Effect of applying different "levels of evidence" criteria on conclusions of Cochrane reviews of interventions for low back pain

The effects of whole-body muscle stimulation on body composition and strength parameters: A PRISMA systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis set out to determine the efficacy of whole-body muscle electrostimulation on body composition, strength, and muscle power in active and non-active adults (aged ≥18 years).

METHOD

This review was reported in accordance with the Protocol Statement of Preferred Reporting Element Guidelines for Systematic Reviews and Meta-Analysis included controlled trials; whole-body electromyostimulation trials with at least 1 exercise and control group; participants >18 years old. Outcome measures were defined as standardized mean differences for muscle mass, body fat mass, strength, and power. Studies were searched in the following electronic databases: PubMed, Web of Science, Scopus, SPORTDiscus, and EMBASE for all articles published up to July 30, 2021. The risk of bias was assessed by 2 independent researchers using the Physiotherapy Evidence Database scale and Grading of Recommendations, Assessment, Development and Evaluations approach. Analyses were performed using the metafor package of the statistical software R (version 4.0.3; R Core Team, 2020). Random effects models, forest, and funnel plots to quantify the asymmetry associated with publication bias were fitted using the metafor library in R. Statistical heterogeneity was assessed using I2 statistics.

RESULTS

In total, 26 studies representing 1183 participants were included (WB-electromyostimulation: n = 586 and control group: n = 597). The mean age of the participants ranged from a minimum of 20.4 to a maximum of 77.4 years old. Interventions lasted a minimum of 4 and a maximum of 54 weeks. Standardized mean difference was 0.36 (95% confidence interval [CI]: 0.16-0.57) for muscle mass, -0.38 (95% CI: -0.62-0.15) for body fat, 0.54 (95% CI: 0.35-0.72) for strength, and 0.36 (95% CI: 0.02-0.71) for power with significant differences between groups (all P < .04). I2 revealed low heterogeneity of muscle mass (15%) and power (0%) between trials and medium heterogeneity of body fat (45%) and strength (55%).

CONCLUSION

We concluded that WB-electromyostimulation has significant positive effects on muscle mass, body fat, strength, and power.

Equine-assisted activities and therapies in children with attention-deficit/hyperactivity disorder: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Attention-deficit/hyperactivity disorder (ADHD) is characterized by problems of inattention and impulsive hyperactivity in children. Equine-assisted activities and therapies (EAATs) have been used as alternative non-pharmacological intervention option in patients with ADHD. WHAT DOES THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Nowadays, more studies of high methodological quality are needed to determine whether EAAT is an effective intervention for the treatment in children with ADHD. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Between 15 and 40 min of rising horses, 8-32 total sessions, for 4-32 weeks, seem to be beneficial to reduce the symptoms of ADHD.

ABSTRACT

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is a disorder characterized by problems of inattention and impulsive hyperactivity. Equine-assisted activities and therapies (EAATs) have become an emerging non-pharmacological intervention option in patients with ADHD.

AIM

To perform a systematic review of updated literature about EAAT in children with ADHD.

METHOD

A systematic review was performed until 28 November 2019, in four electronic databases: PubMed, Web of Science, Embase and Google Scholar. The inclusion criteria were as follows: (a) intervention programme, with pre- and post-data, based on EAAT, (b) children with ADHD and (c) articles written in English.

RESULTS

A total of 9 articles were found that meet the inclusion criteria. The evidence level was C for 7 studies and B for 2 studies. The level of conclusion was 3.

DISCUSSION

There are few studies with high methodological quality, and there is a high heterogeneity in the variables included, what make that the level of evidence and conclusion are low.

CONCLUSION

There is no account with enough studies of high methodological quality to determine whether EAAT is an effective intervention for the treatment in children with ADHD.

The effects of whole-body muscle stimulation on body composition and strength parameters: A protocol for systematic review and meta-analysis

BACKGROUND

This study will analyze the effect of Whole Body Electromyostimulation (WB-EMS) in strength and body composition outcomes in adult population.

METHODS

This study will search the following electronic databases up to July 21, 2020: PubMed, WOS, Scopus, SPORTDiscus y EMBASE. There will be no language limitation. Two authors will independently identify titles/abstracts and full text all potential studies, and will collect data from eligible studies. Additionally, study quality will be assessed by PEDro Scale risk of bias. We will conduct meta-analysis if enough trials are included.

RESULTS

This study will explore the effects of WB-EMS in strength and body composition outcomes.

CONCLUSION

The findings of this study may summarize the effectiveness of WB-EMS in increasing strength and improving body composition in adult population.

INPLASY REGISTRATION NUMBER

INPLASY202120050.

The relationship between organisational stressors and mental wellbeing within police officers: a systematic review

BACKGROUND

Occupational stressors in police work increase the risk for officer mental health morbidities. Officers' poor mental wellbeing is harmful to the individual, can affect professionalism, organisational effectiveness, and public safety. While the impact of operational stressors on officers' mental wellbeing is well documented, no review has systematically investigated organisational stressor impacts. This study aimed to conduct a systematic review to assess the relationship between organisational stressors and police officer mental wellbeing.

METHODS

Systematic review conducted following PRISMA and Cochrane Collaboration guidelines. Literature search was undertaken from 1990 to May 2017 on four databases (EBSCOHOST Medline/SocINDEX/PsycINFO/OVID Embase) and grey literature. Included articles were critically appraised and assessed for risk of bias. Narrative and evidence syntheses were performed by specific mental health outcomes.

