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Parreira PCS, Maher CG, Megale RZ, March L, Ferreira ML. An overview of clinical guidelines for the management of vertebral compression fracture: a systematic review. Spine J 2017; 17:1932-1938. [PMID: 28739478 DOI: 10.1016/j.spinee.2017.07.174] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 07/07/2017] [Accepted: 07/17/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Vertebral compression fractures (VCFs) are the most common type of osteoporotic fracture comprising approximately 1.4 million cases worldwide. Clinical practice guidelines can be powerful tools for promoting evidence-based practice as they integrate research findings to support decision making. However, currently available clinical guidelines and recommendations, established by different medical societies, are sometimes contradictory. PURPOSE The aim of this study was to appraise the recommendations and the methodological quality of international clinical guidelines for the management of VCFs. STUDY DESIGN This is a systematic review of clinical guidelines for the management of VCF. METHODS Guidelines were selected by searching MEDLINE and PubMed, PEDro, CINAHL, and EMBASE electronic databases between 2010 and 2016. We also searched clinical practice guideline databases, including the National Guideline Clearinghouse and the Canadian Medical Association InfoBase. The methodological quality of the guidelines was assessed by two authors independently using the Appraisal of Guidelines, Research and Evaluation (AGREE) II Instrument. We also classified the strength of each recommendation as either strong (ie, based on high-quality studies with consistent findings for recommending for or against the intervention), weak (ie, based on a lack of compelling evidence resulting in uncertainty for benefit or potential harm), or expert consensus (ie, based on expert opinion of the working group rather than on scientific evidence). Guideline recommendations were grouped into diagnostic, conservative care, interventional care, and osteoporosis treatment and prevention of future fractures. Our study was prospectively registered on PROSPERO. RESULTS Four guidelines from three countries, published in the period 2010-2013, were included. In general, the quality was not satisfactory (50% or less of the maximum possible score). The domains scoring 50% or less of the maximum possible score were rigor of development, clarity of presentation, and applicability. The use of plain radiography or dual-energy X-ray absorptiometry for diagnosis was recommended in two of the four guidelines. Vertebroplasty or kyphoplasty was recommended in three of the four guidelines. The recommendation for bed rest, trunk orthoses, electrical stimulation, and supervised or unsupervised exercise was inconsistent across the included guidelines. CONCLUSIONS The comparison of clinical guidelines for the management of VCF showed that diagnostic and therapeutic recommendations were generally inconsistent. The evidence available to guideline developers was limited in quantity and quality. Greater efforts are needed to improve the quality of the majority of guidelines.
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Machado GC, Rogan E, Maher CG. Managing non-serious low back pain in the emergency department: Time for a change? Emerg Med Australas 2017; 30:279-282. [DOI: 10.1111/1742-6723.12903] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/16/2017] [Accepted: 10/24/2017] [Indexed: 12/19/2022]
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Dannaway J, New CC, New CH, Maher CG. Exercise therapy is a beneficial intervention for chronic fatigue syndrome (PEDro synthesis). Br J Sports Med 2017; 52:542-543. [PMID: 28982730 DOI: 10.1136/bjsports-2017-098407] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2017] [Indexed: 11/03/2022]
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Stevens ML, Lin CWC, de Carvalho FA, Phan K, Koes B, Maher CG. Advice for acute low back pain: a comparison of what research supports and what guidelines recommend. Spine J 2017; 17:1537-1546. [PMID: 28713052 DOI: 10.1016/j.spinee.2017.05.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/02/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Advice is widely considered an effective treatment for acute low back pain (LBP); however, details on what and how to deliver this intervention is less clear. PURPOSE We assessed and compared clinical trials that test advice for acute LBP with practice guidelines for their completeness of reporting and concordance on the content, method of delivery, and treatment regimen of advice interventions. DESIGN/SETTING Systematic review. METHODS Advice randomized controlled trials were identified through a systematic search. Guidelines were taken from recent overviews of guidelines for LBP. Completeness of reporting was assessed using the Template for Intervention Description and Replication checklist. Thematic analysis was used to characterize advice interventions into topics across the aspects of content, method of delivery, and regimen. Concordance between clinical trials and guidelines was assessed by comparing the number of trials that found a statistically significant treatment effect for an intervention that included a specific advice topic with the number of guidelines recommending that topic. RESULTS The median (interquartile range) completeness of reporting for clinical trials and guidelines was 8 (7-9) and 3 (2-4) out of nine items on the Template for Intervention Description and Replication checklist, respectively. Guideline recommendations were discordant with clinical trials for 50% of the advice topics identified. CONCLUSION Completeness of reporting was less than ideal for randomized controlled trials and extremely poor for guidelines. The recommendations made in guidelines of advice for acute LBP were often not concordant with the results of clinical trials. Taken together, these findings mean that the potential clinical value of advice interventions for patients with acute LBP is probably not being realized.
