A randomized-control study of active and passive treatments for chronic low back pain following L5 laminectomy

Impact of Active Physiotherapy on Physical Activity Level in Stroke Survivors: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke survivors are frequently physically inactive. However, evidence of the effectiveness of active physiotherapy on physical activity level in stroke survivors is scarce.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, covering electronic searches from inception to March 16, 2022. Participants: Stroke survivors living in the community. Intervention: Any active physiotherapy, that is, involving exercises that require voluntary effort. Outcome measure: Objective and subjective physical activity level.

RESULTS

Of 5590 identified references, 25 randomized controlled trials were eligible, and 21 had available data. The random-effects meta-analysis resulted in a small, significant effect size in favor of active physiotherapy measured using objective or subjective tools (21 studies, 1834 participants, standardized mean difference, 0.22 [95% CI, 0.04-0.40]; heterogeneity I2=65%), and a medium significant effect when objective tools were used (9 studies, 424 participants, standardized mean differences, 0.48 [95% CI, 0.03-0.92]; I2=73%). Meta-regression showed that 35% of the variance in trial outcome was explained by the measurement tool (objective or subjective) and 23% by age. None of the variances were associated with a specific dosage in terms of frequency, time, exercise duration, or the severity of the disability.

CONCLUSIONS

Active physiotherapy seems to increase objective physical activity in community-dwelling stroke survivors. However, the evidence is of very low certainty.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022315639.

Rehabilitation after lumbar spine surgery in adults: a systematic review with meta-analysis

BACKGROUND

The role of rehabilitation after surgery in patients with low back pain is well recognized. The aim of this systematic review is to summarize and update the existing evidence according to the type of clinical condition and rehabilitation approach.

METHODS

This systematic review included RCTs on the effectiveness of rehabilitation after surgery for lumbar disc herniation, spinal stenosis, and spondylolisthesis. We searched the literature for randomized controlled trials indexed in MEDLINE, Embase, CINHAL, CENTRAL, Scopus, PEDro, and Web of Science databases, up to April 15, 2023. We used Cochrane Risk of Bias 2.0 tool to assess each study. We conducted a quantitative synthesis when population, intervention, control, and outcome were sufficiently homogeneous; otherwise, we conducted a qualitative analysis.

RESULTS

Forty-five studies (3.036 subjects) were included and analyzed according to the population considered: lumbar stenosis (1 trial), spondylolisthesis (3 trials), and disc herniation (41 trials). Regarding lumbar stenosis, a supervised active exercise program appears to improve outcomes related to pain, disability, and quality of life both in the short- and mid-term (1 study, n = 60). Concerning spondylolisthesis, kinesiophobia is reduced in the home exercises group compared to usual care, at 3-months follow-up (3 studies, n = 98). For disk herniation, supervised exercises are better than non-supervised exercises to reduce pain (MD -1.14; 95% CIs -1.65, -0.62; 5 trials, n = 250) and disability (SMD -0.70; 95% CIs -1.14, -0.26; 4 trials, n = 175). Supervised exercises are better than advice in reducing pain (SMD -0.91; 95% CIs -1.61, -0.21; 5 trials, n = 341) and disability (SMD -0.80; 95% CIs -1.59, -0.01; 4 trials, n = 261), in the short-term. Supervised exercises are equal to no treatment in reducing pain and disability, at 3 and 6 months after intervention (2 trials, n = 166). These results are supported by a very low to low quality of evidence.

CONCLUSIONS

Our research suggests that supervised exercise may be effective in improving patient's pain and disability after lumbar surgery, but RCTs regarding lumbar spinal stenosis and lumbar spondylolisthesis are still scarce, with significant heterogeneity of proposed interventions.

Effectiveness of exercise therapy on pain relief and jaw mobility in patients with pain-related temporomandibular disorders: a systematic review

Background

Orofacial pain conditions are complex disorders that involve biological, social, and psychological factors. Temporomandibular Disorders (TMDs) are one of the most common orofacial pain conditions, and our previous literature review indicated that exercise therapy has shown promise in reducing TMD-related pain. However, more evidence is needed to firmly establish its effectiveness.

Objectives

This systematic review aims to investigate the effectiveness of exercise therapy on pain relief and jaw mobility in patients with pain-related TMDs.

Methods

To include randomized controlled trials (RCTs) written in English, a literature search was performed using PubMed, Scopus, Web of Science, Cochrane Library, Ovid, EBM reviews, and Academic Search Complete initially from 4th November 2020 until March 2022. A PICOS for this review was as follows; P: Patients with TMD myalgia or arthralgia, I: Excursion exercise, Stretch exercises, Resistance exercise, or Coordination exercise, C: No treatment or education only. O: Pain intensity and Range of Motion (ROM), S: RCTs. After title screening, a full-text assessment was done to extract data. According to Risk of Bias (RoB) 2.0, risk of bias was assessed in each included paper by 2 reviewers independently.

Results

A total of 3,388 titles were identified from the electronic database search. After the screening and full-text evaluation, only 5 studies (145 participants) were eligible to be included. Among the exercise modalities, coordination exercise showed a significant effect on pain relief and improvement of joint mobility.

Discussion

Due to the heterogeneity and small sample size of the included studies, a meta-analysis was not feasible. However, this systematic review suggested that exercise therapy, especially coordinate exercise, can be effective in managing painful TMD conditions. Further research is needed to establish optimal parameters for this patient population, as well as standardization and consistency in terminology and treatment structure.

Machine-learning model successfully predicts patients at risk for prolonged postoperative opioid use following elective knee arthroscopy

PURPOSE

Recovery following elective knee arthroscopy can be compromised by prolonged postoperative opioid utilization, yet an effective and validated risk calculator for this outcome remains elusive. The purpose of this study is to develop and validate a machine-learning algorithm that can reliably and effectively predict prolonged opioid consumption in patients following elective knee arthroscopy.

METHODS

A retrospective review of an institutional outcome database was performed at a tertiary academic medical centre to identify adult patients who underwent knee arthroscopy between 2016 and 2018. Extended postoperative opioid consumption was defined as opioid consumption at least 150 days following surgery. Five machine-learning algorithms were assessed for the ability to predict this outcome. Performances of the algorithms were assessed through discrimination, calibration, and decision curve analysis.

RESULTS

Overall, of the 381 patients included, 60 (20.3%) demonstrated sustained postoperative opioid consumption. The factors determined for prediction of prolonged postoperative opioid prescriptions were reduced preoperative scores on the following patient-reported outcomes: the IKDC, KOOS ADL, VR12 MCS, KOOS pain, and KOOS Sport and Activities. The ensemble model achieved the best performance based on discrimination (AUC = 0.74), calibration, and decision curve analysis. This model was integrated into a web-based open-access application able to provide both predictions and explanations.

CONCLUSION

Following appropriate external validation, the algorithm developed presently could augment timely identification of patients who are at risk of extended opioid use. Reduced scores on preoperative patient-reported outcomes, symptom duration and perioperative oral morphine equivalents were identified as novel predictors of prolonged postoperative opioid use. The predictive model can be easily deployed in the clinical setting to identify at risk patients thus allowing providers to optimize modifiable risk factors and appropriately counsel patients preoperatively.

LEVEL OF EVIDENCE

III.

Minimally versus conventional-invasive transforaminal lumbar interbody fusion in patients with failed back surgery syndrome

BACKGROUND

Failed back surgery syndrome is an important cause of back and leg pain after spinal surgery. Transforaminal lumbar interbody fusion (TLIF) is commonly used in revision surgery for failed back surgery syndrome. In the literature, there is a lack of evidence concerning the minimally and conventional-invasive TLIF and debates are ongoing. The purpose of the present study was to compare efficacy and safety of minimally versus conventional-invasive TLIF for failed back surgery syndrome.

