Less Is More

Simpler & Better Medicine

Single Dose of Oral Non-Opioid and Opioid Analgesics for Acute Extremity Pain — November 14, 2017

Single Dose of Oral Non-Opioid and Opioid Analgesics for Acute Extremity Pain

Summary: For adult patients with moderate to severe acute extremity pain, treatment with ibuprofen (400mg) + acetaminophen (1000mg) may provide the same amount of analgesia at 2 hours as treatment with either oxycodone (5mg) + acetaminophen (325mg) or hydrocodone (5 mg) + acetaminophen (300mg); but without the need for use of an opioid medication.

https://www.ncbi.nlm.nih.gov/m/pubmed/29114833/

Strength of Recommendation = B

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Inpatient Rehabilitation vs Monitored Home-Based Rehabilitation after Total Knee Arthroplasty — October 24, 2017

Inpatient Rehabilitation vs Monitored Home-Based Rehabilitation after Total Knee Arthroplasty

Summary: For patients having primary total knee replacement for osteoarthritis of the knee, a clinician-monitored home-based rehabilitation program appears lead to the same performance on a 6-minute walk test at the end of therapy as a program of inpatient rehabilitation followed by home rehabilitation (however, patient satisfaction could be lower with home-based-only rehabilitation)

https://www.ncbi.nlm.nih.gov/m/pubmed/28291891/

Strength of Recommendation = B

Over-the-counter transdermal lidocaine 3.6% menthol 1.25%, Rx lidocaine 5% and placebo for back pain and arthritis. — September 5, 2017
Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation. — July 18, 2017

Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation.

Summary: For adult patients with complete (grade III, IV, and V) dislocations of the acromio-clavicular (AC) joint, non-operative management with a sling for 4 weeks followed by an exercise program may be associated with a lower level of disability at 6 weeks and 3 months as well as a lower likelihood of needing subsequent surgery, compared to an approach of operative repair with hook plate fixation; although the degree of disability at 2-year follow up may be the same for both approaches.

https://www.ncbi.nlm.nih.gov/m/pubmed/26489055/

Strength of Recommendation = B

Intra-articular Triamcinolone vs Saline for Patients With Knee Osteoarthritis — June 13, 2017

Intra-articular Triamcinolone vs Saline for Patients With Knee Osteoarthritis

Summary: For patients with symptomatic knee osteoarthritis, an approach of NOT using intra-articular corticosteroid injections may lead to less loss of knee cartilage, compared to an approach of using regular (every-3-month) intra-articular injections of triamcinolone, without any difference pain or function.

https://www.ncbi.nlm.nih.gov/m/pubmed/28510679/

Strength of Recommendation = B

Endoscopic release for carpal tunnel syndrome — March 14, 2017

Endoscopic release for carpal tunnel syndrome

Summary: For patients needing surgical treatment for carpal tunnel syndrome, endoscopic carpal tunnel release (ECTR) may be associated with a shorter time to return-to-work, improved post-operative grip strength, and fewer minor surgical complications compared to open carpal tunnel release (OCTR).

https://www.ncbi.nlm.nih.gov/m/pubmed/24482073/

Strength of Recommendation = B

Comparison of radiography and point-of-care ultrasonography in the diagnosis and management of metatarsal fractures — January 17, 2017

Comparison of radiography and point-of-care ultrasonography in the diagnosis and management of metatarsal fractures

Summary: For patients witn suspected metatarsal fracture due to a low-impact injury, point-of-care ultrasound (POCUS) may provide more diagnostic information that radiography, with the same sensitivity and specificity for detecting fracture as radiography, while at the same time being potentially available for use in settings without radiography equipment.

https://www.ncbi.nlm.nih.gov/m/pubmed/28069140/

Strength of Recommendation = B

Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting. — December 9, 2016

Thromboprophylaxis after Knee Arthroscopy and Lower-Leg Casting.

Summary: For patients who have arthroscopic knee surgery or casting of the lower leg, an approach of not administering prophylactic-dose low-molecular weight heparin (LMWH) appears to be associated with the same risks of deep-vein thrombosis (DVT) and pulmonary embolism (PE) as an approach of administering LWMH (for 8 days after arthroscopy or for the duration of casting), but without the added patient care burden of daily injections.

https://www.ncbi.nlm.nih.gov/m/pubmed/27959702/

Strength of Recommendation = B

Does bariatric surgery prior to total hip or knee arthroplasty reduce complications and improve outcomes for obese patients? — November 29, 2016

Does bariatric surgery prior to total hip or knee arthroplasty reduce complications and improve outcomes for obese patients?