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Almeida MO, Saragiotto BT, Maher CG, Pena Costa LO. Influence of allocation concealment and intention-to-treat analysis on treatment effects of physical therapy interventions in low back pain randomised controlled trials: a protocol of a meta-epidemiological study. BMJ Open 2017; 7:e017301. [PMID: 28963300 PMCID: PMC5623523 DOI: 10.1136/bmjopen-2017-017301] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Meta-epidemiological studies examining the influence of methodological characteristics, such as allocation concealment and intention-to-treat analysis have been performed in a large number of healthcare areas. However, there are no studies investigating these characteristics in physical therapy interventions for patients with low back pain. The aim of this study is to investigate the influence of allocation concealment and the use of intention-to-treat analysis on estimates of treatment effects of physical therapy interventions in low back pain clinical trials. METHODS AND ANALYSIS Searches on PubMed, Embase, Cochrane Database of Systematic Reviews, Physiotherapy Evidence Database (PEDro) and CINAHL databases will be performed. We will search for systematic reviews that include a meta-analysis of randomised controlled trials that compared physical therapy interventions in patients with low back pain with placebo or no intervention, and have pain intensity or disability as the primary outcomes. Information about selection (allocation concealment) and attrition bias (intention-to-treat analysis) will be extracted from the PEDro database for each included trial. Information about bibliographic data, study characteristics, participants' characteristics and study results will be extracted. A random-effects model will be used to provide separate estimates of treatment effects for trials with and without allocation concealment and with and without intention-to-treat analysis (eg, four estimates). A meta-regression will be performed to measure the association between methodological features and treatment effects from each trial. The dependent variable will be the treatment effect (the mean between-group differences) for the primary outcomes (pain or disability), while the independent variables will be the methodological features of interest (allocation concealment and intention-to-treat analysis). Other covariates will include sample size and sequence generation. ETHICS AND DISSEMINATION No ethical approval will be required for this study. The study findings will be published in a peer-reviewed journal and presented at international conferences. REGISTRATION NUMBER International Prospective Register of Systematic Reviews (CRD42016052347).
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Panagopoulos J, Magnussen JS, Hush J, Maher CG, Crites-Battie M, Jarvik JG, Jensen TS, Hancock MJ. Prospective Comparison of Changes in Lumbar Spine MRI Findings over Time between Individuals with Acute Low Back Pain and Controls: An Exploratory Study. AJNR Am J Neuroradiol 2017; 38:1826-1832. [PMID: 28775056 DOI: 10.3174/ajnr.a5357] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/09/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE The clinical importance of lumbar MR imaging findings is unclear. This study was an exploratory investigation of whether lumbar spine MR imaging findings change more commonly during a 12-week period in individuals with acute low back pain compared with pain-free controls. MATERIALS AND METHODS Twenty individuals with recent-onset low back pain and 10 pain-free controls were recruited into an exploratory prospective cohort study. All participants had a lumbar spine MR imaging at baseline and repeat MR imaging scans at 1, 2, 6, and 12 weeks. The proportion of individuals who had MR imaging findings that changed during the 12-week period was compared with the same proportion in the controls. RESULTS In 85% of subjects, we identified a change in at least 1 MR imaging finding during the 12 weeks; however, the proportion was similar in the controls (80%). A change in disc herniation, annular fissure, and nerve root compromise was reported more than twice as commonly in the subjects as in controls (65% versus 30%, 25% versus 10%, and 15% versus 0%, respectively). Caution is required in interpreting these findings due to wide confidence intervals, including no statistical difference. For all other MR imaging findings, the proportions of subjects and controls in whom MR imaging findings were reported to change during 12 weeks were similar. CONCLUSIONS Changes in MR imaging findings were observed in a similar proportion of the low back pain and control groups, except for herniations, annular fissures, and nerve root compromise, which were twice as common in subjects with low back pain.