MATERIALS AND METHODS

This study was conducted according to the STROBE Statement. Between 2011 and 2014, thirty patients with failed back surgery syndrome underwent TLIF. Group I (15 patients) received minimally invasive TLIF through paramedian approach using microscopy and fluoroscopy. Group II (15 patients) received conventional-invasive TLIF. Minimum follow-up was 12 months.

RESULTS

There was a significant improvement of Oswestry Disability Index (ODI) and visual analogue scale (VAS) in both groups postoperatively. There was no statistically significant difference between both groups regarding ODI, VAS, leg and back pain pre- and postoperatively. There was a tendency to better postoperative ODI and VAS scores in group I; however this did not reach the statistical significance. One case showed adjacent segment degeneration in group I. In group II, one case had screw mal-positioning with foot drop. Another case had dural injury with postoperative fistula.

CONCLUSION

TLIF is a valuable option after failed back surgery syndrome providing statistically significant improvement postoperatively. Both minimally and conventional-invasive TLIF represent a safe and reliable treatment of patients with failed back syndrome, achieving satisfactory outcome along with low rate of complications. Although the minimally invasive TLIF scored better, these differences did not reach the threshold of significance.

Manipulative and manual therapies in the management of patients with prior lumbar surgery: A systematic review

BACKGROUND AND PURPOSE

Pain and disability may persist following lumbar spine surgery and patients may subsequently seek providers trained in manipulative and manual therapy (MMT). This systematic review investigates the effectiveness of MMT after lumbar surgery through identifying, summarizing, assessing quality, and grading the strength of available evidence. Secondarily, we synthesized the impact on medication utilization, and reports on adverse events.

METHODS

Databases and grey literature were searched from inception through August 2020. Article extraction consisted of principal findings, pain and function/disability, medication consumption, and adverse events.

RESULTS

Literature search yielded 2025 articles,117 full-text articles were screened and 51 citations met inclusion criteria.

CONCLUSION

There is moderate evidence to recommend neural mobilization and myofascial release after lumbar fusion, but inconclusive evidence to recommend for or against most manual therapies after most surgical interventions. The literature is primarily limited to low-level studies. More high-quality studies are needed to make recommendations.

Therapeutic ultrasound for chronic low back pain

BACKGROUND

This is an update of a Cochrane Review published in 2014. Chronic non-specific low back pain (LBP) has become one of the main causes of disability in the adult population around the world. Although therapeutic ultrasound is not recommended in recent clinical guidelines, it is frequently used by physiotherapists in the treatment of chronic LBP.

OBJECTIVES

The objective of this review was to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP. A secondary objective was to determine the most effective dosage and intensity of therapeutic ultrasound for chronic LBP.

SEARCH METHODS

We performed electronic searches in CENTRAL, MEDLINE, Embase, CINAHL, PEDro, Index to Chiropractic Literature, and two trials registers to 7 January 2020. We checked the reference lists of eligible studies and relevant systematic reviews and performed forward citation searching.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on therapeutic ultrasound for chronic non-specific LBP. We compared ultrasound (either alone or in combination with another treatment) with placebo or other interventions for chronic LBP.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of each trial and extracted the data. We performed a meta-analysis when sufficient clinical and statistical homogeneity existed. We determined the certainty of the evidence for each comparison using the GRADE approach.

MAIN RESULTS

We included 10 RCTs involving a total of 1025 participants with chronic LBP. The included studies were carried out in secondary care settings in Turkey, Iran, Saudi Arabia, Croatia, the UK, and the USA, and most applied therapeutic ultrasound in addition to another treatment, for six to 18 treatment sessions. The risk of bias was unclear in most studies. Eight studies (80%) had unclear or high risk of selection bias; no studies blinded care providers to the intervention; and only five studies (50%) blinded participants. There was a risk of selective reporting in eight studies (80%), and no studies adequately assessed compliance with the intervention. There was very low-certainty evidence (downgraded for imprecision, inconsistency, and limitations in design) of little to no difference between therapeutic ultrasound and placebo for short-term pain improvement (mean difference (MD) -7.12, 95% confidence interval (CI) -17.99 to 3.75; n = 121, 3 RCTs; 0-to-100-point visual analogue scale (VAS)). There was also moderate-certainty evidence (downgraded for imprecision) of little to no difference in the number of participants achieving a 30% reduction in pain in the short term (risk ratio 1.08, 95% CI 0.81 to 1.44; n = 225, 1 RCT). There was low-certainty evidence (downgraded for imprecision and limitations in design) that therapeutic ultrasound has a small effect on back-specific function compared with placebo in the short term (standardised mean difference -0.29, 95% CI -0.51 to -0.07 (MD -1.07, 95% CI -1.89 to -0.26; Roland Morris Disability Questionnaire); n = 325; 4 RCTs), but this effect does not appear to be clinically important. There was moderate-certainty evidence (downgraded for imprecision) of little to no difference between therapeutic ultrasound and placebo on well-being (MD -2.71, 95% CI -9.85 to 4.44; n = 267, 2 RCTs; general health subscale of the 36-item Short Form Health Survey (SF-36)). Two studies (n = 486) reported on overall improvement and satisfaction between groups, and both reported little to no difference between groups (low-certainty evidence, downgraded for serious imprecision). One study (n = 225) reported on adverse events and did not identify any adverse events related to the intervention (low-certainty evidence, downgraded for serious imprecision). No study reported on disability for this comparison. We do not know whether therapeutic ultrasound in addition to exercise results in better outcomes than exercise alone because the certainty of the evidence for all outcomes was very low (downgraded for imprecision and serious limitations in design). The estimate effect for pain was in favour of the ultrasound plus exercise group (MD -21.1, 95% CI -27.6 to -14.5; n = 70, 2 RCTs; 0-to-100-point VAS) at short term. Regarding back-specific function (MD - 0.41, 95% CI -3.14 to 2.32; n = 79, 2 RCTs; Oswestry Disability Questionnaire) and well-being (MD -2.50, 95% CI -9.53 to 4.53; n = 79, 2 RCTs; general health subscale of the SF-36), there was little to no difference between groups at short term. No studies reported on the number of participants achieving a 30% reduction in pain, patient satisfaction, disability, or adverse events for this comparison.

AUTHORS' CONCLUSIONS

The evidence from this systematic review is uncertain regarding the effect of therapeutic ultrasound on pain in individuals with chronic non-specific LBP. Whilst there is some evidence that therapeutic ultrasound may have a small effect on improving low back function in the short term compared to placebo, the certainty of evidence is very low. The true effect is likely to be substantially different. There are few high-quality randomised trials, and the available trials were very small. The current evidence does not support the use of therapeutic ultrasound in the management of chronic LBP.

Systematic review of management of chronic pain after surgery

BACKGROUND

Pain present for at least 3 months after a surgical procedure is considered chronic postsurgical pain (CPSP) and affects 10-50 per cent of patients. Interventions for CPSP may focus on the underlying condition that indicated surgery, the aetiology of new-onset pain or be multifactorial in recognition of the diverse causes of this pain. The aim of this systematic review was to identify RCTs of interventions for the management of CPSP, and synthesize data across treatment type to estimate their effectiveness and safety.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library were searched from inception to March 2016. Trials of pain interventions received by patients at 3 months or more after surgery were included. Risk of bias was assessed using the Cochrane risk-of-bias tool.

