The Minimal Clinically Important Difference Changes Greatly Based on the Different Calculation Methods

Cognitive stimulation in activities of daily living for individuals with mild-to-moderate dementia (CS-ADL): Study protocol for a randomised controlled trial

BACKGROUND

Multi-component CS programs incorporating practice of activities of daily living (ADL) into intervention have reported benefits for ADL outcomes in individuals living with mild-to-moderate dementia. A randomised controlled trial (RCT) within community occupational therapy services in Ireland, is planned to evaluate the effects of CS-ADL, an ADL-focused, multi-component CS program, on ADL outcomes for individuals living with mild-to-moderate dementia.

METHOD

A single-blind RCT with a calculated sample size of 34 participants has been planned to compare the effects of CS-ADL versus treatment as usual on the outcomes of basic ADLs and instrumental ADLs. Cognition, mood, communication, and quality of life will also be evaluated as secondary outcomes. CS-ADL sessions will run once weekly for a total of seven weeks, lasting approximately two hours each. Outcome data will be collected at baseline, within sessions and post-intervention at week eight. Descriptive statistics will be used to analyse the data. This study has been registered at clinicaltrials.gov (NCT06147479).

DISCUSSION

CS programs are commonly conducted by occupational therapists working with individuals living with mild-to-moderate dementia. This study aims to demonstrate the effectiveness of a multi-component CS program delivered through an occupational therapy lens, potentially influencing the approach to CS and ADL interventions undertaken by occupational therapists.

Outcomes after multiligament knee injury worsen over time: A systematic review and meta-analysis

PURPOSE

Multiligament knee injuries (MLKIs) are devastating injuries that can have life-long consequences. A management plan requires the decision to perform surgery or not, timing of surgery, consideration of repair versus reconstruction, reconstruction technique and reconstruction graft choice. The purpose of this study was to analyze development of clinical outcomes of MLKIs over time at a minimum of 2 years of follow-up.

METHODS

Four databases were queried for surgical outcome-based studies of MLKIs published from 01/2000 through 09/2022 with a minimum 2-year follow-up. Technique articles, nonoperative treatment, arthroplasty, pediatric and review articles were excluded. Study characteristics including design, number of patients, age, follow-up period, anatomical region and posterior-cruciate ligament (PCL)-based injury were collected. Primary outcomes were Lysholm, International Knee Documentation Committee (IKDC) outcome scores and Tegner activity score. Random-effects model analysis was performed.

RESULTS

After the application of inclusion and exclusion criteria, 3571 patients in 79 studies were included in the analysis. The mean age at surgery was 35.6 years. The mean follow-up was 4.06 years (range 2-12.7). The mean Lysholm score at 2-year follow-up was 86.09 [95% confidence interval [CI]: 82.90-89.28], with a yearly decrease of -0.80 [95% CI: -1.47 -0.13], (p = 0.0199). The mean IKDC at 2 years was 81.35 [95% CI: 76.56-86.14], with a yearly decrease of -1.99 [95% CI: -3.14 -0.84] (p < 0.001). Non-PCL-based injuries had a higher IKDC 83.69 [75.55-91.82] vs. 75.00 [70.75-79.26] (p = 0.03) and Lysholm score 90.84 [87.10-94.58] versus 84.35 [82.18-86.52] (p < 0.01) than PCL-based injuries, respectively.

CONCLUSION

According to the present systematic review and meta-analysis of MLKIs with minimum 2-year follow-ups, the patients who suffered an MLKI can expect to retain around 80-85% of knee function at 2 years and can expect a yearly deterioration of knee function, depending on the score used. Inferior outcomes can be expected for PCL-based injuries at 2 years postoperative.

LEVEL OF EVIDENCE

Level IV meta-analysis.

Minimal Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) Values Following Hip Arthroscopy for Femoroacetabular Impingement Are Highly Dependent on Their Study Population and Calculation Methods: A Systematic Review

PURPOSE

To provide a summary of available literature on the Minimal Clinically Important Difference (MCID), Substantial Clinical Benefit (SCB), and Patient Acceptable Symptom State (PASS) after hip arthroscopy for femoroacetabular impingement (FAI).

METHODS

A systematic review was conducted via the Cochrane Library, Pubmed, Ovid MEDLINE, and Embase to identify studies that calculated MCID, SCB, or PASS for Patient Reported Outcome Measures PROMs after hip arthroscopy for FAI. The electronic search strategy used was as follows: hip AND arthroscopy AND (MCID OR "minimal clinically important difference" OR SCB OR "substantial clinical benefit" OR PASS OR "patient acceptable symptom state"). Inclusion criteria were English language studies published from 1980 to 2023 reporting clinical outcome scores and calculated values of MCID, PASS, or SCB for patients undergoing hip arthroscopy for FAI.

RESULTS

Forty-two studies (5 level II, 19 level III, and 18 level IV) met inclusion and exclusion criteria. The most commonly used outcome measures across MCID, SCB, and PASS were the Hip Outcome Score sports-specific subscale (HOS-SSS) and the activities of daily living subscale (HOS-ADL), the modified Harris Hip Score (mHHS), and the twelve-item international Hip Outcome Tool (iHOT-12). The range of MCID values for HOS-SSS, HOS-ADL, mHHS, and iHOT-12 were 7.2-15.7, 7.3-15.4, 7.2-16.8, and 8.8-16.2 respectively. Similarly, for SCB the values ranged from 77.9-96.9, 90.4-98.5, 20.0-98.4, and 66.7-87.5, respectively. Lastly, the PASS values ranged from 63.9-80.9, 85.9-99.2, 74.0-97.0, and 59.5-86.0, respectively.

CONCLUSION

MCID, SCB, and PASS values for PROMs following hip arthroscopy for the management of FAI are highly dependent on their associated study including study population and calculation methods.

LEVEL OF EVIDENCE

IV, systematic review of Level II-IV studies.