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Machado GC, Maher CG, Ferreira PH, Latimer J, Koes BW, Steffens D, Ferreira ML. Can Recurrence After an Acute Episode of Low Back Pain Be Predicted? Phys Ther 2017; 97:889-895. [PMID: 28969347 DOI: 10.1093/ptj/pzx067] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/29/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Although recurrence is common after an acute episode of low back pain, estimates of recurrence rates vary widely and predictors of recurrence remain largely unknown. OBJECTIVE The purposes of the study were to determine the 1-year incidence of recurrence in participants who recovered from an acute episode of low back pain and to identify predictors of recurrence. DESIGN The design was an inception cohort study nested in a case-crossover study. METHODS For 12 months, 832 of the 999 participants who initially presented to primary care within the first 7 days of an episode of low back pain were followed. Of these participants, 469 recovered (1 month pain free) from the index episode within 6 weeks and were included in this study. Recurrence was defined as a new episode lasting more than 1 day, or as an episode of care seeking. Putative predictors were assessed at baseline and chosen a priori. Multivariable regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). RESULTS The 1-year incidence of recurrence of low back pain was 33%, and the 1-year incidence of recurrence of low back pain with care seeking was 18%. Participants reporting more than 2 previous episodes of low back pain had increased odds of future recurrences (OR = 3.18, CI = 2.11-4.78). This factor was also associated with recurrent episodes that led to care seeking (OR = 2.87, CI = 1.73-4.78). No other factors were associated with recurrences. LIMITATIONS There are limitations inherent in reliance on recall. CONCLUSIONS After an acute episode of low back pain, one-third of patients will experience a recurrent episode, and approximately half of those will seek care. Experiencing more than 2 previous episodes of low back pain triples the odds of a recurrence within 1 year.
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Yamato TP, Maher CG, Saragiotto BT, Shaheed CA, Moseley AM, Lin CWC, Koes B, McLachlan AJ. Comparison of effect sizes between enriched and nonenriched trials of analgesics for chronic musculoskeletal pain: a systematic review. Br J Clin Pharmacol 2017. [PMID: 28636752 DOI: 10.1111/bcp.13350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AIMS To investigate the use of an enriched study design on the estimates of treatment effect in analgesic trials for chronic musculoskeletal pain. METHODS Database searches were conducted from 2004 to 2014. We included randomized placebo-controlled trials evaluating pain medications for chronic musculoskeletal pain. Methodological quality was assessed using the PEDro scale. The estimates of treatment effect on pain and adverse events were compared between enriched and nonenriched designs. Metaregression was used to assess the association between the effect size estimate and the study design controlling for analgesic dose and methodological quality. RESULTS We included 108 trials, of which 99 were included in the meta-analysis (n = 44 171). There were no overall differences in effect sizes between enriched and nonenriched designs for pain intensity. There was a significant difference for a reduction in any adverse events favouring enriched designs for opioids, but not for other analgesics or the outcome serious adverse events. There was an association between effect size and methodological quality, with failure to blind the outcome assessor and failure to use intention-to-treat analysis being associated with larger effect sizes. CONCLUSIONS There is no evidence that the use of an enriched study design changes the treatment effect size estimate for pain. There is some evidence that clinical trials that employ enriched designs report a reduced risk of adverse events in trials for chronic musculoskeletal pain, but it is unclear whether enriched designs influence estimates of serious adverse events. Features of trial design and study quality were associated with treatment effect estimates.
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de Campos TF, Maher CG, Clare HA, da Silva TM, Hancock MJ. Effectiveness of McKenzie Method-Based Self-Management Approach for the Secondary Prevention of a Recurrence of Low Back Pain (SAFE Trial): Protocol for a Pragmatic Randomized Controlled Trial. Phys Ther 2017; 97:799-806. [PMID: 28789465 DOI: 10.1093/ptj/pzx046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 03/24/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND Although many people recover quickly from an episode of low back pain (LBP), recurrence is very common. There is limited evidence on effective prevention strategies for recurrences of LBP. OBJECTIVE The purpose of this study was to determine the effectiveness of a McKenzie method-based self-management approach in the secondary prevention of LBP. DESIGN This will be a pragmatic randomized controlled trial. SETTING Participants will be recruited from the community and primary care, with the intervention delivered in a number of physical therapist practices in Sydney, Australia. PARTICIPANTS The study will have 396 participants, all of whom are at least 18 years old. INTERVENTION Participants will be randomly assigned to either the McKenzie method-based self-management approach group or a minimal intervention control group. MEASUREMENTS The primary outcome will be days to first self-reported recurrence of an episode of activity-limiting LBP. The secondary outcomes will include: days to first self-reported recurrence of an episode of LBP, days to first self-reported recurrence of an episode of LBP leading to care seeking, and the impact of LBP over a 12-month period. All participants will be followed up monthly for a minimum of 12 months or until they have a recurrence of activity-limiting LBP. All participants will also be followed-up at 3, 6, 9, and 12 months to assess the impact of back pain, physical activity levels, study program adherence, credibility, and adverse events. LIMITATIONS Participants and therapists will not be masked to the interventions. CONCLUSIONS To our knowledge, this will be the first large, high-quality randomized controlled trial investigating the effectiveness of a McKenzie method-based self-management approach for preventing recurrences of LBP. If this approach is found to be effective, it will offer a low-cost, simple method for reducing the personal and societal burdens of LBP.
