Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults

BACKGROUND

Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS).

OBJECTIVES

This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied.

SELECTION CRITERIA

We included randomised and non-randomised controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence.

MAIN RESULTS

For this update we included six additional studies; 21 trials in total. Seventeen trials included people with chronic non-specific neck or shoulder complaints, or non-specific upper extremity disorders. Over 25 interventions were evaluated; five main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, and energised splint. Overall, the quality of the studies was poor. In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome.

AUTHORS' CONCLUSIONS

There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage; breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy; and manual therapy as an add-on treatment to exercises.

Prognostic indicators for non-recovery of non-traumatic complaints at arm, neck and shoulder in general practice--6 months follow-up

OBJECTIVES

To identify predictors of non-recovery in non-traumatic complaints at the arm, neck and shoulder in general practice 6 months after the first consultation.

METHODS

A prospective cohort study was set in 21 Dutch general practices. Consulters with a first or new episode of non-traumatic arm, neck or shoulder complaints and age 18 through 64 yrs entered the cohort. Complaint, patient, physical, psychosocial and work characteristics were investigated as possible predictors of non-recovery at 6 months using multiple logistic regression analyses (backward Wald).

RESULTS

At 6 months, 46% of the total population (n = 612) and 42% of the working subpopulation (n = 473) still reported complaints. Complaint characteristics (long duration of the complaint before consultation, recurrent complaint, musculoskeletal comorbidity and complaint mainly located at wrist or hand) were most predictive of non-recovery followed by psychosocial characteristics (more somatization and experiencing less social support). Having a specific diagnosis was associated with recovery. In the working subpopulation, the same variables were predictors of non-recovery. Additionally, low supervisory support was associated with non-recovery. The models correctly classified 72-75% of the patients (explained variance 0.27-0.28).

CONCLUSIONS

Besides questions on complaint characteristics, information on somatization and support can help a general practitioner to recognize patients at risk of persistent complaints.

General practitioners' management of lumbosacral radicular syndrome compared with a clinical guideline

OBJECTIVE

To investigate the current treatment policy of general practitioners (GPs) in patients with a lumbosacral radicular syndrome (LRS) compared with their clinical guideline.

DESIGN

A cross sectional survey.

METHODS

Sixty-three GPs completed questionnaires about their treatment policy in individual LRS patients at baseline and at six months follow-up. Simultaneously, 136 LRS patients of these GPs were interviewed at baseline, and at three and six month's follow-up.

RESULTS

Of the 12 recommendations in the guideline related to history taking, four were not adhered to by the GPs in about 25% of the patients. Of the ten recommended physical examinations, three are not frequently carried out by the GPs. Almost 40% of the patients were referred to physiotherapy and 27% received muscle relaxants.

CONCLUSION

The majority of the GPs support the content of the LRS guideline. Overall, there was a good adherence with the guideline for history taking and physical examination, and a moderate adherence for treatment policy.

Prophylactic treatment of migraine in children. Part 1. A systematic review of non-pharmacological trials

The aim of this study was to assess the efficacy of non-pharmacological prophylactic treatments of migraine in children. Databases were searched from inception to June 2004 and references were checked. We selected controlled trials reporting the effects of non-pharmacological prophylactic treatments in children with migraine. We assessed trial quality using the Delphi list and extracted data. Analyses were carried out according to type of intervention. A total of 19 trials were included. Relaxation, relaxation + biofeedback, relaxation + biofeedback + cognitive behavioural treatment were more effective compared with waiting list controls. Relaxation + behavioural therapy was more effective than placebo. There is conflicting evidence for the use of oligoantigenic diets. A few non-pharmacological treatments such as relaxation may be effective as prophylactic treatment for migraine in children. Because of the small number of studies and the methodological shortcomings, conclusions on effectiveness have to be drawn with caution.

Reliability and responsiveness of the Dutch version of the Neck Disability Index in patients with acute neck pain in general practice

A prospective cohort study with a 1 week follow-up. To examine the reliability and responsiveness of the Dutch version of the Neck Disability Index (NDI) in patients with acute neck pain in general practice. An increasing number of studies on treatment options is published in which the NDI is used. Reports of the ability of the NDI to detect change over time, often called responsiveness, however have not yet been published. At baseline 187 patients (119 women, 68 men) were included. They completed a questionnaire on demographic variables, self-reported cause of their complaints and the NDI. After 1 week, 86 patients were sent the NDI again together with the perceived recovery scale which was used as our external criterion. The scale ranged from 1 (complete recovery) to 7 (complaints are worse than ever). Response rate was 93%. Test-retest scores on reliability were good (ICC = 0.90). A Bland and Altman plot and a graph of total sum score differences showed no visible tendency towards unequal spreading of the data. For patients that reported on the perceived recovery scale that they were "stable" we found a responsiveness ratio of 1.82. The standard error of measurement (SEM) was 0.60 what resulted in a minimal detectable change (MDC) of 1.66. The NDI has shown to be a reliable and responsive instrument in patients with acute neck pain in general practice.

Daily spinal mechanical loading as a risk factor for acute non-specific low back pain: a case-control study using the 24-Hour Schedule

A case-control study was conducted to assess the daily loading of the spine as a risk factor for acute non-specific low back pain (acute LBP). Acute LBP is a benign, self-limiting disease, with a recovery rate of 80-90% within 6 weeks irrespective of the treatment type. Unfortunately, recurrence rates are high. Therefore, prevention of acute LBP could be beneficial. The 24-Hour Schedule (24HS) is a questionnaire developed to quantify physical spinal loading, which is regarded as a potential and modifiable risk factor for acute and recurrent low back pain. A total of 100 cases with acute LBP and 100 controls from a primary care setting were included. Cases and controls completed questionnaires regarding acute LBP status and potential risk factors. Trained examiners blinded to subjects' disease status (acute LBP or not) assessed spinal loading using the 24HS. The mean difference of 24HS sum-scores between groups was statistically significant (P < 0.0001). After multivariate regression analysis, previous episode(s), the 24HS and the Nottingham Health Profile were associated with the presence of acute LBP. High 24HS scores, indicating longer and more intensive spinal loading in flexed position, are strongly associated with acute LBP.

Education by general practitioners or education and exercises by physiotherapists for patients with whiplash-associated disorders? A randomized clinical trial

STUDY DESIGN

Randomized clinical trial.

OBJECTIVE

To compare the effectiveness of education and advice given by general practitioners (GPs) with education, advice, and active exercise therapy given by physiotherapists (PTs) for patients with whiplash-associated disorders.

SUMMARY OF BACKGROUND DATA

Available evidence from systematic reviews has indicated beneficial effects for active interventions in patients with whiplash-associated disorders. However, it remained unclear which kind of active treatment was most effective.

METHODS

Whiplash patients with symptoms or disabilities at 2 weeks after accident were recruited in primary care. Eligible patients still having symptoms or disabilities at 4 weeks were randomly allocated to GP care or physiotherapy. GPs and PTs treated patients according to a dynamic multimodal treatment protocol primarily aimed to increase activities and influence unfavorable psychosocial factors for recovery. We trained all health care providers about the characteristics of the whiplash problem, available evidence regarding prognosis and treatment, and protocol of the interventions. The content of the information provided to patients during treatment depended on the treatment goals set by the GPs or PTs. Also, the type of exercises chosen by the PTs depended on the treatment goals, and it was not explicitly necessary that exercise therapy was provided in all patients. Primary outcome measures included neck pain intensity, headache intensity, and work activities. Furthermore, an independent blinded assessor measured functional recovery, cervical range of motion, disability, housekeeping and social activities, fear of movement, coping, and general health status. We assessed outcomes at 8, 12, 26, and 52 weeks after the accident.