Minimal Clinically Important Change of Movement Pain in Musculoskeletal Pain Conditions

Movement pain, which is distinct from resting pain, is frequently reported by individuals with musculoskeletal pain. There is growing interest in measuring movement pain as a primary outcome in clinical trials, but no minimally clinically important change (MCIC) has been established, limiting interpretations. We analyzed data from 315 participants who participated in previous clinical trials (65 with chronic Achilles tendinopathy; 250 with fibromyalgia) to establish an MCIC for movement pain. A composite movement pain score was defined as the average pain (Numeric Rating Scale: 0-10) during 2 clinically relevant activities. The change in movement pain was calculated as the change in movement pain from pre-intervention to post-intervention. A Global Scale (GS: 1-7) was completed after the intervention on perceived change in health status. Participants were dichotomized into non-responders (GS ≥4) and responders (GS <3). Receiver operating characteristic curves were calculated to determine threshold values and corresponding sensitivity and specificity. We used the Euclidean method to determine the optimal threshold point of the Receiver operating characteristic curve to determine the MCIC. The MCIC for raw change in movement pain was 1.1 (95% confidence interval [CI]: .9-1.6) with a sensitivity of .83 (95% CI: .75-.92) and specificity of .79 (95% CI: .72-.86). For percent change in movement pain the MCIC was 27% (95% CI: 10-44%) with a sensitivity of .79 (95% CI: .70-.88) and a specificity of .82 (95% CI: .72-.90). Establishing an MCIC for movement pain will improve interpretations in clinical practice and research. PERSPECTIVE: A minimal clinically important change (MCIC) of 1.1- points (95% CI: .9-1.6) for movement pain discriminates between responders and non-responders to rehabilitation. This MCIC provides context for interpreting the meaningfulness of improvement in pain specific to movement tasks.

Superior capsular reconstruction with the long head of the biceps tendon achieves excellent clinical results and low rotator cuff rerupture rates one year after cuff repair surgery

PURPOSE

To analyze the clinical one-year evolution of healed and rerupture lesions in patients who received a rotator cuff repair plus Superior Capsular Reconstruction (SCR) with the long head of the biceps (LHB). Moreover, to compare this evolution between men and women.

METHODS

A pilot study was conducted on patients who underwent a rotator cuff repair plus SCR with LHB between February 2021 and June 2022. All patients completed pre-operative and one-year post-operative evaluations for tendon type of tear and tendon integrity using Magnetic Resonance Imaging (MRI)after one year of the surgery. Besides, functionality was evaluated with the American Shoulder and Elbow Surgeons (ASES) score; the visual analog scale for pain (VAS); and the Constant score.

RESULTS

A total of 38 patients completed the one-year final evaluation, they presented an increased functionality score to 83 and 86 in Constant and ASES scales (p < .001), respectively. Besides, 84% of the patients presented a healed cuff, while rerupture occurred in 16% of the patients. There were differences between the healed and rerupture patients in the total Constant score, with a remarkable increase in the strength subscale, almost double for patients with healed cuff (p < .001); in the same way, daily life activity score, and balance subscale increased, while pain score decreased in the healed cuff group (p < .05). There was no difference in functionality between men and women (p > .05). Besides, almost all patients achieved the MCID in both ASES and Constant total scores, irrespectively of the healing group.

CONCLUSION

The cuff repair using SCR with the LHB achieved a low percentage of rerupture and a functional improvement after one year of follow-up. Patients who healed the lesion presented more strength and better performance in daily life activities than those with cuff repurture. Thus, SCR + LHB procedure can be considered an efficient technique for rotator cuff repair surgery for both men and women. Although a comparison with a control group is needed to confirm these findings.

H-Wave® Device Stimulation for Chronic Neck Pain: A Patient-Reported Outcome Measures (PROMs) Study

INTRODUCTION

Chronic neck pain (cNP) is one of the leading causes of disability worldwide, often being refractory to conventional forms of treatment. Various forms of electrical stimulation have been proposed to decrease pain and improve function. Patient-reported outcome measures (PROMs) for treatment of cNP have rarely been published.

METHODS

An independent retrospective statistical analysis of PROMs data for users of H-Wave® device stimulation (HWDS), prospectively collected by the device manufacturer over a 4-year period, was conducted. Final surveys for 34,192 pain management patients were filtered for pain chronicity limited to 3-24 months and device use of 22-365 days, resulting in 11,503 patients with "all diagnoses"; this number was further reduced to 1482 patients with cNP, sprain, or strain.

RESULTS

Neck pain was reduced by 3.13 points (0-10 pain scale), with significant (≥ 20%) relief in 86.6%. Function/activities of daily living (ADL) improved in 96.19%, while improved work performance was reported in 84.76%. Medication use decreased or stopped in 65.42% and sleep improved in 60.39%. Over 95% reported having expectations met or exceeded, service satisfaction, and confidence in device use, while no adverse events were reported. Subgroup analyses found positive benefit associations with longer duration of device use.

CONCLUSION

Near-equivalent outcomes were self-reported by cNP HWDS patients as for (previously published) chronic low back pain (cLBP) patients. HWDS provided effective and safe cNP relief, improvements in function and ADL, along with additional benefits including decreased medication use, better sleep, and improved work performance.

Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial

Chronic primary low back pain (CPLBP) refers to low back pain that persists over 3 months, that cannot be explained by another chronic condition, and that is associated with emotional distress and disability. Previous studies have shown that spinal manipulative therapy (SMT) is effective in relieving CPLBP, but the underlying mechanisms remain elusive. This randomized placebo-controlled dual-blind mixed experimental trial (NCT05162924) aimed to investigate the efficacy of SMT to improve CPLBP and its underlying mechanisms. Ninety-eight individuals with CPLBP and 49 controls were recruited. Individuals with CPLBP received SMT (n = 49) or a control intervention (n = 49), 12 times over 4 weeks. The primary outcomes were CPLBP intensity (0-100 on a numerical rating scale) and disability (Oswestry Disability Index). Secondary outcomes included pressure pain thresholds in 4 body regions, pain catastrophizing, Central Sensitization Inventory, depressive symptoms, and anxiety scores. Individuals with CPLBP showed widespread mechanical hyperalgesia (P < .001) and higher scores for all questionnaires (P < .001). SMT reduced pain intensity compared with the control intervention (mean difference: -11.7 [95% confidence interval, -11.0 to -12.5], P = .01), but not disability (P = .5). Similar mild to moderate adverse events were reported in both groups. Mechanical hyperalgesia at the manipulated segment was reduced after SMT compared with the control intervention (P < .05). Pain catastrophizing was reduced after SMT compared with the control intervention (P < .05), but this effect was not significant after accounting for changes in clinical pain. Although the reduction of segmental mechanical hyperalgesia likely contributes to the clinical benefits of SMT, the role of pain catastrophizing remains to be clarified. PERSPECTIVE: This randomized controlled trial found that 12 sessions of SMT yield greater relief of CPLBP than a control intervention. These clinical effects were independent of expectations, and accompanied by an attenuation of hyperalgesia in the targeted segment and a modulation of pain catastrophizing.

Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials

BACKGROUND

The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures.

METHODS

Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes.

RESULTS

A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing.

CONCLUSIONS

A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Further psychometric evaluation of the WOUND-Q: A responsiveness study

The WOUND-Q is a modular patient-reported outcome measure (PROM) with 13 scales measuring constructs across 4 domains (i.e., wound characteristics, health related quality of life, experience of care and wound treatment). The psychometrics of the WOUND-Q were previously assessed and the 13 scales evidenced good validity and reliability. However, the responsiveness (i.e., ability to detect clinical change) of the WOUND-Q has yet to be assessed. The objective of this study was to evaluate responsiveness for 9 WOUND-Q scales that assess outcomes, in a sample of people 18 years of age or older with chronic wounds that were present for at least 3 months. This study conducted a 4 month follow-up of 421 participants who completed the WOUND-Q as part of a previous psychometric study. Participants completed an online survey answering questions about their current wound state (e.g., number, type, size, smell, drainage), anchor questions about change, as well as the WOUND-Q scales that they had completed in their initial assessment. Pre-defined hypotheses were tested with a 75% acceptance threshold indicating sufficient evidence of responsiveness. Minimally important differences (MIDs) were also calculated using both anchor-based and distribution-based methods. Of 390 invited participants, 320 provided responses, ranging in age from 19 to 84 years. Acceptance of hypotheses ranged from 60% to 100%, with only the Symptom scale not meeting the 75% threshold. The findings of this study provide evidence that the WOUND-Q can validly measure clinical change in patients with chronic wounds.

The smallest worthwhile effect on pain intensity of exercise therapy for people with chronic low back pain: a discrete choice experiment study

OBJECTIVE: To identify the smallest worthwhile effect (SWE) of exercise therapy for people with non-specific chronic low back pain (CLBP). DESIGN: Discrete choice experiment. METHODS: The SWE was estimated as the lowest reduction in pain that participants would consider exercising worthwhile, compared to not exercising i.e., effects due to natural history and other components (e.g., regression to the mean). We recruited English-speaking adults in Australia with non-specific CLBP to our online survey via email obtained from a registry of previous participants and advertisements on social media. We used discrete choice experiment to estimate the SWE of exercise compared to no exercise for pain intensity. We analysed the discrete choice experiment using a mixed logit model, and mitigated hypothetical bias through certainty calibration, with sensitivity analyses performed with different certainty calibration thresholds. RESULTS: Two-hundred and thirteen participants completed the survey. The mean age (±SD) was 50.7±16.5, median (IQR) pain duration 10 years (5-20), and mean pain intensity (±SD) was 5.8±2.3 on a 0-10 numerical rating scale. For people with CLBP the SWE of exercise was a between-group reduction in pain of 20%, compared to no exercise. In the sensitivity analyses, the SWE varied with different levels of certainty calibration; from 0% without certainty calibration to 60% with more extreme certainty calibration. CONCLUSION: This patient-informed threshold of clinical importance could guide the interpretation of findings from randomised trials and meta-analyses of exercise therapy compared to no exercise.

Minimal important difference of the Migraine Disability Assessment (MIDAS): Longitudinal data from the DMKG Headache Registry

BACKGROUND

The Migraine Disability Assessment (MIDAS) is widely used. However, there are limited data on how much a reduction in the MIDAS score indicates a change that matters to the patient.

METHODS

Data from the DMKG (i.e. German Migraine and Headache Society) Headache Registry were used to determine the minimal important difference (MID) of the MIDAS, using the Patient Global Impression of Change (PGIC) as anchor and applying average change and receiver operating characteristic curve methods.

RESULTS

In total, 1218 adult migraine patients (85.6% female, 40.2 ± 12.8 years, baseline MIDAS 44.2 ± 47.4, follow-up MIDAS 36.5 ± 45.3) were included. For patients with baseline MIDAS >20 (MIDAS grade IV, n = 757), different methods using PGIC "somewhat improved" as anchor yielded percent change MIDs of the MIDAS between -29.4% and -33.2%. For baseline MIDAS between 6 and 20 (grades II and III, n = 334), using PGIC "much improved" as anchor, difference change MIDs were between -3.5 and -4.5 points.

CONCLUSIONS

Based on the above results, we estimated the MID of the MIDAS at -30% for patients with a baseline MIDAS >20, and at -4 points for those with a baseline MIDAS of 6-20, for a tertiary headache care population.

TRIAL REGISTRATION

The DMKG Headache Registry is registered with the German Clinical Trials Register (DRKS 00021081).

Calculation of the minimum clinically important difference (MCID) using different methodologies: case study and practical guide

INTRODUCTION

Establishing thresholds of change that are actually meaningful for the patient in an outcome measurement instrument is paramount. This concept is called the minimum clinically important difference (MCID). We summarize available MCID calculation methods relevant to spine surgery, and outline key considerations, followed by a step-by-step working example of how MCID can be calculated, using publicly available data, to enable the readers to follow the calculations themselves.

