Ep 192: DREAMing of better care for meniscus tears, with Drs Jonas Thorlund and Søren Skou

[00:00:04] [SPEAKER_01]: Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research

[00:00:10] [SPEAKER_01]: to quality practice.

[00:00:12] [SPEAKER_01]: I'm Claire Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical

[00:00:16] [SPEAKER_01]: Therapy.

[00:00:17] [SPEAKER_01]: It's great to have you listening today.

[00:00:22] [SPEAKER_01]: Imagine this scenario.

[00:00:24] [SPEAKER_01]: A 30 year old woman who plays social basketball once a week and who you'll find in the

[00:00:32] [SPEAKER_01]: next.

[00:00:34] [SPEAKER_01]: She's been diagnosed with a traumatic medial meniscus tear and told that surgery is the

[00:00:39] [SPEAKER_01]: only way to quote unquote fix her knee so she can get back to playing basketball and

[00:00:44] [SPEAKER_01]: climbing.

[00:00:46] [SPEAKER_01]: But is that really what the research evidence says?

[00:00:49] [SPEAKER_01]: Joining me today to discuss the options are two Danish leaders in clinical trials that

[00:00:54] [SPEAKER_01]: are set up to guide best practice in treating and managing knee pain in adults of all

[00:00:59] [SPEAKER_01]: walks of life.

[00:01:00] [SPEAKER_01]: Dr Jonas Thorlund is a professor of musculoskeletal health at the University of Southern Denmark,

[00:01:06] [SPEAKER_01]: where he's head of the research unit for musculoskeletal function and physiotherapy.

[00:01:11] [SPEAKER_01]: Dr Thorlund co-leads the Centre for Muscle and Joint Health, which is a research centre

[00:01:16] [SPEAKER_01]: with about 50 researchers dedicated to researching musculoskeletal health.

[00:01:22] [SPEAKER_01]: Dr Søren Skou is professor of exercise and human health at the University of

[00:01:26] [SPEAKER_01]: Denmark, and he's also head of the multi-professional research and implementation unit Progress

[00:01:32] [SPEAKER_01]: at Slagosa Hospital in Denmark.

[00:01:35] [SPEAKER_01]: Dr Skou was one of the co-developers of the Good Life with Osteoarthritis in Denmark

[00:01:40] [SPEAKER_01]: or GLAD initiative, a highly successful now global initiative to manage osteoarthritis.

[00:01:48] [SPEAKER_01]: Jonas Søren, welcome to JOSPT Insights.

[00:01:51] [SPEAKER_00]: Thank you very much.

[00:01:52] [SPEAKER_00]: Thank you.

[00:01:53] [SPEAKER_01]: Thanks for making the time to join the podcast today.

[00:01:55] [SPEAKER_01]: Our chat is all about the knee and those two small yet important menisci in the joint.

[00:02:03] [SPEAKER_01]: Jonas, let's start with you.

[00:02:05] [SPEAKER_01]: How common are meniscal tears?

[00:02:07] [SPEAKER_00]: So meniscal tears are very common, but it's actually quite hard to make precise

[00:02:12] [SPEAKER_00]: estimates of how common they are.

[00:02:15] [SPEAKER_00]: There was a Swedish study at one time based on diagnostic codes that found that

[00:02:21] [SPEAKER_00]: meniscal tears was one of the most common types of knee injuries.

[00:02:25] [SPEAKER_00]: If we look more into surgical studies, there was a UK study, a more recent one,

[00:02:31] [SPEAKER_00]: that reported that from 1997 to 2017, 1.1 million arthroscopic partial

[00:02:39] [SPEAKER_00]: menesectomies were performed in the UK over a 20-year period.

[00:02:44] [SPEAKER_00]: So that would correspond to about 54,000 APM surgeries per year in the UK.

[00:02:50] [SPEAKER_00]: But obviously that doesn't encompass those patients who do not have surgery and

[00:02:55] [SPEAKER_00]: only have non-surgical treatment.

[00:02:58] [SPEAKER_01]: And we will definitely get into the treatment questions here because that's a big focus of

[00:03:04] [SPEAKER_01]: today's podcast.

[00:03:05] [SPEAKER_01]: I guess to follow up on the epidemiology, Jonas, what numbers do we see in people who

[00:03:10] [SPEAKER_01]: are active and playing sports in terms of meniscus tears versus people who are

[00:03:16] [SPEAKER_01]: walking around in the general population not being particularly physically active?

[00:03:21] [SPEAKER_00]: So basically when we talk about meniscal injuries, we often divide them into

[00:03:25] [SPEAKER_00]: different subtypes.

[00:03:27] [SPEAKER_00]: Often they are divided into two subtypes, degenerative meniscal tears and

[00:03:31] [SPEAKER_00]: traumatic meniscal tears.

[00:03:33] [SPEAKER_00]: Degenerative meniscal tears are mainly seen in the middle-aged and older

[00:03:38] [SPEAKER_00]: population where symptoms typically develop over time.

[00:03:43] [SPEAKER_00]: And these injuries are typically an injury to an already degenerated meniscus.