RESULTS

A total of 80 patients were randomized to either GP care (n = 42) or physiotherapy (n = 38). At 12 and 52 weeks, no significant differences were found concerning the primary outcome measures. At 12 weeks, physiotherapy was significantly more effective than GP care for improving 1 of the measures of cervical range of motion (adjusted mean difference 12.3 degrees ; 95% confidence interval [CI] 2.7-21.9). Long-term differences between the groups favored GP care but were statistically significant only for some secondary outcome measures, including functional recovery (adjusted relative risk 2.3; 95% CI 1.0-5.0), coping (adjusted mean difference 1.7 points; 95% CI 0.2-3.3), and physical functioning (adjusted mean difference 8.9 points; 95% CI 0.6-17.2).

CONCLUSIONS

We found no significant differences for the primary outcome measures. Treatment by GPs and PTs were of similar effectiveness. The long-term effects of GP care seem to be better compared to physiotherapy for functional recovery, coping, and physical functioning. Physiotherapy seems to be more effective than GP care on cervical range of motion at short-term follow-up.

The effect of Tai Chi Chuan in reducing falls among elderly people: design of a randomized clinical trial in the Netherlands [ISRCTN98840266]

BACKGROUND

Falls are a significant public health problem. Thirty to fifty percent of the elderly of 65 years and older fall each year. Falls are the most common type of accident in this age group and can result in fractures and subsequent disabilities, increased fear of falling, social isolation, decreased mobility, and even an increased mortality. Several forms of exercise have been associated with a reduced risk of falling and with a wide range of physiological as well as psychosocial health benefits. Tai Chi Chuan seems to be the most promising form of exercise in the elderly, but the evidence is still controversial. In this article the design of a randomized clinical trial is presented. The trial evaluates the effect of Tai Chi Chuan on fall prevention and physical and psychological function in older adults.

METHODS/DESIGN

270 people of seventy years and older living at home will be identified in the files of the participating general practitioners. People will be asked to participate when meeting the following inclusion criteria: have experienced a fall in the preceding year or suffer from two of the following risk factors: disturbed balance, mobility problems, dizziness, or the use of benzodiazepines or diuretics. People will be randomly allocated to either the Tai Chi Chuan group (13 weeks, twice a week) or the no treatment control group. The primary outcome measure is the number of new falls, measured with a diary. The secondary outcome measures are balance, fear of falling, blood pressure, heart rate, lung function parameters, physical activity, functional status, quality of life, mental health, use of walking devices, medication, use of health care services, adjustments to the house, severity of fall incidents and subsequent injuries. Process parameters will be measured to evaluate the Tai Chi Chuan intervention. A cost-effectiveness analysis will be carried out alongside the evaluation of the clinical results. Follow-up measurements will be collected at 3, 6 and 12 months after randomization.

DISCUSSION

As far as we know this is the first trial in Europe considering Tai Chi Chuan and fall prevention. This project will answer a pragmatic research question regarding the efficacy of Tai Chi Chuan regarding fall reduction.

Conservative treatments of children with episodic tension–type headache

OBJECTIVE

We aimed to assess the effectiveness of conservative treatments in children with tension-type headaches (TTH).

METHOD

We searched Medline, Embase and the Cochrane Library and performed reference checking. Two independent authors assessed trial quality and extracted data. Analysis was carried out according to type of intervention.

RESULTS

In total we included 11 trials (427 TTH patients, age between 7-18 years) in this review. None of the studies were considered to be of high quality. Eight studies evaluated the effectiveness of relaxation training. Four studies included a waiting list or no treatment control group and in one study a placebo was used.

CONCLUSION

We found conflicting evidence about the effectiveness of relaxation therapy when compared with no treatment or other treatments, with Relative Risks varying from 1.4 (0.6-3.2) to 10.6 (1.6-71.3). With regard to all other interventions evaluated (such as biofeedback, cognitive therapy or flupirtin) no evidence is found for or against their effectiveness.

Symptomatic treatment of migraine in children: a systematic review of medication trials

OBJECTIVE

Treatment of pediatric migraine includes an individually tailored regimen of both nonpharmacologic and pharmacologic measures. The mainstay of symptomatic treatment in children with migraine is intermittent oral or suppository analgesics, but there is no coherent body of evidence on symptomatic treatment of childhood migraine available. The objective of this review is to describe and assess the evidence from randomized and clinical controlled trials concerning the efficacy and tolerability of symptomatic treatment of migraine in children.

DESIGN

Systematic review according to the standards of the Cochrane Collaboration.

METHODS

Databases were searched from inception to June 2004. Additional reference checking was performed. Two authors independently selected randomized and controlled trials evaluating the effects of symptomatic treatment in children (<18 years old) with migraine, using headache (HA) clinical improvement as an outcome measure. Two authors assessed trial quality independently by using the Delphi list, and data were extracted from the original reports by using standardized forms. Quantitative and qualitative analysis was conducted according to type of intervention.

RESULTS

A total of 10 trials were included in this review, of which 6 studies were considered to be of high quality. The number of included participants in each trial ranged from 14 to 653, with a total of 1575 patients included in this review. Mean dropout rate was 19.8% (range: 0-39.1%), and the mean age of participants was 11.7 +/- 2.2 years (range: 4-18 years). All studies used HA diaries to assess outcomes. In most studies, a measure of clinical improvement was calculated by using these diaries. Improvement often was regarded as being clinically relevant when the patients' HA declined by > or =50%. Regarding oral analgesic treatment, the effectiveness of acetaminophen, ibuprofen, and nimesulide were evaluated. When compared with placebo, acetaminophen (relative risk [RR]: 1.5; 95% confidence interval [CI]: 1.0-2.1) and ibuprofen (pooled RR: 1.5; 95% CI: 1.2-1.9) significantly reduced HAs. We conclude that there is moderate evidence that both acetaminophen and ibuprofen are more effective in reduction of symptoms 1 and 2 hours after intake than placebo with minor adverse effects. No clear differences in effect were found between acetaminophen and ibuprofen or nimesulide. Regarding the nonanalgesic interventions, nasal-spray sumatriptan, oral sumatriptan, oral rizatriptan, oral dihydroergotamine, intravenous prochlorperazine, and ketorolac were evaluated. When compared with placebo, nasal-spray sumatriptan (pooled RR: 1.4; 95% CI: 1.2-1.7) seemed to significantly reduce HAs. We conclude that there is moderate evidence that nasal-spray sumatriptan is more effective in reduction of symptoms than placebo but with significantly more adverse events. No differences in effect were found between oral triptans and placebo. All medications were well tolerated, but significantly more adverse events were reported for nasal-spray sumatriptan compared with placebo. We also conclude that there is moderate evidence that intravenous prochlorperazine is more effective than intravenous ketorolac in the reduction of symptoms 1 hour after intake. No differences in effect were found between oral dihydroergotamine and placebo.

CONCLUSIONS

Acetaminophen, ibuprofen, and nasal-spray sumatriptan are all effective symptomatic pharmacologic treatments for episodes of migraine in children. The new frontier for symptomatic treatment is likely to be the development of triptan agents for use in children. Most treatments have only been evaluated in 1 or 2 studies, which limits the generalizability of the findings. We strongly recommend performing a large, high-quality randomized, controlled trial evaluating different symptomatic medications compared with each other or to placebo treatment. Favorable high-quality studies should be performed and reported according to the CONSORT statement. Clinical improvement of HA should be used as the primary outcome measure, but quality of life, days missed at school, and satisfaction of child or parents should also be used as an outcome measure in future studies.