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Ramanathan SA, Hibbert PD, Maher CG, Day RO, Hindmarsh DM, Hooper TD, Hannaford NA, Runciman WB. CareTrack: Toward Appropriate Care for Low Back Pain. Spine (Phila Pa 1976) 2017; 42:E802-E809. [PMID: 27831965 DOI: 10.1097/brs.0000000000001972] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective medical record review to assess compliance with low back pain (LBP) care indicators. OBJECTIVE To establish baseline estimates of the appropriateness of LBP care in the general Australian population provided by a range of healthcare providers in various real-world settings. SUMMARY OF BACKGROUND DATA LBP is a costly condition and accounts for the greatest burden of disease worldwide, yet the care provided is often at variance with guidelines. No baseline estimates of performance are currently available in Australia across various aspects of LBP care, practitioners, and settings. METHODS A population-based sample of patients with 22 common conditions was recruited by telephone; consents were obtained to review their medical records against indicators ("CareTrack"). Care for LBP was reviewed against 10 indicators used in a previous study and ratified by experts as representing appropriate LBP care in Australia during 2009 and 2010. RESULTS Of the 22 CareTrack conditions, LBP had the highest number of eligible healthcare encounters (6588 of 35,573, 19%), 125 to 884 per indicator among 164 LBP patients. Overall compliance with LBP indicators was 72% (range 42%-98%). Allied health practitioners and hospitals were the most compliant (82%-83% respectively), followed by general practitioners (54%). Some aspects of care were poor, such as documenting a thorough neurological examination, screening for serious diseases such as infection and inappropriate use of drugs such as steroids and treatments such as traction. CONCLUSION Over a quarter of LBP care was not appropriate despite the availability of guidelines. There is a need for national and, potentially, international agreement on clinical standards, indicators and tools to guide, document and monitor the appropriateness of care for LBP, and for measures to increase their uptake, particularly where deficiencies have been identified. LEVEL OF EVIDENCE N /A.
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Bardin LD, King P, Maher CG. Diagnostic triage for low back pain: a practical approach for primary care. Med J Aust 2017; 206:268-273. [PMID: 28359011 DOI: 10.5694/mja16.00828] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/26/2016] [Indexed: 01/02/2023]
Abstract
Diagnostic triage is an essential guideline recommendation for low back pain (LBP), which is the most frequent musculoskeletal condition that general practitioners encounter in Australia. Clinical diagnosis of LBP - informed by a focused history and clinical examination - is the key initial step for GPs, and determines subsequent diagnostic workup and allied health and medical specialist referral. The goal of diagnostic triage of LBP is to exclude non-spinal causes and to allocate patients to one of three broad categories: specific spinal pathology (< 1% of cases), radicular syndrome (∼ 5-10% of cases) or non-specific LBP (NSLBP), which represents 90-95% of cases and is diagnosed by exclusion of the first two categories. For specific spinal pathologies (eg, vertebral fracture, malignancy, infection, axial spondyloarthritis or cauda equina syndrome), a clinical assessment may reveal the key alerting features. For radicular syndrome, clinical features distinguish three subsets of nerve root involvement: radicular pain, radiculopathy and spinal stenosis. Differential diagnosis of back-related leg pain is complex and clinical manifestations are highly variable. However, distinctive clusters of characteristic history cues and positive clinical examination signs, particularly from neurological examination, guide differential diagnosis within this triage category. A diagnosis of NSLBP presumes exclusion of specific pathologies and nerve root involvement. A biopsychosocial model of care underpins NSLBP; this includes managing pain intensity and considering risk for disability, which directs matched pathways of care. Back pain is a symptom and not a diagnosis. Careful diagnostic differentiation is required and, in primary care, diagnostic triage of LBP is the anchor for a diagnosis.
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Traeger AC, Moynihan RN, Maher CG. Wise choices: making physiotherapy care more valuable. J Physiother 2017; 63:63-65. [PMID: 28325482 DOI: 10.1016/j.jphys.2017.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/06/2017] [Accepted: 02/20/2017] [Indexed: 02/03/2023] Open
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Maher CG, Hancock MJ, Steffens D. Author response: Unfounded criticisms. Br J Sports Med 2017; 51:552. [DOI: 10.1136/bjsports-2016-096467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 11/04/2022]
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O'Keeffe M, Maher CG, O'Sullivan K. Unlocking the potential of physical activity for back health. Br J Sports Med 2017; 51:760-761. [PMID: 28202450 DOI: 10.1136/bjsports-2016-097009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2017] [Indexed: 11/03/2022]
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Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis 2017; 76:1269-1278. [PMID: 28153830 DOI: 10.1136/annrheumdis-2016-210597] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 12/20/2016] [Accepted: 12/27/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND While it is now clear that paracetamol is ineffective for spinal pain, there is not consensus on the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for this condition. We performed a systematic review with meta-analysis to determine the efficacy and safety of NSAIDs for spinal pain. METHODS We searched MEDLINE, EMBASE, CINAHL, CENTRAL and LILACS for randomised controlled trials comparing the efficacy and safety of NSAIDs with placebo for spinal pain. Reviewers extracted data, assessed risk of bias and evaluated the quality of evidence using the Grade of Recommendations Assessment, Development and Evaluation approach. A between-group difference of 10 points (on a 0-100 scale) was used for pain and disability as the smallest worthwhile effect, as well as to calculate numbers needed to treat. Random-effects models were used to calculate mean differences or risk ratios with 95% CIs. RESULTS We included 35 randomised placebo-controlled trials. NSAIDs reduced pain and disability, but provided clinically unimportant effects over placebo. Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction. When looking at different types of spinal pain, outcomes or time points, in only 3 of the 14 analyses were the pooled treatment effects marginally above our threshold for clinical importance. NSAIDs increased the risk of gastrointestinal reactions by 2.5 times (95% CI 1.2 to 5.2), although the median duration of included trials was 7 days. CONCLUSIONS NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition.
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Schreijenberg M, Luijsterburg PAJ, Van Trier YDM, Rizopoulos D, Koopmanschap MA, Voogt L, Maher CG, Koes BW. Efficacy of paracetamol, diclofenac and advice for acute low back pain in general practice: design of a randomized controlled trial (PACE Plus). BMC Musculoskelet Disord 2017; 18:56. [PMID: 28143496 PMCID: PMC5286693 DOI: 10.1186/s12891-017-1432-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/26/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Low back pain is common and associated with a considerable burden to patients and society. There is uncertainty regarding the relative benefit of paracetamol and diclofenac and regarding the additional effect of pain medication compared with advice only in patients with acute low back pain. This trial will assess the effectiveness of paracetamol, diclofenac and placebo for acute low back pain over a period of 4 weeks. Furthermore, this trial will assess the additional effectiveness of paracetamol, diclofenac and placebo compared with advice only for acute low back pain over a period of 4 weeks. METHODS The PACE Plus trial is a multi-center, placebo-blinded, superiority randomized controlled trial in primary care, with a follow-up of 12 weeks. Patients with acute low back pain aged 18-60 years presenting in general practice will be included. Patients are randomized into four groups: 1) Advice only (usual care conforming with the clinical guideline of the Dutch College of General Practitioners); 2) Advice and paracetamol; 3) Advice and diclofenac; 4) Advice and placebo. The primary outcome is low back pain intensity measured with a numerical rating scale (0-10). Secondary outcomes include compliance to treatment, disability, perceived recovery, costs, adverse reactions, satisfaction, sleep quality, co-interventions and adequacy of blinding. Between group differences for low back pain intensity will be evaluated using a repeated measurements analysis with linear effects models. An economic evaluation will be performed using a cost-effectiveness analysis with low back pain intensity and a cost-utility analysis with quality of life. Explorative analyses will be performed to assess effect modification by predefined variables. Ethical approval has been granted. Trial results will be released to an appropriate peer-viewed journal. DISCUSSION This paper presents the design of the PACE Plus trial: a multi-center, placebo-blinded, superiority randomized controlled trial in primary care that will assess the effectiveness of advice only, paracetamol, diclofenac and placebo for acute low back pain. TRIAL REGISTRATION Dutch Trial Registration NTR6089 , registered September 14th, 2016. PROTOCOL Version 4, June 2016.
