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Low back pain is one of the most common causes of permanent functional impairment 47 and is recognized as a key cost driver in the medical system. 11 Anatomical structures of the lumbar spine, such as the intervertebral discs, ligaments, facet joints, or musculature, may cause low back pain. 6,7,30,38 However, others view this model of a peripheral pain generator in a critical light and propose other causes of pain, including neurophysiological, psychological, and social factors. 28,42,46

IMPORTANCE Preoperative and postoperative exercise interventions are commonly used in patients with total hip arthroplasty despite a lack of established efficacy. OBJECTIVE To explore clinical outcomes associated with exercise training before and after hip arthroplasty. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Google Scholar were searched from their inception to March 2020. Reference lists of included trials and related reviews were also searched. STUDY SELECTION Randomized clinical trials of land-based exercise interventions before or after total hip arthroplasty were included. DATA EXTRACTION AND SYNTHESIS This systematic review and meta-analysis is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data extraction was independently performed in duplicate. Random-effects meta-analyses with restricted maximum likelihood were performed for pooling the data. MAIN OUTCOMES AND MEASURES The primary prespecified outcome was self-reported physical function. Secondary prespecified outcomes were self-reported pain intensity, quality of life, gait speed, lower body muscle strength, lower body flexibility, anxiety, hospital length of stay, and adverse events. RESULTS A total of 32 randomized clinical trials with 1753 patients were included in the qualitative synthesis, and 26 studies with 1004 patients were included in the meta-analysis. Compared with usual care or no or minimal intervention, postoperative exercise training was not associated with improved self-reported physical function, with a moderate level of certainty, at 4 weeks

ObjectiveCompare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture.DesignLiving systematic review and meta-analysis.Data sourcesSix databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed.Eligibility criteriaRandomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery.Data synthesisBayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence.ResultsOf 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified.ConclusionsThere is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes.PROSPERO registration numberCRD42021256537.

Synopsis In 2020, 6 meta-analyses comparing arthroscopic hip surgery to physical therapy were published. All included the same 3 randomized controlled trials, and none used methods suitable for the analysis of fewer than 5 studies. When there are fewer than 5 studies and heterogeneity, a random-effects model with the Hartung-Knapp-Sidik-Jonkman adjustment for a maximally conservative estimate should be employed; if reliable prior information is available, a Bayesian random-effects meta-analysis should be employed. Our re-analysis, which employed the appropriate model, found that there is currently insufficient evidence to conclude that surgery is superior to physical therapy for femoroacetabular impingement (FAI) syndrome. Further randomized controlled trials are required to resolve the clinical question of what the best treatment approach is for FAI syndrome. We provide readers with tools to conduct appropriate meta-analysis of fewer than 5 trials. J Orthop Sports Phys Ther 2021;51(5):201–203. doi:10.2519/jospt.2021.0107