[High level of satisfaction among patients despite persistent symptoms in the mid-long-term following surgery for lumbosacral radicular syndrome]

OBJECTIVE

To determine the mid-long-term outcomes after surgery in patients with lumbosacral radicular syndrome (LRS) and to identify prognostic factors for persisting LRS symptoms.

DESIGN

Descriptive retrospective and prospective.

METHOD

A total of 250 consecutive patients operated on by 7 neurosurgeons in four hospitals between May and December 2001 were selected from medical records. They were asked to take part in a telephone questionnaire at 6 and 19 months after operation. They had all undergone discectomy for LRS at L4-L5 or L5-S1 and were aged from 18 to 65.

RESULTS

Of the 250 patients, 163 participated in the study: 63% reported that they still had LRS-related symptoms 19 months after surgery. However, severe leg pain had decreased in 83% of the patients. In general the patients were satisfied with their treatment. Female gender and an age of 51-65 were prognostic factors for persistent LRS symptoms.

CONCLUSION

More than half of the patients reported LRS symptoms 19 months after surgery.

Prognostic factors for poor recovery in acute whiplash patients

The objective of our prospective inception cohort study was to identify prognostic factors for poor recovery in patients with whiplash-associated disorders grade 1 or 2 who still had neck pain and accompanying complaints 2 weeks after the accident. The study was carried out in a primary health care setting in The Netherlands and included 125 patients. The primary outcome measure was functional recovery defined in terms of neck pain intensity or work disability without medication use. The secondary outcome measures included neck pain intensity, work disability and sick leave. The outcomes were assessed at 4, 12 and 52 weeks after the accident. Prognostic factors were identified by logistic regression analyses. One year after the injury, 64% of the patients were recovered. Factors related to poor recovery were female gender, a low level of education, high initial neck pain, more severe disability, higher levels of somatisation and sleep difficulties. Neck pain intensity and work disability proved to be the most consistent predictors for poor recovery. The accuracy of the predictions of the prognostic models was high, meaning that the models adequately distinguished patients with poor recovery from those regarded as recovered. These findings add to the growing body of evidence, indicating that socio-demographic, physical and psychological factors affect short- and long-term outcome after whiplash injury. Our findings also indicate that care providers can easily identify patients at risk for poor recovery with a visual analogue scale for initial pain intensity and work-related activities.

Braces and orthoses for treating osteoarthritis of the knee

BACKGROUND

Patients with osteoarthritis of the knee can be treated with a brace or orthosis (shoe insole). The main purpose of these aids is to reduce pain, improve physical function and, possibly, to slow disease progression.

OBJECTIVES

To assess the effectiveness of a brace or orthosis in the treatment of osteoarthritis of the knee.

SEARCH STRATEGY

We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE (Current contents, Health STAR) up to October 2002. The reference lists of the publications in the identified trials were also screened.

SELECTION CRITERIA

Extracted studies were included in the final analysis if they met the pre-defined inclusion criteria: 1) a randomised controlled clinical trial or a controlled clinical trial, 2) all patients had osteoarthritis of the knee, 3) the intervention in one of the studied groups was a brace or an orthosis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected the trials and assessed the methodological quality using the Delphi-list and one additional question about care programs. Three reviewers independently extracted the data on the intervention, type of outcome measures, follow-up, loss to follow-up, and results, using a pre-tested standardized form. Study authors were contacted for additional information.

MAIN RESULTS

Four trials involving a total of 444 people were included in this review. One study investigated a knee brace and three studies examined different types of orthoses for medial compartment osteoarthritis of the knee. Two studies were of high methodological quality while the other two studies were low. Notably, the randomisation and the blinding procedures were either insufficient or not described. The follow-up period (six weeks to six months) was too short to demonstrate long-term results. Pooling was difficult primarily due to the heterogeneity of the data and the way the information was presented. The pain, stiffness and physical function (WOMAC and MACTAR) scores of a brace group showed greater improvement at six months compared with a neoprene sleeve group, which showed greater improvement compared with a control group. The numbers of days of non-steroidal anti-inflammatory drug (NSAID) intake decreased significantly (relative percentage difference 23.9%) compared with baseline in a group with laterally wedged insoles,and remained unchanged in the neutrally wedged group. Patient compliance with the laterally wedged insole was significantly better compared with the neutrally wedged insole. In one study, the Visual Analogue Pain (VAS) pain score was significantly decreased from baseline in a strapped insole group (RPD - 24%), but not in the traditional lateral wedge group, but this strapped insole showed more adverse effects (popliteal pain, low back pain, and foot sole pain) compared with the traditional lateral wedge insole. Pain during bed rest, after getting up, after getting up from seated position and walking distance was significantly improved in a subtalar strapped group compared with baseline, and no improvement was found in a sock type group. No studies were found that assessed the effectiveness of a brace or orthosis to treat lateral compartment osteoarthritis or general osteoarthritis of the knee, or that compared a knee brace with a wedge insole, or that compared a brace or orthosis with operative treatment.

AUTHORS' CONCLUSIONS

Based on one brace study we conclude there is limited evidence that: a brace has additional beneficial effect (WOMAC, MACTAR, function tests) for knee osteoarthritis compared with medical treatment alone.(Silver) a sleeve has additional beneficial effect (WOMAC, function tests) for knee osteoarthritis compared with medical treatment alone.(Silver) a brace is more effective (WOMAC, function tests) than a neoprene sleeve.(Silver) Based on 3 orthoses studies, of which 2 were high quality, (n=2) we conclude there is limited evidence that: a laterally wedged insole decreases NSAID intake compared with a neutral insole. (Silver) patient compliance is better in the laterally wedged insole compared with a neutral insole. (Silver) a strapped insole has more adverse effects than a lateral wedge insole. (Silver).

Osteotomy for treating knee osteoarthritis

BACKGROUND

Patients with unicompartmental osteoarthritis of the knee can be treated with a correction osteotomy. The goal of the correction osteotomy is to transfer the load bearing from the pathologic to the normal compartment of the knee. A successful outcome of the osteotomy relies on proper patient selection, stage of osteoarthritis, achievement and maintenance of adequate operative correction.

OBJECTIVES

To assess the effectiveness and safety of an osteotomy for treating osteoarthritis of the knee.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE (Current contents, Health STAR) were searched up until October 2002 for controlled clinical trials. The reference lists of publications in the identified trials were also screened.

SELECTION CRITERIA

Extracted studies were included in the final analysis if they met the pre-defined inclusion criteria: 1) a randomised controlled clinical trial or a controlled clinical trial 2) all patients had unicompartmental osteoarthritis of the medial or lateral compartment of the knee 3) the intervention in one of the studied groups was a high tibial osteotomy or a distal femoral osteotomy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected the trials, assessed the methodological quality using a validated tool and extracted the data. The planned analysis was to pool the results where appropriate, however, due the heterogeneity of the studies, pooling of the outcome measures was not possible. Results are described for each study and presented as a best evidence synthesis.

MAIN RESULTS

Following the search strategy and applications of selection criteria, eleven studies were included in this review. All the studies concerned a valgus high tibial osteotomy (HTO) for medial compartment osteoarthritis of the knee. Four studies compared two techniques of HTO. One study compared HTO alone versus HTO with additional treatment. Four studies compared within the same type of HTO, different per-operative conditions (two studies) or two different types of post-operative treatment (two studies). Two studies compared HTO with unicompartmental joint replacement. No study compared an osteotomy with conservative treatment. Most studies showed improvement of the patient (less pain and improvement of function scores) after osteotomy surgery, but in the majority of the studies there was no significant difference with other operative treatment (other technique of HTO/ unicompartmental joint replacement). Overall, the methodological quality was low.