Summary: For obese patients needing total hip or knee arthroplasty, an approach of not undergoing bariatric surgery prior to arthroplasty may be associated with the same rates of wound infection, venous thromboembolism, subsequent revision, and mortality as an approach of undergoing bariatric surgery PRIOR to arthroplasty, while allowing patients to potentially avoid one major surgery.

https://www.ncbi.nlm.nih.gov/m/pubmed/27587514/

Strength of Recommendation = B

Unloading Shoes for Self-management of Knee Osteoarthritis. — November 18, 2016

Unloading Shoes for Self-management of Knee Osteoarthritis.

Summary: For adults with symptomatic osteoarthritis of the knee, regular use of commercially available neutral walking shoes may provide the same improvements in pain and function as regular use of commercially available “unloading” walking shoes, but with a lower associated risk of developing foot or ankle pain.

https://www.ncbi.nlm.nih.gov/m/pubmed/27398991/

Strength of Recommendation = B

Long-term effects of Tailored Physical Activity or Chronic Pain Self-Management Programme on return-to-work. — November 11, 2016

Long-term effects of Tailored Physical Activity or Chronic Pain Self-Management Programme on return-to-work.

Summary: For adults sick-listed due to pain in the back or the upper body, providing a 90-minute session of health coaching centered on lifestyle, motivation, resources and “power to act” may be associated with the same likelihood of returning to work within the next 11 months as approaches using either supervised tailored group physical activity for 10 weeks or 6 workshops (2.5 hours each) on chronic pain self-management; however the health coaching approach involves much less time commitment and could potentially be far less costly.

https://www.ncbi.nlm.nih.gov/m/pubmed/27786344/

Strength of Recommendation = B

Nutritional strategies for skeletal and cardiovascular health. — October 25, 2016
Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures. — October 18, 2016

Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures.

Summary: For adults over 60 with an unstable acute ankle fracture, use of a molded below-knee cast with minimal padding (applied under anesthesia by a trained surgeon) may lead to the same functional outcomes for the ankle at 6 months as surgical internal fixation but with lower likelihood of infection and less operating room time. (However, casting may be associated with a higher rate of radiologic malunion than surgery).

https://www.ncbi.nlm.nih.gov/m/pubmed/27727383/

Strength of Recommendation = B

Cold Water Immersion Versus Whole Body Cryotherapy for Recovery From Exercise-Induced Muscle Damage. — October 14, 2016

Cold Water Immersion Versus Whole Body Cryotherapy for Recovery From Exercise-Induced Muscle Damage.

Summary: For physically active individuals, cold water immersion (10 minutes at 10°C) after intense exercise appears to be more effective for accelerating recovery kinetics, for relief of soreness, and for perceived recovery than whole-body cryotherapy. (Although not specifically addressed, it is likely cold-water immersion would also be significantly less expensive)

https://www.ncbi.nlm.nih.gov/m/pubmed/27396361/

Strength of Recommendation = B

Treatment of mid-clavicular fractures: Figure-of-eight bandage versus a simple sling. — September 16, 2016
Recovery following fractures of the clavicle treated conservatively. — September 9, 2016
Paracetamol for low back pain. — September 6, 2016

Paracetamol for low back pain.

Summary: For patients with acute and chronic low back pain, treatment with paracetamol does not appear to provide any benefit beyond that experienced by patients treated with placebo. (In other words, paracetamol does not appear to provide any relief for patients with either acute or chronic low back pain)

http://www.ncbi.nlm.nih.gov/m/pubmed/27271789/

Strength of Recommendation = A

(additional commentary at: http://www.evidentlycochrane.net/paracetamol-widely-used-ineffective/)

Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders. — September 2, 2016

Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders.

Summary: For patients with rotator cuff disorder, ultrasound appears to be as sensitive and specific as magnetic resonance imaging or magnetic resonance arthrography for diagnosis of full-thickness rotator cuff tears, potentially at much lower cost.

http://www.ncbi.nlm.nih.gov/m/pubmed/25677796/

Strength of Recommendation = C

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up — August 12, 2016

Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up

Summary: For adults with a degenerative medial meniscal tear, treatment with 12 weeks of supervised neuromuscular and strength exercises may lead to the same level of function, pain reduction and quality of life over 2 years as treatment with arthroscopic partial meniscetomy, but patients treated with supervised exercise may have greater short-term (3 month) improvement in thigh muscle strength.

http://www.ncbi.nlm.nih.gov/m/pubmed/27440192/

Strength of Recommendation = B

Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain — June 15, 2016
Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients With Degenerative Meniscus Tear: A Secondary Analysis of a Randomized Trial. — June 10, 2016

Mechanical Symptoms and Arthroscopic Partial Meniscectomy in Patients With Degenerative Meniscus Tear: A Secondary Analysis of a Randomized Trial.