METHODS

Thirteen MCID calculations methods were summarized, including anchor-based methods, distribution-based methods, Reliable Change Index, 30% Reduction from Baseline, Social Comparison Approach and the Delphi method. All methods, except the latter two, were used to calculate MCID for improvement of Zurich Claudication Questionnaire (ZCQ) Symptom Severity of patients with lumbar spinal stenosis. Numeric Rating Scale for Leg Pain and Japanese Orthopaedic Association Back Pain Evaluation Questionnaire Walking Ability domain were used as anchors.

RESULTS

The MCID for improvement of ZCQ Symptom Severity ranged from 0.8 to 5.1. On average, distribution-based methods yielded lower MCID values, than anchor-based methods. The percentage of patients who achieved the calculated MCID threshold ranged from 9.5% to 61.9%.

CONCLUSIONS

MCID calculations are encouraged in spinal research to evaluate treatment success. Anchor-based methods, relying on scales assessing patient preferences, continue to be the "gold-standard" with receiver operating characteristic curve approach being optimal. In their absence, the minimum detectable change approach is acceptable. The provided explanation and step-by-step example of MCID calculations with statistical code and publicly available data can act as guidance in planning future MCID calculation studies.

Outpatient interdisciplinary multimodal pain treatment programme for patients with chronic musculoskeletal pain: a longitudinal cohort study

PURPOSE

To describe the outcomes of an interdisciplinary multimodal pain treatment (IMPT) for chronic musculoskeletal pain (CMP) patients up until 12 months post-treatment.

MATERIALS AND METHODS

Data were gathered during routine clinical practice during a 3-year period (2019-2021) at six Dutch rehabilitation centres. Assessments included patient-reported outcome measures for multiple domains including disability, pain and fatigue. Longitudinal data were analysed using repeated-measures models and by quantifying responder rates.

RESULTS

Included were 2309 patients with a mean age of 43.7 (SD 12.9) years, of which 73% female. All outcomes showed significant improvements at each timepoint. At discharge, large effect sizes were found for disability, average and worst pain, fatigue and health-related quality of life. Improvements were largely sustained at 12-months. Relatively large proportions of patients had clinically relevant improvements after treatment (pain-related disability: 60%; average pain: 52%; worst pain: 37.4%; work capacity: 50%; concentration: 50%; fatigue: 46%). Patients who received a treatment extension showed further improvements for all outcome measures, except average pain.

CONCLUSIONS

At group level, all outcomes significantly improved with mainly large effect sizes. The results were mostly sustained. The proportion of patients showing clinically relevant improvements tends to be larger than previously reported for mixed CMP patients.

Comparative Study for Surgical Treatment of Acute Distal Tibiofibular Syndesmotic Lesions Using the Modified Suture-Button Fixation Versus Static Syndesmotic Screw Fixation

INTRODUCTION

Several techniques to treat acute distal tibiofibular instability are described consisting in static and dynamic fixation procedures. The aim of our work is to compare the outcomes of acute syndesmotic injury fixation between the modified technique of dynamic fixation using the suture-button principle as an efficient and low-cost method and the classic static fixation.

METHODS

It is a prospective study including patients presenting with acute syndesmotic injury. After fracture fixation, residual syndesmotic instability was managed using syndesmotic screw in group A and dynamic fixation with a double Ethibond suture in group B. Functional results were assessed using the American Orthopaedic Foot and Ankle Society score (AOFAS) score. Radiological evaluation was done by a postoperative computed tomography (CT) scan of both ankles and plain X-rays of the ankle after surgery and at 18 months.

RESULTS

Group A included 20 patients meanwhile 35 patients were in group B. The reduction was satisfactory in the 2 groups according to the postoperative CT scan measurements. The mean healing time in group A was 49.65 days and 51.49 days in group B (P = .45). We did not find any significant difference in terms of loss of reduction in the 2 groups. The return to work was faster in group B (P = .04). Patients in group B had better AOFAS score (P = .03) and ankle range of motion than those in group A. The difference was statistically significant (P = .02 for dorsal flexion and P = .001 for plantar flexion). For group A, we did not note any early complications. Meanwhile, 7 patients developed skin complications in group B (P = .03). However, no significant difference was found in terms of late complications.

CONCLUSIONS

The modified dynamic suture-button fixation remains a therapeutic alternative in low-income countries that could achieve better outcomes than static fixation, with easy postoperative follow-up.

LEVELS OF EVIDENCE

Level II.

Leveraging patient experience data to guide medicines development, regulation, access decisions and clinical care in the EU

Patient experience data (PED), provided by patients/their carers without interpretation by clinicians, directly capture what matters more to patients on their medical condition, treatment and impact of healthcare. PED can be collected through different methodologies and these need to be robust and validated for its intended use. Medicine regulators are increasingly encouraging stakeholders to generate, collect and submit PED to support both scientific advice in development programs and regulatory decisions on the approval and use of these medicines. This article reviews the existing definitions and types of PED and demonstrate the potential for use in different settings of medicines' life cycle, focusing on Patient-Reported Outcomes (PRO) and Patient Preferences (PP). Furthermore, it addresses some challenges and opportunities, alluding to important regulatory guidance that has been published, methodological aspects and digitalization, highlighting the lack of guidance as a key hurdle to achieve more systematic inclusion of PED in regulatory submissions. In addition, the article discusses opportunities at European and global level that could be implemented to leverage PED use. New digital tools that allow patients to collect PED in real time could also contribute to these advances, but it is equally important not to overlook the challenges they entail. The numerous and relevant initiatives being developed by various stakeholders in this field, including regulators, show their confidence in PED's value and create an ideal moment to address challenges and consolidate PED use across medicines' life cycle.

Return to Sports in Patients Aged 50 Years or Younger After Robotic-Assisted Patellofemoral Arthroplasty: A 10-Year Experience Reporting High Clinical Benefits and High Patient Satisfaction With Return to an Active Lifestyle

BACKGROUND

Limited data are available on return to sports and patient psychometric ratings of success after patellofemoral arthroplasty (PFA) in younger patients with high expectations to return to an active lifestyle.