AUTHORS' CONCLUSIONS

Based on 11 studies, of which 6 were high quality, we conclude that there is silver level evidence that valgus HTO improves knee function and reduces pain. There is no evidence whether an osteotomy is more effective than conservative treatment and the results so far do not justify a conclusion about effectiveness of specific surgical techniques.

Neurosurgeons' management of lumbosacral radicular syndrome evaluated against a clinical guideline

To establish to what extent neurosurgeons subscribe to the lumbosacral radicular syndrome (LRS) guideline, and to evaluate their current management of patients with LRS against the guideline. All active neurosurgeons in the Netherlands (n=92) were mailed a questionnaire about the guideline and data from 66 responders were analysed. Patients were recruited via seven of the participating neurosurgeons and were interviewed once by telephone. The medical records of the participating patients (n=163) were also examined. Of the 26 propositions in the LRS guideline, seven were not fully endorsed by the neurosurgeons. Three of these seven propositions may need updating based on "new evidence". The time between the onset of the LRS episode and the actual moment of surgery was considerably longer than that recommended in the guideline. Based on their current management of LRS patients, the neurosurgeons largely adhere with the LRS guideline.

The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review

The study design is a systematic review of randomised clinical trials (RCTs). The objectives of the present study are to assess the effectiveness of physiotherapy and (spinal) manipulation in patients with tension-type headache (TTH). No systematic review exists concerning the effectiveness of physiotherapy and (spinal) manipulation primarily focussing on TTH. Literature was searched using a computerised search of MEDLINE, EMBASE and the Cochrane library. Only RCTs including physiotherapy and/or (spinal) manipulation used in the treatment of TTH in adults were selected. Two reviewers independently assessed the methodological quality of the RCTs using the Delphi-list. A study was considered of high quality if it satisfied at least six points on the methodological quality list. Twelve publications met the inclusion criteria, including three dual or overlapping publications resulting in eight studies included. These studies showed a large variety of interventions, such as chiropractic spinal manipulation, connective tissue manipulation or physiotherapy. Only two studies were considered to be of high quality, but showed inconsistent results. Because of clinical heterogeneity and poor methodological quality in many studies, it appeared to be not possible to draw valid conclusions. Therefore, we conclude that there is insufficient evidence to either support or refute the effectiveness of physiotherapy and (spinal) manipulation in patients with TTH.

Do neurosurgeons subscribe to the guideline lumbosacral radicular syndrome?

BACKGROUND

This study presents a survey of the opinion of neurosurgeons on the multidisciplinary clinical guideline 'lumbosacral radicular syndrome'. The aim was to describe to what extent neurosurgeons in the Netherlands endorse the content of this guideline. The guideline was issued in 1996 by the Netherlands Institute of Quality Health Care and this is the first attempt to evaluate the implementation of this guideline.

METHODS

All active neurosurgeons (n=92) in the Netherlands were invited to complete a questionnaire investigating to what extent they agree with the 26 recommendations in the guideline 'lumbosacral radicular syndrome'. The results are represented in frequencies (%) in order to express the magnitude of their consent or dissent with the recommendations.

RESULTS

Overall, 75% of the neurosurgeons responded and, of these, 94% agreed (at least partially) with the content of the guideline. Of the 26 recommendations in the guideline, seven were not fully endorsed by the neurosurgeons. Three of these seven recommendations may need revision based on newly published data.

CONCLUSION

This survey shows that almost all neurosurgeons subscribed (at least partially) to the multidisciplinary LRS guideline. Therefore, one important aspect of the implementation process has been fulfilled, i.e. acceptance of the content of the guideline.

Pelvic pain during pregnancy: a descriptive study of signs and symptoms of 870 patients in primary care

STUDY DESIGN

The authors conducted a cross-sectional analysis.

OBJECTIVE

The objective of this study was to describe the signs and symptoms of pregnant women with pain and dysfunction in the pelvic area.

SUMMARY OF BACKGROUND DATA

Pelvic pain during pregnancy is common with incidence rates of 48% to 56%. The exact cause of pelvic pain during pregnancy is still unclear. Also unclear is the association between physical examination and the occurrence of pelvic pain during pregnancy.

METHODS

Pregnant women with pelvic pain were sent for treatment to 2 physical therapy practices between January 1997 and January 2002. A standardized clinical examination protocol and an extensive questionnaire were used to obtain relevant clinical and demographic characteristics.

RESULTS

In total, 870 women were included. The average score of the overall severity of the complaints was 7.8 (scale 0-15). Main complaints were located around the sacroiliac joints (76.6%) and the pubic symphysis (57.2%). The area of pain was not related to positive signs in passive hip movements and sacroiliac tests. The highest positive test results were found for Patrick sign (71.7%), active straight leg raise (ASLR) test (66.4%), resisted adduction (54.4%), and passive hip abduction (36.9%). Overall severity of complaints was related to age, number of weeks pregnant, passive hip flexion and internal rotation, and swimming. The total explained variance of these factors was 15.9%. No relationship was found between overall complaints and sacroiliac tests, pelvic pain during a previous pregnancy, extremely painful or type of previous deliveries.

CONCLUSIONS

Pregnant patients with pelvic pain show a considerable level of complaints. The overall severity of complaints is not related to previous peripartum pelvic pain or type of deliveries or to commonly used tests. Further study on the role of clinical examination, including passive flexion and internal rotation of the hip joints, is recommended.

Conservative treatment in patients with an acute lumbosacral radicular syndrome: design of a randomised clinical trial [ISRCTN68857256]

Background

The objective is to present the design of randomised clinical trial (RCT) on the effectiveness of physical therapy added to general practitioners management compared to general practitioners management only in patients with an acute lumbosacral radicular syndrome (also called sciatica).

Methods/Design

Patients in general practice diagnosed with an acute (less than 6 weeks) lumbosacral radicular syndrome and an age above 18 years are eligible for participation. The general practitioners treatment follows their clinical guideline. The physical therapy treatment will consist of patient education and exercise therapy. The primary outcome measure is patients reported global perceived effect. Secondary outcome measures are severity of complaints, functional status, health status, fear of movement, medical consumption, sickness absence, costs and treatment preference. The follow-up is 52 weeks.

Discussion

Treatment by general practitioners and physical therapists in this study will be transparent and not a complete "black box". The results of this trial will contribute to the decision of the general practitioner regarding referral to physical therapy in patients with an acute lumbosacral radicular syndrome.

Does this patient have an instability of the shoulder or a labrum lesion?

CONTEXT

History taking and clinical tests are commonly used to diagnose shoulder pain. Unclear is whether tests and history accurately diagnose instability or intra-articular pathology (IAP).

OBJECTIVE

To analyze the accuracy of clinical tests and history taking for shoulder instability or IAP.

DATA SOURCES

Relevant studies identified through PubMed, EMBASE, CINAHL, and bibliographies of known primary and review articles.

STUDY SELECTION

Studies comparing the performance of history items or physical examination with a reference standard were included. Studies on fibromyalgia, fractures, or systemic disorders were excluded. Of 1449 articles, 35 were eligible, and 17 were selected.

DATA EXTRACTION

Data were extracted on study population, clinical tests, reference tests, and outcome. The studies' methodological quality (patient spectrum, verification, blinding, and replication) was assessed with the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) checklist.