Summary: Patients with catching or locking of the knee may have the same likelihood of having catching or locking at 2, 6, and 12 months, whether or not they have arthroscopic partial meniscectomy (APM). (In other words, surgical resection of a torn meniscus does not appear to be useful for treating knee catching or occasional locking)

http://www.ncbi.nlm.nih.gov/m/pubmed/26856620/

Strength of Recommendation = B

Naturopathic care for chronic low back pain: a randomized trial. — June 3, 2016

Naturopathic care for chronic low back pain: a randomized trial.

Summary: For patients with chronic low back pain (> 6 weeks’ duration), “naturopathic” care (dietary counseling, deep breathing relaxation techniques and acupuncture) may be more effective for improving improving low back pain and overall quality of life than standardized education and instruction on physiotherapy exercises.

http://www.ncbi.nlm.nih.gov/m/pubmed/17878954/

Strength of Recommendation = B

Cost-effectiveness of naturopathic care for chronic low back pain. — May 31, 2016
Advice to rest in bed versus advice to stay active for acute low‐back pain and sciatica. — April 19, 2016

Advice to rest in bed versus advice to stay active for acute low‐back pain and sciatica.

Summary: For patients with acute low back pain, advice to “stay active” appears to lead to better pain relief and functional improvement than to advice to rest in bed (although this may not apply to patients with acute low back pain plus sciatica)

https://www.ncbi.nlm.nih.gov/m/pubmed/20556780/

Strength of Recommendation = B

Improved endurance capacity following chocolate milk consumption compared with 2 commercially available sport drinks. — March 25, 2016
Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence. — March 8, 2016

Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence.

Summary: For patients with knee osteoarthritis (OA), placebo, “sham” or no-treatment works just as well as injectable hyaluronic acid (HA) for improving pain, stiffness, or function, and is less invasive. (In other words, HA injection for knee OA does not appear to provide any clinically significant benefit when compared to placebo)

http://www.ncbi.nlm.nih.gov/m/pubmed/26677239/

Strength of Recommendation = A

Prevention of Low Back Pain: A Systematic Review and Meta-analysis. — March 4, 2016

Prevention of Low Back Pain: A Systematic Review and Meta-analysis.

Summary: For patients with low back pain, exercise (with or without education) appears to be effective at reducing the likelihood of back pain recurrence and the likelihood of using sick time, while it appears that education alone, back belts, and shoe insoles have no effect on back pain recurrence or use of sick time.

http://www.ncbi.nlm.nih.gov/m/pubmed/26752509/

Strength of Recommendation = B

Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee: a randomized clinical trial. — February 16, 2016

Evaluation of the benefit of corticosteroid injection before exercise therapy in patients with osteoarthritis of the knee: a randomized clinical trial.

Summary: For patients with osteoarthritis (OA) of the knee, there does not appear to be a measurable benefit to administering an intra-articular corticosteroid prior to a starting 12-week supervised exercise program.

http://www.ncbi.nlm.nih.gov/m/pubmed/25822572/

Strength of Recommendation = B

Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial. — January 19, 2016
Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. — January 6, 2016

Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis.

Summary: A more restrictive use of red blood cell (RBC) transfusions (eg, using a hemoglobin threshold of <7.0 g/dL) may be associated with a lower risk of serious infections than a more liberal approach to transfusions, especially for orthopedic patients and for patients presenting with sepsis.

http://www.ncbi.nlm.nih.gov/m/pubmed/24691607/

Strength of Recommendation = A

Rehabilitation After Immobilization for Ankle Fracture: The EXACT Randomized Clinical Trial. — December 21, 2015

Rehabilitation After Immobilization for Ankle Fracture: The EXACT Randomized Clinical Trial.

Summary: For patients with isolated ankle fracture treated with immobilization (with or without surgical fixation), use of tailored advice after removal of immobilization was just as effective at restoring activity tolerance and quality of life as was a supervised exercise program, at lower cost.

http://www.ncbi.nlm.nih.gov/m/pubmed/26441182/

Strength of Recommendation = B

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. — December 11, 2015

Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial.

Summary: For patients with suspected neck injury, use of the Canadian C-spine Rule may allow for appropriate clinical assessment for neck injury with a decreased need for imaging without injuries being missed and without any increase in patient morbidity.

https://www.ncbi.nlm.nih.gov/m/pubmed/19875425/

Strength of Recommendation = A

Advice to Stay Active or Structured Exercise in the Management of Sciatica: A Systematic Review and Meta-analysis. — December 7, 2015

Advice to Stay Active or Structured Exercise in the Management of Sciatica: A Systematic Review and Meta-analysis.