[00:03:49] [SPEAKER_00]: On the other hand, traumatic meniscal tears are most commonly seen in younger

[00:03:54] [SPEAKER_00]: patients and these are tears to a healthy meniscus and they are typically

[00:03:59] [SPEAKER_00]: sustained from a work or sports-related trauma.

[00:04:03] [SPEAKER_00]: If we talk about how common the different types of tears are, I would say from

[00:04:08] [SPEAKER_00]: epidemiological studies, about two thirds of meniscus tears are seen in middle-aged

[00:04:13] [SPEAKER_00]: and older patients and about one third are seen in younger patients.

[00:04:18] [SPEAKER_00]: At least that's when you look at surgical data.

[00:04:21] [SPEAKER_00]: That's kind of the division in surgeries across different studies.

[00:04:25] [SPEAKER_01]: And I think that's a really nice place, a really nice scene setting

[00:04:29] [SPEAKER_01]: and a nice place to then get into the debate.

[00:04:33] [SPEAKER_01]: And I think there's lots of debate about how to treat these meniscus tears.

[00:04:37] [SPEAKER_01]: Can you remind us, Jonas, what's the current consensus about how to manage meniscus tears

[00:04:43] [SPEAKER_01]: in middle-aged and older adults with knee pain?

[00:04:47] [SPEAKER_01]: And we'll focus on that population to start with.

[00:04:50] [SPEAKER_00]: Sure.

[00:04:50] [SPEAKER_00]: And actually this is a very studied population.

[00:04:54] [SPEAKER_00]: I think about at least 10 trials has been published in the period from 2002 to 2018.

[00:05:03] [SPEAKER_00]: Looking at meniscal surgery, arthroscopic partial menesectomy versus either placebo

[00:05:09] [SPEAKER_00]: surgery or exercise.

[00:05:11] [SPEAKER_00]: These studies mainly focused on middle-aged and older patients with degenerative meniscal tears

[00:05:16] [SPEAKER_00]: and patients in those studies, they were kind of in the continuum from patients with a

[00:05:21] [SPEAKER_00]: degenerative meniscal tear and no osteoarthritis to patients with a meniscal tear and moderate to

[00:05:27] [SPEAKER_00]: severe osteoarthritis.

[00:05:29] [SPEAKER_00]: If we look at systematic reviews of these studies, they show that arthroscopic partial

[00:05:34] [SPEAKER_00]: menesectomy has no better effect than placebo surgery or exercise on patient-reported outcomes.

[00:05:42] [SPEAKER_00]: And based on these reviews, guidelines have been made from different interest groups

[00:05:47] [SPEAKER_00]: and associations that have been issued.

[00:05:51] [SPEAKER_00]: And these recommendations differ a little bit.

[00:05:55] [SPEAKER_00]: Some recommend against APM surgery in the middle-aged and older populations with degenerative

[00:06:01] [SPEAKER_00]: tears, whereas others state that exercise is first line treatment and only to offer

[00:06:08] [SPEAKER_00]: surgery to select populations with degenerative meniscal tears.

[00:06:13] [SPEAKER_01]: And I would think that these guidelines and this philosophy of how to approach treating

[00:06:19] [SPEAKER_01]: more degenerative meniscus tears is likely familiar to our listeners.

[00:06:24] [SPEAKER_01]: Where there is maybe a bit more even strident debate in the literature and I think in

[00:06:31] [SPEAKER_01]: clinical practice and at conferences certainly, is what to do for meniscus tears in younger

[00:06:37] [SPEAKER_01]: people, those so-called traumatic tears.

[00:06:40] [SPEAKER_01]: So tell us about the DREAM trial and why this is such an important clinical trial.

[00:06:46] [SPEAKER_02]: We actually initiated the DREAM trial based on the fact that we had a lot of evidence

[00:06:50] [SPEAKER_02]: in the middle-aged and older population while there was no randomized control trials

[00:06:56] [SPEAKER_02]: in the younger population.

[00:06:57] [SPEAKER_02]: And when we talk about younger here, we study people between 18 and 40 years of age

[00:07:03] [SPEAKER_02]: because all of the previous studies had a mean age above 40, some of them way above

[00:07:09] [SPEAKER_02]: 40.

[00:07:10] [SPEAKER_02]: So we kind of didn't know what to do with in the younger population.

[00:07:14] [SPEAKER_02]: Quite interesting at the time we started the DREAM trial, which I'll talk a bit

[00:07:20] [SPEAKER_02]: more about later, a Dutch group started another study called the STAR trial.

[00:07:24] [SPEAKER_02]: So there's actually two randomized control trials in the younger population started

[00:07:29] [SPEAKER_02]: and finalizing approximately at the same time, which also is quite important when you

[00:07:34] [SPEAKER_02]: do research that is not only based on one trial but more trials showing similar results.

[00:07:41] [SPEAKER_02]: And the aim of our study, the DREAM trial was to investigate whether early

[00:07:46] [SPEAKER_02]: arthroscopic meniscal surgery that's both repair and resection was superior to 12 weeks

[00:07:53] [SPEAKER_02]: of supervised exercise therapy and patient education with the option of later surgery

[00:07:59] [SPEAKER_02]: is if needed.