DATA SYNTHESIS

Six tests showed positive likelihood ratios (LRs) and confidence intervals (CIs). Tests favoring the diagnosis for establishing instability included: relocation (LR, 6.5; 95% CI, 3.0-14.0) and anterior release (LR, 8.3; 95% CI, 3.6-19). Tests showing promise for establishing labral lesions included: the biceps load I and II (LR, 29; 95% CI, 7.3-115.0 and LR, 26; 95% CI, 8.6-80.0), respectively, pain provocation of Mimori (LR, 7.2; 95% CI, 1.6-32.0), and internal rotation resistance strength (LR, 25; 95% CI, 8.1-76.0). The apprehension, clunk, release, load and shift, and sulcus sign tests proved less useful. Results should be cautiously interpreted because studies were completed in select populations in orthopedic practice, mostly assessed by the test designers, and evaluated in single studies only. No accuracy studies were found for history taking or for clinical tests in primary care.

CONCLUSIONS

Shoulder complaints are frequently recurrent. Instability might cause some of these complaints. Best evidence supports the value of the relocation and anterior release tests. Symptoms related to IAP (labral tears) remain unclear. Most promising for establishing labral tears are currently the biceps load I and II, pain provocation of Mimori, and the internal rotation resistance strength tests.

Effectiveness of behavioural graded activity compared with physiotherapy treatment in chronic neck pain: design of a randomised clinical trial [ISRCTN88733332]

Background

Chronic neck pain is a common complaint in the Netherlands with a point prevalence of 14.3%. Patients with chronic neck pain are often referred to a physiotherapist and, although many treatments are available, it remains unclear which type of treatment is to be preferred.

The objective of this article is to present the design of a randomised clinical trial, Ephysion, which examines the clinical and cost effectiveness of behavioural graded activity compared with a physiotherapy treatment for patients with chronic non-specific neck pain.

Methods

Eligible patients with non-specific neck pain persisting longer than 3 months will be randomly allocated to either the behavioural graded activity programme or to the physiotherapy treatment. The graded activity programme is based on an operant approach, which uses a time-contingent method to increase the patient's activity level. This treatment is compared with physiotherapy treatment using a pain-contingent method.

Primary treatment outcome is the patient's global perceived effect concerning recovery from the complaint. Global perceived effect on daily functioning is also explored as primary outcome to establish the impact of treatment on daily activity. Direct and indirect costs will also be assessed. Secondary outcomes include the patient's main complaints, pain intensity, medical consumption, functional status, quality of life, and psychological variables. Recruitment of patients will take place up to the end of the year 2004 and follow-up measurement will continue until end 2005.

Influence of hip dysplasia on the development of osteoarthritis of the hip

BACKGROUND

It has been suggested that in some patients with primary hip osteoarthritis (OA), the disease occurs as a consequence of acetabular dysplasia or hip dysplasia (HD).

OBJECTIVE

To carry out a systematic review to investigate the association between acetabular dysplasia and hip OA.

METHODS

A database search of Medline, Embase, and the Cochrane library was carried out, and articles that aimed at studying the relationship between HD and hip OA were identified. The methodological quality of the selected studies was assessed using a standardised set of criteria, and a best evidence synthesis was used to summarise the results from the individual studies.

RESULTS

Five cohort studies and four case-control studies were included in this review. One cohort study had the correct design to answer the question and was considered to be a high quality study. This study reported a positive association between HD and hip OA. Overall, limited evidence was found for a positive association between HD and hip OA. Most studies included older people. In younger age groups the relation between HD and OA or hip complaints may be much higher.

CONCLUSION

The evidence for the influence of HD on the occurrence of hip OA, at age 50-60 or older, is limited.

Prevalence and incidence of shoulder pain in the general population; a systematic review

OBJECTIVE

To investigate the incidence and prevalence of shoulder complaints in the general population.

METHOD

A systematic review of the literature was conducted. Medline, Embase, and Cinahl were searched for relevant studies.

RESULTS

Eighteen studies on prevalence and one study on incidence met the inclusion criteria. Incidence figures of 0.9-2.5% were found for different age groups. Prevalence figures differed from 6.9 to 26% for point prevalence, 18.6-31%, for 1-month prevalence, 4.7-46.7% for 1-year prevalence and 6.7-66.7% for lifetime prevalence. Prevalence rates decreased when the case definition was restricted, in terms of duration of pain or the presence of limited movements, and increased when the location for pain was enlarged.

CONCLUSION

The reported prevalence figures on shoulder complaints diverged strongly. Health professionals and policymakers who estimate the amount of medical care needed and related costs should be aware of the variations in prevalence rate and the underlying reasons for these differences.

Validity, reliability, and applicability of seven definitions of hip osteoarthritis used in epidemiological studies: a systematic appraisal

OBJECTIVE

To summarise and review articles addressing the quality (validity, reliability, applicability) of seven commonly used definitions of hip osteoarthritis (OA) for epidemiological studies in order to use it primarily as a classification criterion.

METHODS

Medline and Embase were searched and articles studying the validity, reliability, or applicability of the definitions of hip OA were selected. Two reviewers independently extracted data on the quality of the seven definitions.

RESULTS

Review of the literature showed the validity of the various definitions of hip OA, in particular, has barely been investigated. Minimal joint space (MJS) demonstrated the highest (intra- and interrater) reliability, and showed the highest association with hip pain and restricted internal rotation compared with the other definitions of hip OA. The reliability of the Kellgren and Lawrence grade and the index according to Lane is comparable with that of the MJS, but the construct validity should be investigated more thoroughly. The reliability and validity according to the Croft grade were inferior to the MJS, the Kellgren and Lawrence grade, and the index according to Lane. Despite precise and extensive development, the ACR criteria showed poor reliability and poor cross-validity (agreement between three ACR criteria sets) in a primary care setting.

CONCLUSIONS

The reliabilities of MJS, Kellgren and Lawrence, and the index according to Lane were comparable, but the MJS had the highest relationship with hip pain in a male population. Considering how often definitions of hip OA are used, it is surprising that the validity has been so poorly investigated, and the validity needs to be studied more thoroughly.

The efficacy of Tai Chi Chuan in older adults: a systematic review

OBJECTIVES

The purpose of this study was to assess the effect of Tai Chi Chuan (TCC) on fall prevention, balance and cardiorespiratory functions in the elderly.

METHODS

A systematic review was carried out according to the Cochrane standards. A computerized literature search was carried out. Studies were selected when they had an experimental design; the age of the study population was >50; one of the interventions was a form of TCC; and when falls, balance or cardiorespiratory functions were used as an outcome measure. A total of seven studies were included, with in total 505 participants, of whom all but 27 were healthy seniors, age between 53 and 96 years.

RESULTS

In most studies, the intervention of TCC is a modified Yang style, varying from 10 to 24 forms. The intensity of TCC varies from 1 h weekly for 10 weeks to 1 h every morning for 1 year. One study used falls as outcome measure and reported a beneficial effect of 47% in the TCC group. All studies mention a beneficial effect of TCC, but in most studies this conclusion was based on a pre-post analysis.

CONCLUSION

There is limited evidence that TCC is effective in reducing falls and blood pressure in the elderly.

Conservative treatments for whiplash

BACKGROUND

Our previous review examining conservative treatments for whiplash was published in 2001. Since then, new trials have been published.Whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms: WAD Grade 0 indicates no complaints or physical signs; Grade 1 indicates neck complaints but no physical signs; Grade 2 indicates neck complaints and musculoskeletal signs; Grades 3 and 4 indicate neck complaints and neurological signs or fracture/dislocation, respectively.

OBJECTIVES

To assess the effectiveness of conservative treatment in patients with WAD Grades 1 or 2.

SEARCH STRATEGY

We completed a computerised search of CENTRAL, MEDLINE, EMBASE, CINAHL, PsycLIT, and PEDro, to April 2003. We also screened references of identified trials and relevant systematic reviews.