RESULTS

In total, 3571 results were returned, and 15 studies met the inclusion criteria. All included studies were published in English between 1995 and 2016, had cross-sectional study designs, spanned across four continents and covered 15,150 officers. Strong evidence of significant associations was identified for organisational stressors and the outcomes of: occupational stress, psychiatric symptoms/psychological distress, emotional exhaustion and personal accomplishment. The organisational stressors most often demonstrating consistently significant associations with mental health outcomes included lack of support, demand, job pressure, administrative/organisational pressure and long working-hours.

CONCLUSIONS

This review is the first to systematically examine organisational stressors and mental health in police officers. Organisational stressors that can be targeted by interventions and policy changes to secure officer wellbeing, a healthy work environment, and benefits to the organisation and the public are identified.

Common mental disorders related to incidents and behaviour in physicians

BACKGROUND

Common mental disorders (CMD-burnout, stress, depression and anxiety disorders) are prevalent in physicians.

AIMS

To investigate the relationship between CMD and medical incidents and/or unprofessional behaviour in hospital physicians.

METHODS

PubMed was searched for all articles published between 2003 and 2013 that study a relationship between CMD and medical incidents and/or unprofessional behaviour in hospital physicians. The strength of evidence was assessed through five levels of evidence.

RESULTS

We included 15 studies. We found strong evidence for a significant association between burnout and the occurrence of medical incidents, based on two longitudinal and seven cross-sectional studies with a positive association [odds ratio (OR) 1.07-5.5]; one longitudinal study found a non-significant association (strong evidence). For the association between depression and medical incidents, four longitudinal studies and three cross-sectional studies found a significant positive association (strong evidence; OR 2.21-3.29). For the association between fatigue and medical incidents, one longitudinal study and one cross-sectional study showed a significant positive association, but one cross-sectional study showed a non-significant association (strong evidence; OR 1.37). For the association between sleepiness and medical incidents, one longitudinal study and two cross-sectional studies showed a significant positive association (strong evidence; OR 1.10-1.37). No significant association was found between burnout and unprofessional behaviour (inconsistent evidence). Nor was any evidence found for the association between unprofessional behaviour and depression, fatigue or sleepiness.

CONCLUSIONS

CMD in hospital physicians were associated with the occurrence of self-reported medical incidents, but there was inconsistent evidence for unprofessional behaviour.

Effects of Whole-Body Vibration Therapy in Patients with Fibromyalgia: A Systematic Literature Review

Objective. To review the literature on the effects of whole-body vibration therapy in patients with fibromyalgia. Design. Systematic literature review. Patients. Patients with fibromyalgia. Methods. An electronic search of the literature in four medical databases was performed to identify studies on whole-body vibration therapy that were published up to the 15th of January 2015. Results. Eight articles satisfied the inclusion and exclusion criteria and were analysed. According to the Dutch CBO guidelines, all selected trials had a B level of evidence. The main outcomes that were measured were balance, fatigue, disability index, health-related quality of life, and pain. Whole-body vibration appeared to improve the outcomes, especially balance and disability index. Conclusion. Whole-body vibration could be an adequate treatment for fibromyalgia as a main therapy or added to a physical exercise programme as it could improve balance, disability index, health-related quality of life, fatigue, and pain. However, this conclusion must be treated with caution because the paucity of trials and the marked differences between existing trials in terms of protocol, intervention, and measurement tools hampered the comparison of the trials.

Aquatic exercise & balneotherapy in musculoskeletal conditions

This is a best-evidence synthesis providing an evidence-based summary on the effectiveness of aquatic exercises and balneotherapy in the treatment of musculoskeletal conditions. The most prevalent musculoskeletal conditions addressed in this review include: low back pain, osteoarthritis, fibromyalgia and rheumatoid arthritis. Over 30 years of research demonstrates that exercises in general, and specifically aquatic exercises, are beneficial for reducing pain and disability in many musculoskeletal conditions demonstrating small to moderate effect sizes ranging between 0.19 and 0.32. Balneotherapy might be beneficial, but the evidence is yet insufficient to make a definitive statement about its use. High-quality trials are needed on balneotherapy and aquatic exercises research especially in specific patient categories that might benefit most.

A framework for best evidence approaches can improve the transparency of systematic reviews

OBJECTIVE

Systematic reviewers often use a "best evidence" approach to address the key questions, but what is meant by "best" is often unclear. The goal of this project was to create a decision framework for "best evidence" approaches to increase transparency in systematic reviews.

STUDY DESIGN AND SETTING

The project was separated into three areas: 1) inclusion criteria, 2) evidence prioritization strategies, and 3) evaluative approaches. This commentary focuses only on the second task. The full report is available on the Effective Healthcare Web site of the Agency for Healthcare Research and Quality.

RESULTS

The four identified strategies were as follows: 1) Use only the single best study; 2) Use the best set of studies; 3) Same as 2, but also consider whether the evidence permits a conclusion; and 4) Same as 3, but also consider the overall strength of the evidence. Simpler strategies (such as #1) are less likely to produce false conclusions, but are also more likely to yield insufficient evidence (possibly because of imprecise data).

CONCLUSION

Systematic reviewers routinely prioritize evidence in numerous ways. This document provides a conceptual construct to enhance the transparency of systematic reviewers' decisions.

Psychosocial work environment and stress-related disorders, a systematic review

BACKGROUND

Knowledge on the impact of the psychosocial work environment on the occurrence of stress-related disorders (SRDs) can assist occupational physicians in the assessment of the work-relatedness of these disorders.