PURPOSE/HYPOTHESIS

The purpose of this article was to determine the role of PFA and its success in meeting patient expectations regarding the return to low-impact recreational sports and an active lifestyle in younger, active patients. It was hypothesized that PFA would allow younger patients to return to low-impact sports and an active lifestyle and achieve high patient psychometric ratings.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

In this 10-year prospective study (2009-2018), robotic-assisted PFA was performed on 44 patients (32 women and 12 men; n = 51 consecutive knees), with a mean age of 37.2 years (range, 21-50 years). The follow-up rate was 98%, with a mean of 5.3 years (range, 2-9.3 years). Primary clinical outcomes were as follows: the validated Cincinnati Knee Rating System sports activity and symptom rating scales, patient psychometric ratings of the substantial clinical benefit (SCB), and the Patient Acceptable Symptom State (PASS). Secondary outcomes were the Cincinnati Knee Rating System occupational rating, visual analog pain scale, and the 12-Item Short Form Health Survey. Survivorship was defined by conversion to total knee replacement (TKR).

RESULTS

Before PFA, 78% of patients (35/45 knees) were symptomatic and unable to perform recreational sports, with only 20% of patients (9/45 knees) performing some low-impact sports. After PFA, 80% of patients (36/45 knees) were able to perform low-impact sports, and 7% (3/45 knees) performed jumping-pivoting sports (P < .001). The SCB scored by the patient showed 87% of knees as good, very good, or normal. On the PASS analysis, 89% of patients (95% CI, 76%-96%) were "pleased," and 93% (95% CI, 82%-99%) would undergo surgery again. There were clinically relevant improvements in symptoms of pain, swelling, and giving way (P = .0001). Preoperatively, 91% of knees had moderate to severe pain with activities of daily living, and only 11% of knees had pain at the follow-up. Five of the 50 knees (10%) underwent TKR conversion with one patient lost to follow-up.

CONCLUSION

PFA resulted in a high return of patients to low-impact sports with high SCB and PASS psychometric ratings. The robotic-assisted 3-dimensional preoperative planning allowed precise intraoperative trochlear implant alignment in knees with severe trochlear dysplasia. PFA is recommended as an alternative treatment in younger patients with end-stage symptomatic patellofemoral arthritis.

REGISTRATION

NCT02738476 (ClinicalTrials.gov identifier).

Ingelsrud L, Roos EM, Silbernagel KG, Snyder-Mackler L, Risberg MA. Patient Acceptable Symptom State Thresholds for IKDC-SKF and KOOS at the 10-Year Follow-up After Anterior Cruciate Ligament Injury: A Study From the Delaware-Oslo ACL Cohort

Background

Clinicians need thresholds for the Patient Acceptable Symptom State (PASS) and Treatment Failure to interpret group-based patient-reported outcome measures after anterior cruciate ligament (ACL) injury. Validated thresholds that are crucial for accurately discerning patient symptom state and facilitating effective interpretation have not been determined for long-term follow-up after ACL injury.

Purpose

To calculate and validate thresholds for PASS and Treatment Failure for the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales at the 10-year follow-up after ACL injury.

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 163 participants with unilateral ACL injury (treated with reconstruction or rehabilitation alone) from the Delaware-Oslo ACL Cohort were included. Thresholds for PASS were calculated for IKDC-SKF and KOOS subscales using anchor-based predictive modeling and receiver operating characteristic (ROC) analysis. Too few participants had self-reported Treatment Failure to calculate thresholds for that outcome. Nonparametric bootstrapping was used to derive 95% CIs. The criterion validity of the predictive modeling and ROC-derived thresholds were assessed by comparing actual patient-reported PASS outcome with the calculated PASS outcome for each method of calculation and calculating their positive and negative predictive values with respect to the anchor questions.

Results

A total of 127 (78%) participants reported satisfactory symptom state. Predictive modeling PASS thresholds (95% CIs) were 76.2 points (72.1-79.4 points) for IKDC-SKF, 85.4 points (80.9-89.2 points) for KOOS Pain, 76.5 points (67.8-84.7 points) for KOOS Symptoms, 93.8 points (90.1-96.9 points) for KOOS activities of daily living, 71.6 points (63.4-77.7 points) for KOOS Sports, and 59.0 points (53.7-63.9 points) for KOOS quality of life (QoL). Predictive modeling thresholds classified 81% to 93% of the participants as having satisfactory symptom state, whereas ROC-derived thresholds classified >50% as unsatisfied. The thresholds for IKDC-SKF, KOOS Sports, and KOOS QoL resulted in the most accurate percentages of PASS among all identified thresholds and therefore demonstrate the highest validity.

Conclusion

Predictive modeling provided valid PASS thresholds for IKDC-SKF and KOOS at the 10-year follow-up after ACL injury. The thresholds for IKDC-SKF, KOOS Sports, and KOOS QoL should be used when determining satisfactory outcomes. ROC-derived thresholds result in substantial misclassification rates of the participants who reported satisfactory symptom state.

Minimal important clinical difference values are not uniformly valid in the active duty military population recovering from shoulder surgery

BACKGROUND

There are multiple methods for calculating the minimal clinically important difference (MCID) threshold, and previous reports highlight heterogeneity and limitations of anchor-based and distribution-based analyses. The Warfighter Readiness Survey assesses the perception of a military population's fitness to deploy and may be used as a functional index in anchor-based MCID calculations. The purpose of the current study in a physically demanding population undergoing shoulder surgery was to compare the yields of 2 different anchor-based methods of calculating MCID for a battery of PROMs, a standard receiver operating characteristic (ROC) curve-based MCIDs and baseline-adjusted ROC curve MCIDs.

METHODS

All service members enrolled prospectively in a multicenter database with prior shoulder surgery that completed pre- and postoperative PROMs at a minimum of 12 months were included. The PROM battery included Single Assessment Numeric Evaluation (SANE), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Patient Reported Outcome Management Information System (PROMIS) physical function (PF), PROMIS pain interference (PI), and the Warfighter Readiness Survey. Standard anchor-based and baseline-adjusted ROC curve MCIDs were employed to determine if the calculated MCIDs were both statistically and theoretically valid (95% confidence interval [CI] either completely negative or positive).

