise for osteoarthritis of the hip’, 2014
Conclusion: More research needed..
PubMed
Osteoarthritis AND hip AND exercise
Clinical Queries filter: systematic reviews
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’
1
117 results
Third on list
is the
reference
chosen
below
731
94
(Article
chosen is
number 3)
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
2
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.
3
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..)
4
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.
Results:
The primary evidence included in the review showed significant between-study
heterogeneity, and had small patient numbers, both of which reduce the validity of
the findings.
Applicability:
The results are applicable to my patient, but as the exercise details were not
standardised, it is difficult to tell whether these options are available to my patient.
Ideally, the forms of exercise studied would be suitable for home rather than
hospital implementation, as this would reduce the cost of delivering the exercise
programme.
Summary:
I think that I would advise my patient to as I could inform him that there is some
evidence of benefit to both pain scores and physical function.
I would keep an eye out for further updates of this systematic review, addressing
this common and useful topic.
5
‘Adhere to the rules and regulations, policies and procedures governing plagiarism
and falsification of data in any academic and clinical activities’.
Copying and pasting is also considered plagiarism and will result in zero marks.
Case
Give brief ANONYMISED details of the case you saw in practice which involved a clinical
dilemma for which you used a systematic review of randomised controlled trials to answer your
clinical question.
PICO
Formulate a PICO for your case, and clarify your clinical question
P
Population
I
Intervention
C
Comparison
O
Outcome
CCQ
Clinical Question
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
DynaMed
Source
Cochrane Library
PubMed
Guidelines
(derived from Dynamed,
UpToDate, Library EBM
webpage)
From these searches, choose a systematic review of randomized controlled trials appropriate to
your clinical question to critically appraise.
Title
Lead Author
Journal
PDF of paper
Critical Appraisal: Validity
Are the results of the study valid?
Did the review address a sensible clinical question?
Were the methods clearly stated? Briefly explain
Was the search for relevant studies detailed and exhaustive? Please explain.
Were the primary studies (i.e. the studies found by the reviewers) of high methodologic quality?
Was biased selection and reporting of the primary studies unlikely?
Were selection and assessments of studies reproducible?
Results
What are the overall results of this study?
Were the results similar from study to study?
How precise were the results? Were confidence intervals provided? If so, what are they? Please
comment on their precision.
Applicability
How can I apply the results to care of MY patient?
Were all patient-important outcomes considered?
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.
Are the benefits worth the costs and potential risks?
Conclusions
What are MY conclusions regarding this article?
Validity
Results
Applicability
Summary