RESULTS

Some 66 trials with data from 3149 participants were included. Most trials included patients with chronic pain after spinal surgery (25 trials) or phantom limb pain (21 trials). Interventions were predominantly pharmacological, including antiepileptics, capsaicin, epidural steroid injections, local anaesthetic, neurotoxins, N-methyl-d-aspartate receptor antagonists and opioids. Other interventions included acupuncture, exercise, postamputation limb liner, spinal cord stimulation, further surgery, laser therapy, magnetic stimulation, mindfulness-based stress reduction, mirror therapy and sensory discrimination training. Opportunities for meta-analysis were limited by heterogeneity. For all interventions, there was insufficient evidence to draw conclusions on effectiveness.

CONCLUSION

There is a need for more evidence about interventions for CPSP. High-quality trials of multimodal interventions matched to pain characteristics are needed to provide robust evidence to guide management of CPSP.

Treatment Options for Failed Back Surgery Syndrome Patients With Refractory Chronic Pain: An Evidence Based Approach

STUDY DESIGN

A significant number of lumbar postsurgical patients continue to suffer persistent pain and limited function and are termed to have "Failed back surgery syndrome" (FBSS). This review evaluates clinical trial data for the treatment of FBSS patients.

OBJECTIVE

Using an evidence-based approach to evaluate FBSS treatments will assist clinicians in choosing the most effective options for FBSS patients. Furthermore, reducing the utilization of less effective therapies may result in substantial financial savings for this patient population.

SUMMARY OF BACKGROUND DATA

Treatments for FBSS may be generally categorized as physical therapy and exercise, medications, interventional procedures, neuromodulation, and reoperation. Careful review and classification of the level of evidence available for each category of treatment for FBSS patients will help guide clinical decision-making.

METHODS

A literature review was performed for FBSS treatments. The publications were arranged hierarchically according to the North American Spine Society's guidelines as randomized controlled trials (RCTs), prospective studies, retrospective chart, and systematic reviews. Book chapters, nonsystematic reviews, and expert opinions were excluded. The review focused on studies with at least 20 FBSS patients and 6-month follow-up.

RESULTS

Evidence is weak for medications and reoperation, but strong for active exercise and interventional procedures such as adhesiolysis. The strongest evidence for long-term treatment is for spinal cord stimulation (SCS), showing favorable Level I RCT results compared with conventional medical management and reoperation. In addition, high-frequency SCS at 10 kHz has demonstrated superiority over traditional, low-frequency SCS for treating low back and leg pain in a recent Level I RCT.

CONCLUSION

Clinicians may increasingly utilize levels of evidence during their evaluation of each FBSS patient to render the best therapeutic plan, likely resulting in improved long-term pain control and reducing costs by avoiding less effective modalities. New directions in SCS show promising results for the treatment of FBSS.

LEVEL OF EVIDENCE

1.

An Overview of Chronic Spinal Pain: Revisiting Diagnostic Categories and Exploring an Evolving Role for Neurostimulation

STUDY DESIGN

Topic overview.

OBJECTIVE

To describe the varied etiologies resulting in chronic spinal pain and review the current available evidence for treatments.

SUMMARY OF BACKGROUND DATA

Chronic pain conditions, especially those that affect the axial back and radiate to the extremities, affect a large population. This results in pronounced disability and a high socioeconomic burden. Our understanding of the underlying mechanisms for chronic pain is limited. This prevents a comprehensive diagnostic approach. Evidence from high-level clinical trials supporting treatments for chronic spinal pain is also limited.

METHODS

Articles were identified through PubMed searches or already known to the author. The literature was reviewed and summarized, indicating the strength of evidence available for many treatment modalities.

RESULTS

There are very few studies published that evaluate behavioral modifications for chronic spinal pain and only one long-term study investigating chronic pharmacological treatments. The data on the success of spinal surgeries to relieve chronic spinal pain suggest an unacceptably high failure rate. The best evidence (Level I) currently available suggests that spinal cord stimulation is a safe, effective, and durable treatment for chronic spinal pain. Recent clinical data support further investigation of new innovations and earlier therapeutic consideration of currently employed approaches.

CONCLUSION

Currently, physicians are limited in the practice of evidence-based medicine regarding chronic spinal pain treatments due to both the paucity of data available and an inconsistent diagnostic nomenclature. The introduction of new neurostimulation modalities is promising but requires better characterization through ongoing prospective clinical investigation.

LEVEL OF EVIDENCE

5.

The role of physical therapy and rehabilitation after lumbar fusion surgery for degenerative disease: a systematic review

OBJECTIVE The purpose of this study was to provide a systematic and comprehensive review of the existing literature regarding postfusion rehabilitation. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the authors conducted an exhaustive review of multiple electronic databases. Potential articles were screened using inclusion/exclusion criteria. Two authors independently analyzed these studies using predefined data fields, including study quality indicators such as level of evidence and availability of accepted patient-reported outcomes measures. These findings were synthesized in a narrative format. A third author resolved disagreements regarding the inclusion of a study. RESULTS Twenty-one articles with I or II levels of evidence were included in the review. The authors divided the findings of the literature review into several groups: rehabilitation terminology, timing and duration of postfusion rehabilitation, the need for rehabilitation relative to surgery-related morbidity, rehabilitation's relationship to outcomes, and cognitive and psychosocial aspects of postsurgical rehabilitation. Current evidence generally supports formal rehabilitation after lumbar fusion surgery. Starting physical therapy at the 12-week postoperative mark results in better outcomes at lower cost than an earlier, 6-week start. Where available, psychosocial support improves outcomes. However, a number of the questions could not be answered with high-grade evidence. In these cases, the authors used "best evidence available" to make recommendations. There are many cases in which different types of caregivers use clinical terminology differently. The data supporting an optimal protocol for postfusion rehabilitation remains elusive but, using the data available, the authors have crafted recommendations and a model protocol, which is currently undergoing prospective study. CONCLUSIONS Rehabilitation has long been a common feature in the postoperative management of patients undergoing spinal fusion. Although caregivers from multiple disciplines agree that the majority of their patients will benefit from this effort, the supporting data remain sparse. In creating a model protocol for postlumbar fusion rehabilitation, the authors hope to share a starting point for future postoperative lumbar fusion rehabilitation research.

An abbreviated therapeutic neuroscience education session improves pain knowledge in first-year physical therapy students but does not change attitudes or beliefs

OBJECTIVE

To determine if a 3-hour therapeutic neuroscience education session alters physical therapy student's knowledge of pain and effects their attitudes and beliefs regarding treating chronic pain.

METHODS

Seventy-seven entry-level doctoral physical therapy students participated in the study. Following consent, demographic data were obtained and then the subjects completed the Neuroscience of Pain Questionnaire, the Health Care Provider's Pain and Impairment Relationship Scale and an additional questionnaire designed by the researchers. The subjects then received a 3-hour educational session developed by the researchers, focusing on the neurobiology and physiology of pain. The questionnaires were re-administered immediately after the educational session and at 6 months post-education.

RESULTS

Seventy-seven subjects (mean age = 24.7 years, 57.1% female and 81.8% white) completed the questionnaires pre- and post-educational session with 75 completing the questionnaires at 6 months. To assess the effect of the education on the scores of the questionnaires, a repeated measures ANOVA was conducted. Students demonstrated significantly higher scores on the neuroscience of pain questionnaire (p < 0.001) with no significant effect found on the attitudes and beliefs questionnaire at any of the time points. There were significant differences found on some of the individual questions that were part of the additional questionnaire.

DISCUSSION

An educational session on the neuroscience of pain is beneficial for educating entry-level doctoral physical therapy students immediately post-education and at 6 months. This educational session had no effect on the student's attitudes and beliefs regarding treating the chronic pain population. There were additional significant findings regarding individual questions posed to the subjects.