RESULTS

A total of 117 patients (136 operations) were identified, comprising 83% males with a mean age of 35.7 ± 10.4 years and 47% arthroscopic labral repair/capsulorrhaphy. Using the standard, anchor-based ROC curve MCID calculation, the area under the curve (AUC) for SANE, ASES, PROMIS PF, and PROMIS PI were greater than 0.5 (statistically valid). For ASES, PROMIS PF, and PROMIS PI, the calculated MCID 95% CI all crossed 0 (theoretically invalid). Using the baseline-adjusted ROC curve MCID calculation, the MCID estimates for SANE, ASES, and PROMIS PI were both statistically and theoretically valid if the baseline score was less than 70.5, 69, and 65.7.

CONCLUSION

When MCIDs were calculated and anchored to the results of standard, anchor-based MCID, a standard ROC curve analysis did not yield statistically or theoretically valid results across a battery of PROMs commonly used to assess outcomes after shoulder surgery in the active duty military population. Conversely, a baseline-adjusted ROC curve method was more effective at discerning changes across a battery of PROMs among the same cohort.

Editorial Commentary: The Minimal Clinically Important Difference Is Less Important Than It Sounds: Patients Seek to Achieve Substantial Clinical Benefits and Not Minimally Perceptible Improvements When They Undergo Arthroscopic Surgery

The minimal clinically important difference (MCID) is a frequently reported metric for describing within-patient improvement in patient-reported outcome measures (PROMs). It was originally defined by Jaeschke et al. as "the smallest difference in score in the domain of interest which patients perceive as beneficial and which would mandate, in the absence of troublesome side effects and excessive cost, a change in the patient's management." The latter part of this statement is often omitted, and this results in a loss of the originally intended value through lack of sufficient clinical importance to change management. Other pitfalls in the use of the MCID include that they are population- and condition-specific. As such, MCIDs lack external validity and cannot easily be extrapolated from one study to another. Furthermore, broadly different values can be obtained depending on the calculation method used. This makes the MCID an unhelpful metric when seeking to understand the true efficacy of a given intervention. The Food and Drug Administration recommends anchor-based methodologies (which take into account patient perception), over distribution-based methods (which are purely statistical and do not account for clinical meaningfulness to patients). Regardless, it should be noted that even anchor-based methodologies are susceptible to statistical bias, and measures are apt to be influenced by the regression to mean phenomena, where the value of the preintervention scores and their relationship to postintervention scores can bias estimates of the MCID. Finally, when using MCIDs, one must consider that they are a low bar. This means that patients do not undergo treatment to achieve minimally perceptible clinical improvements; instead, they undergo treatment with the hope of achieving substantial clinical benefit or a patient acceptable symptom state, and so these are more appropriate individual-level metrics to consider when evaluating clinically meaningful outcomes of treatment.

Intra-articular corticosteroid injections provide a clinically relevant benefit compared to placebo only at short-term follow-up in patients with knee osteoarthritis: A systematic review and meta-analysis

PURPOSE

To quantify the clinical relevance of intra-articular corticosteroid effects compared to placebo for the injective treatment of knee osteoarthritis (OA).

METHODS

The PubMed, Cochrane Library and Web of Science databases were searched on May 3, 2023. This study was conducted in accordance with the PRISMA guidelines. The inclusion criteria were randomized controlled trials (RCTs), published in English, with no time limitation regarding publication date, comparing intra-articular corticosteroids and placebo injections for knee OA. The effects were quantified at short- (≤6 weeks), mid- (>6 weeks and ≤3 months), and long-term (≥6 months) follow-ups. The minimal clinically important difference (MCID) for the outcomes (visual analogue scale for pain - VAS: 1.4, Western Ontario and McMaster University Osteoarthritis Index - WOMAC: 9) was used to interpret the clinical improvement provided by intra-articular corticosteroid injections compared to placebo. The quality of each article was assessed using the Cochrane RoB 2 tool and the GRADE guidelines.

RESULTS

Among the 1030 articles retrieved, 11 RCTs (842 patients) were included. A comparison of the two groups revealed statistically significant differences in the improvement of VAS and WOMAC scores in terms of the mean difference (MD); this difference was in favour of corticosteroids at short-term (p < 0.001, MD = -1.6 and p < 0.001, MD = -9.9, respectively) and mid-term follow-ups (p = 0.001, mean MD = -1.3 and p = 0.005, MD = -4.9, respectively). No difference was observed at the long-term follow-up. The MDs between the improvements in the two groups reached the MCID values for the VAS and WOMAC only at the short-term follow-up. The RoB 2 tool and the GRADE evaluations showed the presence of risk of bias and limited quality of evidence.

CONCLUSION

This systematic review and meta-analysis demonstrated that intra-articular corticosteroid injections offer clinically perceivable pain relief and functional improvement higher than the placebo effect only at short-term follow-up in patients affected by knee OA, with benefits losing clinical relevance already after 6 weeks. These results, together with the low number and the limited quality of the RCTs comparing this treatment with placebo, question the indication for the use of corticosteroid injections in clinical practice for the treatment of knee OA.

LEVEL OF EVIDENCE

Level I.

Minimal Clinically Important Difference of Scales Reported in Stroke Trials: A Review

There is a growing awareness of the significance of using minimum clinically important differences (MCIDs) in stroke research. An MCID is the smallest change in an outcome measure that is considered clinically meaningful. This review is the first to provide a comprehensive summary of various scales and patient-reported outcome measures (PROMs) used in stroke research and their MCID values reported in the literature, including a concise overview of the concept of and methods for determining MCIDs in stroke research. Despite the controversies and limitations surrounding the estimation of MCIDs, their importance in modern clinical trials cannot be overstated. Anchor-based and distribution-based methods are recommended for estimating MCIDs, with patient self-evaluation being a crucial component in capturing the patient's perspective on their health. A combination of methods can provide a more comprehensive understanding of the clinical relevance of treatment effects, and incorporating the patient's perspective can enhance the care of stroke patients.