AIMS

To systematically review the contribution of work-related psychosocial risk factors to SRDs.

METHODS

A systematic review of the literature was carried out by searching Medline, PsycINFO and Embase for studies published up until October 2008. Studies eligible for inclusion were prospective cohort studies or patient-control studies of workers at risk for SRDs. Studies were included in the review when data on the association between exposure to psychosocial work factors and the occurrence of SRDs were presented. Where possible, meta-analysis was conducted to obtain summary odds ratios of the association. The strength of the evidence was assessed using four levels of evidence.

RESULTS

From the 2426 studies identified, seven prospective studies were included in this review. Strong evidence was found that high job demands, low job control, low co-worker support, low supervisor support, low procedural justice, low relational justice and a high effort-reward imbalance predicted the incidence of SRDs.

CONCLUSIONS

This systematic review points to the potential of preventing SRDs by improving the psychosocial work environment. However, more prospective studies are needed on the remaining factors, exposure assessment and the relative contributions of single factors, in order to enable consistent assessment of the work-relatedness of SRDs by occupational physicians.

Exposure-in-vivo containing interventions to improve work functioning of workers with anxiety disorder: a systematic review

BACKGROUND

Anxiety disorders are associated with functional disability, sickness absence, and decreased productivity. Effective treatments of anxiety disorders can result in remission of symptoms. However the effects on work related outcomes are largely unknown. Exposure in vivo is potentially well fit to improve work-related outcomes. This study systematically reviews the effectiveness of exposure-in-vivo containing interventions in reducing work-related adverse outcomes in workers with anxiety disorders.

METHODS

A systematic study search was conducted in Medline, Cinahl, Embase and Psycinfo. Two reviewers independently extracted data and from each study assessed the quality of evidence by using the GRADE approach. We performed a meta-analysis if data showed sufficient clinical homogeneity.

RESULTS

Seven studies containing 11 exposure-in-vivo interventions were included. Four studies were focused on Obsessive Compulsive Disorder (OCD), two on Post Traumatic Stress Disorder (PTSD), and one on a mixed group of OCD and severe phobias. The studies were grouped according to type of anxiety disorder and subsequently according to type of comparisons. For OCD, exposure-in-vivo containing interventions can yield better work-related outcomes compared to medication (SSRIs) and relaxation but not better compared to response prevention. The results on anxiety outcomes were similar. The net contribution of exposure in vivo in two OCD intervention programs is also presented as a meta-analysis and shows significant positive results on work role limitations. The calculated pooled effect size with 95% confidence interval was 0.72 (0.28, 1.15). For PTSD, exposure-in-vivo containing interventions can yield better work-related and anxiety-related outcomes compared to a waiting-list but not better compared to imaginal exposure.

CONCLUSIONS

Exposure in vivo as part of an anxiety treatment can reduce work-related adverse outcomes in workers with OCD and PTSD better than various other anxiety treatments or a waiting-list. We recommend that it should be studied how the results of these studies can be transferred to the practice of occupational health professionals and how clinicians can make better use of them to improve work-related outcomes. In future research, priority should be given to high-quality randomised controlled trials (RCTs) in which exposure-in-vivo containing interventions are applied to a variety of anxiety disorders and compared with other clinical anxiety treatments such as SSRIs. Work-related outcomes, in particular work functioning and sickness absence, need to be assessed with reliable and valid measures.

Eficácia dos exercícios de controle motor na dor lombopélvica: uma revisão sistemática

O objetivo da revisão foi avaliar a eficácia dos exercícios de controle motor nas dores lombares (DL) e pélvicas. O estudo foi uma revisão sistemática de ensaios clínicos aleatorizados que investigaram a eficácia dos exercícios de controle motor no tratamento da DL e pélvica de várias populações. A eficácia desses exercícios foi sumarizada de acordo com os níveis de evidência empregados pela organização Cochrane. Oito ensaios cumpriram os critérios de inclusão. Há evidência limitada de que, a curto prazo, nos casos de DL aguda, exercícios de controle motor não sejam mais eficazes do que tratamento médico em diminuir dor e incapacidade. Entretanto, a longo prazo, há evidência limitada de que são capazes de reduzir o índice de recorrência nesses pacientes. Na DL crônica, existe forte evidência da eficácia dos exercícios de controle motor na diminuição da dor e incapacidade, quando comparados à fisioterapia convencional ou a nenhum tratamento. Há evidência limitada de que exercícios de controle motor sejam tão eficazes quanto a cirurgia de fusão lombar. Há evidência limitada de que, a curto e longo prazo, exercícios de controle motor sejam eficazes no tratamento das dores pélvicas pós-parto. Assim, exercícios de controle motor não melhoram a dor e incapacidades nos casos agudos. No entanto, podem ser indicados como prevenção de recorrência e para indivíduos com quadros crônicos a fim de aliviar a dor, reduzir a incapacidade e melhorar a qualidade de vida.

Role of technology assessment in orthopaedics

A technology assessment is a literature-based research project that seeks to determine whether a medical device, drug, procedure, or biologic is effective or to summarize literature on a given technology. A well-conducted assessment is a form of secondary research that employs the same steps used in primary research studies (ie, well-designed clinical trials). The primary difference is that in technology assessment the investigator does not collect the raw data. Rather, (s)he must use data collected by someone else. Nevertheless, a well-designed assessment, like a well-designed study, employs the scientific method, which is a method designed to combat bias. When there is little available information, such as with new technologies, unbiased examinations can typically show that enthusiasm for that technology is not backed by much data. When there is more information, assessments can not only determine whether a technology is effective, but also how effective it is. Technology assessments can provide busy orthopaedic surgeons (who do not have the time to keep up with and critically evaluate current literature) with succinct information that enables them to rapidly determine what is and what is not known about any given medical technology.

Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health

OBJECTIVES

The purposes of this study were to (1) determine whether sagittal spinal curves are associated with health in epidemiological studies, (2) estimate the strength of such associations, and (3) consider whether these relations are likely to be causal.

METHODS

A systematic critical literature review of epidemiological (cross-sectional, case-control, cohort) studies published before 2008 including studies identified in the CINAHL, EMBASE, Mantis, and Medline databases was performed using a structured checklist and a quality assessment. Level of evidence analysis was performed as outlined by van Tulder et al (Spine. 2003;28:1290-9), and the strength of associations were determined using the procedure outlined by Hemingway and Marmot (BMJ. 1999;318:1460-7). Quality of the included articles were assessed by our own scoring system based on the STrengthening the Reporting of OBservational studies in Epidemiology checklist. Studies scoring maximum points (4/4 or 3/3) were considered to be of higher quality.

RESULTS

Fifty-four original studies were included. We found no strong evidence for any association between sagittal spinal curves and any health outcomes including spinal pain. The included studies were generally of low methodological quality. There is moderate evidence for association between sagittal spinal curves and 4 health outcomes as follows: temporomandibular disorders (no odds ratios [ORs] provided), pelvic organ prolapse (OR, 3.18; 95% confidence interval [CI], 1.46-96.93), daily function (OR range, 1.8-3.7; 95% CI range, 1.1-6.3), and death (OR, 1.40; 95% CI, 1.08-1.91). These associations are however unlikely to be causal.

CONCLUSIONS

Evidence from epidemiological studies does not support an association between sagittal spinal curves and health including spinal pain. Further research of better methodological quality may affect this conclusion, and causal effects cannot be determined in a systematic review.

Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review

QUESTIONS

Which intervention(s) best augment early mobilisation and external support after an acute ankle sprain? What is the most appropriate method of preventing re-injury?

DESIGN

A systematic review of randomised controlled trials published from 1993 to April 2005.

PARTICIPANTS

People with an acute ankle sprain.

INTERVENTION

Any pharmacological, physiotherapeutic, complementary or electrotherapeutic intervention added to controlled mobilisation with external support. Immobilisation, surgical intervention, and use of external ankle supports in isolation were excluded.

OUTCOMES

Pain, function, swelling, re-injury, and global improvement; assessed at short, intermediate, and long-term follow-up.

RESULTS

23 trials were included with a mean PEDro score of 6/10. There was strong evidence that non-steroidal anti-inflammatory drugs can reduce pain and improve short-term ankle function. There was moderate evidence that neuromuscular training decreases functional instability and minimises re-injury; and that comfrey root ointment decreases pain and improves function. There was also moderate evidence that manual therapy techniques improve ankle dorsiflexion. There was no evidence to support the use of electrophysical agents or hyperbaric oxygen therapy. Very few long-term follow-ups were undertaken, and few studies focused on preventing long-term morbidity.

CONCLUSIONS

Non-steroidal anti-inflammatory drugs, comfrey root ointment, and manual therapy can significantly improve short-term symptoms after ankle sprain, and neuromuscular training may prevent re-injury. More high quality studies are needed to develop evidence-based guidelines on ankle rehabilitation beyond the acute phases of injury management.

Interventions to improve occupational health in depressed people

BACKGROUND

Work disability such as sickness absence is common in people with depression.

OBJECTIVES

To evaluate the effectiveness of interventions aimed at reducing work disability in depressed workers.

SEARCH STRATEGY

We searched the CCDANCTR-Studies and CCDANCTR-References on 2/8/2006, Cochrane Library CENTRAL register, MEDLINE, EMBASE, CINAHL, PsycINFO, OSH-ROM (Occupational Safety and Health), NHS-EED, and DARE.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster RCTs of work-directed and worker-directed interventions for depressed people, using sickness absence as the primary outcome

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality. We used standardised mean differences (SMD) with 95% confidence intervals (CIs) to pool study results where possible.

MAIN RESULTS

We included eleven studies, all of worker-directed interventions, involving 2556 participants. Only one study addressed work issues using adjuvant occupational therapy. Other interventions evaluated anti-depressant medication (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamino-oxidase inhibitors), psychodynamic therapy, enhanced primary care and psychological treatment. For medication, the combined results of three studies (n=864) showed no difference between antidepressant medication and alternative medication in their effect on days of sickness absence (SMD 0.09; 95% CI -0.05 to 0.23) In two pooled studies (n=969), the effect of enhanced primary care on days of sickness absence did not differ from usual care in the medium term (SMD -0.02; 95% CI -0.15 to 0.12). All other comparisons were based on single studies (n=6), all of which showed a lack of significant difference for sickness absence between groups, with the exception of one small study, combined psychodynamic therapy and TCAs versus TCAs alone, which favoured the combined treatment.

AUTHORS' CONCLUSIONS

Based on a heterogeneous sample of studies, there is currently no evidence of an effect of medication alone, enhanced primary care, psychological interventions or the combination of those with medication on sickness absence of depressed workers. In future RCTs, interventions should specifically address work issues, and occupational outcomes should be used to measure the effect..