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Bagg MK, Hübscher M, Rabey M, Wand BM, O'Hagan E, Moseley GL, Stanton TR, Maher CG, Goodall S, Saing S, O'Connell NE, Luomajoki H, McAuley JH. The RESOLVE Trial for people with chronic low back pain: protocol for a randomised clinical trial. J Physiother 2017; 63:47-48. [PMID: 27939089 DOI: 10.1016/j.jphys.2016.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 10/16/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Low back pain is the leading worldwide cause of disability, and results in significant personal hardship. Most available treatments, when tested in high-quality randomised, controlled trials, achieve only modest improvements in pain, at best. Recently, treatments that target central nervous system function have been developed and tested in small studies. Combining treatments that target central nervous system function with traditional treatments directed towards functioning of the back is a promising approach that has yet to be tested in adequately powered, prospectively registered, clinical trials. The RESOLVE trial will be the first high-quality assessment of two treatment programs that combine central nervous system-directed and traditional interventions in order to improve chronic low back pain. AIM To compare the effectiveness of two treatment programs that combine central nervous system-directed and traditional interventions at reducing pain intensity at 18 weeks post randomisation in a randomised clinical trial of people with chronic low back pain. DESIGN Two-group, randomised, clinical trial with blinding of participants and assessors. PARTICIPANTS AND SETTING Two hundred and seventy-five participants with chronic low back pain that has persisted longer than 3 months and no specific spinal pathology will be recruited from the community and primary care in Sydney, Australia. INTERVENTIONS Both of the interventions contain treatments that target central nervous system function combined with treatments directed towards functioning of the back. Adherence to the intervention will be monitored using an individual treatment diary and adverse events recorded through passive capture. Participants are informed prior to providing informed consent that some of the treatments are not active. Blinding is maintained by not disclosing any further information. Complete disclosure of the contents of the intervention has been made with the UNSW HREC (HC15357) and an embargoed project registration has been made on the Open Science Framework to meet the Declaration of Helsinki requirement for transparent reporting of trial methods a priori. INTERVENTION A Participants randomised to Intervention A will receive a 12-session treatment program delivered as 60-minute sessions, scheduled approximately weekly, over a period of 12 to 18 weeks. All treatment sessions are one-on-one. The program includes a home treatment component of 30minutes, five times per week. The intervention comprises discussion of the participant's low back pain experience, graded sensory training, graded motor imagery training and graded, precision-focused and feedback-enriched, functional movement training. Treatment progression is determined by participant proficiency, with mandatory advancement at set time points with respect to a standard protocol. INTERVENTION B Participants randomised to Intervention B will receive a 12-session treatment program of the same duration and structure as Intervention A. The intervention comprises discussion of the participant's low back pain experience, transcranial direct current stimulation to the motor and pre-frontal cortices, cranial electrical stimulation, and low-intensity laser therapy and pulsed electromagnetic energy to the area of greatest pain. Treatment is delivered according to published recommendations and progressed with respect to a standard protocol. MEASUREMENTS The primary outcome is pain intensity at 18 weeks post randomisation. Secondary outcomes will include disability, depression, pain catastrophising, kinesiophobia, beliefs about back pain, pain self-efficacy, quality of life, healthcare resource use, and treatment credibility. Assessment will occur at baseline and at 18, 26 and 52 weeks after randomisation. Treatment credibility will be assessed at baseline and 2 weeks after randomisation only. ANALYSIS A statistician blinded to group status will analyse the data by intention-to-treat using linear mixed models with random intercepts. Linear contrasts will be constructed to compare the adjusted mean change (continuous variables) in outcome from baseline to each time point between intervention A and intervention B. This will provide effect estimates and 95% confidence intervals for any difference between the interventions. SIGNIFICANCE Preliminary data suggest that combining treatments that target central nervous system function with traditional interventions is a promising approach to chronic low back pain treatment. In the context of modest effects on pain intensity from most available treatments, this approach may lead to improved clinical outcomes for people with chronic low back pain. The trial will determine which, if either, of two treatment programs that combine central nervous system-directed and traditional interventions is more effective at reducing pain intensity in a chronic low back pain cohort. Central nervous system-directed interventions constitute a completely new treatment paradigm for chronic low back pain management. The results have the potential to be far reaching and change current physiotherapy management of chronic low back pain in Australia and internationally.
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Dannaway J, New CC, New CH, Maher CG. Aquatic exercise for osteoarthritis of the knee or hip (PEDro synthesis). Br J Sports Med 2016; 51:1233-1234. [DOI: 10.1136/bjsports-2016-097240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2016] [Indexed: 11/04/2022]
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Stevens ML, Moseley AM, Elkins MR, Lin CWC, Maher CG. Evidence-based physiotherapy and the use of PEDro: Re: Condon C, McGrane N, Mockler D, et al. Ability of physiotherapists to undertake evidence-based practice steps: a scoping review. Physiotherapy 2016; 103:337-338. [PMID: 27919408 DOI: 10.1016/j.physio.2016.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 07/22/2016] [Indexed: 11/16/2022]
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Machado GC, Ferreira PH, Maher CG, Latimer J, Steffens D, Koes BW, Li Q, Ferreira ML. Transient physical and psychosocial activities increase the risk of nonpersistent and persistent low back pain: a case-crossover study with 12 months follow-up. Spine J 2016; 16:1445-1452. [PMID: 27503263 DOI: 10.1016/j.spinee.2016.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 06/27/2016] [Accepted: 08/02/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT A previous study has shown that transient physical and psychosocial activities increased the risk of developing low back pain. However, the link between these factors in triggering nonpersistent or persistent episodes remains unclear. PURPOSE We aimed to investigate the association of transient exposures to physical and psychosocial activities with the development of nonpersistent or persistent low back pain. STUDY DESIGN This was a case-crossover study with 12 months follow-up. PATIENT SAMPLE We included 999 consecutive participants seeking care for a sudden onset of low back pain. OUTCOME MEASURES Development of low back pain was the outcome measure. MATERIALS AND METHODS At baseline, participants reported transient exposures to 12 predefined activities over the 4 days preceding pain onset. After 12 months, participants were asked whether they had recovered and the date of recovery. Exposures in the 2-hour period preceding pain onset (case window) were compared with the 2-hour period, 24 hours before pain onset (control window) in a case-crossover design for all participants. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CI), and interaction analyses were used to compare estimates of nonpersistent (i.e., <6 weeks duration) and persistent cases. This study received funding from Australia's National Health and Medical Research Council (APP1003608). RESULTS There were 832 participants (83%) who completed the 12 months follow-up successfully. Of these, 430 participants had nonpersistent low back pain (<6 weeks duration), whereas 352 reported persistent symptoms (≥6 weeks duration). Exposure to several transient activities, such as manual tasks involving heavy loads, awkward postures, live people or animals, moderate or vigorous physical activity, and being fatigued or tired during a task or activity, significantly increased the risk of both nonpersistent and persistent low back pain, with ORs ranging from 2.9 to 11.7. Overall, the risk of developing a persistent or a nonpersistent episode of low back pain associated with the included physical factors did not differ significantly. CONCLUSIONS Our results revealed that previously identified triggers contribute equally to the development of both nonpersistent and persistent low back pain. Future prevention strategies should focus on controlling exposure to these triggers as they have the potential to decrease the burden associated with both acute and chronic low back pain.
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Beckenkamp PR, Lin CWC, Macaskill P, Michaleff ZA, Maher CG, Moseley AM. Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis. Br J Sports Med 2016; 51:504-510. [PMID: 27884861 DOI: 10.1136/bjsports-2016-096858] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates. DESIGN Systematic review with meta-analysis. DATA SOURCES MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Primary diagnostic studies reporting the accuracy of the Rules in people with ankle and/or midfoot injury were retrieved. Diagnostic accuracy estimates, overall and for subgroups (patient's age, profession of the assessor and setting of application), were made. Sensitivity analyses included studies with a low risk of bias and studies where all patients received radiographs. RESULTS 66 studies were included. Ankle and Midfoot Rules presented similar accuracies, which were homogeneous and high for sensitivity and negative likelihood ratios and poor and heterogeneous for specificity and positive likelihood ratios (mean, 95% CI pooled sensitivity of Ankle Rules: 99.4%, 97.9% to 99.8%; specificity: 35.3%, 28.8% to 42.3%). Sensitivity of the Ankle Rules was higher in adults than in children, but the profession of the assessor did not appear to influence accuracy. Specificity was higher for Midfoot than for Ankle Rules. There were not enough studies to allow comparison according to setting of application. Studies with a low risk of bias and where all patients received radiographs provided lower accuracy estimates. Specificity heterogeneity was not explained by assessor training, use of imaging in all patients and low risk of bias. CONCLUSIONS Study features and the methodological quality influence estimates of the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules.