The Between-Day Reliability of Correlation Properties of Heart Rate Variability During Running

The short-term scaling exponent of detrended fluctuation analysis (DFA-a1) of heart rate variability may be a helpful tool to assess autonomic balance as a prelude to daily, individualized training. For this concept to be useful, between-session reliability should be acceptable. The aim of this study was to explore the reliability of DFA-a1 during a low-intensity exercise session in both a non-fatigued and a fatigued condition in healthy males and females. Ten participants completed two sessions with each containing an exhaustive treadmill ramp protocol. Before and after the fatiguing ramp, a standardized submaximal low-intensity exercise bout was performed during which DFA-a1, heart rate, and oxygen consumption (VO2) were measured. We compared between-session reliability of all metrics prior to the ramps (i.e., non-fatigued status) and after the first ramp (i.e., fatigued status). Intraclass correlation coefficients (ICC) with 95% confidence intervals (CI), the standard error of measurement, and the smallest worthwhile change (SWC) were determined. The ICC and SWC pre fatiguing ramp were 0.85 (95% CI 0.39-0.96) and 5.5% for DFA-a1, 0.85 (0.38-0.96) and 2.2% for heart rate, and 0.84 (0.31-0.96) and 3.1% for VO2. Post fatiguing ramp, the ICC and SWC were 0.55 (0.00-0.89) and 7.9% for DFA-a1, 0.91 (0.62-0.98) and 1.6% for heart rate, and 0.80 (0.17-0.95) and 3.0% for VO2. DFA-a1 shows generally acceptable to good between-session reliability with a SWC of 0.06 and 0.07 (5.5-7.9%) during non-fatigued and fatigued conditions. This suggests that this metric may be useful to inform on training readiness.

Cognitive behavioural therapy (CBT) with and without exercise to reduce fear of falling in older people living in the community

BACKGROUND

Fear of falling (FoF) is a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing. It is a common condition amongst older adults and may occur independently of previous falls. Cognitive behavioural therapy (CBT), a talking therapy that helps change dysfunctional thoughts and behaviour, with and without exercise, may reduce FoF, for example, by reducing catastrophic thoughts related to falls, and modifying dysfunctional behaviour.

OBJECTIVES

To assess the benefits and harms of CBT for reducing FoF in older people living in the community, and to assess the effects of interventions where CBT is used in combination with exercise.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2023), MEDLINE Ovid (from 1946 to 11 January 2023), Embase Ovid (from 1980 to 11 January 2023), CINAHL Plus (Cumulative Index to Nursing and Allied Health Literature) (from 1982 to 11 January 2023), PsycINFO (from 1967 to 11 January 2023), and AMED (Allied and Complementary Medicine from 1985 to 11 January 2023). We handsearched reference lists and consulted experts for identifying additional studies.

SELECTION CRITERIA

This review included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs assessing CBT with and without exercise interventions compared to control groups with sham-treatment, or treatment as usual. We defined CBT as a collaborative, time-limited, goal-oriented, and structured form of speaking therapy. Included studies recruited community-dwelling older adults, with a mean population age of at least 60 years minus one standard deviation, and not defined by a specific medical condition.

DATA COLLECTION AND ANALYSIS

Two review authors used standard methodological procedures expected by Cochrane. For continuous data, as assessed by single- or multiple-item questionnaires, we report the mean difference (MD) with 95% confidence interval (CI) when studies used the same outcome measures, and standardised mean difference (SMD) when studies used different measures for the same clinical outcome. For dichotomous outcomes, we reported the treatment effects as risk ratios (RR) with 95% CIs. We measured the primary outcome, FoF, immediately, up to, and more than six months after the intervention. We analysed secondary outcomes of activity avoidance, occurrence of falls, depression, and quality of life when measured immediately after the intervention. We assessed risk of bias for each included study, using the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We selected 12 studies for this review, with 11 studies included for quantitative synthesis. One study could not be included due to missing information. Of the 11 individual studies, two studies provided two comparisons, which resulted in 13 comparisons. Eight studies were RCTs, and four studies were cluster-RCTs. Two studies had multiple arms (CBT only and CBT with exercise) that fulfilled the inclusion criteria. The primary aim of 10 studies was to reduce FoF. The 11 included studies for quantitative synthesis involved 2357 participants, with mean ages between 73 and 83 years. Study total sample sizes varied from 42 to 540 participants. Of the 13 comparisons, three investigated CBT-only interventions while 10 investigated CBT with exercise. Intervention duration varied between six and 156 hours, at a frequency between three times a week and monthly over an eight- to 48-week period. Most interventions were delivered in groups of between five and 10 participants, and, in one study, up to 25 participants. Included studies had considerable heterogeneity, used different questionnaires, and had high risks of bias. CBT interventions with and without exercise probably improve FoF immediately after the intervention (SMD -0.23, 95% CI -0.36 to -0.11; 11 studies, 2357 participants; moderate-certainty evidence). The sensitivity analyses did not change the intervention effect significantly. Effects of CBT with or without exercise on FoF may be sustained up to six months after the intervention (SMD -0.24, 95% CI -0.41 to -0.07; 8 studies, 1784 participants; very low-certainty evidence). CBT with or without exercise interventions for FoF probably sustains improvements beyond six months (SMD -0.28, 95% CI -0.40 to -0.15; 5 studies, 1185 participants; moderate-certainty of evidence). CBT interventions for reducing FoF may reduce activity avoidance (MD -2.57, 95% CI -4.67 to -0.47; 1 study, 312 participants; low-certainty evidence), and level of depression (SMD -0.41, 95% CI -0.60 to -0.21; 2 studies, 404 participants; low-certainty evidence). We are uncertain whether CBT interventions reduce the occurrence of falls (RR 0.96, 95% CI 0.66 to 1.39; 5 studies, 1119 participants; very low-certainty evidence). All studies had a serious risk of bias, due to performance bias, and at least an unclear risk of detection bias, as participants and assessors could not be blinded due to the nature of the intervention. Downgrading of certainty of evidence also occurred due to heterogeneity between studies, and imprecision, owing to limited sample size of some studies. There was no reporting bias suspected for any article. No studies reported adverse effects due to their interventions.