Rehabilitation after lumbar disc surgery

BACKGROUND

Several rehabilitation programmes are available for individuals after lumbar disc surgery.

OBJECTIVES

To determine whether active rehabilitation after lumbar disc surgery is more effective than no treatment, and to describe which type of active rehabilitation is most effective. This is the second update of a Cochrane Review first published in 2002.First, we clustered treatments according to the start of treatment.1. Active rehabilitation that starts immediately postsurgery.2. Active rehabilitation that starts four to six weeks postsurgery.3. Active rehabilitation that starts longer than 12 months postsurgery.For every cluster, the following comparisons were investigated.A. Active rehabilitation versus no treatment, placebo or waiting list control.B. Active rehabilitation versus other kinds of active rehabilitation.C. Specific intervention in addition to active rehabilitation versus active rehabilitation alone.

SEARCH METHODS

We searched CENTRAL (2013, Issue 4) and MEDLINE, EMBASE, CINAHL, PEDro and PsycINFO to May 2013.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for eligibility and risk of bias. Meta-analyses were performed if studies were clinically homogeneous. The GRADE approach was used to determine the overall quality of evidence.

MAIN RESULTS

In this update, we identified eight new studies, thereby including a total of 22 trials (2503 participants), 10 of which had a low risk of bias. Most rehabilitation programmes were assessed in only one study. Both men and women were included, and overall mean age was 41.4 years. All participants had received standard discectomy, microdiscectomy and in one study standard laminectomy and (micro)discectomy. Mean duration of the rehabilitation intervention was 12 weeks; eight studies assessed six to eight-week exercise programmes, and eight studies assessed 12 to 13-week exercise programmes. Programmes were provided in primary and secondary care facilities and were started immediately after surgery (n = 4) or four to six weeks (n = 16) or one year after surgery (n = 2). In general, the overall quality of the evidence is low to very low. Rehabilitation programmes that started immediately after surgery were not more effective than their control interventions, which included exercise. Low- to very low-quality evidence suggests that there were no differences between specific rehabilitation programmes (multidisciplinary care, behavioural graded activity, strength and stretching) that started four to six weeks postsurgery and their comparators, which included some form of exercise. Low-quality evidence shows that physiotherapy from four to six weeks postsurgery onward led to better function than no treatment or education only, and that multidisciplinary rehabilitation co-ordinated by medical advisors led to faster return to work than usual care. Statistical pooling was performed only for three comparisons in which the rehabilitation programmes started four to six weeks postsurgery: exercise programmes versus no treatment, high- versus low-intensity exercise programmes and supervised versus home exercise programmes. Very low-quality evidence (five RCTs, N = 272) shows that exercises are more effective than no treatment for pain at short-term follow-up (standard mean difference (SMD) -0.90; 95% confidence interval (CI) -1.55 to -0.24), and low-quality evidence (four RCTs, N = 252) suggests that exercises are more effective for functional status on short-term follow-up (SMD -0.67; 95% CI -1.22 to -0.12) and that no difference in functional status was noted on long-term follow-up (three RCTs, N = 226; SMD -0.22; 95% CI -0.49 to 0.04). None of these studies reported that exercise increased the reoperation rate. Very low-quality evidence (two RCTs, N = 103) shows that high-intensity exercise programmes are more effective than low-intensity exercise programmes for pain in the short term (weighted mean difference (WMD) -10.67; 95% CI -17.04 to -4.30), and low-quality evidence (two RCTs, N = 103) shows that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36). Very low-quality evidence (four RCTs, N = 154) suggests no significant differences between supervised and home exercise programmes for short-term pain relief (SMD -0.76;  95% CI -2.04 to 0.53) or functional status (four RCTs, N = 154; SMD -0.36; 95% CI -0.88 to 0.15).

AUTHORS' CONCLUSIONS

Considerable variation was noted in the content, duration and intensity of the rehabilitation programmes included in this review, and for none of them was high- or moderate-quality evidence identified. Exercise programmes starting four to six weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment, with small to medium effect sizes, and high-intensity exercise programmes seem to lead to a slightly faster decrease in pain and disability than is seen with low-intensity programmes, but the overall quality of the evidence is only low to very low. No significant differences were noted between supervised and home exercise programmes for pain relief, disability or global perceived effect. None of the trials reported an increase in reoperation rate after first-time lumbar surgery. High-quality randomised controlled trials are strongly needed.

Therapeutic ultrasound for chronic low-back pain

BACKGROUND

Chronic non-specific low-back pain (LBP) has become one of the main causes of disability in the adult population around the world. Therapeutic ultrasound is frequently used by physiotherapists in the treatment of LBP and is one of the most widely used electro-physical agents in clinical practice.

OBJECTIVES

The objective of this review is to determine the effectiveness of therapeutic ultrasound in the management of chronic non-specific LBP.

SEARCH METHODS

Electronic searches were performed using CENTRAL, MEDLINE, EMBASE, PEDro, and PsycLIT databases in October 2013. Reference lists of eligible studies and relevant systematic reviews were checked and forward citation searching was also performed.

SELECTION CRITERIA

Randomised controlled trials on therapeutic ultrasound for non-specific chronic LBP were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of each trial and extracted the data. When sufficient clinical and statistical homogeneity existed, a meta-analysis was performed. The quality of the evidence for each comparison was determined using the GRADE approach.

MAIN RESULTS

Seven small randomised controlled trials involving a total of 362 participants with chronic LBP were included. Two of the studies had a low risk of bias, meeting six or more of the 12 criteria used for assessing risk of bias. All studies were carried out in secondary care settings and most applied therapeutic ultrasound in addition to exercise therapy, at various intensities for six to 18 treatment sessions. There was moderate quality evidence that therapeutic ultrasound improves back-specific function (standardised mean difference (SMD) [95%CI] -0.45 [-0.84 to -0.05]) compared with placebo in the short term. There was low quality evidence that therapeutic ultrasound is no better than placebo for short-term pain improvement (mean difference (MD) [95%CI] -7.12 [-17.99 to 3.75]; zero to100-point scale). There was low quality evidence that therapeutic ultrasound plus exercise is no better than exercise alone for short-term pain improvement (MD [95%CI] -2.16 [-4.66 to 0.34]; zero to 50-point scale), or functional disability (MD [95%CI] -0.41 [-3.14 to 2.32]; per cent). The studies comparing therapeutic ultrasound versus placebo or versus exercise alone did not report on overall satisfaction with treatment, or quality of life. There was low quality evidence that spinal manipulation reduces pain and functional disability more than ultrasound over the short to medium term. There is also very low quality evidence that there is no clear benefit on any outcome measure between electrical stimulation and therapeutic ultrasound; and that phonophoresis results in improved SF-36 scores compared to therapeutic ultrasound. None of the included studies reported on adverse events related to the application of therapeutic ultrasound.

AUTHORS' CONCLUSIONS

No high quality evidence was found to support the use of ultrasound for improving pain or quality of life in patients with non-specific chronic LBP. There is some evidence that therapeutic ultrasound has a small effect on improving low-back function in the short term, but this benefit is unlikely to be clinically important. Evidence from comparisons between other treatments and therapeutic ultrasound for chronic LBP were indeterminate and generally of low quality. Since there are few high quality randomised trials and the available trials are very small, future large trials with valid methodology are likely to have an important impact on our confidence in the estimate of effect and may change the estimate.

The effect of swiss ball stabilization exercise on pain and bone mineral density of patients with chronic low back pain

[Purpose] The purpose of this study was to carry out a 16-week treatment of lumbar stabilization exercise with a ball targeting patients with chronic low back pain and investigate its effect on alleviation of low back pain and bone mineral density. [Subjects and Methods] The subjects of this study were 36 patients who were diagnosed with chronic low back pain. They were divided into a conservative treatment group (CTG, n=12), floor exercise group (FEG, n=12), and ball exercise group (BEG, n=12). The degree of recovery from pain was looked into using a visual analogue scale (VAS) and DEXXUM T (OsteoSys, Seoul, Korea) which was used to observe the changes in bone mineral density. [Result] Although the VAS score was reduced in FEG and BEG with treatment, it was not reduced in CTG. Also, the bone mineral density was increased in FEG and BEG, while it was reduced in CTG. [Conclusion] Lumbar stabilization exercises using a ball are thought to be an effective interventional therapy for the alleviation of chronic low back pain and to increase bone mineral density of patients.

Publication patterns of comparative effectiveness research in spine neurosurgery

OBJECT

The purpose of this study was to investigate publication patterns for comparative effectiveness research (CER) on spine neurosurgery.

METHODS

The authors searched the PubMed database for the period 1980-2012 using the key words "cost analysis," "utility analysis," "cost-utility," "outcomes research," "practical clinical research," "comparator trial," and "comparative effectiveness research," linked with "effectiveness" and "spine neurosurgery."

RESULTS

From 1980 through April 9, 2012, neurosurgery CER publications accounted for 1.38% of worldwide CER publications (8657 of 626,330 articles). Spine neurosurgery CER accounted for only 0.02%, with 132 articles. The journal with the greatest number of publications on spine neurosurgery CER was Spine, followed by the Journal of Neurosurgery: Spine. The average annual publication rate for spine neurosurgery CER during this period was 4 articles (132 articles in 33 years), with 68 (51.52%) of the 132 articles being published within the past 5 years and a rising trend beginning in 2008. The top 3 contributing countries were the US, Turkey, and Japan, with 68, 8, and 7 articles, respectively. Only 8 regular articles (6.06%) focused on cost analysis.

CONCLUSIONS

There is a paucity of publications using CER methodology in spine neurosurgery. Few articles address the issue of cost analysis. The promotion of continuing medical education in CER methodology is warranted. Further investigations to address cost analysis in comparative effectiveness studies of spine neurosurgery are crucial to expand the application of CER in public health.

WITHDRAWN: Spinal manipulative therapy for low-back pain

BACKGROUND

Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain.

OBJECTIVES

To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened.

SELECTION CRITERIA

Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure.

DATA COLLECTION AND ANALYSIS

Two authors, who served as the authors for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).

MAIN RESULTS

Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.

AUTHORS' CONCLUSIONS

There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain

Background. Back pain is a common problem and a major cause of disability and health care utilization. Purpose. To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain. Data Sources. Records without language restriction from various databases up to February 2010. Data Extraction. The efficacy outcomes of interest were pain intensity and disability. Data Synthesis. Reports of 147 randomized trials and 5 nonrandomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically nonsignificant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature. Conclusions. CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments.

Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review

STUDY DESIGN

Systematic review of interventions.

OBJECTIVE

To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain.

SUMMARY OF BACKGROUND DATA

SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention.

METHODS

Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. The primary outcomes were pain, functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence.

RESULTS

We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief (mean difference -4.16, 95% confidence interval -6.97 to -1.36) and functional status (standardized mean difference -0.22, 95% confidence interval -0.36 to -0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.

CONCLUSIONS

High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.

Potential roles of the pharmacist in chronic pain management: a multidisciplinary perspective in primary care

Patients in the community with chronic pain may have poor pain control and use both prescribed and alternative therapies, often inappropriately, to try to optimise pain relief. They may benefit from management by a multidisciplinary primary care team involving a pharmacist. This study used postal questionnaires to determine community pharmacists' attitudes to involvement in pain management and the perceptions of general practitioners and physiotherapists of the current and potential roles of the pharmacist within a chronic pain care team. The three professions' views on factors which could influence chronic pain management were also determined. Sixty-three GPs (63 per cent), 59 community pharmacists (59 per cent) and 33 physiotherapists (66 per cent) responded. None of the pharmacists was currently involved in chronic pain management, but 58 (98 per cent) wanted to develop such a role, especially within pain clinics. Pharmacists and physiotherapists were more likely than GPs to identify that limited opportunity for personal involvement and expertise within a pain team reduced the likelihood of achieving optimal chronic pain management. Only 17 of the GPs had an established multidisciplinary pain care team; two of these had pharmacist involvement. All GPs and physiotherapists agreed that pharmacists had an important role to play in chronic pain management, particularly in the provision of drug information to patients and medication review.

Spinal manipulative therapy for chronic low-back pain

BACKGROUND

Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention.

OBJECTIVES

To assess the effects of SMT for chronic low-back pain.

SEARCH STRATEGY

An updated search was conducted by an experienced librarian to June 2009 for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2009, issue 2), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature.  

SELECTION CRITERIA

RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses.

MAIN RESULTS

We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.

AUTHORS' CONCLUSIONS

High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.

Spinal manipulation or mobilization for radiculopathy: a systematic review

In this systematic review, we present a comprehensive and up-to-date systematic review of the literature as it relates to the efficacy and effectiveness of spinal manipulation or mobilization in the management of cervical, thoracic, and lumbar-related extremity pain. There is moderate quality evidence that spinal manipulation is effective for the treatment of acute lumbar radiculopathy. The quality of evidence for chronic lumbar spine-related extremity symptoms and cervical spine-related extremity symptoms of any duration is low or very low. At present, no evidence exists for the treatment of thoracic radiculopathy. Future high-quality studies should address these conditions.

A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain

The purpose of this systematic review was to assess the effects of spinal manipulative therapy (SMT), acupuncture and herbal medicine for chronic non-specific LBP. A comprehensive search was conducted by an experienced librarian from the Cochrane Back Review Group (CBRG) in multiple databases up to December 22, 2008. Randomised controlled trials (RCTs) of adults with chronic non-specific LBP, which evaluated at least one clinically relevant, patient-centred outcome measure were included. Two authors working independently from one another assessed the risk of bias using the criteria recommended by the CBRG and extracted the data. The data were pooled when clinically homogeneous and statistically possible or were otherwise qualitatively described. GRADE was used to determine the quality of the evidence. In total, 35 RCTs (8 SMT, 20 acupuncture, 7 herbal medicine), which examined 8,298 patients, fulfilled the inclusion criteria. Approximately half of these (2 SMT, 8 acupuncture, 7 herbal medicine) were thought to have a low risk of bias. In general, the pooled effects for the studied interventions demonstrated short-term relief or improvement only. The lack of studies with a low-risk of bias, especially in regard to SMT precludes any strong conclusions; however, the principal findings, which are based upon low- to very-low-quality evidence, suggest that SMT does not provide a more clinically beneficial effect compared with sham, passive modalities or any other intervention for treatment of chronic low-back pain. There is evidence, however, that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention. Although there are some good results for individual herbal medicines in short-term individual trials, the lack of homogeneity across studies did not allow for a pooled estimate of the effect. In general, these results are in agreement with other recent systematic reviews on SMT, but in contrast with others. These results are also in agreement with recent reviews on acupuncture and herbal medicine. Randomized trials with a low risk of bias and adequate sample sizes are direly needed.

Cost-effectiveness of interventions based on physical exercise in the treatment of various diseases: A systematic literature review

Objectives:The aim of this study was to review studies reporting cost-effectiveness of exercise-based interventions in treatment of various diseases.

Methods:Systematic literature search using several databases. Abstracts initially screened independently by two authors, full-text articles again evaluated by two authors, who decided whether an article should be included. Included were scientifically valid articles describing controlled studies that included an exercise-based intervention in the treatment of an established medical condition, and also reported on the cost-effectiveness of the intervention, or its effect on the utilization of health services. Quality was assessed with an established approach.

Results:A total of 914 articles were identified, of them 151 were obtained for closer review. Sixty-five articles describing sixty-one studies were included. Most (82 percent) were randomized trials. Twenty-eight studies dealt with musculoskeletal disorders, fifteen with cardiology, four with rheumatic diseases, four with pulmonary diseases, three with urinary incontinence, and two with vascular disorders. There was one study each in the fields of oncology, chronic fatigue, endocrinology, psychiatry, and neurology. Exercise interventions in musculoskeletal disorders were deemed to be cost-effective in 54 percent, in cardiology in 60 percent, and in rheumatic diseases in 75 percent of the cases. There was some evidence that exercise might be cost-effective in intermittent claudication, breast cancer patients, diabetes, and schizophrenia.

Conclusions:The number of studies assessing cost-effectiveness of exercise interventions in various diseases is still limited. The results show large variation but suggest that some exercise interventions can be cost-effective. Most convincing evidence was found for rehabilitation of cardiac and back pain patients; however, even in these cases, the evidence was partly contradictory.

Rehabilitation after lumbar disc surgery: an update Cochrane review

STUDY DESIGN

Cochrane systematic review of randomized controlled trials.

OBJECTIVE

To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery.

SUMMARY OF BACKGROUND DATA

Several rehabilitation programs are available for individuals after lumbar disc surgery, however, little is known about the efficacy of these treatments.

METHODS

Search strategies were performed on CENTRAL (The Cochrane Library 2007, Issue 2) and MEDLINE, EMBASE, CINAHL, and PsycINFO up to May 2007. All randomized controlled trials without language limitations were included. Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence.

RESULTS

Fourteen studies were included, 7 of which had a low risk of bias. Most programs were only assessed in 1 study. Statistical pooling was only completed for 3 comparisons in which exercises started 4 to 6 weeks postsurgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises. We found low quality evidence (3 randomized controlled trials [RCTs], N = 122) that exercises are more effective than no treatment for pain at short-term follow-up (weighted mean difference [WMD]:-11.13; 95% CI: -18.44 to -3.82) and moderate evidence (2 RCTs, N = 102) that exercises are more effective for functional status on short-term follow-up (WMD: -6.50; 95% CI: -9.26 to -3.74). None of the studies reported that exercises increased the reoperation rate. We also found low quality evidence (2 RCTs, N = 103) that high intensity exercises are slightly more effective than low intensity exercise programs for pain in the short-term (WMD: -10.67; 95% CI: -17.04 to -4.30) and moderate evidence (2 RCTs, N = 103) that they are more effective for functional status in the short-term (standardized mean difference [SMD] -0.77; 95% CI: -1.17 to -0.36). Finally, we found low quality evidence (3 RCTs, N = 95) that there were no significant differences between supervised and home exercises for short-term pain relief (SMD: -1.12; 95% CI: -2.77-0.53) or functional status (3 RCT, N = 95; SMD -1.17; 95% CI: -2.63-0.28).

CONCLUSION

Exercise programs starting 4 to 6 weeks postsurgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the reoperation rate after first-time lumbar surgery.

Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis

OBJECTIVES

The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP).

METHODS

A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input.

RESULTS

A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies.

CONCLUSIONS

As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.

Motor control exercise for persistent, nonspecific low back pain: a systematic review

BACKGROUND

Previous systematic reviews have concluded that the effectiveness of motor control exercise for persistent low back pain has not been clearly established.

OBJECTIVE

The objective of this study was to systematically review randomized controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain.

METHODS

Electronic databases were searched to June 2008. Pain, disability, and quality-of-life outcomes were extracted and converted to a common 0 to 100 scale. Where possible, trials were pooled using Revman 4.2.

RESULTS

Fourteen trials were included. Seven trials compared motor control exercise with minimal intervention or evaluated it as a supplement to another treatment. Four trials compared motor control exercise with manual therapy. Five trials compared motor control exercise with another form of exercise. One trial compared motor control exercise with lumbar fusion surgery. The pooling revealed that motor control exercise was better than minimal intervention in reducing pain at short-term follow-up (weighted mean difference=-14.3 points, 95% confidence interval [CI]=-20.4 to -8.1), at intermediate follow-up (weighted mean difference=-13.6 points, 95% CI=-22.4 to -4.1), and at long-term follow-up (weighted mean difference=-14.4 points, 95% CI=-23.1 to -5.7) and in reducing disability at long-term follow-up (weighted mean difference=-10.8 points, 95% CI=-18.7 to -2.8). Motor control exercise was better than manual therapy for pain (weighted mean difference=-5.7 points, 95% CI=-10.7 to -0.8), disability (weighted mean difference=-4.0 points, 95% CI=-7.6 to -0.4), and quality-of-life outcomes (weighted mean difference=-6.0 points, 95% CI=-11.2 to -0.8) at intermediate follow-up and better than other forms of exercise in reducing disability at short-term follow-up (weighted mean difference=-5.1 points, 95% CI=-8.7 to -1.4).

CONCLUSIONS

Motor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise.

Rehabilitation after lumbar disc surgery

BACKGROUND

Several rehabilitation programs are available for individuals after lumbar disc surgery.

OBJECTIVES

To evaluate the effects of active rehabilitation for adults after first-time lumbar disc surgery.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2007, Issue 2) and MEDLINE, EMBASE, CINAHL and PsycINFO to May 2007.

SELECTION CRITERIA

We only included randomised controlled trials (RCTs).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed studies for eligibility and risk of bias. A meta-analysis was performed with clinically homogeneous studies. The GRADE approach was used to determine the quality of evidence.

MAIN RESULTS

Fourteen studies were included, seven of which had a low risk of bias. Most programs were only assessed in one study. Statistical pooling was only completed for three comparisons in which exercises were started four to six weeks post-surgery: exercise programs versus no treatment, high versus low intensity exercise programs, and supervised versus home exercises.There is low quality evidence (three RCTS, N = 156) that exercises are more effective than no treatment for pain at short-term follow-up (WMD -11.13; 95% CI -18.44 to -3.82) and moderate evidence (two RCTs, N = 136) that they are more effective for functional status on short-term follow-up (WMD -6.50; 95% CI -9.26 to -3.74). None of the studies reported that exercises increased the re-operation rate.There is low quality evidence (two RCTs, N =103) that high intensity are slightly more effective than low intensity exercise programs for pain in the short term (WMD -10.67; 95% CI -17.04 to -4.30) and moderate evidence (two RCTs, N = 103) that they are more effective for functional status in the short term (SMD -0.77; 95% CI -1.17 to -0.36).There is low quality evidence (three RCTS, N = 95) that there were no significant differences between supervised and home exercises for short-term pain relief (SMD -1.12; 95% CI -2.77 to 0.53) or functional status (three RCTs, N = 88; SMD -1.18; 95% CI -2.63 to 0.26).

AUTHORS' CONCLUSIONS

Exercise programs starting four to six weeks post-surgery seem to lead to a faster decrease in pain and disability than no treatment. High intensity exercise programs seem to lead to a faster decrease in pain and disability than low intensity programs. There were no significant differences between supervised and home exercises for pain relief, disability, or global perceived effect. There is no evidence that active programs increase the re-operation rate after first-time lumbar surgery.

Transcutaneous electrical nerve stimulation (TENS) for chronic pain

BACKGROUND

Transcutaneous electrical nerve stimulation (TENS) is a popular pain treatment modality but its effectiveness in chronic pain management is unknown. This review is an update of the original Cochrane review published in Issue 3, 2001.

OBJECTIVES

To evaluate the effectiveness of TENS in chronic pain.

SEARCH STRATEGY

The Cochrane Library, EMBASE, MEDLINE and CINAHL were searched. Reference lists from retrieved reports and reviews were examined. Date of the most recent search: April 2008.

SELECTION CRITERIA

RCTs were eligible if they compared active TENS versus sham TENS controls; active TENS versus 'no treatment' controls; or active TENS versus active TENS controls (e.g. High Frequency TENS (HFTENS) versus Low Frequency TENS (LFTENS)). Studies of chronic pain for three months or more which included subjective outcome measures for pain intensity or relief were eligible for evaluation. No restrictions were made to language or sample size. Abstracts, letters, or unpublished studies, and studies of TENS in angina, headache, migraine, dysmenorrhoea and cancer-related pain were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted and summarised on the following items: patients and details of pain condition, treatments, study duration, design, methods, subjective pain outcome measures, methodological quality, results for pain outcome measures and adverse effects, and conclusions by authors of the studies. Extracted data and methodological quality of studies were confirmed by the review authors.

MAIN RESULTS

Of 124 studies identified from the searches, 99 did not fulfil pre-defined entry criteria. Twenty-five RCTs involving 1281 participants were evaluated. Included studies varied in design, analgesic outcomes, chronic pain conditions, TENS treatments and methodological quality. The reporting of methods and results for analgesic outcomes were inconsistent across studies and generally poor. Meta-analysis was not possible. Overall in 13 of 22 inactive control studies, there was a positive analgesic outcome in favour of active TENS treatments. For multiple dose treatment comparison studies, eight of fifteen were considered to be in favour of the active TENS treatments. Seven of the nine active controlled studies found no difference in analgesic efficacy between High Frequency (HF) TENS and Low Frequency (LF) TENS.

AUTHORS' CONCLUSIONS

Since the last version of this review, new relevant studies have not provided additional information to change the conclusions. Published literature on the subject lacks the methodological rigour or robust reporting needed to make confident assessments of the role of TENS in chronic pain management. Large multi-centre RCTs of TENS in chronic pain are still needed.

Evidence-informed management of chronic low back pain with lumbar extensor strengthening exercises

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of to The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this supplement were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Evidence-informed management of chronic low back pain with spinal manipulation and mobilization

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

WITHDRAWN: Transcutaneous electrical nerve stimulation and acupuncture-like transcutaneous electrical nerve stimulation for chronic low back pain

BACKGROUND

In view of the claims and counter-claims of the effectiveness of transcutaneous electrical nerve stimulation, it would seem appropriate to systematically review the literature.

OBJECTIVES

To determine the effectiveness of transcutaneous electrical nerve stimulation in reducing pain and improving range of movement in patients with chronic low back pain.

SEARCH STRATEGY

Electronic searches of EMBASE, MEDLINE, CISCOM, AMED for all studies of TENS in the English language, identifying those treating chronic low back pain and hand searching their references.

SELECTION CRITERIA

The inclusion criterion for studies included in this review, 6 of 68 identified, was comparisons of TENS/ALTENS versus placebo in patients with chronic low back pain.

DATA COLLECTION AND ANALYSIS

Outcome data on pain reduction, range of movement, functional status and work was extracted by two independent reviewers together with trial design qualities to construct a Quality Index.

MAIN RESULTS

The ratio of odds of improvement in pain for each comparison was calculated: TENS vs. placebo at 1.62 (95% CI 0.90, 2.68); ALTENS vs. placebo at 7.22 (95% CI 2.60, 20.01) and TENS/ALTENS vs. placebo at 2.11 (95% CI 1.32, 3.38) times that of placebo. An improvement in pain reduction was seen in 45.80% (CI 37.00%, 55.00%) of TENS; 86.70% (CI 80.00%, 93.00%) of ALTENS; 54.00% (CI 46.20%, 61.80%) of TENS/ ALTENS and 36.40% (95%CI 28.40%, 44.40%) of placebo subjects. The odds of improvement in range of movement on ALTENS vs. placebo was 6.61 times (95% CI 2.36, 18.55) that of placebo.

AUTHORS' CONCLUSIONS

Transcutaneous electrical nerve stimulation appears to reduce pain and improve the range of movement in chronic low back pain subjects. A definitive randomised controlled study of ALTENS, TENS, placebo/no treatment controls, of sufficient power, is needed to confirm these findings.

Unloaded movement facilitation exercise compared to no exercise or alternative therapy on outcomes for people with nonspecific chronic low back pain: a systematic review

OBJECTIVE

The purpose of this study was to determine the effect of unloaded movement facilitation exercises on outcomes for people with nonspecific chronic low back pain (NSCLBP).

METHODS

This systematic review was conducted according to Cochrane Back Review Group and Quality of Reporting of Meta-analyses (QUORUM) guidelines. Exercise effects were reported as standardized mean difference (SMD) with 95% confidence intervals (95% CI).

RESULTS

Six high-quality randomized controlled trials were included. For NSCLBP effects favored McKenzie therapy over intensive trunk strengthening for pain: SMD: short-term: 0.35 (0.10, 0.59); long-term 0.36 (0.12, 0.61) and short-term function: SMD: 0.45 (0.20, 0.70) and were comparable for medium-term function: SMD: 0.15 (-0.90, 0.40). Effects of favored McKenzie therapy were comparable to specific spinal stabilization exercises for short-term pain: SMD: 0.63 (-0.11, 1.38) and function: SMD: 0.47 (-0.27, 1.20). Pooled effects favored McKenzie therapy over other exercises for short-term pain (pooled SMD: 0.38 (0.14, 0.61)) and were comparable for short-term function: SMD: 0.10 (-0.20, 0.40). Yoga compared to trunk strengthening produced comparable effects for pain: (SMD: short-term: 0.13 (-0.46, 0.71); medium-term 0.51 (-0.08, 1.11)) and function SMD: short-term: 0.51 (-0.08, 1.10); medium-term 0.38 (-0.22, 0.97)). Compared to education, effects of yoga were large for medium-term pain and function (pooled SMDs: 0.92 (0.47, 1.37); 0.95 (0.50, 1.40)). Effects favored unloaded movement facilitation exercises of McKenzie compared to other or no exercise and were comparable for yoga.

CONCLUSIONS

For NSCLBP, there is strong evidence that unloaded movement facilitation exercise, compared to no exercise, improves pain and function. Compared to other types of exercise, including effort-intensive strengthening and time-intensive stabilization exercise, the effects are comparable. This challenges the role of strengthening for NSCLBP.

[Chronic low back pain and vertebral manipulation]

OBJECTIVE

This study examined the short-term effectiveness of vertebral manipulation for treating chronic low back pain and disability.

METHODS

Sixty-four patients were randomly assigned into two groups. One group received 4 true vertebral manipulations (VMG), and the other group received sham manipulations (sham-VMG) under the same conditions as for the first technique. Patients formulated assessments after the manipulations and 1 month later.

RESULTS

Sixty-four patients participated in the study. Patients receiving the true manipulations showed significant improvement in pain (visual analogic scale score decrease from 71.8+/-18.11 to 49.37+/-16.78; P<0.001) and function (Oswestry scale score decrease from 15.59+/-6.03 to 12.25+/-5.69; P<0.001). Pain improvement persisted at the second month (P=0.01). The improvement was more evident in the VMG than the sham-VMG. No change in perceived disability was observed in the sham-VMG.