[00:08:00] [SPEAKER_02]: And we evaluated pain, function, quality of life at 12 months as the primary end

[00:08:07] [SPEAKER_02]: point and outcomes.

[00:08:09] [SPEAKER_02]: So we had a population of younger people luckily because that's our focus.

[00:08:13] [SPEAKER_02]: They were the mean age was between 28, 31 years of age.

[00:08:20] [SPEAKER_02]: We had a population that was active, not elite active individual but still active

[00:08:26] [SPEAKER_02]: individual and most of them had a medial meniscal tear.

[00:08:32] [SPEAKER_02]: And also importantly, we did exclude some people with meniscal tears.

[00:08:37] [SPEAKER_02]: Specifically, we decided not to include the people who had prior surgery of the

[00:08:43] [SPEAKER_02]: affected knee or had a fracture of the leg during the last year.

[00:08:47] [SPEAKER_02]: People who had a displaced bucket hand tear confirmed on MRI and people who had

[00:08:52] [SPEAKER_02]: a complete rupture of any knee ligament.

[00:08:56] [SPEAKER_02]: But other than that, we tried to include everyone who were eligible for surgery as

[00:09:02] [SPEAKER_02]: confirmed by the surgeon.

[00:09:05] [SPEAKER_02]: And we evaluated both groups at baseline at three and six and 12 months.

[00:09:13] [SPEAKER_02]: And the primary endpoint or outcome was the QS4, which was symptoms during sport

[00:09:19] [SPEAKER_02]: and recreation, pain and quality of life and other symptoms, which excluded the

[00:09:25] [SPEAKER_02]: activities of daily living subscale for those who are a bit nerdy in terms of the

[00:09:30] [SPEAKER_02]: QS questionnaire.

[00:09:32] [SPEAKER_02]: What we found was that at 12 months, there were no difference.

[00:09:37] [SPEAKER_02]: We're not able to identify a statistical significant difference between groups.

[00:09:42] [SPEAKER_02]: We found that both groups improved.

[00:09:45] [SPEAKER_02]: The scale is from zero to 100 and the surgical group improved by 19 points while

[00:09:51] [SPEAKER_02]: the non-surgical group, exercise and education group improved by 16%.

[00:09:55] [SPEAKER_02]: So it seemed that both groups improved.

[00:09:59] [SPEAKER_02]: And looking at the secondary outcomes, most outcomes pointed in the same

[00:10:05] [SPEAKER_02]: direction and we only saw very few serious adverse events in both groups.

[00:10:10] [SPEAKER_02]: We ended up concluding that in this group of patients with meniscal tear, a young

[00:10:16] [SPEAKER_02]: active population, that the strategy of early meniscal surgery was not superior to a

[00:10:21] [SPEAKER_02]: exercise and education with the option of later surgery.

[00:10:26] [SPEAKER_02]: I think importantly, because this is something that is quite often questioned

[00:10:30] [SPEAKER_02]: or studies in trials of surgery, where you cannot easily cross over after

[00:10:35] [SPEAKER_02]: surgery to exercise, but you can cross over from exercise to surgery.

[00:10:39] [SPEAKER_02]: There were 26% from the exercise group who crossed over during the 12 months to

[00:10:44] [SPEAKER_02]: the surgical arm.

[00:10:46] [SPEAKER_01]: So about one in four people needed to have that later meniscectomy.

[00:10:52] [SPEAKER_01]: And I think it's important, Suran, you pointed out that the secondary outcomes

[00:10:57] [SPEAKER_01]: were all almost exclusively pointing in the same direction as the primary

[00:11:01] [SPEAKER_01]: outcome, which is really important when you're doing a clinical trial like

[00:11:04] [SPEAKER_01]: this, that it's not only one outcome where you find a significant effect.

[00:11:08] [SPEAKER_01]: When you're seeing that effect consistently across all of the outcomes

[00:11:11] [SPEAKER_01]: that you're measuring, then the strength of your conclusion or the

[00:11:15] [SPEAKER_01]: comfort with which you feel you can draw a conclusion goes up.

[00:11:19] [SPEAKER_01]: You mentioned the STAR trial from the Netherlands.

[00:11:22] [SPEAKER_01]: Quickly, what were the results there and did the STAR trial align with what

[00:11:26] [SPEAKER_01]: you found in the DREAM trial?

[00:11:28] [SPEAKER_02]: And I think that's quite important to flag that the studies actually

[00:11:33] [SPEAKER_02]: found quite similar results.

[00:11:36] [SPEAKER_02]: The difference identified in our study, which was very small and not

[00:11:39] [SPEAKER_02]: significant, was even smaller in the STAR trial.

[00:11:42] [SPEAKER_02]: And interestingly, in the STAR trial, they had a population which was only

[00:11:49] [SPEAKER_02]: traumatic tears.

[00:11:50] [SPEAKER_02]: Our population was primarily traumatic tears, but it also included people

[00:11:55] [SPEAKER_02]: with non-traumatic origin.

[00:11:58] [SPEAKER_02]: But if we looked at their intervention, while we had, as I said before,

[00:12:02] [SPEAKER_02]: a 12-week supervised program, their exercise program was a bit more

[00:12:08] [SPEAKER_02]: at the discretion of the individual physiotherapist.