AUTHORS' CONCLUSIONS

CBT with and without exercise interventions probably reduces FoF in older people living in the community immediately after the intervention (moderate-certainty evidence). The improvements may be sustained during the period up to six months after intervention (low-certainty evidence), and probably are sustained beyond six months (moderate-certainty evidence). Further studies are needed to improve the certainty of evidence for sustainability of FoF effects up to six months. Of the secondary outcomes, we are uncertain whether CBT interventions for FoF reduce the occurrence of falls (very low-certainty evidence). However, CBT interventions for reducing FoF may reduce the level of activity avoidance, and may reduce depression (low-certainty evidence). No studies reported adverse effects. Future studies could investigate different populations (e.g. nursing home residents or people with comorbidities), intervention characteristics (e.g. duration), or comparisons (e.g. CBT versus exercise), investigate adverse effects of the interventions, and add outcomes (e.g. gait analysis). Future systematic reviews could search specifically for secondary outcomes.

Methotrexate to treat hand osteoarthritis with synovitis (METHODS): an Australian, multisite, parallel-group, double-blind, randomised, placebo-controlled trial

BACKGROUND

Hand osteoarthritis is a disabling condition with few effective therapies. Hand osteoarthritis with synovitis is a common inflammatory phenotype associated with pain. We aimed to examine the efficacy and safety of methotrexate at 6 months in participants with hand osteoarthritis and synovitis.

METHODS

In this multisite, parallel-group, double-blind, randomised, placebo-controlled trial, participants (aged 40-75 years) with hand osteoarthritis (Kellgren and Lawrence grade ≥2 in at least one joint) and MRI-detected synovitis of grade 1 or more were recruited from the community in Melbourne, Hobart, Adelaide, and Perth, Australia. Participants were randomly assigned (1:1) using block randomisation, stratified by study site and self-reported sex, to receive methotrexate 20 mg or identical placebo orally once weekly for 6 months. The primary outcome was pain reduction (measured with a 100 mm visual analogue scale; VAS) in the study hand at 6 months assessed in the intention-to-treat population. Safety outcomes were assessed in all randomly assigned participants. This trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000877381).

FINDINGS

Between Nov 22, 2017, and Nov 8, 2021, of 202 participants who were assessed for eligibility, 97 (48%) were randomly assigned to receive methotrexate (n=50) or placebo (n=47). 68 (70%) of 97 participants were female and 29 (30%) were male. 42 (84%) of 50 participants in the methotrexate group and 40 (85%) of 47 in the placebo group provided primary outcome data. The mean change in VAS pain at 6 months was -15·2 mm (SD 24·0) in the methotrexate group and -7·7 mm (25·3) in the placebo group, with a mean between-group difference of -9·9 (95% CI -19·3 to -0·6; p=0·037) and an effect size (standardised mean difference) of 0·45 (0·03 to 0·87). Adverse events occurred in 31 (62%) of 50 participants in the methotrexate group and 28 (60%) of 47 participants in the placebo group.

INTERPRETATION

Treatment of hand osteoarthritis and synovitis with 20 mg methotrexate for 6 months had a moderate but potentially clinically meaningful effect on reducing pain, providing proof of concept that methotrexate might have a role in the management of hand osteoarthritis with an inflammatory phenotype.

FUNDING

National Health and Medical Research Council of Australia.

Responsiveness and Minimal Clinically Important Difference of the Thai Version of the International Knee Documentation Committee Subjective Knee Form in Patients With Anterior Cruciate Ligament Injury

Background

The International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) is a knee-specific patient-reported outcome (PRO) measure that is commonly used to evaluate patients with various knee disorders. The Thai version of the IKDC-SKF (Thai IKDC-SKF) was shown to have good validity and reliability; nonetheless, no data regarding its responsiveness are available.

Purpose

To evaluate the responsiveness of the Thai IKDC-SKF for assessing patients with anterior cruciate ligament (ACL) injury and determine the minimal clinically important difference (MCID) for this PRO measure.

Study Design

Cohort study (diagnosis); Level of evidence, 3.

Methods

This prospective study included ACL-injured patients who were scheduled for ACL reconstruction (ACLR) at a single institution. The patients completed the Thai IKDC-SKF at the baseline and the 6-month postoperative follow-up. The global rating of change scale was an anchor question that evaluated patients' overall perception of a clinical change compared with their preoperative condition. The effect size and standardized response mean were calculated. The MCID was identified with an anchor-based approach by plotting a receiver operating characteristic curve and calculating the value that maximized the Youden index.

Results

Of 59 enrolled patients, 53 patients (89.8%) completed the preoperative and 6-month postoperative Thai IKDC-SKF. The mean (±SD) age of the participants was 32.3 ± 10.3 years, and 86.8% were men. The mean Thai IKDC-SKF score improved significantly from preoperatively to the 6-month follow-up (from 56.3 ± 14.9 to 70.8 ± 14.1, respectively; P < .001), with an effect size of 0.975 and a standardized response mean of 0.977. A receiver operating characteristic curve was generated to determine the ability of the Thai IKDC-SKF to distinguish between improved patients and unimproved patients, and the area under the curve was 0.80 (95% CI, 0.68-0.92), which was considered excellent. The MCID was 15.5, which yielded a sensitivity and specificity of 0.55 and 1, respectively.

Conclusion

This study confirmed the responsiveness of the Thai IKDC-SKF for detecting a clinical change in ACL-injured patients after ACLR. The identified MCID of 15.5 can be used to calculate the significant clinical change and sample size in future studies.

The importance of clinical importance when determining the target difference in sample size calculations

Recently, it was argued that clinically important differences should play no role in sample size calculations. Instead, it was proposed that sample size calculations should focus on setting realistic estimates of treatment benefit. We disagree, and argue in this article that considering the importance of a target difference is necessary in the context of randomised controlled trials of effectiveness, particularly definitive phase III trials. Ignoring clinical importance could have serious ethical and practical consequences.