Limitations of the randomized controlled trial in evaluating population-based health interventions

Population- and systems-based interventions need evaluation, but the randomized controlled trial (RCT) research design has significant limitations when applied to their complexity. After some years of being largely dismissed in the ranking of evidence in medicine, alternatives to the RCT have been debated recently in public health and related population and social service fields to identify the trade-offs in their use when randomization is impractical or unethical. This review summarizes recent debates and considers the pragmatic and economic issues associated with evaluating whole-population interventions while maintaining scientific validity and credibility.

Probleme der „evidence-based medicine“ in der Psychopharmakotherapie: Problematik der Evidenzgraduierung und der Evidenzbasierung komplexer klinischer Entscheidungsprozesse

Psychopharmacotherapy should now be regulated in the sense of evidence based medicine, as is the case in other areas of therapeutic medicine. In general, this is a meaningful development which will have a positive impact on routine health care. However, related problems should not be ignored. One important problem is the different definition of degrees of evidence. If placebo-controlled studies are prioritized, evidence deviates too much from the conditions of routine clinical care. However, the restriction to active comparative trials could lead to false conclusions about efficacy. In addition, if the focus is placed on the results of meta-analyses instead of considering relevant single studies, the result is a decision making logic contrary to that of the licensing process.Due to inherent methodological problems of the meta-analytical approach, the narrative, systematic review should retain its traditional importance and be used to provide a complementary view. Attempts to regulate psychopharmacotherapy in the sense of evidence based medicine come closer to their limits the more complex the clinical situation and the respective decision making logic are. Even in times of evidence based medicine, a large part of complex clinical decision making in psychopharmacotherapy still relies more on a consensus about clinical experience and traditions than on relevant empirical databases.

Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO)

Considerable variation in grading systems used to rate the strength of guideline recommendations and the quality of the supporting evidence in Nephrology highlights the need for a uniform, internationally accepted, rigorous system. In 2004, Kidney Disease: Improving Global Outcomes (KDIGO) commissioned a methods expert group to recommend an approach for grading in future nephrology guidelines. This position statement by KDIGO recommends adopting the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach for the grading of evidence and guidelines on interventions. The GRADE approach appraises systematic reviews of the benefits and harms of an intervention to determine its net health benefit. The system considers the design, quality, and quantity of studies as well as the consistency and directness of findings when grading the quality of evidence. The strength of the recommendation builds on the quality of the evidence and additional considerations including costs. Adaptations of the GRADE approach are presented to address some issues pertinent to the field of nephrology, including (1) the need to extrapolate from studies performed predominantly in patients without kidney disease, and (2) the need to use qualitative summaries of effects when it is not feasible to quantitatively summarize them. Further refinement of the system will be required for grading of evidence on questions other than those related to intervention effects, such as diagnostic accuracy and prognosis.

Perspective: a new ethic for health promotion: reflections on a philosophy of health education for the 21st century

This article describes two models for thinking about the purposes of health education-a medical model and an education model--and traces how concerns about the validity of research have driven preference for the medical model. In the medical model, the purpose of health education is to develop effective interventions that will prevent people from adopting unhealthy behaviors. Here, health educators are expected to replicate the methods identified by researchers to effect targeted changes in health behavior. The article then describes an alternative way of thinking about the purposes of health education. In pursuing a philosophy of education, the purpose of research and practice would be to clarify basic social values and to strengthen one's faculty for making value judgments. Practitioners here use research results as a stimulus for dialogue about the role of good health habits in living the kind of life that community members find most valuable.

Defining the clinical improvement in cancer drug therapy: implications for priority setting in healthcare

An explicit approach to funding decisions has become increasingly important to ensure fairness and consistency in resource allocation in cancer therapy. Funding decisions are often based on whether a treatment is 'medically necessary' and the level of clinical improvement. Currently, there is a lack of consensus on defining different levels of clinical improvement, leading to controversies on the values placed on different outcomes and degrees of clinical improvements during funding evaluation. More information on how clinicians and patients define the levels of clinical improvement can help ensure the evaluation and decision-making processes of funding to become more predictable, consistent, understandable and therefore accountable to providers and consumers of healthcare.

Clinical heterogeneity was a common problem in Cochrane reviews of physiotherapy and occupational therapy

BACKGROUND AND OBJECTIVE

To identify the strategies used to deal with the clinical heterogeneity of interventions and multiple outcome measures used in Cochrane reviews on physiotherapy and occupational therapy.

METHODS

A search for systematic reviews on physiotherapy and occupational therapy in the Cochrane Library was performed. Data on the method of categorization of interventions, on measures, and on the method of data synthesis were systematically extracted.

RESULTS

52 reviews were identified. In 22 (42%) reviews only one index intervention was evaluated, in the other 30 reviews index interventions were categorized. A large diversity in the number and type of outcome measures was found (median 6.5, range 1-23). In 48% of the reviews one or more primary outcome measures were defined. In 52% of the reviews no quantitative data synthesis was performed, whereas five different methods for qualitative data synthesis were applied in 11 reviews.

CONCLUSIONS

Limitation to a few outcome measures and explicit procedures for the categorization of interventions might increase the transparency and reproducibility of systematic reviews on physiotherapy and occupational therapy. Qualitative data synthesis is not often applied, although it is a useful tool to summarize results if a quantitative synthesis is not appropriate. International consensus on a method for qualitative synthesis is clearly needed.

[The critical role of research evidence in the framework of health technology assessment]

In spite of their different aims, evidence-based medicine (EBM) and health technology assessment (HTA) to some extent use similar methodologies for the assessment of a technology's efficacy. The decision to include only a certain quality of studies in a HTA report usually follows the hierarchy of evidence with different levels of evidence. Problems arise if study evidence is completely lacking or if it is extrapolated or transferred to other healthcare settings. As subjectivity is inevitable when critically appraising the evidence or combining it with other sources of information, HTA decisions should be presented with maximum transparency. Since physicians usually have only limited knowledge of research methodology and read only an average of 20 articles per year, a cooperative approach is required when appraising the evidence for HTA.

