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An Overview of Randomization Techniques for Clinical Trials Minsoo Kang, Phd*; Brian G

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An Overview of Randomization Techniques for Clinical Trials Minsoo Kang, Phd*; Brian G Journal of Athletic Training 2008;43(2):215–221 g by the National Athletic Trainers’ Association, Inc communications www.nata.org/jat Issues in Outcomes Research: An Overview of Randomization Techniques for Clinical Trials Minsoo Kang, PhD*; Brian G. Ragan, PhD, ATCÀ; Jae-Hyeon Park, PhD` *Middle Tennessee State University, Murfreesboro, TN; 3University of Northern Iowa, Cedar Falls, IA; 4Korea National Sport University, Seoul, Korea Objective: To review and describe randomization tech- controlling the influence of covariates a priori are important. niques used in clinical trials, including simple, block, stratified, Various techniques have been developed to account for these and covariate adaptive techniques. issues, including block, stratified randomization, and covariate Background: Clinical trials are required to establish treat- adaptive techniques. ment efficacy of many athletic training procedures. In the past, Advantages: Athletic training researchers and scholarly we have relied on evidence of questionable scientific merit to aid clinicians can use the information presented in this article to the determination of treatment choices. Interest in evidence- better conduct and interpret the results of clinical trials. based practice is growing rapidly within the athletic training Implementing these techniques will increase the power and profession, placing greater emphasis on the importance of well- validity of findings of athletic medicine clinical trials, which will conducted clinical trials. One critical component of clinical trials ultimately improve the quality of care provided. that strengthens results is random assignment of participants to Key Words: minimization, simple randomization, block control and treatment groups. Although randomization appears randomization, stratified randomization, covariate adaptive to be a simple concept, issues of balancing sample sizes and randomization utcomes research is critical in the evidence-based such as flipping a coin, may result in imbalanced sample health care environment because it addresses size and baseline characteristics (ie, covariates) among Oscientific questions concerning the efficacy of treatment and control groups.9,10 This imbalance of treatments. Clinical trials are considered the ‘‘gold baseline characteristics can influence the comparison standard’’ for outcomes in biomedical research. In athletic between treatment and control groups and introduce training, calls for more evidence-based medical research, potential confounding factors. Many procedures have been specifically clinical trials, have been issued.1,2 proposed for random group assignment of participants in The strength of clinical trials is their superior ability to clinical trials.11 Simple, block, stratified, and covariate measure change over time from a treatment. Treatment adaptive randomizations are some examples. Each tech- differences identified from cross-sectional observational nique has advantages and disadvantages, which must be designs rather than experimental clinical trials have carefully considered before a method is selected. Our methodologic weaknesses, including confounding, cohort purpose is to introduce the concept and significance of effects, and selection bias.3 For example, using a non- randomization and to review several conventional and randomized trial to examine the effectiveness of prophy- relatively new randomization techniques to aid in the lactic knee bracing to prevent medial collateral ligament design and implementation of valid clinical trials. injuries may suffer from confounders and jeopardize the results. One possible confounder is a history of knee WHAT IS RANDOMIZATION? injuries. Participants with a history of knee injuries may be more likely to wear braces than those with no such history. Randomization is the process of assigning participants Participants with a history of injury are more likely to to treatment and control groups, assuming that each suffer additional knee injuries, unbalancing the groups and participant has an equal chance of being assigned to any influencing the results of the study. group.12 Randomization has evolved into a fundamental The primary goal of comparative clinical trials is to aspect of scientific research methodology. Demands have provide comparisons of treatments with maximum preci- increased for more randomized clinical trials in many areas sion and validity.4 One critical component of clinical trials of biomedical research, such as athletic training.2,13 In fact, is random assignment of participants into groups. Ran- in the last 2 decades, internationally recognized major domizing participants helps remove the effect of extraneous medical journals, such as the Journal of the American variables (eg, age, injury history) and minimizes bias Medical Association and the BMJ, have been increasingly associated with treatment assignment. Randomization is interested in publishing studies reporting results from considered by most researchers to be the optimal approach randomized controlled trials.5 for participant assignment in clinical trials because it Since Fisher14 first introduced the idea of randomization strengthens the results and data interpretation.4–9 in a 1926 agricultural study, the academic community has One potential problem with small clinical trials (n , deemed randomization an essential tool for unbiased 100)7 is that conventional simple randomization methods, comparisons of treatment groups. Five years after Fisher’s Journal of Athletic Training 215 introductory paper, the first randomized clinical trial involving tuberculosis was conducted.15 A total of 24 participants were paired (ie, 12 comparable pairs), and by a flip of a coin, each participant within the pair was assigned to either the control or treatment group. By employing randomization, researchers offer each participant an equal chance of being assigned to groups, which makes the groups comparable on the dependent variable by eliminat- ing potential bias. Indeed, randomization of treatments in clinical trials is the only means of avoiding systematic characteristic bias of participants assigned to different treatments. Although randomization may be accomplished with a simple coin toss, more appropriate and better methods are often needed, especially in small clinical trials. These other methods will be discussed in this review. WHY RANDOMIZE? Researchers demand randomization for several reasons. Figure 1. Imbalance of sample size between treatment arms due to First, participants in various groups should not differ in simple randomization (coin toss) in a small trial (n = 10). any systematic way. In a clinical trial, if treatment groups are systematically different, trial results will be biased. HOW TO RANDOMIZE? Suppose that participants are assigned to control and Many procedures have been proposed for the random treatment groups in a study examining the efficacy of a assignment of participants to treatment groups in clinical walking intervention. If a greater proportion of older trials. In this article, common randomization techniques, adults is assigned to the treatment group, then the outcome including simple randomization, block randomization, of the walking intervention may be influenced by this stratified randomization, and covariate adaptive random- imbalance. The effects of the treatment would be indistin- ization, are reviewed. Each method is described along with guishable from the influence of the imbalance of covari- its advantages and disadvantages. It is very important to ates, thereby requiring the researcher to control for the select a method that will produce interpretable, valid covariates in the analysis to obtain an unbiased result.16 results for your study. Second, proper randomization ensures no a priori knowl- edge of group assignment (ie, allocation concealment). Simple Randomization That is, researchers, participants, and others should not know to which group the participant will be assigned. Randomization based on a single sequence of random Knowledge of group assignment creates a layer of potential assignments is known as simple randomization.10 This selection bias that may taint the data. Schulz and Grimes17 technique maintains complete randomness of the assign- stated that trials with inadequate or unclear randomization ment of a person to a particular group. The most common tended to overestimate treatment effects up to 40% and basic method of simple randomization is flipping a compared with those that used proper randomization. coin. For example, with 2 treatment groups (control versus The outcome of the trial can be negatively influenced by treatment), the side of the coin (ie, heads 5 control, tails 5 this inadequate randomization. treatment) determines the assignment of each participant. Statistical techniques such as analysis of covariance Other methods include using a shuffled deck of cards (eg, (ANCOVA), multivariate ANCOVA, or both, are often even 5 control, odd 5 treatment) or throwing a die (eg, used to adjust for covariate imbalance in the analysis stage below and equal to 3 5 control, over 3 5 treatment). A of the clinical trial. However, the interpretation of this random number table found in a statistics book or postadjustment approach is often difficult because imbal- computer-generated random numbers can also be used ance of covariates frequently leads to unanticipated for simple randomization of participants. interaction effects, such as unequal slopes among sub- This randomization approach is simple and
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