SELECTION CRITERIA

Studies were selected if they were a (randomised) clinical trial, examined patients with a WAD, examined conservative treatments, measured one of: pain, global perceived effect or participation in daily activities, and were published in English, French, German or Dutch.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the methodological quality using the Delphi list and extracted the data using standardised forms. Because the population, interventions and outcome measures were heterogeneous, we used a rating system with levels of evidence rather than statistical pooling for the analysis. Clinically relevant improvement was defined as a 15% improvement relative to a control. A pre-planned stratified analysis was performed in three groups.

MAIN RESULTS

We found four new studies since the previous review, resulting in 15 studies that met the inclusion criteria. Just one study evaluated patients with chronic WAD. Only three studies satisfied one of our criteria of high quality, indicating overall a poor methodological quality. The broad array of conservative interventions were divided into passive and active interventions and were compared with each other, no treatment, or a placebo group. There was limited evidence that both passive and active interventions seemed to be more effective than no treatment. Contrary to our earlier review, we found conflicting evidence about the effectiveness of active interventions compared to passive ones. All but one study mentioned positive results, but the actual data of the high quality studies were conflicting.

REVIEWER'S CONCLUSIONS

When looking at the actual data presented in the current included trials, our conclusion from the previous version of this review, that 'rest makes rusty', can no longer be justified. There is a trend suggesting that active interventions are more effective than passive ones, but no clear conclusion can be drawn. We can draw no conclusion about the most effective therapy for patients with chronic WAD, because only one low quality trial was found.

Ergonomic and physiotherapeutic interventions for treating upper extremity work related disorders in adults

BACKGROUND

Conservative interventions such as physiotherapy and ergonomic adjustments play a major part in the treatment of most work-related musculoskeletal disorders (WRMD).

OBJECTIVES

The objective of this systematic review is to determine whether conservative interventions have a significant impact on short and long-term outcomes for upper extremity WRMD in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002) and Cochrane Rehabilitation and Related Therapies Field specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2001), PubMed (1966 to November 2001), EMBASE (1988 to November 2001), and CINAHL (1982 to November 2001). We also searched the Physiotherapy Index (1988 to November 2001) and reference lists of articles. No language restrictions were applied.

SELECTION CRITERIA

Only randomised controlled trials and concurrent controlled trials studying conservative interventions for adults suffering from upper extremity WRMD were included. Conservative interventions may include exercises, relaxation, physical applications, biofeedback, myofeedback and work place adjustments.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected the trials from the search yield and assessed the clinical relevance and methodological quality using the Delphi list. In the event of clinical heterogeneity or lack of data we used a rating system to assess levels of evidence.

MAIN RESULTS

We included 15 trials involving 925 people. Twelve trials included people with chronic non-specific neck or shoulder complaints, or non-specific upper extremity disorders. Over 20 interventions were evaluated; seven main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, multidisciplinary treatment, energised splint and individual treatment versus group therapy. Overall, the quality of the studies appeared to be poor. In 10 studies a form of exercise was evaluated, and there is limited evidence about the effectiveness of exercises only when compared to no treatment. Concerning manual therapy (1 study), massage (4 studies), multidisciplinary treatment (1 study) and energised splint (1 study) no conclusions can be drawn. Limited evidence is found concerning the effectiveness of specific keyboards for patients with carpal tunnel syndrome.

REVIEWER'S CONCLUSIONS

This review shows limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of individual exercises. The benefit of expensive ergonomic interventions (such as new chairs, new desks etc) in the workplace is not clearly demonstrated.

Interventions for impetigo

BACKGROUND

Impetigo is a common superficial bacterial skin infection, most frequently encountered in children. There is no standard therapy and guidelines for treatment differ widely. Treatment options include many different oral and topical antibiotics as well as disinfectants.

OBJECTIVES

To assess the effects of treatments for impetigo, including waiting for natural resolution.

SEARCH STRATEGY

We searched the Skin Group Specialised Trials Register (March 2002), Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1 2002), the National Research Register (2002), MEDLINE (from 1966 to January 2003), EMBASE (from 1980 to March 2000) and LILACS (November 2001). We handsearched the Yearbook of Dermatology (1938-1966), the Yearbook of Drug Therapy (1949-1966), used reference lists of articles and contacted pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials of treatments for non-bullous and bullous, primary and secondary impetigo.

DATA COLLECTION AND ANALYSIS

All steps in data collection were done by two independent reviewers. We performed quality assessments and data collection in two separate stages.

MAIN RESULTS

We included 57 trials including 3533 participants in total which studied 20 different oral and 18 different topical treatments. CURE OR IMPROVEMENT: Topical antibiotics showed better cure rates than placebo (pooled odds ratio (OR) 6.49, 95% confidence interval (CI) 3.93 to 10.73), and no topical antibiotic was superior (pooled OR of mupirocin versus fusidic acid 1.76, 95% CI 0.69 to 2.16). Topical mupirocin was superior to oral erythromycin (pooled OR 1.22, 95% CI 1.05 to 2.97). In most other comparisons, topical and oral antibiotics did not show significantly different cure rates, nor did most trials comparing oral antibiotics. Penicillin was inferior to erythromycin and cloxacillin and there is little evidence that using disinfectant solutions improves impetigo.

SIDE EFFECTS

The reported number of side effects was low. Oral antibiotic treatment caused more side effects, especially gastrointestinal ones, than topical treatment.

REVIEWERS' CONCLUSIONS

Data on the natural course of impetigo are lacking. Placebo controlled trials are scarce. There is little evidence about the value of disinfecting measures. There is good evidence that topical mupirocin and topical fusidic acid are equally, or more effective than oral treatment for people with limited disease. It is unclear if oral antibiotics are superior to topical antibiotics for people with extensive impetigo. Fusidic acid and mupirocin are of similar efficacy. Penicillin was not as effective as most other antibiotics. Resistance patterns against antibiotics change and should be taken into account in the choice of therapy.

Randomized clinical trial of conservative treatment for patients with whiplash-associated disorders: considerations for the design and dynamic treatment protocol

BACKGROUND

Whiplash concerns a considerable problem to health care. Available evidence from systematic reviews indicates beneficial effects of active interventions for patients with whiplash injury. In order to evaluate whether a general practitioner or a physiotherapist should provide these active interventions, we have designed a randomized clinical trial.

OBJECTIVE

The purpose of this article is to present the design of the trial and to provide transparency into the dynamic treatment protocol used.

PATIENTS

Patients with whiplash-associated disorders grade I and II who still have symptoms and disabilities 4 weeks after the accident.

INTERVENTIONS

A dynamic treatment protocol consisting of 4 different subprotocols. The primary aim is to increase their activities and to improve their quality of life. Content and intensity of treatment are described. Outcome measures The primary outcome measures are pain and disability. The short-term effects are measured at 12 weeks and long-term effects at 1 year after the trauma.

CONCLUSION

To date, generally the effect of one intervention compared to another intervention has been examined. In our opinion, this cannot be considered as usual care for physiotherapy or general practice. Therefore, a dynamic treatment protocol has been developed to structure the black box of usual physiotherapy and general practice treatment. The results of this trial will be available in 0.5 year.

Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies

We present a systematic review of prospective cohort studies. Our aim was to assess prognostic factors associated with functional recovery of patients with whiplash injuries. The failure of some patients to recover following whiplash injury has been linked to a number of prognostic factors. However, there is some inconsistency in the literature and there have been no systematic attempts to analyze the level of evidence for prognostic factors in whiplash recovery. Studies were selected for inclusion following a comprehensive search of MEDLINE, EMBASE, CINAHL, the database of the Dutch Institute of Allied Health Professions up until April 2002 and hand searches of the reference lists of retrieved articles. Studies were selected if the objective was to assess prognostic factors associated with recovery; the design was a prospective cohort study; the study population included at least an identifiable subgroup of patients suffering from a whiplash injury; and the paper was a full report published in English, German, French or Dutch. The methodological quality was independently assessed by two reviewers. A study was considered to be of 'high quality' if it satisfied at least 50% of the maximum available quality score. Two independent reviewers extracted data and the association between prognostic factors and functional recovery was calculated in terms of risk estimates. Fifty papers reporting on twenty-nine cohorts were included in the review. Twelve cohorts were considered to be of 'high quality'. Because of the heterogeneity of patient selection, type of prognostic factors and outcome measures, no statistical pooling was able to be performed. Strong evidence was found for high initial pain intensity being an adverse prognostic factor. There was strong evidence that for older age, female gender, high acute psychological response, angular deformity of the neck, rear-end collision, and compensation not being associated with an adverse prognosis. Several physical (e.g. restricted range of motion, high number of complaints), psychosocial (previous psychological problems), neuropsychosocial factors (nervousness), crash related (e.g. accident on highway) and treatment related factors (need to resume physiotherapy) showed limited prognostic value for functional recovery. High initial pain intensity is an important predictor for delayed functional recovery for patients with whiplash injury. Often mentioned factors like age, gender and compensation do not seem to be of prognostic value. Scientific information about prognostic factors can guide physicians or other care providers to direct treatment and to probably prevent chronicity.

Interobserver reliability of the 24-hour schedule in patients with low back pain: a questionnaire measuring the daily use and loading of the spine

BACKGROUND

Low back pain is a major health problem in western industrialized countries. The 24-Hour Schedule (24HS) is an instrument which intends to obtain insight in the use (ie, posture and applied load) of the back. It consists of a questionnaire, a series of photos, and a registration form.

OBJECTIVE

To assess the interexaminer reliability of the 24-Hour Schedule in patients with low back pain. Study design Reliability study.

METHODS

People with low back pain were included in the study. Sample size calculation indicated that 40 participants would be sufficient to answer the research question. Participants were coded to remain anonymous, and after giving informed consent, they completed a questionnaire. Two trained examiners assessed each participant independently. In total, 5 examiners participated.

RESULTS

Forty participants were analyzed. In our study population, the use of the back was approximately 10 times more in a flexed position compared to a lordotic position. Flexed activity was registered in all 80 assessments, but in 39 assessments, there was no registration of any activity in a lordotic posture. In only 1 participant (diagnosed with Bechterew's disease), the use of the back was more in a lordotic than in a flexed posture. The intraclass correlation coefficient of the assessment was 0.81 (95% confidence interval = 0.67-0.89), corresponding with a high level of agreement between the examiners.

CONCLUSION

The interobserver reliability of the 24HS appeared to be high.

Balneotherapy for rheumatoid arthritis

BACKGROUND

Balneotherapy (spa therapy) for patients with arthritis is one of the oldest forms of therapy. One of the aims of balneotherapy is to soothe the pain, improve joint motion and as a consequence to relieve people' suffering and make them feel well.

OBJECTIVES

To perform a systematic review on the effectiveness of balneotherapy for rheumatoid arthritis.

SEARCH STRATEGY

Using the Cochrane search strategy, studies were found by screening: 1) The MEDLINE CD-ROM database from 1966 to June 2002 and 2) the database from the Cochrane 'Rehabilitation and Related Therapies' Field, the Pedro database up to June 2002. Also, 3) reference checking and 4) personal communications with authors was carried out to retrieve eligible studies. Date of the most recent literature search: June, 2002

SELECTION CRITERIA

Studies were eligible if they were randomised controlled trials (RCTs) comparing balneotherapy with any other intervention or with no intervention. Included participants all suffered from definite or classical rheumatoid arthritis (RA) as defined by the American Rheumatism Association Criteria (ARA) or by the criteria of Steinbrocker. At least one of the WHO/ILAR core set of endpoints for RA clinical trials had to be among the main outcome measures.

DATA COLLECTION AND ANALYSIS

The Delphi list was the criteria list used to assess the components of methodological quality. Two reviewers carried out quality assessment and data extraction of the studies. Disagreements were solved by consensus.

MAIN RESULTS

Six trials, representing 355 people, were included in this review. Most trials reported positive findings (the absolute improvement in measured outcomes ranged from 0 to 44%), but were methodologically flawed to some extent. A 'quality of life' outcome was reported by two trials. None of the trials performed an intention-to-treat analysis and only two performed a comparison of effects between groups. Pooling of the data was not performed; because of heterogeneity of the studies, multiple outcome measurements, and the overall data presentation was too scarce.

REVIEWER'S CONCLUSIONS

One cannot ignore the positive findings reported in most trials. However the scientific evidence is insufficient because of the poor methodological quality, the absence of an adequate statistical analysis, and the absence, for the patient, of most essential outcome measures (pain, self assessed function, quality of life). Therefore, the noted "positive findings" should be viewed with caution. Because of the methodological flaws an answer about the apparent effectiveness of balneotherapy cannot be provided at this moment. A large, methodological sound trial is needed.

Influence of obesity on the development of osteoarthritis of the hip: a systematic review

OBJECTIVE

To evaluate the evidence for the influence of obesity as a risk factor for the occurrence of osteoarthritis (OA) of the hip.

METHODS

A bibliographical search of Medline, EMBASE and the Cochrane library until April 2000 was carried out. Articles describing studies of the relationship between obesity and the occurrence of hip OA were selected. The quality of the studies was assessed with a standardized set of criteria. The outcome of the studies was compared with respect to study characteristics and the quality score for the study. A best-evidence synthesis was used to summarize the results of the individual studies.

RESULTS

Five longitudinal and seven cross-sectional studies were included in this review. There was no association between outcome and study design or methodological quality. The associations between obesity and hip OA were, however, stronger in studies in which the diagnosis of hip OA was based not only on radiological criteria but also on clinical symptoms. Overall, moderate evidence was found for a positive association between obesity and the occurrence of hip OA, with an odds ratio of approximately 2.

CONCLUSION

The evidence for a positive influence of obesity on the development of hip OA is moderate.

The influence of methodologic quality on the conclusion of a landmark meta-analysis on thrombolytic therapy

OBJECTIVE

We studied the influence of the methodologic quality of individual trials on the outcome of a landmark meta-analysis on thrombolytic therapy in acute myocardial infarction. From each study we extracted the number of patients in both groups who died in hospital or during follow-up. Methodologic quality was assessed using the Delphi list. We first recalculated pooled odds ratios (ORs) and 95% confidence intervals (CIs), on the studies found and compared them with the original results of Yusuf et al. Next we incorporated the results of quality assessment in five different ways in the calculation of the pooled ORs: a) component analysis; b) visual plot; c) quality score as a threshold score; d) quality score as a weighting factor; and e) cumulative pooling.

RESULTS AND CONCLUSION

No correlation between quality scores and ORs was found. Studies with a proper description of the different quality components provided an estimate close to the true treatment effect. No major differences were found between the results of the five different methods of incorporating the quality scores into the final conclusion.

Clinical practice guideline for the physiotherapy of patients with whiplash-associated disorders

STUDY DESIGN

A clinical practice guideline.

OBJECTIVES

To assist physiotherapists in decision making and to improve the efficacy and uniformity of care for patients with whiplash-associated disorders Grades I and II.

SUMMARY OF BACKGROUND DATA

Whiplash constitutes a considerable problem in health care. Many interventions are used in physiotherapy practice, despite increasing evidence for the use of active interventions. There is still no clinical practice guideline for the management of patients with whiplash-associated disorders. METHOD OF DEVELOPMENT: A computerized literature search of Medline, Cinahl, Cochrane Controlled Trial Register, Cochrane Database of Systematic Reviews, and the Database of the Dutch National Institute of Allied Health Professions was performed to search for information about the diagnostic process and the therapeutic process in whiplash patients. When no evidence was available, consensus between experts was achieved to develop the guideline. Practicing physiotherapists reviewed the clinical applicability and feasibility of the guideline, and their comments were used to improve it.