CONCLUSION

Our study confirms the efficiency of short-term vertebral manipulation for treating chronic low back pain. The assessment of vertebral manipulation effectiveness is difficult. This manual therapy must be preceeded by a specific clinical exam performed by a trained physician.

The development of an evidence-based patient booklet for patients undergoing lumbar discectomy and un-instrumented decompression

Post-operative management after lumbar surgery is inconsistent leading to uncertainty amongst surgeons and patients about post-operative restrictions, reactivation, and return to work. This study aimed to review the evidence on post-operative management, with a view to developing evidence-based messages for a patient booklet on post-operative management after lumbar discectomy or un-instrumented decompression. A systematic literature search produced a best-evidence synthesis of information and advice on post-operative restrictions, activation, rehabilitation, and expectations about outcomes. Evidence statements were extracted and developed into patient-centred messages for an educational booklet. The draft text was evaluated by peer and patient review. The literature review found little evidence for post-operative activity restrictions, and a strong case for an early active approach to post-operative management. The booklet was built around key messages derived from the literature review and aimed to reduce uncertainty, promote positive beliefs, encourage early reactivation, and provide practical advice on self-management. Feedback from the evaluations were favourable from both review groups, suggesting that this evidence-based approach to management is acceptable and it has clinical potential.

Trunk-strengthening exercises for chronic low back pain: a systematic review

OBJECTIVE

The objective of this systematic review was to determine the effect of lumbar spine-strengthening exercises on outcomes for people with chronic low back pain.

METHODS

Two independent reviewers followed Cochrane Back Review Group and QUORUM Statement guidelines to complete this systematic review. Exercise effects were reported as standardized mean difference (SMD) with 95% confidence intervals.

RESULTS

Thirteen high-quality randomized controlled trials were included. For chronic low back pain, trunk strengthening is more effective than no exercise on long-term pain (SMD 0.95 [0.35-1.55]; intensive trunk strengthening is more effective than less intensive on function (pooled SMD: short-term, 0.58 [0.22-0.94]; long-term, 0.77 [0.33-1.20]). Compared with physiotherapy or aerobics, effects are comparable on pain and function. Motivation strategies increase effectiveness. After disk surgery, effects are significant for function (pooled SMD: short-term, 1.08 (0.76-1.41); long-term, 0.53 (0.03-1.04). For severe degeneration, trunk strengthening is less favorable than fusion on long-term pain (SMD, -0.50 [-0.99 to -0.01]) or function (SMD, -0.76 [-1.25 to -0.26]). Intensive trunk strengthening is less effective than McKenzie exercises for pain reduction (SMD: short-term, -0.29 [-0.54 to -0.05]; long-term, -0.31 [-0.55 to -0.06]). We estimated that moderate effect sizes (0.5) indicate that approximately 50% of participants and large effect sizes (0.8) indicate that approximately 80% of participants would achieve important improvement.

CONCLUSIONS

Trunk strengthening appears effective compared with no exercise. Increasing exercise intensity and adding motivation increase treatment effects. Trunk strengthening, compared with aerobics or McKenzie exercises, showed no clear benefit of strengthening. It is unclear whether observed benefits are due to tissue loading or movement repetition.

A Randomized, Controlled Trial of Manual Therapy and Specific Adjuvant Exercise for Chronic Low Back Pain

OBJECTIVE

This article examines the effectiveness of manual therapy with specific adjuvant exercise for treating chronic low back pain and disability.

METHODS

A single blind, randomized, controlled trial was employed. Patients were prescribed an exercise program that was tailored to treat their musculoskeletal dysfunctions or given a nonspecific program of general stretching and aerobic conditioning. In addition, patients received manual therapy or sham manual therapy. Participants were seen for 6 weekly sessions and were asked to perform their exercise program twice daily.

RESULTS

Seventy-two out of 100 patients completed the study. Multivariate tests conducted for measures of pain and disability revealed a significant group by time interaction (P = 0.04 and P = 0.05, respectively), indicating differential change in these measures pretreatment to posttreatment as a function of the treatment received. When controlling for pretreatment scores, patients receiving manual therapy with specific adjuvant exercise reported significant reductions in pain. No change in perceived disability was observed, with the exception that patients receiving sham manual therapy with specific adjuvant exercise reported significantly greater disability at posttreatment.

DISCUSSION

Manual therapy with specific adjuvant exercise appears to be beneficial in treating chronic low back pain. Despite changes in pain, perceived function did not improve. It is possible that impacting chronic low back pain alone does not address psychosocial or other factors that may contribute to disability. Further studies are needed to examine the long-term effects of these interventions and to address what adjuncts are beneficial in improving function in this population.

Physician referrals to physical therapists for the treatment of spine disorders

BACKGROUND CONTEXT

Individuals with spine disorders often seek care from physical therapists (PTs). Because most insurance plans will reimburse only for PT services prescribed by a physician, physicians play an important role in access to and the appropriate use of PTs. Problems with access to or inappropriate use of PTs may affect the quality and cost of care received by patients with spine problems.

PURPOSE

To identify factors associated with physician referrals to PTs for the treatment of spine disorders.

STUDY DESIGN/SETTING

Cross-sectional analysis of data collected at 20 US spine centers (1998-2002).

PATIENT SAMPLE

A total of 30,255 patients with spine disorders who were seen for an initial evaluation.

OUTCOME MEASURE

Whether the physician made a PT referral.

METHODS

A logistic regression analysis was conducted to identify factors associated with physician referrals to PTs. Explanatory variables included health-related characteristics, compensation-related characteristics, past provider use, demographics, and patient expectations. Center effects were also accounted for in the analysis.

RESULTS

Of the total sample, 38% was referred to a PT. Although several health-related variables explained variation in PT referral, other variables were also associated with PT referral. Patients who were older or male were less likely to be referred. Patients who were more educated were more likely to be referred. There was also significant center-to-center variation in PT referral.

CONCLUSIONS

Variation in PT referral, as a result of factors other than health and need, may be indicative of problems with access to or inappropriate use of PT.

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.

Differences in outcome of a multidisciplinary treatment between subgroups of chronic low back pain patients defined using two multiaxial assessment instruments: the multidimensional pain inventory and lumbar dynamometry

OBJECTIVE

To investigate the effects of a multidisciplinary back school programme (Roessingh Back Rehabilitation Programme, RRP) compared with usual care, as well as differences in treatment outcome between subgroups defined using two multiaxial assessment instruments: the Multidimensional Pain Inventory (MPI-DLV) and lumbar dynamometry.

DESIGN

Randomized controlled trial.

SETTING

Rehabilitation.

SUBJECTS

One hundred and sixty-three patients with chronic, aspecific low back pain.

INTERVENTION

All subjects were randomly assigned either to a multidisciplinary, physically oriented group treatment or to their usual care.

MAIN OUTCOME MEASURES

The Roland Disability Questionnaire and health-related quality of life (EuroQol, EQ5-D) were measured as primary outcomes before randomization and after eight weeks and six months follow-up.

RESULT

Only 30-50% of the patients in the RRP group showed improvement and this number is not significantly different from the control group. Subgroup analyses give some first indications that multiaxial measurement instruments can be used to identify subgroups with differences in treatment effects.

CONCLUSION

The overall effect of a multidisciplinary treatment is disappointing, however multiaxial assessment before admission might be valuable in clinical practice, resulting in more effective treatments for patients with chronic low back pain.