Summary: For patients with sciatica, at both intermediate and long-term  (12-month) followup, advice to exercise or to “stay active” appears just as effective as a supervised exercise program for improving leg pain and disability, with “advice” offering a potentially simpler and less expensive approach.

http://www.ncbi.nlm.nih.gov/m/pubmed/26165218/

Strength of Recommendation = B

Validation of the Ottawa ankle rules in France: a study in the surgical emergency department of a teaching hospital. — December 4, 2015
Implementation of the Ottawa ankle rules. — November 11, 2015
Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial (ISRCTN17592092). — October 26, 2015

Supervised walking in comparison with fitness training for chronic back pain in physiotherapy: results of the SWIFT single-blinded randomized controlled trial (ISRCTN17592092).

Summary: Supervised walking may provide an effective and lower-cost alternative to group exercise classes or usual physiotherapy for management of chronic low back pain, and may be associated with higher levels of adherence.

http://www.ncbi.nlm.nih.gov/m/pubmed/25599309/

Strength of Recommendation = B

Use of rib belts in acute rib fractures. — October 5, 2015
Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. — September 16, 2015

Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis.

Summary: Use of the Ottawa Ankle Rules (OAR) for ankle injury in children may allow 25% more children to avoid the costs or radiation exposure associated with imaging, with out any increase in the rate of missed fracture. (In other words, using the OAR to exclude ankle and mid-foot fractures in children may reduce imaging use by approximately 25% with a low likelihood of missing a fracture.)

http://www.ncbi.nlm.nih.gov/m/pubmed/19187397/

Strength of Recommendation = B

Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. — September 4, 2015

Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study.

Summary: For patients with lumbosacral radicular pain due to a herniated disc or spinal stenosis, treatment with gabapentin (up to 1200 mg three times daily) may provide provide the same degree of improvement in leg pain as a lumbar epidural steroid injection (LESI) when assessed at 3 months, without the need for an interventional procedure and potentially at lower cost.

www.ncbi.nlm.nih.gov/m/pubmed/25883095

Strength of Recommendation = B

Treatment of proximal humerus fractures in the elderly. — July 29, 2015

Treatment of proximal humerus fractures in the elderly.

Summary: For an elderly patient with a proximal humeral fracture, limited quality evidence suggests non-operative treatment may lead to the same degree of shoulder function as operative treatment, without the high risk of complications that may be associated with operative treatment.

http://www.ncbi.nlm.nih.gov/m/pubmed/25574643/

Strength of Recommendation = B

A Comparison of Various Contemporary Methods to Prevent a Wet Cast. — July 1, 2015
Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. — June 29, 2015

Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials.

Summary: For patients with shoulder or elbow tendonitis, use of either physiotherapy or non-steroidal anti-inflammatory medications (NSAIDs) may provide better long-term improvements in function and pain than use of corticosteroid injection.

http://www.ncbi.nlm.nih.gov/m/pubmed/19054817/

Strength of Recommendation = A

Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. —

Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial.

Summary: For patients with chronic unilateral lateral epicondylitis, local corticosteroid injection may result in lower rates of complete recovery and higher rates of symptomatic recurrence at both 6 months and 1 year after treatment, compared to use of a placebo injection. (In other words, for a patient with unilateral epicondylitis, NOT treating with a local corticosteroid injection may lead to a better long-term outcome).

http://www.ncbi.nlm.nih.gov/m/pubmed/23385272/

Strength of Recommendation = B

Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. — June 17, 2015

Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms.

Summary: For patients with knee pain who are middle aged or older, whether or not they have knee osteoarthritis, there may be no long-term difference in physical function outcomes between arthroscopic and non-operative management, while arthroscopic surgery may be associated with increased risk of deep-vein thrombosis, infection, pulmonary embolism, or death. (In other words, patients with knee pain who are treated non-operatively may function just as well over time as those who have arthroscopic surgery, without the risks that may accompany arthroscopic surgery.)

http://www.ncbi.nlm.nih.gov/m/pubmed/26080045/

Strength of Recommendation = A

Association of early imaging for back pain with clinical outcomes in older adults. — May 20, 2015

Association of early imaging for back pain with clinical outcomes in older adults.

Summary: For patients 65 or older with a new episode of back pain and no “red flags”, delaying imaging until at least 4 to 6 weeks after symptom onset is not associated with any worse clinical outcomes, but is associated with significantly lower resource use and costs (potential “red flags” that may warrant earlier imaging include risk factors for cancer, cauda equina syndrome or severe neurologic deficits, and fever with a history of IV drug use or recent infection).

http://www.ncbi.nlm.nih.gov/m/pubmed/25781443/

Strength of Recommendation = B

Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. — May 15, 2015

Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial.

Summary: For patients with a displaced proximal humeral fracture, there appears to be no significant difference in patient-reported clinical outcomes over 2 years following fracture occurrence when comparing sling immobilization to surgical management, and patients receiving surgical management may be at increased risk of adverse post-operative medical events.
http://www.ncbi.nlm.nih.gov/m/pubmed/25756440/

Strength of Recommendation= B

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