[00:12:11] [SPEAKER_02]: But still, the results were the same.

[00:12:14] [SPEAKER_02]: And at least to me, that points to the direction that it seems that we're

[00:12:18] [SPEAKER_02]: onto something here also in the younger population.

[00:12:21] [SPEAKER_01]: And we'll come back to those clinical implications for musculoskeletal

[00:12:26] [SPEAKER_01]: rehab clinicians like physiotherapists, physical therapists in a

[00:12:29] [SPEAKER_01]: moment.

[00:12:30] [SPEAKER_01]: But before we get there, Jonas, the DREAM trial concluded that on

[00:12:34] [SPEAKER_01]: average, meniscus surgery wasn't superior to a 12-week program of

[00:12:38] [SPEAKER_01]: supervised exercise in education, as you said, Søren.

[00:12:43] [SPEAKER_01]: And there was the option of having surgery later for people who it was

[00:12:47] [SPEAKER_01]: necessary.

[00:12:48] [SPEAKER_01]: What about the people with a big traumatic bucket-handle tear, someone

[00:12:52] [SPEAKER_01]: who comes in with what looks like a locked knee?

[00:12:55] [SPEAKER_01]: Isn't this a completely different clinical picture that really needs

[00:12:59] [SPEAKER_01]: immediate surgery?

[00:13:01] [SPEAKER_00]: Jonas So that's a very good question.

[00:13:03] [SPEAKER_00]: I perhaps I'll start answering that question a little bit in a different

[00:13:08] [SPEAKER_00]: place, and then I'll get back to that specific question.

[00:13:11] [SPEAKER_00]: So in the DREAM trial, we actually did try to perform a secondary

[00:13:16] [SPEAKER_00]: analysis looking at the different subgroups with traumatic and

[00:13:19] [SPEAKER_00]: non-traumatic meniscal tears.

[00:13:21] [SPEAKER_00]: And this paper was actually published in JOSPT in May this year.

[00:13:27] [SPEAKER_01]: Loretta We'll put the links in the show notes so people can find

[00:13:29] [SPEAKER_01]: the link to the original DREAM trial and also the new JOSPT

[00:13:33] [SPEAKER_01]: publication.

[00:13:34] [SPEAKER_00]: Jonas Excellent.

[00:13:35] [SPEAKER_00]: And the results of this secondary analysis was actually similar to

[00:13:40] [SPEAKER_00]: the main results of the trial.

[00:13:42] [SPEAKER_00]: So in the subgroup with traumatic meniscal tears, there was no

[00:13:46] [SPEAKER_00]: difference in improvement in the primary outcome between patients

[00:13:50] [SPEAKER_00]: having early surgery or those having exercise.

[00:13:53] [SPEAKER_00]: And the same was observed in those who had non-traumatic tears.

[00:13:57] [SPEAKER_00]: Of course, it's important to note that in secondary analysis, the

[00:14:02] [SPEAKER_00]: subgroups are smaller and the precision of the estimates are

[00:14:05] [SPEAKER_00]: less here.

[00:14:06] [SPEAKER_00]: But it pointed in the same direction.

[00:14:09] [SPEAKER_00]: So getting back to your question regarding the patients with

[00:14:13] [SPEAKER_00]: big traumatic bucket-handle tears and a locked knee.

[00:14:16] [SPEAKER_00]: In the DREAM trial and actually also in the STAR trial that

[00:14:20] [SPEAKER_00]: CERN mentioned, these patients were actually excluded.

[00:14:24] [SPEAKER_00]: And this was something that we actually discussed quite a lot in

[00:14:28] [SPEAKER_00]: the steering group of the DREAM trial before initiating the

[00:14:33] [SPEAKER_00]: study.

[00:14:34] [SPEAKER_00]: We decided to exclude those patients as there was a strong

[00:14:38] [SPEAKER_00]: feeling among some of the people in the steering group that

[00:14:41] [SPEAKER_00]: these were a group of patients that really needed the surgery.

[00:14:45] [SPEAKER_00]: But that also has the consequence that we can actually not

[00:14:49] [SPEAKER_00]: answer this question because those patients were excluded in

[00:14:52] [SPEAKER_00]: the study.

[00:14:52] [SPEAKER_00]: So I tend to agree with that, that those patients with large

[00:14:57] [SPEAKER_00]: bucket-handle tears and a complete locked knee, they would

[00:15:00] [SPEAKER_00]: need surgery.

[00:15:01] [SPEAKER_00]: But from kind of a scientific perspective, we can really not

[00:15:05] [SPEAKER_00]: answer that question as we haven't investigated that.

[00:15:09] [SPEAKER_01]: It's tricky, isn't it?

[00:15:10] [SPEAKER_01]: Because as clinicians, we sometimes do have to make

[00:15:13] [SPEAKER_01]: different decisions than what is studied in the research.

[00:15:16] [SPEAKER_01]: And sometimes that's really frustrating because you think,

[00:15:19] [SPEAKER_01]: I don't have so much to guide my clinical decision.

[00:15:23] [SPEAKER_01]: It's important to know who was involved in these studies and

[00:15:27] [SPEAKER_01]: which types of meniscus tears we can really draw conclusions

[00:15:30] [SPEAKER_01]: about.