The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach

STUDY DESIGN AND OBJECTIVES

Meta-analysis of randomized controlled trials to evaluate the effectiveness of the McKenzie method for low back pain (LBP).

SUMMARY OF BACKGROUND DATA

The McKenzie method is a popular classification-based treatment for LBP. The faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials.

METHODS

MEDLINE, EMBASE, PEDro, and LILACS were searched up to August 2003. Two independent reviewers extracted the data and assessed methodologic quality. Pooled effects were calculated among homogeneous trials using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie.

RESULTS

Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up. Heterogeneity prevented pooling of studies on chronic LBP as well as pooling of studies included in the sensitivity analysis.

CONCLUSIONS

There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.

Factors influencing death at home in terminally ill patients with cancer: systematic review

OBJECTIVES

To determine the relative influence of different factors on place of death in patients with cancer.

DATA SOURCES

Four electronic databases-Medline (1966-2004), PsycINFO (1972-2004), CINAHL (1982-2004), and ASSIA (1987-2004); previous contacts with key experts; hand search of six relevant journals.

REVIEW METHODS

We generated a conceptual model, against which studies were analysed. Included studies had original data on risk factors for place of death among patients, > 80% of whom had cancer. Strength of evidence was assigned according to the quantity and quality of studies and consistency of findings. Odds ratios for home death were plotted for factors with high strength evidence.

RESULTS

58 studies were included, with over 1.5 million patients from 13 countries. There was high strength evidence for the effect of 17 factors on place of death, of which six were strongly associated with home death: patients' low functional status (odds ratios range 2.29-11.1), their preferences (2.19-8.38), home care (1.37-5.1) and its intensity (1.06-8.65), living with relatives (1.78-7.85), and extended family support (2.28-5.47). The risk factors covered all groups of the model: related to illness, the individual, and the environment (healthcare input and social support), the latter found to be the most important.

CONCLUSIONS

The ne of factors that influence where patients with cancer die is complicated. Future policies and clinical practice should focus on ways of empowering families and public education, as well as intensifying home care, risk assessment, and training practitioners in end of life care.

Treadmill training and body weight support for walking after stroke

BACKGROUND

Treadmill training, with or without some body weight supported using a harness, is a method of treating walking after stroke. A systematic review is required to assess the cost, effectiveness, and acceptability of this treatment.

OBJECTIVES

To assess the effectiveness of treadmill training and body weight support, individually or in combination, in the treatment of walking after stroke. The primary outcomes investigated were walking speed, endurance and dependency.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 2 March 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to January 2005), EMBASE (1980 to February 2005), CINAHL (1982 to February 2005) and PEDro (last searched 2 March 2005). In addition, we handsearched relevant conference proceedings, screened reference lists and contacted trialists to identify further published and unpublished trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke were eligible.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, extracted data, and assessed quality. We contacted trialists for additional information. We used a fixed-effect model for analysis, but if heterogeneity existed a random-effects model was used. We analysed the results as weighted mean differences (WMD) for continuous variables and relative risk (RR) for dichotomous variables.

MAIN RESULTS

Fifteen trials (622 participants) were included. There were no statistically significant differences between treadmill training, with or without body weight support, and other interventions for walking speed or dependence. Among participants who could walk independently at the start of treatment, treadmill training with body weight support tended to produce higher walking speeds (WMD 0.09 m/s, 95% confidence interval (CI) -0.02 to 0.20 for speed; fixed-effect), but this result was not statistically significant. An individual trial tended to support the use of treadmill training with body weight support for dependent walkers as compared to treadmill training alone. One of three individual trials indicated that independent walkers may benefit from treadmill training combined with other task-orientated exercise. However, data are very limited. Adverse events occurred more frequently in participants receiving treadmill training but these were not judged to be clinically serious events.

AUTHORS' CONCLUSIONS

Overall no statistically significant effect of treadmill training with or without body weight support was detected. Although individual studies suggested that treadmill training with body weight support may be more effective than treadmill training alone and that treadmill training plus task-oriented exercise may be more effective than sham exercises, further trials are required to confirm these findings.

Evidence-Based Medicine and the Challenge of Low Back Pain: Where Are We Now?

Low back pain has long been described as a challenge for both primary care physicians and specialists. Management of low back pain has also been criticized as frequently arbitrary, inappropriate, or ineffective. Contributing factors have been an inadequate evidence base and a need for more rigorous appraisals of the available literature. Evidence-based medicine, an approach to clinical problem solving, is predicated on the premise that high-quality health care will result from practices consistent with the best evidence. In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion, authority, and unsystematic clinical observations, evidence-based medicine emphasizes the need for rigorous critical appraisals of the scientific literature to inform medical decision making. Evidence-based medicine places strong weight on the requirement for valid studies, particularly randomized controlled trials, to appropriately evaluate the effectiveness of health care interventions. Because of the rapidly increasing volume of medical literature, however, most clinicians are unable to keep up-to-date with all the new data. Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic reviews and evidence-based clinical practice guidelines. Like primary studies, systematic reviews and clinical practice guidelines must adhere to high methodologic standards to reduce error and bias. As in other areas of medicine, the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings. In addition to more rigorous primary studies, an increasing number of high-quality systematic reviews and evidence-based clinical practice guidelines for low back pain are also available. Although some research gaps and methodologic shortcomings persist, the richer evidence base has greatly improved our understanding of what does and does not work for low back pain. Despite these advances, the best available evidence often does not inform everyday clinical decisions for low back pain. Nonetheless, there is widespread agreement that adherence to evidence-based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care. This article reviews basic principles of evidence-based medicine, discusses evidence-based medicine in the context of low back pain management, and summarizes some useful evidence-based medicine resources.