RECOMMENDATIONS

The diagnostic process consists of systematic history taking and a physical examination supported by reliable and valid assessment tools to document symptoms and functional disabilities. The primary goals of treatment are a quick return to normal activities and the prevention of chronicity. Active interventions such as education, exercise therapy, training of functions, and activities are recommended according to the length of time since the accident and the rate of recovery. The biopsychosocial model is used to address the consequences of whiplash trauma.

CONCLUSIONS

Scientific evidence for the diagnosis and physiotherapeutic management of whiplash is sparse; therefore, consensus is used in different parts of the guideline. The guideline reflects the current state of knowledge of the effective and appropriate physiotherapy in whiplash patients. More and better research is necessary to validate this guideline in the future.

The art of quality assessment of RCTs included in systematic reviews

The best evidence on the efficacy of medical interventions is provided by high-quality trials summarized in high-quality systematic reviews or meta-analyses. The methodological quality of studies included in a systematic review can have a substantial impact on the estimates of the treatment effect and therefore on the conclusions of such a review. But what is the empirical evidence to support quality assessment of randomized clinical trials (RCTs)? We elaborate on questions such as: what is the concept of quality of individual studies (RCTs), can quality be measured validly and reliably? Plans for future research on this issue are proposed.

Impact of quality items on study outcome. Treatments in acute lateral ankle sprains

OBJECTIVE

This study investigates the influence of different aspects of methodologic quality on the conclusions of a systematic review concerning treatments of acute lateral ankle sprain.

METHOD

A data set of a systematic review of 44 trials was used, of which 22 trials could be included in this study. Quality assessment of the individual studies was performed using the Delphi list. We calculated effect sizes of the main outcome measure in each study in order to evaluate the relationship between overall quality scores and outcome. Next, we investigated the impact of design attributes on pooled effect sizes by subgroup analysis.

RESULTS

The quality of most studies (82%) was low; only 4 of 22 trials were of high quality. Studies with proper randomization and blinding procedure produce a slightly higher (not statistically significant) effect estimate compared to the other studies.

CONCLUSION

Previous research has suggested that methodologically poorly designed studies tend to over-estimate the effect estimate. Our study does not confirm these conclusions.

The efficacy of conservative treatment in patients with whiplash injury: a systematic review of clinical trials

STUDY DESIGN

A systematic review of the literature.

OBJECTIVES

To assess the efficacy of conservative treatment in patients with whiplash injuries.

SUMMARY OF BACKGROUND DATA

Many treatments are available for patients with whiplash injury, but there continues to be no evidence for their accepted use.

METHODS

A computerized literature search of Medline, Embase, Cinahl, Psychlit, and the Cochrane Controlled Trial Register was performed. Studies were selected if the design was a (randomized) clinical trial; if all patients had sustained a whiplash injury; if the type of intervention was a conservative one; if pain, global perceived effect, and participation in daily activities were used as one of the outcome measures, and if the publication was written in English, French, German, or Dutch. The methodologic quality was independently assessed by two reviewers by using the Maastricht-Amsterdam list. Three quality scores were calculated using this criteria list: the Overall Methodologic Quality Score, the Internal Validity Score, and the Delphi Quality Score. The conclusion of the review was based on articles that scored a quality score of at least 50% of the maximum available score on two of three quality scores.

RESULTS

Eleven studies met the inclusion criteria. Only three studies satisfied at least 50% on two of three ways of calculating a quality score, indicating overall poor methodology. There was a high rank correlation among the three ways of calculating a quality score. No statistical pooling was performed because of the heterogeneity of the interventions. This review indicates that active treatments show a beneficial long-term effect on at least one of the primary outcome measures.

CONCLUSION

Caution is needed when drawing a valid conclusion on the efficacy of conservative treatments in patients with whiplash injury. It appears that "rest makes rusty," whereas active interventions have a tendency to be more effective in patients with whiplash injury.

Conservative treatment for whiplash

BACKGROUND

Many treatments are available for whiplash-patients, but to date, no evidence exists for their effectiveness.

OBJECTIVES

The objective of this systematic review was to assess the efficacy of conservative treatment in patients with whiplash-injuries (rated as Whiplash-Associated Disorders [WAD] I or II).

SEARCH STRATEGY

A computerized literature search of Medline, Embase, Cinahl, Psychlit and the Cochrane Controlled Trial Register through June 1998 was carried out. We also screened reference lists of publications of identified randomized trials and relevant systematic reviews.

SELECTION CRITERIA

Studies were selected for inclusion if they fit the following criteria: design was a (randomized) clinical trial (RCT); all patients had suffered a whiplash-injury; the type of intervention was a conservative one; pain, global perceived effect, or participation in daily activities was used as one of the outcome measures; and the publication was written in English, French, German or Dutch.

DATA COLLECTION AND ANALYSIS

The methodological quality of the studies was independently assessed by two reviewers using the Maastricht-Amsterdam list. Three quality scores were calculated using this criteria list: the Overall methodological Quality Score, the Internal Validity Score and the Delphi Quality Score. The conclusion of the review was based on articles that scored a quality score of at least 50 percent of the maximum available score on two out of three quality scores.

MAIN RESULTS

Eleven studies met the inclusion criteria. A broad variety of conservative interventions were evaluated, and only one study was performed in chronic whiplash patients. Only three studies satisfied at least 50 percent on two out of three quality scores indicating poor overall methodological quality. A high rank correlation was observed among the three methods of quality. Because of the heterogeneity of patient selection, interventions and outcome measures, no statistical pooling was performed. This review indicates that active treatments show a beneficial effect on at least one of the primary outcome measures, preferably pain.

REVIEWER'S CONCLUSIONS

It appears that "Rest makes rusty." In other words, rest and immobilization using collars are not recommended for the treatment of whiplash, while active interventions, such as advice to 'maintain usual activities' might be effective in whiplash-patients. Nevertheless, caution is needed when attempting to draw conclusions regarding the efficacy of conservative treatments in whiplash-patients, because of the paucity of high-quality studies. No conclusions can be drawn about the most effective therapy for chronic whiplash-patients because only one low quality trial was identified.

Elevated risk of cancer of the urinary tract for alcohol drinkers: a meta-analysis

OBJECTIVES

Recent narrative reviews have concluded that there is no support for an association between alcohol consumption and urinary tract cancer. Many individual studies, however, have reported positive associations, although rarely statistically significant. The purpose of this meta-analysis is to summarize and quantify this relationship with more statistical power and to perform a sensitivity analysis on the study characteristics.

METHODS

We included 16 epidemiological studies published up to April 1999 and calculated summary odds ratios (SORs), both upgraded and adjusted for age, sex and smoking by meta-regression analyses. The age- and smoking-adjusted SORs (current alcohol drinking vs. non-drinking) were 1.3 (95% CI 0.9-2.0) for six studies with men and 1.0 (95% CI 0.4-2.6) for four studies with women.

RESULTS

The age-, sex- and smoking-adjusted SOR was 1.2 (95% CI 0.9-1.7) for seven studies with men and women combined.

CONCLUSION

Even though studies differed in methodology, the results were rather consistent. Subgroup analyses by type or amount of alcohol were not possible due to sparse data. We conclude that the available data suggest a slightly increased risk of urinary tract cancer from alcohol consumption for men. The risk related to alcohol consumption for women and the influence of the amount and type of alcohol remain unclear.