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Saragiotto BT, Maher CG, Traeger AC, Li Q, McAuley JH. Dispelling the myth that chronic pain is unresponsive to treatment. Br J Sports Med 2016; 51:986-988. [DOI: 10.1136/bjsports-2016-096821] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2016] [Indexed: 11/04/2022]
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Carvalho FA, Maher CG, Franco MR, Morelhão PK, Oliveira CB, Silva FG, Pinto RZ. Fear of Movement Is Not Associated With Objective and Subjective Physical Activity Levels in Chronic Nonspecific Low Back Pain. Arch Phys Med Rehabil 2016; 98:96-104. [PMID: 27713076 DOI: 10.1016/j.apmr.2016.09.115] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/12/2016] [Accepted: 09/07/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To assess the association of physical activity measures, derived with an accelerometer and a self-reported questionnaire, with fear of movement in patients with chronic nonspecific low back pain (LBP) and to investigate the association between disability and fear of movement in this population. DESIGN Cross-sectional study. SETTING Outpatient physical therapy university clinics. PARTICIPANTS Patients (N=119) presenting with nonspecific LBP of >3 months' duration. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Physical activity levels measured objectively with an accelerometer (ie, counts per minute, time spent in moderate-to-vigorous and light physical activity per day, number of steps per day, and number of 10-minute bouts of moderate-to-vigorous physical activity per day) and subjectively with a self-reported questionnaire (Baecke Physical Activity Questionnaire); fear of movement (Tampa Scale of Kinesiophobia); pain (11-point numerical rating scale); disability (Roland Morris Disability Questionnaire); and depression (Beck Depression Inventory). The associations were examined with correlational, univariate, and multivariable linear regression analyses. RESULTS None of the objective physical activity measures were associated with fear of movement. The apparent association of self-reported physical activity levels with fear of movement (correlational analyses: r=-.18; P<.05; univariate regression analyses: β=-.04; 95% confidence interval [CI], -.07 to -.01; P=.04) was not confirmed in multivariable analyses. Fear of movement was consistently associated with disability in both correlational (r=.42; P<.01) and multivariable (β=.21; 95% CI, .11-.31; P<.001) analyses. CONCLUSIONS Our data support one aspect of the fear-avoidance model-that higher fear of movement is associated with more disability-but not the aspect of the model linking fear of movement with inactivity.
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Lin CWC, McLachlan AJ, Latimer J, Day RO, Billot L, Koes BW, Maher CG. OPAL: a randomised, placebo-controlled trial of opioid analgesia for the reduction of pain severity in people with acute spinal pain. Trial protocol. BMJ Open 2016; 6:e011278. [PMID: 27558901 PMCID: PMC5013345 DOI: 10.1136/bmjopen-2016-011278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Low back pain and neck pain are extremely prevalent and are responsible for an enormous burden of disease globally. Strong analgesics, such as opioid analgesics, are recommended by clinical guidelines for people with acute low back pain or neck pain who are slow to recover and require more pain relief. Opioid analgesics are widely and increasingly used, but there are no strong efficacy data supporting the use of opioid analgesics for acute low back pain or neck pain. Concerns regarding opioid use are further heightened by the risks of adverse events, some of which can be serious (eg, dependency, misuse and overdose). METHODS AND ANALYSIS OPAL is a randomised, placebo-controlled, triple-blinded trial that will investigate the judicious use of an opioid analgesic in 346 participants with acute low back pain and/or neck pain who are slow to recover. Participants will be recruited from general practice and randomised to receive the opioid analgesic (controlled release oxycodone plus naloxone up to 20 mg per day) or placebo in addition to guideline-based care (eg, reassurance and advice of staying active) for up to 6 weeks. Participants will be followed-up for 3 months for effectiveness outcomes. The primary outcome will be pain severity. Secondary outcomes will include physical functioning and time to recovery. Medication-related adverse events will be assessed and a cost-effectiveness analysis will be conducted. We will additionally assess long-term use and risk of misuse of opioid analgesics for up to 12 months. ETHICS AND DISSEMINATION Ethical approval has been obtained. Trial results will be disseminated by publications and conference presentations, and via the media. TRIAL REGISTRATION NUMBER ACTRN12615000775516: Pre-results.
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Yamato TP, Maher CG, Saragiotto BT, Hoffmann TC, Moseley AM, Elkins M, Lin C, Söderlund A. The TIDieR checklist will benefit the physiotherapy profession. EUROPEAN JOURNAL OF PHYSIOTHERAPY 2016. [DOI: 10.1080/21679169.2016.1195042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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