Manual therapy treatment of cervicogenic dizziness: a systematic review

Dizziness is a common and often disabling disorder. In some people the cause of their dizziness is pathology or dysfunction of upper cervical vertebral segments that can be treated with manual therapy. The aim of the present study was to systematically review the literature on the manual therapy treatment of patients with cervicogenic dizziness, by identifying and evaluating both randomized controlled trials (RCTs) and non-RCTs (controlled clinical trials and non-controlled studies). Seven electronic databases were searched up to July 2003, article reference lists were screened and an expert panel elicited to obtain relevant trials. Nine studies met the inclusion criteria and key data was extracted. Two reviewers assessed the validity of the studies using the Cochrane format and found that all studies had low methodological quality. However, a consistent finding was that all studies had a positive result with significant improvement in symptoms and signs of dizziness after manual therapy treatment. Therefore, Level 3 evidence for manual therapy treatment of cervicogenic dizziness was obtained indicating it should be considered in the management of patients with this disorder provided there is evidence of improvement. This review has identified the need for further RCTs of acceptable methodological quality.

The updated cochrane review of bed rest for low back pain and sciatica

STUDY DESIGN

A systematic review within the Cochrane Collaboration Back Review Group.

OBJECTIVES

To report the main results from the updated version of the Cochrane Review on bed rest for low back pain.

SUMMARY OF BACKGROUND DATA

There has been a growing amount of evidence showing that bed rest is not beneficial for people with low back pain. However, existing systematic reviews are unclear regarding the effects of bed rest for different types of low back pain.

METHODS

All randomized studies available in systematic searches up to March 2003 were included. Two reviewers independently selected trials for inclusion assessed the validity of included trials and extracted data. Investigators were contacted to obtain missing information.

RESULTS

Two new trials comparing advice to rest in bed with advice to stay active were included. There is high quality evidence that people with acute low back pain who are advised to rest in bed have a little more pain (standardized mean difference 0.22, 95% confidence interval: 0.02-0.41) and a little less functional recovery (standardized mean difference 0.29, 95% confidence interval: 0.05-0.45) than those advised to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain (standardized mean difference -0.03, 95% confidence interval: -0.24-0.18) or functional status (standardized mean difference 0.19, 95% confidence interval: -0.02-0.41) between bed rest and staying active.

CONCLUSION

For people with acute low back pain, advice to rest in bed is less effective than advice to stay active. For patients with sciatica, there is little or no difference between advice to rest in bed and advice to stay active.

A systematic review of efficacy of McKenzie therapy for spinal pain

A systematic review of randomised clinical trials was conducted to investigate the efficacy of McKenzie therapy in the treatment of spinal pain. Databases searched included DARE, CINAHL, CENTRAL, EMBASE, MEDLINE and PEDro. To be eligible for inclusion trials had to provide treatment according to McKenzie principles and report on one of the following outcomes: pain, disability, quality of life, work status, global perceived effect, medication use, health care contacts, or recurrence. Six trials were found to be eligible, all comparing McKenzie therapy to a comparison treatment. These included NSAIDS, educational booklet, back massage and back care advice, strength training, and spinal mobilisation and general exercises. The data from five lumbar trials were pooled at short term (less than three months) and from three at intermediate (3-12 months) follow-up. At short term follow-up the McKenzie therapy provided a mean 8.6 point greater pain reduction on a 0 to 100 point scale (95% CI 3.5 to 13.7) and a 5.4 point greater reduction in disability on a 0 to 100 point scale (95% CI 2.4 to 8.4) than comparison. At intermediate follow-up, relative risk of work absence was 0.81 (0.46 to 1.44) favouring McKenzie, however the comparison treatments provided a 1.2 point greater disability reduction (95% CI -2.0 to 4.5). In the one cervical trial, McKenzie therapy provided similar benefits to an exercise program. The results of this review show that for low back pain patients McKenzie therapy does result in a greater decrease in pain and disability in the short term than other standard therapies. Making a firm conclusion on low back pain treatment effectiveness is difficult because there are insufficient data on long term effects on outcomes other than pain and disability, and no trial has yet compared McKenzie to placebo or no treatment. There are also insufficient data available on neck pain patients.

Two models for defining the relationship between theory and practice in nutrition education: is the scientific method meeting our needs?

This article describes two models for linking theory and practice in nutrition education and traces how concerns about the validity of different types of research drive the choice of models. In the scientific model, theory is defined in terms of statements from which one can deduce hypotheses, which can then be tested in experimental research designs. In the scientific model, practitioners are expected to replicate the methods used by researchers to effect targeted changes in the dependent variable of interest, usually health or eating behaviors. The ethical and epistemological shortcomings of the scientific model are then examined. The report goes on to describe an alternative approach, termed the humanistic model. In the humanistic model, theory is defined in terms of statements that seek to clarify basic social values. In the humanistic model, practitioners use theory as a stimulus for dialogue about the role of eating habits in living the kind of life that community members find most valuable. Examples of humanistic research relevant to nutrition education are presented, and the limitations of establishing the certainty of claims made using humanistic criteria are discussed. The article concludes with a discussion of the implications of the humanistic model for professional preparation.