[00:15:31] [SPEAKER_01]: So thanks for that.

[00:15:32] [SPEAKER_01]: So I want to come back to you about the content of the

[00:15:36] [SPEAKER_01]: exercise therapy and education intervention.

[00:15:39] [SPEAKER_01]: And it's interesting that you mentioned that the STAR trial had a

[00:15:43] [SPEAKER_01]: slightly different approach to rehabilitation, and that does

[00:15:46] [SPEAKER_01]: give flexibility in the sorts of interventions and treatment

[00:15:50] [SPEAKER_01]: programs that people listening could put together.

[00:15:53] [SPEAKER_01]: Give us a bit of a sense of what you feel is important to

[00:15:57] [SPEAKER_01]: include in any sort of program that someone listening today

[00:16:00] [SPEAKER_01]: might think about putting together for a patient with a

[00:16:04] [SPEAKER_01]: meniscus tear.

[00:16:06] [SPEAKER_02]: Well, it's important to consider both self-management

[00:16:10] [SPEAKER_02]: support or education or whatever you call it, but also

[00:16:13] [SPEAKER_02]: exercises.

[00:16:13] [SPEAKER_02]: These are two main non-surgical components of a program

[00:16:18] [SPEAKER_02]: towards young people with a meniscal tear.

[00:16:21] [SPEAKER_02]: And I think sometimes we tend to put less effort in the

[00:16:27] [SPEAKER_02]: patient education part because we feel that the active part,

[00:16:30] [SPEAKER_02]: at least as vicious as myself, we tend to think that

[00:16:33] [SPEAKER_02]: the exercise is the most important thing.

[00:16:36] [SPEAKER_01]: That's where the magic happens.

[00:16:38] [SPEAKER_02]: Yeah, exactly.

[00:16:39] [SPEAKER_02]: We tend to think that at least.

[00:16:40] [SPEAKER_02]: And I think that's a misconception because obviously if

[00:16:43] [SPEAKER_02]: you're part of a supervised program, at least partially

[00:16:46] [SPEAKER_02]: supervised, the fissure will be helpful in terms of

[00:16:50] [SPEAKER_02]: encouraging and motivating the patient to be active and

[00:16:53] [SPEAKER_02]: exercise.

[00:16:54] [SPEAKER_02]: But if you're not as a patient provided with

[00:16:57] [SPEAKER_02]: information on why it's important to continue

[00:17:01] [SPEAKER_02]: exercise and what you can do to kind of avoid or at

[00:17:05] [SPEAKER_02]: least reduce the risk of the long-term consequences of

[00:17:08] [SPEAKER_02]: a meniscal tear, then you're not as well equipped in

[00:17:12] [SPEAKER_02]: terms of continuing the exercise and the activity and

[00:17:16] [SPEAKER_02]: perhaps even avoiding things that could worsen your

[00:17:20] [SPEAKER_02]: knee status as much as if you had received it.

[00:17:23] [SPEAKER_02]: So I think that's quite important to acknowledge that

[00:17:26] [SPEAKER_02]: that is important as well as exercise is important.

[00:17:31] [SPEAKER_02]: And I think gradually across many different conditions,

[00:17:35] [SPEAKER_02]: we tend to see a shift now that while supervised

[00:17:39] [SPEAKER_02]: sessions is important, it might not be as important for

[00:17:44] [SPEAKER_02]: everyone.

[00:17:46] [SPEAKER_02]: So I think individualizing the sessions or

[00:17:48] [SPEAKER_02]: individualizing the program is something that we can

[00:17:52] [SPEAKER_02]: learn not only from these studies but also others.

[00:17:54] [SPEAKER_02]: And we've talked about that for years, but we at least

[00:17:57] [SPEAKER_02]: tend to provide three months of exercise two times a

[00:18:01] [SPEAKER_02]: week for everyone.

[00:18:01] [SPEAKER_02]: It might be that some can use e-based solutions, some

[00:18:05] [SPEAKER_02]: need fewer sessions and some might need more sessions

[00:18:08] [SPEAKER_02]: or even booster sessions along the way to ensure that

[00:18:11] [SPEAKER_02]: they continue being active also in the long term, which

[00:18:14] [SPEAKER_02]: is crucial to the long-term effects.

[00:18:17] [SPEAKER_01]: This point about the number of sessions is really

[00:18:20] [SPEAKER_01]: important, Søren, because we've got people listening

[00:18:24] [SPEAKER_01]: to us from all over the world who operate in very

[00:18:27] [SPEAKER_01]: different health systems.

[00:18:28] [SPEAKER_01]: And for some people, particularly I'm thinking of

[00:18:30] [SPEAKER_01]: our friends and colleagues in the United States where

[00:18:34] [SPEAKER_01]: you are often really limited in the number of

[00:18:36] [SPEAKER_01]: sessions that an insurance company will pay for.

[00:18:39] [SPEAKER_01]: Having the flexibility and knowing that you have

[00:18:41] [SPEAKER_01]: flexibility there in how to structure the program

[00:18:44] [SPEAKER_01]: is really important to putting together something

[00:18:47] [SPEAKER_01]: that's giving the patient the best chance of

[00:18:50] [SPEAKER_01]: success.

[00:18:52] [SPEAKER_00]: One thing that I could add in terms of also the

[00:18:55] [SPEAKER_00]: importance of this patient education part is that

[00:18:58] [SPEAKER_00]: it's really important for balancing the patient's

[00:19:02] [SPEAKER_00]: expectations also.

[00:19:03] [SPEAKER_00]: When patients start rehabilitation after a knee

[00:19:06] [SPEAKER_00]: injury, they often have the idea or the expectation

[00:19:11] [SPEAKER_00]: that they will get a completely healthy knee

[00:19:13] [SPEAKER_00]: again.

[00:19:14] [SPEAKER_00]: But as we can see in this trial, and this also

[00:19:17] [SPEAKER_00]: goes for a lot of other types of knee injuries

[00:19:19] [SPEAKER_00]: that people can improve and they can actually

[00:19:22] [SPEAKER_00]: improve quite a lot from well, in this trial,

[00:19:25] [SPEAKER_00]: the same amount from the surgery and the exercise,

[00:19:28] [SPEAKER_00]: they improve quite a lot.

[00:19:30] [SPEAKER_00]: I think it's also important to state that it's

[00:19:33] [SPEAKER_00]: very few who actually get the feeling of having

[00:19:36] [SPEAKER_00]: a healthy knee again.

[00:19:37] [SPEAKER_00]: I think that is important and that goes for

[00:19:40] [SPEAKER_00]: both the surgical group and the exercise group.

[00:19:42] [SPEAKER_00]: I think that's important to consider that when

[00:19:45] [SPEAKER_00]: you have a knee injury, that actually has some

[00:19:47] [SPEAKER_00]: consequences for you.

[00:19:49] [SPEAKER_00]: It might mean that you need to adjust some

[00:19:53] [SPEAKER_00]: of the things that you're doing or your

[00:19:55] [SPEAKER_00]: expectations of what you can do in the future.

[00:19:58] [SPEAKER_01]: Really important points.

[00:20:00] [SPEAKER_01]: To come back to the exercise therapy more

[00:20:03] [SPEAKER_01]: specifically, some of the people listening

[00:20:06] [SPEAKER_01]: to us today are probably really familiar with

[00:20:08] [SPEAKER_01]: the GLAD program and that's typically rolled

[00:20:11] [SPEAKER_01]: out for people with osteoarthritis.

[00:20:14] [SPEAKER_01]: Are we putting something together a bit similar

[00:20:16] [SPEAKER_01]: to the GLAD program where you've got some

[00:20:18] [SPEAKER_01]: quad strength, you've got some lower limb

[00:20:21] [SPEAKER_01]: general strength training, physical activity?

[00:20:24] [SPEAKER_01]: What does this program for younger people

[00:20:26] [SPEAKER_01]: with meniscus tears look like?

[00:20:28] [SPEAKER_02]: We did include a neuromuscular component.

[00:20:31] [SPEAKER_02]: We had a feasibility study with a group

[00:20:33] [SPEAKER_02]: of patients which also helped us develop

[00:20:36] [SPEAKER_02]: this program, but we did have a neuromuscular

[00:20:38] [SPEAKER_02]: focus like in the GLAD program, obviously

[00:20:41] [SPEAKER_02]: adapted to a younger population so the

[00:20:43] [SPEAKER_02]: exercises had some higher levels of the

[00:20:47] [SPEAKER_02]: different exercises.

[00:20:48] [SPEAKER_02]: But we wanted to include strength training

[00:20:51] [SPEAKER_02]: more specifically in strength training machines

[00:20:54] [SPEAKER_02]: because strength is always important, I would

[00:20:57] [SPEAKER_02]: say, but especially in this younger

[00:20:59] [SPEAKER_02]: population it's quite important to regain

[00:21:02] [SPEAKER_02]: strength and be able to adapt to the new

[00:21:06] [SPEAKER_02]: situation with their knee.

[00:21:07] [SPEAKER_02]: So we had four exercise training on top

[00:21:12] [SPEAKER_02]: of the neuromuscular focus and that also

[00:21:14] [SPEAKER_02]: led to that the program was actually

[00:21:17] [SPEAKER_02]: sometimes a bit longer than what you

[00:21:19] [SPEAKER_02]: would typically receive in clinical

[00:21:21] [SPEAKER_02]: practice as it was up to 90 minutes of

[00:21:23] [SPEAKER_02]: exercise, but also based on the somewhat

[00:21:26] [SPEAKER_02]: active population we included, we felt

[00:21:29] [SPEAKER_02]: and also by the feedback we got from

[00:21:31] [SPEAKER_02]: physiotherapists and patients in the

[00:21:33] [SPEAKER_02]: feasibility trial, we also found that

[00:21:36] [SPEAKER_02]: that was important to ensure that they

[00:21:39] [SPEAKER_02]: regained as much of their strength and

[00:21:41] [SPEAKER_02]: function as they had before the injury.

[00:21:46] [SPEAKER_01]: Okay, Søren, I think we're up to

[00:21:48] [SPEAKER_01]: that key point in the podcast where I

[00:21:51] [SPEAKER_01]: need to ask you to tell us what does

[00:21:52] [SPEAKER_01]: the DREAM trial mean for the

[00:21:54] [SPEAKER_01]: rehabilitation clinicians like physios

[00:21:56] [SPEAKER_01]: who are listening to us today and the

[00:21:58] [SPEAKER_01]: patients with whom they're working?

[00:22:01] [SPEAKER_02]: First of all, I think it's quite

[00:22:02] [SPEAKER_02]: important always to acknowledge the

[00:22:06] [SPEAKER_02]: population you looked at and as we

[00:22:08] [SPEAKER_02]: talked about already there were some

[00:22:11] [SPEAKER_02]: types of knee injury that we did not

[00:22:14] [SPEAKER_02]: include, sometimes of meniscal tears or

[00:22:17] [SPEAKER_02]: more complex knee injuries that we

[00:22:20] [SPEAKER_02]: didn't include and obviously these

[00:22:21] [SPEAKER_02]: results are not something that you

[00:22:25] [SPEAKER_02]: generalized to them but if we look at

[00:22:27] [SPEAKER_02]: the specific population we did include,

[00:22:29] [SPEAKER_02]: it seems that starting with exercise

[00:22:32] [SPEAKER_02]: and education with the option of

[00:22:34] [SPEAKER_02]: later surgery is a feasible approach.

[00:22:37] [SPEAKER_02]: Obviously it's at the discretion of

[00:22:39] [SPEAKER_02]: the patient and the doctor while

[00:22:40] [SPEAKER_02]: discussing the opportunities but up

[00:22:43] [SPEAKER_02]: until our study and the STAR trial

[00:22:45] [SPEAKER_02]: we didn't know whether it was as good

[00:22:48] [SPEAKER_02]: to start with exercise and education

[00:22:50] [SPEAKER_02]: and that is the new thing here,

[00:22:52] [SPEAKER_02]: something that we haven't discussed

[00:22:54] [SPEAKER_02]: yet in this podcast or some of the

[00:22:57] [SPEAKER_02]: other sub-analysis we did because

[00:22:59] [SPEAKER_02]: the question might arise, well how

[00:23:01] [SPEAKER_02]: about the later osteoarthritis or MRI

[00:23:04] [SPEAKER_02]: findings and one of our colleagues

[00:23:06] [SPEAKER_02]: actually studied whether there were

[00:23:09] [SPEAKER_02]: differences at two years in the MRI

[00:23:12] [SPEAKER_02]: worsening whether you started with

[00:23:14] [SPEAKER_02]: exercise and education or surgery

[00:23:16] [SPEAKER_02]: and it seems that there were no

[00:23:18] [SPEAKER_02]: differences so also at that stage in

[00:23:20] [SPEAKER_02]: the clinical discussion with the

[00:23:21] [SPEAKER_02]: patient it looks like that both

[00:23:24] [SPEAKER_02]: groups are doing quite similar in

[00:23:26] [SPEAKER_02]: terms of the changes.

[00:23:28] [SPEAKER_02]: In the clinical discussion with

[00:23:30] [SPEAKER_02]: the patient it's about talking to

[00:23:32] [SPEAKER_02]: them about the needs, about the

[00:23:34] [SPEAKER_02]: preferences and knowing now that

[00:23:36] [SPEAKER_02]: exercise is a viable alternative

[00:23:38] [SPEAKER_02]: to surgery for those who want it.

[00:23:41] [SPEAKER_01]: Absolutely.

[00:23:42] [SPEAKER_01]: And Jonas what's next?

[00:23:44] [SPEAKER_01]: What are the plans to follow up

[00:23:46] [SPEAKER_01]: on the results of the DREAM trial?

[00:23:49] [SPEAKER_00]: So we have some more studies going

[00:23:52] [SPEAKER_00]: on at the moment looking more

[00:23:53] [SPEAKER_00]: detail into the data that we have

[00:23:56] [SPEAKER_00]: from the trial.

[00:23:57] [SPEAKER_00]: Obviously there is a lot of data

[00:23:58] [SPEAKER_00]: when you collect data for a long

[00:24:00] [SPEAKER_00]: period of time on a relatively

[00:24:03] [SPEAKER_00]: large group of patients.

[00:24:04] [SPEAKER_00]: We've already published some of

[00:24:06] [SPEAKER_00]: these secondary analysis as we

[00:24:07] [SPEAKER_00]: talked about but we have also

[00:24:09] [SPEAKER_00]: others planned that are in the

[00:24:11] [SPEAKER_00]: pipeline so I guess that in the

[00:24:14] [SPEAKER_00]: near future you will see more

[00:24:16] [SPEAKER_00]: data coming out from the trial.

[00:24:18] [SPEAKER_00]: That's fantastic.

[00:24:20] [SPEAKER_01]: Now I do want to give you both

[00:24:21] [SPEAKER_01]: the opportunity to say some

[00:24:23] [SPEAKER_01]: thank yous and to acknowledge

[00:24:25] [SPEAKER_01]: maybe some of the behind the

[00:24:26] [SPEAKER_01]: scenes work that goes into a

[00:24:28] [SPEAKER_01]: massive trial like the DREAM

[00:24:30] [SPEAKER_01]: trial.

[00:24:31] [SPEAKER_01]: So maybe Jonas let's start with

[00:24:33] [SPEAKER_01]: you since you've got the mic.

[00:24:35] [SPEAKER_00]: First of all we need to thank

[00:24:36] [SPEAKER_00]: all the patients who

[00:24:37] [SPEAKER_00]: participate and were actually

[00:24:38] [SPEAKER_00]: willing to be randomized.

[00:24:40] [SPEAKER_00]: That's obviously a big decision

[00:24:42] [SPEAKER_00]: for a patient when it's

[00:24:44] [SPEAKER_00]: concerning your treatment.

[00:24:46] [SPEAKER_00]: And then obviously there's a

[00:24:47] [SPEAKER_00]: large team of clinicians and

[00:24:50] [SPEAKER_00]: research collaborators on the

[00:24:52] [SPEAKER_00]: studies so obviously a big

[00:24:54] [SPEAKER_00]: shout out to those and perhaps

[00:24:56] [SPEAKER_00]: then Søren can mention the

[00:24:58] [SPEAKER_00]: people from the study committee

[00:25:00] [SPEAKER_00]: and give them some extra credit.

[00:25:03] [SPEAKER_02]: Yeah, obviously the study

[00:25:05] [SPEAKER_02]: funders and we had as Jonas

[00:25:08] [SPEAKER_02]: said many participating clinics

[00:25:10] [SPEAKER_02]: and orthopedic departments and

[00:25:13] [SPEAKER_02]: in the study committee outside

[00:25:14] [SPEAKER_02]: Jonas and myself it's also

[00:25:16] [SPEAKER_02]: Professor Per Hulmik and

[00:25:17] [SPEAKER_02]: Professor Martin Lind.

[00:25:18] [SPEAKER_02]: And I think you know the courage

[00:25:21] [SPEAKER_02]: among the orthopedic surgeons

[00:25:22] [SPEAKER_02]: to actually question this is

[00:25:24] [SPEAKER_02]: quite important because we are

[00:25:27] [SPEAKER_02]: not now saying that you

[00:25:28] [SPEAKER_02]: shouldn't do surgery.

[00:25:29] [SPEAKER_02]: We are saying that starting

[00:25:30] [SPEAKER_02]: with exercise and education

[00:25:32] [SPEAKER_02]: with the option of later

[00:25:33] [SPEAKER_02]: surgery is also a viable

[00:25:34] [SPEAKER_02]: option and that provides their

[00:25:37] [SPEAKER_02]: colleagues with the option of

[00:25:38] [SPEAKER_02]: discussing the treatment

[00:25:39] [SPEAKER_02]: options with the patients

[00:25:41] [SPEAKER_02]: based on evidence.

[00:25:42] [SPEAKER_02]: So a big shout out and thanks

[00:25:44] [SPEAKER_02]: to the courage of the

[00:25:47] [SPEAKER_02]: orthopedic surgeons in Denmark.

[00:25:49] [SPEAKER_01]: When you're questioning accepted

[00:25:51] [SPEAKER_01]: or what has seemed to have

[00:25:52] [SPEAKER_01]: become accepted practice that

[00:25:54] [SPEAKER_01]: we need to have surgery for

[00:25:56] [SPEAKER_01]: these types of injuries or

[00:25:57] [SPEAKER_01]: these types of pain problems

[00:25:59] [SPEAKER_01]: as you say Søren there is

[00:26:01] [SPEAKER_01]: a degree of courage to say

[00:26:03] [SPEAKER_01]: actually is that true and

[00:26:05] [SPEAKER_01]: I'm going to subject that

[00:26:06] [SPEAKER_01]: idea that I've had all that

[00:26:08] [SPEAKER_01]: heuristic that I use in my

[00:26:09] [SPEAKER_01]: clinical practice to the rigors

[00:26:11] [SPEAKER_01]: of a randomized controlled trial

[00:26:13] [SPEAKER_01]: and it's been wonderful to get

[00:26:15] [SPEAKER_01]: some of the insight into how

[00:26:17] [SPEAKER_01]: those decisions come into a

[00:26:19] [SPEAKER_01]: trial and just how much work

[00:26:21] [SPEAKER_01]: is involved in doing a big

[00:26:24] [SPEAKER_01]: influential clinical trial

[00:26:25] [SPEAKER_01]: like the dream trial.

[00:26:27] [SPEAKER_01]: So I want to say a big thanks

[00:26:28] [SPEAKER_01]: to both of you,

[00:26:29] [SPEAKER_01]: Jonas Doeland and Søren Skal

[00:26:31] [SPEAKER_01]: for joining me on the

[00:26:33] [SPEAKER_01]: JOSPT Insights podcast today.

[00:26:35] [SPEAKER_02]: Thank you for having us.

[00:26:37] [SPEAKER_02]: You're welcome.

[00:26:42] [SPEAKER_01]: Thanks for listening to this

[00:26:43] [SPEAKER_01]: episode of JOSPT Insights.

[00:26:45] [SPEAKER_01]: For more discussion of the

[00:26:47] [SPEAKER_01]: musculoskeletal rehabilitation

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[00:27:16] Bye.