Is the methodological quality of guidelines declining in the US? Comparison of the quality of US Agency for Health Care Policy and Research (AHCPR) guidelines with those published subsequently

OBJECTIVE

To determine whether North American guidelines published subsequent to and in the same topic areas as those developed by the US Agency for Health Care Policy and Research (AHCPR) meet the same methodological criteria.

STUDY DESIGN

A guideline appraisal instrument containing 30 criteria was used to evaluate the methodological quality of the AHCPR guidelines, "updates" of the AHCPR guidelines authored by others, and guidelines that referenced or were adapted from the AHCPR guidelines. The frequency with which the criteria appeared in each guideline was compared and an analysis was performed to determine guidelines with two key features of the ACHPR guidelines-multidisciplinary guideline development panels and systematic reviews of the literature. Data were extracted from the guidelines by one investigator and then checked for accuracy by the other.

RESULTS

Fifty two guidelines identified by broad based searches were evaluated. 50% of the criteria were present in every AHCPR guideline. The AHCPR guidelines scored 80% or more on 24 of the 30 criteria compared with 14 for the "updates" and 11 for those that referenced/adapted the AHCPR guidelines. All of the 17 AHCPR guidelines had both multidisciplinary development panels and systematic reviews of the literature compared with five from the other two categories (p<0.05).

CONCLUSIONS

North American guidelines developed subsequent to and in the same topic areas as the AHCPR guidelines are of substantially worse methodological quality and ignore key features important to guideline development. This finding contrasts with previously published conclusions that guideline methodological quality is improving over time.

Effective physical treatment for chronic low back pain

It is now feasible to adopt an evidence-based approach when providing physical treatment for patients with chronic LBP. A summary of the efficacy of a range of physical treatments is provided in Table 1. The evidence-based primary care options are exercise, laser, massage, and spinal manipulation; however, the latter three have small or transient effects that limit their value as therapies for chronic LBP. In contrast, exercise produces large reductions in pain and disability, a feature that suggests that exercise should play a major role in the management of chronic LBP. Physical treatments, such as acupuncture, backschool, hydrotherapy, lumbar supports, magnets, TENS, traction, ultrasound, Pilates therapy, Feldenkrais therapy, Alexander technique, and craniosacral therapy are either of unknown value or ineffective and so should not be considered. Outside of primary care, multidisciplinary treatment or functional restoration is effective; however, the high cost probably means that these programs should be reserved for patients who do not respond to cheaper treatment options for chronic LBP. Although there are now effective treatment options for chronic LBP, it needs to be acknowledged that the problem of chronic LBP is far from solved. Though treatments can provide marked improvements in the patient's condition, the available evidence suggests that the typical chronic LBP patient is left with some residual pain and disability. Developing new, more powerful treatments and refining the current group of known effective treatments is the challenge for the future.

Efficacy of spinal manipulative therapy for low back pain of less than three months' duration

OBJECTIVES

To review the efficacy of spinal manipulation for low back pain of less than 3 months duration. Data sources Randomized clinical trials on spinal manipulative therapy for low back pain were identified by searching EMBASE, CINAHL, MEDLINE, and the Physiotherapy Evidence Database (PEDro). Study selection Outcome measures of interest were pain, return to work, adverse events, disability, quality of life, and patient satisfaction with therapy. Data extraction Methodological assessment of the trials was performed using the PEDro scale. Trials were grouped according to the type of intervention, outcome measures, and follow-up time. Where there were multiple studies with sufficient homogeneity of interventions, subjects, and outcomes, the results were analyzed in a meta-analysis using a random effects model. Data synthesis Thirty-four papers (27 trials) met the inclusion criteria. Three small studies showed spinal manipulative therapy produces better outcomes than placebo therapy or no treatment for nonspecific low back pain of less than 3 months duration. The effects are, however, small. The findings of individual studies suggest that spinal manipulative therapy also seems to be more effective than massage and short wave therapy. It is not clear if spinal manipulative therapy is more effective than exercise, usual physiotherapy, or medical care in the first 4 weeks of treatment.

CONCLUSIONS

Spinal manipulative therapy produces slightly better outcomes than placebo therapy, no treatment, massage, and short wave therapy for nonspecific low back pain of less than 3 months duration. Spinal manipulative therapy, exercise, usual physiotherapy, and medical care appear to produce similar outcomes in the first 4 weeks of treatment.

Does spinal manipulative therapy help people with chronic low back pain?

A systematic review of randomised clinical trials was conducted to assess the effect of spinal manipulative therapy on clinically relevant outcomes in patients with chronic low back pain. Databases searched included EMBASE, CINAHL, MEDLINE and PEDro. Methodological assessment of the trials was performed using the PEDro scale. Where there was sufficient homogeneity, a meta-analysis was conducted. Nine trials of mostly moderate quality were included in the review. Two trials were pooled comparing spinal manipulative therapy and placebo treatment, and two other trials were pooled comparing spinal manipulative therapy and non-steroidal anti-inflammatory drugs (NSAIDs). Spinal manipulative therapy reduced pain by 7mm on a 100mm visual analogue scale (95% CI 1 to 14) at one month follow-up when compared with placebo treatment, and by 14mm (95% CI -11 to 40) when compared with NSAIDs. Spinal manipulative therapy reduced disability by 6 points (95% CI 1 to 12) on a 100-point disability questionnaire when compared with NSAIDs. It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain.