The (cost-)effectiveness of combined lifestyle interventions for people with persistent low-back pain who are overweight or obese: A systematic review

INTRODUCTION

Lifestyle factors are expected to contribute to the persistence and burden of low-back pain (LBP). However, there are no systematic reviews on the (cost-)effectiveness of combined lifestyle interventions for overweight or obese people with LBP.

AIM

To assess whether combined lifestyle interventions are (cost-)effective for people with persistent LBP who are overweight or obese, based on a systematic review.

DESIGN

Systematic review METHOD: PubMed, Cochrane, Embase, CINAHL, PsycINFO and the Wiley/Cochrane Library were searched from database inception till January 6^th 2023. Two independent reviewers performed study selection, data-extraction and risk of bias scoring using the Cochrane RoB tool 2 and/or the Consensus Health Economic Criteria list. GRADE was used to assess the level of certainty of the evidence.

RESULTS

In total 2510 records were screened, and 4 studies on 3 original RCTs with 216 participants were included. Low certainty evidence (1 study) showed that combined lifestyle interventions were not superior to usual care for physical functioning, pain and lifestyle outcomes. Compared to usual care, moderate certainty evidence showed that healthcare (-$292, 95%CI: 872; -33), medication (-$30, 95% CI -65; -4) and absenteeism costs (-$1000, 95%CI: 3573; -210) were lower for the combined lifestyle interventions.

CONCLUSION

There is low certainty evidence from 3 studies with predominantly small sample sizes, short follow-up and low intervention adherence that combined lifestyle interventions are not superior to physical functioning, pain and lifestyle outcomes compared to usual care, but are likely to be cost-effective.

Does pain medication influence outcomes in elderly people seeking care for back pain? BACE cohort study

BACKGROUND

Back pain is common among older adults resulting in the high societal and economic burden of persistent pain and disability. Pain medications are frequently prescribed for back pain, especially among older patients, but the efficacy of analgesics on back pain in this patient population remains under debate. In the present study, we investigated the outcomes (i.e. pain intensity and disability) of pain medication use in older people with back pain participating in a prospective cohort study.

METHODS

A total of 669 patients aged >55 years consulting a general practitioner for a new episode of back complaints were included in this study. The association between pain medication use and outcomes (pain intensity and disability) was assessed at 3-month follow-up.

RESULTS

Pain medication users were observed to experience more pain and disability at baseline compared with non-users. At 3-month follow-up, patients from all subgroups (e.g. pain medication users versus non-users) improved over time. Yet medication users had higher pain intensity and poorer disability scores compared with non-users. Patients who de-escalated or stopped pain medication had lower pain and disability than non-users. When comparing different types of medications (i.e. paracetamol, non-steroidal anti-inflammatory drugs, opioids), none of the groups showed better scores regarding pain and disability in users compared with non-users. Opioid users displayed the highest levels of pain and disability.

CONCLUSIONS

In the present study, although patients who de-escalated or stopped analgesics had less pain and disability, pain medication overall does not result in better outcomes in older people with back pain.

SIGNIFICANCE

Older patients taking pain medication did not report better outcomes than the ones who did not, except for those who de-escalated or stopped pain medication. Caution should be taken in prescribing pain medication for older patients with back pain in primary care.

Recovery expectations of neck pain patients do not predict treatments outcome in manual therapy

Patient recovery expectations can predict treatment outcome. Little is known about the association of patient recovery expectations on treatment outcome in patients with neck pain consulting a manual therapist. This study evaluates the predictive value of recovery expectations in neck pain patients consulting manual therapists in the Netherlands. The primary outcome measure 'recovery' is defined as 'reduction in pain and perceived improvement'. A prospective cohort study a total of 1195 neck pain patients. Patients completed the Patient Expectancies List (PEL) at baseline (3 item questionnaire, score range from 3 to 12), functional status (NDI), the Global Perceived Effect (GPE) for recovery (7-points Likert scale) post treatment and pain scores (NRS) at baseline and post treatment. The relationship between recovery expectancy and recovery (dichotomized GPE scores) was assessed by logistic regression analysis. Patients generally reported high recovery expectations on all three questions of the PEL (mean sumscores ranging from 11.3 to 11.6). When adjusted for covariates the PEL sum-score did not predict recovery (explained variance was 0.10 for the total PEL). Separately, the first question of the PEL showed predictive potential (OR 3.7; 95%CI 0.19-73.74) for recovery, but failed to reach statistical significance. In this study patient recovery expectations did not predict treatment outcome. Variables predicting recovery were recurrence and duration of pain. The precise relationship between patient recovery expectations and outcome is complex and still inconclusive. Research on patient expectancy would benefit from more consistent use of theoretical expectancy and outcome models.

Agreement between physical therapists and radiologists of stratifying patients with shoulder pain into new treatment related categories using ultrasound; an exploratory study

STUDY DESIGN

A systematic overview of the literature and an agreement study.

OBJECTIVES

The aim of this study is to explore the inter-professional agreement of diagnostic musculoskeletal ultrasound (DMUS) between physical therapists (PT) and radiologists, using a new classification strategy based upon the therapeutic consequences in patients with shoulder pain.

BACKGROUND

DMUS is frequently used by PTs, although the agreement regarding traditional diagnostic labels between PTs and radiologists is only fair. Nevertheless, DMUS could be useful when used as a stratifying-tool.

METHODS

First, a systematic overview of current evidence was performed to assess which traditional diagnostic labels could be recoded into new treatment related categories (referral to secondary care, corticosteroid injections, physical therapy, watchful waiting). Next, kappa values were calculated for these categories between PTs and radiologists.

RESULTS

Only three categories were extracted, as none of the traditional diagnostic labels were classified into the 'corticosteroid injection' category. Overall, we found moderate agreement to stratify patients into treatment related categories and substantial agreement for the category 'referral to secondary care'. Both categories 'watchful waiting' and 'indication for physical therapy' showed moderate agreement between the two professions.

CONCLUSION

Our results indicate that the agreement between radiologists and PTs is moderate to substantial when labelling is based on treatment consequences. DMUS might be able to help the PT to guide treatment, especially for the category 'referral to secondary care' as this showed the highest agreement. However, as this is just an explorative study, more research is needed, to validate and assess the consequences of this stratification classification for clinical care.

The association between pro-inflammatory biomarkers and nonspecific low back pain: a systematic review

BACKGROUND CONTEXT

About 85% of the patients with low back pain seeking medical care have nonspecific low back pain (NsLBP), implying that no definitive cause can be identified. Nonspecific low back pain is defined as low back pain and disability which cannot be linked to an underlying pathology, such as cancer, spinal osteomyelitis, fracture, spinal stenosis, cauda equine, ankylosing spondylitis, and visceral-referred pain. Many pain conditions are linked with elevated serum levels of pro-inflammatory biomarkers. Outcomes of interest are NsLBP and the level of pro-inflammatory biomarkers.

PURPOSE

To unravel the etiology and get better insight in the prognosis of NsLBP, the aim of this study was to assess the association between pro-inflammatory biomarkers and the presence and severity of NsLBP.

STUDY DESIGN

A systematic literature search was made in Embase, Medline, Cinahl, Webof-science, and Google scholar up to January 19th 2017.

METHODS

Included were cross-sectional and cohort studies reporting on patients aged over 18 years with NsLBP, in which one or more pro-inflammatory biomarkers were measured in blood plasma. The methodological quality of the included studies was assessed using the Newcastle Ottawa Scale. A best-evidence synthesis was used to summarize the results from the individual studies, meaning that the included studies were ranked according to the consistency of the findings and according to their methodological quality score using the Newcastle Ottawa Scale.

RESULTS

Included were 10 studies which assessed four different pro-inflammatory biomarkers. For the association between the presence of NsLBP and C-reactive protein (CRP), interleukin 6 (IL-6) and tumor necrosis factor (TNF)-α limited, conflicting and moderate evidence, respectively, was found. For the association between the severity of NsLBP and CRP and IL-6, moderate evidence was found. For the association between the severity of NsLBP and TNF-α and RANTES Regulated on Activation, Normal T Cell Expressed and Secreted conflicting and limited evidence, respectively, was found.

CONCLUSIONS

This study found moderate evidence for (i) a positive association between the pro-inflammatory biomarkers CRP and IL-6 and the severity of NsLBP, and (ii) a positive association between TNF-α and the presence of NsLBP. Conflicting and limited evidence was found for the association between TNF-α and Regulated on Activation, Normal T Cell Expressed and Secreted and severity of NsLBP, respectively.

Discontinuation of the PACE Plus trial: problems in patient recruitment in general practice

BACKGROUND

The PACE Plus trial was a multi-center, double-blinded, superiority randomized controlled trial (RCT) conducted in patients from Dutch general practice to investigate the efficacy of paracetamol and NSAIDs in acute non-specific low back pain (LBP). Because insufficient numbers of patients could be recruited (only four out of the required 800 patients could be recruited over a period of 6 months), the trial was prematurely terminated in February 2017, 6 months after the start of recruitment. This article aims to transparently communicate the discontinuation of PACE Plus and to make recommendations for future studies.

METHODS

General Practitioners (GPs) from 36 participating practices received a one-question survey in which they were asked to give the three most important factors that in their opinion contributed to failure of patient recruitment.

RESULTS

GPs of 33 out of 36 (92%) participating practices sent a response. A total of 81 factors were reported. These have been categorized into patient factors (26 out of 81 comments, 32%), GP factors (39 out of 81 comments, 48%) and research factors (16 out of 81 comments, 20%).

DISCUSSION

Patient recruitment in the PACE Plus trial may have failed due to inefficient medication distribution, recruitment of incident rather than prevalent cases, a design that was too complicated, adequate self-management of LBP, patient expectations different from the trial's scope and lack of time of participating GPs. Substantial differences in design may explain why the preceding PACE trial did manage to successfully complete patient recruitment.

CONCLUSION

Although the PACE Plus trial was terminated as a result of insufficient patient inclusion, the research questions addressed in this trial remain relevant but unanswered. We hope that lessons learned from the discontinuation of PACE Plus and corresponding recommendations may be helpful in the design of upcoming research projects in LBP in general practice.

TRIAL REGISTRATION

Dutch Trial Registration NTR6089, registered September 14th 2016.

Differences in bone mineral density between normal-weight children and children with overweight and obesity: a systematic review and meta-analysis

OBJECTIVE

This study examines the differences in bone mineral density between normal-weight children and children with overweight or obesity.

METHODS

A systematic review and meta-analysis of observational studies (published up to 22 June 2016) on the differences in bone mineral density between normal-weight children and overweight and obese children was performed. Results were pooled when possible and mean differences (MDs) were calculated between normal-weight and overweight and normal-weight and obese children for bone content and density measures at different body sites.

RESULTS

Twenty-seven studies, with a total of 5,958 children, were included. There was moderate and high quality of evidence that overweight (MD 213 g; 95% confidence interval [CI] 166, 261) and obese children (MD 329 g; 95%CI [229, 430]) have a significantly higher whole body bone mineral content than normal-weight children. Similar results were found for whole body bone mineral density. Sensitivity analysis showed that the association was stronger in girls.

CONCLUSIONS

Overweight and obese children have a significantly higher bone mineral density compared with normal-weight children. Because there was only one study included with a longitudinal design, the long-term impact of childhood overweight and obesity on bone health at adulthood is not clear.

Efficacy of paracetamol, diclofenac and advice for acute low back pain in general practice: design of a randomized controlled trial (PACE Plus)

BACKGROUND

Low back pain is common and associated with a considerable burden to patients and society. There is uncertainty regarding the relative benefit of paracetamol and diclofenac and regarding the additional effect of pain medication compared with advice only in patients with acute low back pain. This trial will assess the effectiveness of paracetamol, diclofenac and placebo for acute low back pain over a period of 4 weeks. Furthermore, this trial will assess the additional effectiveness of paracetamol, diclofenac and placebo compared with advice only for acute low back pain over a period of 4 weeks.

METHODS

The PACE Plus trial is a multi-center, placebo-blinded, superiority randomized controlled trial in primary care, with a follow-up of 12 weeks. Patients with acute low back pain aged 18-60 years presenting in general practice will be included. Patients are randomized into four groups: 1) Advice only (usual care conforming with the clinical guideline of the Dutch College of General Practitioners); 2) Advice and paracetamol; 3) Advice and diclofenac; 4) Advice and placebo. The primary outcome is low back pain intensity measured with a numerical rating scale (0-10). Secondary outcomes include compliance to treatment, disability, perceived recovery, costs, adverse reactions, satisfaction, sleep quality, co-interventions and adequacy of blinding. Between group differences for low back pain intensity will be evaluated using a repeated measurements analysis with linear effects models. An economic evaluation will be performed using a cost-effectiveness analysis with low back pain intensity and a cost-utility analysis with quality of life. Explorative analyses will be performed to assess effect modification by predefined variables. Ethical approval has been granted. Trial results will be released to an appropriate peer-viewed journal.

DISCUSSION

This paper presents the design of the PACE Plus trial: a multi-center, placebo-blinded, superiority randomized controlled trial in primary care that will assess the effectiveness of advice only, paracetamol, diclofenac and placebo for acute low back pain.

TRIAL REGISTRATION

Dutch Trial Registration NTR6089 , registered September 14th, 2016.

PROTOCOL

Version 4, June 2016.

[Can sick leave be predicted in patients with non-traumatic arm, neck and/or shoulder complaints?]

OBJECTIVES

Impediments due to complaints of non-traumatic arm, neck and/or shoulder (CANS) during work often leads to consultation in primary care. This study examines the occurrence of sick leave among workers with new CANS, and evaluates sick leave trajectories and their characteristics.

METHODS

This prospective 2-year cohort study included workers with a new CANS presenting in general practice. Participants filled out postal questionnaires on sick leave at 6-monthly intervals. Latent class growth mixture modelling was used to identify distinct trajectories of sick leave. Multinomial regression analyses identified characteristics of the subgroups.

RESULTS

During follow-up, of the 533 participants 190 reported at least one episode of sick leave due to CANS. Three sick leave trajectories were distinguished: (a) 'low risk' trajectory (n = 366), with a constant low probability over time; (b) 'intermediate risk' trajectory, with a high probability at first consultation followed by a steep decrease in probability of sick leave (n = 122); (c) 'high risk' trajectory (n = 45), with a constant high probability of sick leave. Compared to the 'low-risk' trajectory, the other trajectories were characterised by more functional limitations, less specific diagnoses, more work-related symptoms and low coworker support. Specific for the 'high-risk' subgroup were more recurrent symptoms, more musculoskeletal comorbidity, high score on somatisation and low score on job demands.

CONCLUSIONS

Three trajectories of sick leave were distinguished, graded from favourable to unfavourable. Several complaint-related and work-related factors and somatisation contributed modestly to identify an unfavourable trajectory of sick leave when presenting in primary care with CANS.

Physiotherapy for patients with shoulder pain in primary care: a descriptive study of diagnostic- and therapeutic management

BACKGROUND

Shoulder pain is one of the three main musculoskeletal complaints and more than 50% of the patients have symptoms longer than 6 months. Until now, limited data exist about the content of physiotherapy for patients with shoulder pain in primary care.

OBJECTIVE

Describe current physiotherapeutic diagnostic- and therapeutic management, including the use of diagnostic ultrasound, in patients with shoulder pain in primary care.

DESIGN AND SETTING

A prospective cohort study in primary care physiotherapy with a 12 week follow-up.

METHODS

Descriptive data from physiotherapists was collected, such as: the diagnostic hypotheses after patient history and physical examination, the use of specific tests and diagnostic ultrasound, the interventions used and possible changes in treatment plan.

RESULTS

Subacromial impingement syndrome was the most common hypothesis after patient history (48%) as well as physical examination (39%). Diagnostic ultrasound was used in 31% and of these patients the clinical diagnosis changed in 29%. Various interventions were used in all clinical diagnoses. After 12 weeks 41% of patients still received physiotherapy treatment.

CONCLUSIONS

Patients with shoulder pain in physiotherapy practice frequently show signs of subacromial impingement syndrome. The interventions used by the physiotherapists were generally in line with the guideline for subacromial impingement syndrome however a small proportion of physiotherapists used massage and tape/bracing techniques. A large proportion of patients were still receiving treatment after 12 weeks when no improvement was observed. If treatment for patients with subacromial impingement shows no benefit patients should be referred back to the general practitioner or orthopedic surgeon. Conclusions from this study might be slightly biased because of the selection of physiotherapists.

Sick leave in workers with arm, neck and/or shoulder complaints; defining occurrence and discriminative trajectories over a 2-year time period

OBJECTIVES

Impediments due to complaints of non-traumatic arm, neck and/or shoulder (CANS) during work often leads to consultation in primary care. This study examines the occurrence of sick leave among workers with new CANS, and evaluates sick leave trajectories and their characteristics.

METHODS

This prospective 2-year cohort study included workers with a new CANS presenting in general practice. Participants filled out postal questionnaires on sick leave at 6-monthly intervals. Latent class growth mixture modelling was used to identify distinct trajectories of sick leave. Multinomial regression analyses identified characteristics of the subgroups.

RESULTS

During follow-up, of the 533 participants 190 reported at least one episode of sick leave due to CANS. Three sick leave trajectories were distinguished: (1) 'low-risk' trajectory (n=366), with a constant low probability over time; (2) 'intermediate risk' trajectory, with a high probability at first consultation followed by a steep decrease in probability of sick leave (n=122); (3) 'high-risk' trajectory (n=45), with a constant high probability of sick leave. Compared to the 'low-risk' trajectory, the other trajectories were characterised by more functional limitations, less specific diagnoses, more work-related symptoms and low coworker support. Specific for the 'high-risk' subgroup were more recurrent symptoms, more musculoskeletal comorbidity, high score on somatisation and low score on job demands.

CONCLUSIONS

Three trajectories of sick leave were distinguished, graded from favourable to unfavourable. Several complaint-related and work-related factors and somatisation contributed modestly to identify an unfavourable trajectory of sick leave when presenting in primary care with CANS.

Prophylactic Treatment of Migraine in Children. Part 2. A Systematic Review of Pharmacological Trials∗

The aim of this study was to assess the efficacy of pharmacological prophylactic treatments of migraine in children. Databases were searched from inception to June 2004 and references were checked. We selected controlled trials on the effects of pharmacological prophylactic treatments in children with migraine. We assessed trial quality using the Delphi list and extracted data. Analyses were carried out according to type of intervention. A total of 20 trials were included. Headache improvement was significantly higher for flunarizine compared with placebo (relative risk 4.00, 95% confidence interval 1.60, 9.97). There is conflicting evidence for the use of propranolol. Nimodipine, clonidine, L-5HTP, trazodone and papaverine showed no effect when compared with placebo. All medications were well tolerated and adverse events showed no significant differences. Flunarizine may be effective as prophylactic treatment for migraine in children. Because of the small number of studies and the methodological shortcomings, conclusions regarding effectiveness have to be drawn with caution.

Cost-utility of exercise therapy in patients with hip osteoarthritis in primary care

OBJECTIVE

To determine the cost-effectiveness (CE) of exercise therapy (intervention group) compared to 'general practitioner (GP) care' (control group) in patients with hip osteoarthritis (OA) in primary care.

METHOD

This cost-utility analysis was conducted with 120 GPs in the Netherlands from the societal and healthcare perspective. Data on direct medical costs, productivity costs and quality of life (QoL) was collected using standardised questionnaires which were sent to the patients at baseline and at 6, 13, 26, 39 and 52 weeks follow-up. All costs were based on Euro 2011 cost data.

RESULTS

A total of 203 patients were included. The annual direct medical costs per patient were significantly lower for the intervention group (€ 1233) compared to the control group (€ 1331). The average annual societal costs per patient were lower in the intervention group (€ 2634 vs € 3241). Productivity costs were higher than direct medical costs. There was a very small adjusted difference in QoL of 0.006 in favour of the control group (95% CI: -0.04 to +0.02).

CONCLUSION

Our study revealed that exercise therapy is probably cost saving, without the risk of noteworthy negative health effects.

TRIAL REGISTRATION NUMBER

NTR1462.

Effectiveness of exercise therapy added to general practitioner care in patients with hip osteoarthritis: a pragmatic randomized controlled trial

OBJECTIVE

To assess the effectiveness of exercise therapy added to general practitioner (GP) care compared with GP care alone, in patients with hip osteoarthritis (OA) during 12 months follow-up.

METHODS

We performed a multi-center parallel pragmatic randomized controlled trial in 120 general practices in the Netherlands. 203 patients, aged ≥45 years, with a new episode of hip complaints, complying with the ACR criteria for hip OA were randomized to the intervention group (n = 101; GP care with additional exercise therapy) or the control group (n = 102; GP care only). GP care was given by patient's own GP. The intervention group received, in addition, a maximum of 12 exercise therapy sessions in the first 3 months and hereafter three booster sessions. Blinding was not possible. Primary outcomes were hip pain and hip-related function measured with the HOOS questionnaire (score 0-100).

RESULTS

The overall estimates on hip pain and function during the 12-month follow-up showed no between-group difference (intention-to-treat). At 3-months follow-up there was a statistically significant between-group difference for HOOS pain -3.7 (95% CI: -7.3; -0.2), effect size -0.23 and HOOS function -5.3 (95% CI: -8.9; -1.6), effect size -0.31. No adverse events were reported.

CONCLUSIONS

No differences were found during 12-months follow-up on pain and function. At 3-months follow-up, pain and function scores differed in favor of patients allocated to the additional exercise therapy compared with GP care alone.

TRIAL REGISTRATION

The Netherlands Trial Registry NTR1462.

Prognosis and course of pain in patients with chronic non-specific low back pain: A 1-year follow-up cohort study

BACKGROUND

It remains unclear to what extent patients recover from chronic non-specific low back pain (NSLBP). The objective of this study was to determine (1) the course of chronic NSLBP in tertiary care and (2) which factors predicted 5- and 12-month outcomes.

METHODS

This prospective study includes 1760 chronic NSLBP patients from a rehabilitation clinic (mean age 40.1 years, SD 10.6). After baseline measurement, patients followed a 2-month multidisciplinary therapy programme; evaluation took place at 2, 5 and 12 months post baseline. Recovery was defined as (1) relative recovery [30% improvement on the pain, visual analogue scale (VAS) compared with baseline] and (2) absolute recovery (VAS pain ≤ 10 mm). The multivariate logistic regression analysis included 23 baseline characteristics.

RESULTS

Patient-reported intensity of back pain decreased from 55.5 (SD 23.0) at baseline to 37.0 (SD 23.8), 35.3 (SD 26.1) and 32.3 (SD 26.9) at 2-, 5- and 12-month follow-up, respectively. Younger age, back pain at baseline, no psychological/physical dysfunction (Symptom Check List-90, item 9), and higher baseline scores on the physical component scale and mental component scale of quality of life (Short Form-36) were positively associated with recovery at 5 and 12 months. At 5-month follow-up, higher work participation at baseline was also a prognostic factor for both definitions of recovery. At 12-month follow-up, having co-morbidity was predictive for both definitions.

CONCLUSION

The results of this study indicate that in chronic NSLBP patients, bio-psychosocial prognostic factors may be important for clinicians when predicting recovery in back pain intensity during a 1-year period.

Overweight and obesity are associated with musculoskeletal complaints as early as childhood: a systematic review

In order to examine (i) the association between weight status and musculoskeletal complaints (MSC) in children, and (ii) whether overweight and obese children have a higher risk of developing MSC than normal-weight children Medline, Embase, Web of Science and Cochrane were searched (all years up to 2 January 2013) for observational studies studying direct associations between body mass index (or weight status) and MSC in children. Forty studies, together studying over one million children, were included. There was moderate quality of evidence that being overweight in childhood is positively associated with musculoskeletal pain (risk ratio [RR] 1.26; 95% confidence interval [CI]: 1.09-1.45). In addition, low quality of evidence was found for a positive association between overweight and low back pain (RR 1.42; 95% CI: 1.03-1.97) and between overweight and injuries and fractures (RR 1.08; 95% CI: 1.03-1.14). Although the risk of developing an injury was significantly higher for overweight than for normal-weight adolescents (RR: 2.41, 95% CI: 1.42 to 4.10), this evidence was of very low quality. Overweight and obesity are associated with musculoskeletal pain, injuries and fractures as early as childhood. More high-quality prospective cohort studies are needed to study the nature of this relationship.

Characteristics of older patients with back pain in general practice: BACE cohort study

BACKGROUND

Although back pain is common among older people, limited information is available about the characteristics of these patients in primary care. Earlier research suggests that the severity of back symptoms increases with older age.

METHODS

Patients aged >55 years visiting a general practitioner with a new episode of back pain were included in the BACE study. Information on patients' characteristics, characteristics of the complaint and physical examination were derived from the baseline measurement. Cross-sectional differences between patients aged >55-74 and ≥75 years were analysed using an unpaired t-test, Mann-Whitney U-test or a chi-square test.

RESULTS

A total of 675 back pain patients were included in the BACE study, with a median age of 65 (interquartile range 60-71) years. Patients aged >55-74 years had a mean disability score (measured with the Roland Disability Questionnaire) of 9.4 [standard deviation (SD) 5.8] compared with 12.1 (SD 5.5) in patients aged ≥75 years (p ≤ 0.01). The older group reported more additional musculoskeletal disorders and more often had low bone quality (based on ultrasound measurement of the heel) than patients aged >55-74 years. Average back pain severity over the previous week showed no difference (p = 0.11) between the age groups, but severity of back pain at the moment of filling in the questionnaire was higher (p = 0.03) in the older age group.

CONCLUSIONS

In this study, older back pain patients reported more disabilities and co-morbidity. However, the clinical relevance of these differences for the course of the back pain episode in older patients remains a subject for further research.

Systematic review of prognostic factors predicting outcome in non-surgically treated patients with sciatica

Identification of prognostic factors for surgery in patients with sciatica is important to be able to predict surgery in an early stage. Identification of prognostic factors predicting persistent pain, disability and recovery are important for better understanding of the clinical course, to inform patient and physician and support decision making. Consequently, we aimed to systematically review prognostic factors predicting outcome in non-surgically treated patients with sciatica. A search of Medline, Embase, Web of Science and Cinahl, up to March 2012 was performed for prospective cohort studies on prognostic factors for non-surgically treated sciatica. Two reviewers independently selected studies for inclusion and assessed the risk of bias. Outcomes were pain, disability, recovery and surgery. A best evidence synthesis was carried out in order to assess and summarize the data. The initial search yielded 4392 articles of which 23 articles reporting on 14 original cohorts met the inclusion criteria. High clinical, methodological and statistical heterogeneity among studies was found. Reported evidence regarding prognostic factors predicting the outcome in sciatica is limited. The majority of factors that have been evaluated, e.g., age, body mass index, smoking and sensory disturbance, showed no association with outcome. The only positive association with strong evidence was found for leg pain intensity at baseline as prognostic factor for subsequent surgery.

Course of back complaints in older adults: a systematic literature review

BACKGROUND

Back pain is a common musculoskeletal complaint seen in older people. It is important to get an insight in the course of back complaints and to identify factors associated with a chronic course.

AIM

To describe the course of acute and subacute back complaints in older people (≥ 45 years) and to identify prognostic factors for developing chronic back complaints.

DESIGN

Systematic review of the literature.

METHODS

A database search was conducted in MEDLINE, EMBASE, Cochrane library, CINAHL, PsycINFO and PEDro. Cohort studies or randomized controlled trials reporting on the course of acute or subacute back complaints in older people were included. The percentage of patients that developed chronic back complaints was calculated, if possible.

RESULTS

The search yielded 9293 potentially relevant articles. Of these, 5 studies met all inclusion criteria. At 3 months follow-up 37-40% of the patients still had back complaints. At 12 months follow-up, the percentage ranged from 26-45%. Older age was frequently reported as a prognostic factor for developing chronic back complaints of the whole study population. No prognostic factors could be retrieved for patients aged 45 years and older.

CONCLUSIONS

At 3 and 12 month follow-up, about 40% of the older people still reported back complaints. However, the heterogeneity of the studies made comparisons difficult. In order to get a clear insight in the course of back complaints in the older adult patients and to indentify prognostic factors for developing chronic back complaints in older people, high quality prospective cohort studies are needed.

CLINICAL REHABILITATION IMPACT

More than one-third of the older patients with back pain still experience complaints after 3 and 12 months.

A systematic review on changed biomechanics of lower extremities in obese individuals: a possible role in development of osteoarthritis

Obesity has been identified as a risk factor for osteoarthritis. For the weight-bearing joints, the combination of increased load and changed joint biomechanics could be regarded as underlying principle for this relation. This systematic review of the literature focused on the differences between obese and normal-weight subjects in biomechanics of the hip, knee and ankle joint during every day movements to summarize differences in joint load due to both higher body weight and differences in movement patterns. A systematic search, up to November 2010, was performed in the Pubmed and Embase databases. This review showed that obese individuals adjust their movement strategy of every day movements. At self-selected speed, obese individuals walked slower, with shorter and wider steps, had longer stance duration and had a greater toe-out angle compared with normal-weight individuals. Obese sit-to-stand movement was characterized by less hip flexion and greater foot displacement. Obese individuals showed altered biomechanics during every day movements. These altered biomechanics could be related to the initiation of osteoarthritis by a change in the load-bearing regions of the articular cartilage in the weight-bearing joints.

Impact of different descriptions of the Kellgren and Lawrence classification criteria on the diagnosis of knee osteoarthritis

OBJECTIVES

Although the Kellgren and Lawrence (K&L) criteria for defining radiological osteoarthritis are widely used in epidemiological and clinical studies, the authors previously documented the existence of five different versions of these criteria. This study identifies the impact of the use of alternative versions of the K&L criteria and evaluates which description has the highest association with knee complaints.

METHODS

Two readers scored most radiographs of the knees of participants of the Rotterdam Study with the original K&L description (90%). In addition, each alternative description was used in a random part (20%) of the radiographs. The authors calculated reproducibility of all descriptions, and compared sensitivity and specificity of the alternative descriptions for three cut-off points with the original description as reference standard (K&L≥1, K&L≥2 and K&L≥3). The authors calculated κ statistics to compare agreement between the original and alternative descriptions, and evaluated the association with knee complaints.

RESULTS

The dataset comprises radiographs of knees of 3071 people. For cut-off K&L≥1 all four alternatives classified more people as having osteoarthritis than the original description; κ was low, and sensitivity and specificity were moderate to good. For cut-offs K&L≥2 and K&L≥3 there was little difference in the number of cases and κ, sensitivity and specificity were good to perfect. The original description and alternative 3 showed the strongest association with knee complaints.

CONCLUSIONS

The different descriptions of the K&L criteria have impact on the classification of osteoarthritis in the lowest grade (K&L≥1). All descriptions have strengths and weaknesses. It depends on the purpose which is the best description.

Supervised exercise therapy versus usual care for patellofemoral pain syndrome: an open label randomised controlled trial

OBJECTIVE

To assess the effectiveness of supervised exercise therapy compared with usual care with respect to recovery, pain, and function in patients with patellofemoral pain syndrome.

DESIGN

Open label randomised controlled trial.

SETTING

General practice and sport physician practice.

PARTICIPANTS

Patients with a new episode of patellofemoral pain syndrome recruited by their general practitioner or sport physician.

INTERVENTIONS

The intervention group received a standardised exercise programme for 6 weeks tailored to individual performance and supervised by a physical therapist, and were instructed to practise the tailored exercises at home for 3 months. The control group were assigned usual care, which comprised a "wait and see" approach of rest during periods of pain and refraining from pain provoking activities. Both the intervention group and the control group received written information about patellofemoral pain syndrome and general instructions for home exercises.

MAIN OUTCOME MEASURES

The primary outcomes were self reported recovery (7 point Likert scale), pain at rest and pain on activity (0-10 point numerical rating scale), and function (0-100 point Kujala patellofemoral score) at 3 months and 12 months follow-up.

RESULTS

A total of 131 participants were included in the study: 65 in the intervention group and 66 in the control group. After 3 months, the intervention group showed better outcomes than the control group with regard to pain at rest (adjusted difference -1.07, 95% confidence interval -1.92 to -0.22; effect size 0.47), pain on activity (-1.00, -1.91 to -0.08; 0.45), and function (4.92, 0.14 to 9.72; 0.34). At 12 months, the intervention group continued to show better outcomes than the control group with regard to pain (adjusted difference in pain at rest -1.29, -2.16 to -0.42; effect size 0.56; pain on activity -1.19, -2.22 to -0.16; effect size 0.54), but not function (4.52, -0.73 to 9.76). A higher proportion of patients in the exercise group than in the control group reported recovery (41.9% v 35.0% at 3 months and 62.1% v 50.8% at 12 months), although the differences in self reported recovery between the two groups were not statistically significant. Predefined subgroup analyses revealed that patients recruited by sport physicians (n=30) did not benefit from the intervention, whereas those recruited by general practitioners (n=101) showed significant and clinically relevant differences in pain and function in favour of the intervention group.

CONCLUSION

Supervised exercise therapy resulted in less pain and better function at short term and long term follow-up compared with usual care in patients with patellofemoral pain syndrome in general practice. Exercise therapy did not produce a significant difference in the rate of self reported recovery.

TRIAL REGISTRATION

ISRCTN83938749.

The prognostic value of the clinical ACR classification criteria of knee osteoarthritis for persisting knee complaints and increase of disability in general practice

OBJECTIVE

To assess the prognostic value of the clinical American College of Rheumatism (ACR) classification criteria of knee osteoarthritis (OA) on persisting knee complaints and increase of disability in adult patients with knee pain in general practice after 1-year follow-up.

METHODS

Patients (aged >35 years) consulting for non-traumatic knee complaints in general practice were enrolled in the study. At baseline and 1-year follow-up knee complaints and function were assessed by questionnaires and a physical examination was performed. The prognostic value of fulfilling the clinical ACR criteria of knee OA at baseline on the outcomes persisting knee complaints and increase of disability was determined.

RESULTS

549 patients were included in the study of which 480 (87.4%) were available for follow-up. The studied population consisted of 236 (49.2%) women with mean age 53.6 [standard deviation (sd) 11.3], mean body mass index (BMI) 27.1 (sd 4.2), 288 (60.0%) patients had payed employment, and 292 (60.8%) patients fulfilled the clinical ACR criteria of knee OA. After 1-year follow-up, 236 (49.2%) patients reported persisting knee complaints, and 84 (17.5%) reported an increase of disability. There was no association of fulfilling the clinical ACR criteria of knee OA at baseline with persisting knee complaints [odds ratio (OR) 1.15; 95% Confidence Interval (CI) 0.80; 1.67] or increase of disability (OR 1.05; 95% CI 0.43; 2.58) at follow-up.

CONCLUSION

The clinical ACR classification criteria of knee OA have no prognostic value for predicting persisting knee complaints or an increase of disability at 1-year of follow-up in adult patients with non-traumatic knee complaints in GP.

Effect of glucosamine sulphate on joint space narrowing, pain and function in patients with hip osteoarthritis; subgroup analyses of a randomized controlled trial

OBJECTIVE

Recently we reported that glucosamine sulphate (GS) did not have an effect on the symptoms and progression of primary care patients with hip osteoarthritis (OA). The aim of this present study was to investigate whether there are subgroups of patients with hip OA for whom GS might be an effective therapy.

METHOD

We randomized 222 patients with hip OA that met one of the American College of Rheumatology criteria to either 1500 mg of oral GS or placebo once daily for 2 years. Subgroup analyses were predefined for radiographic severity (Kellgren & Lawrence (KL)=1 vs >or=2) and for type of OA (localised vs generalised). Additional exploratory subgroup analyses focused on groups based on pain level, pain medication use, baseline joint space width (JSW), and concomitant knee OA at baseline. Primary outcome measures were Western Ontario MacMaster Universities (WOMAC) pain and function scores over 24 months, and joint space narrowing (JSN) after 24 months.

RESULTS

In the predefined subgroups based on radiographic severity and type of OA, the outcomes WOMAC pain, function and JSN were similar for the GS and placebo group.

CONCLUSION

GS was not significantly better than placebo in reducing symptoms and progression of hip OA in subgroups of patients.

[Arm injuries due to sport climbing]

There are 26 large climbing centres and 44 smaller indoor or outdoor climbing walls in The Netherlands at this time. Hand and finger injuries are the most common types of sport climbing injuries. Most injuries are caused by overstraining. Injuries include avulsion fractures, arthrosis, pulley rupture, damage to joint capsule and collateral ligaments, 'gamekeeper's thumb', 'climber's finger', lumbrical shift syndrome, 'climber's elbow', shoulder injuries and nerve compression syndromes. Treatment is usually conservative. Depending on the extent of damage surgical intervention may be indicated.

Patients' preferences for osteoporosis drug treatment: a discrete choice experiment

Active case finding for osteoporosis is used to identify patients at high fracture risk who may benefit from preventive drug treatment. We investigated the relative weight that women place on various aspects of preventive drugs in a discrete choice experiment. Our patients said they were prepared to take preventive drugs even if side effects were expected.

INTRODUCTION

Active case finding for osteoporosis is used to identify patients who may benefit from preventive drugs. We aimed to elicit the relative weight that patients place on various aspects of preventive drug treatment for osteoporosis.

METHODS

We designed a discrete choice experiment, in which women had to choose between drug profiles that differed in five treatment attributes: effectiveness, side effects (nausea), total treatment duration, route of drug administration, and out-of-pocket costs. We included 120 women aged 60 years and older, identified by osteoporosis case finding in 34 general practices in the Netherlands. A conditional logit regression model was used to analyse the relative importance of treatment attributes, the trade-offs that women were willing to make between attributes, and their willingness to pay.

RESULTS

All treatment attributes proved to be important for women's choices. A reduction of the relative 10-year risk of hip fracture by 40% or more by the drug was considered to compensate for nausea as a side effect. Women were prepared to pay an out-of-pocket contribution for the currently available drug treatment (bisphosphonate) if the fracture risk reduction was at least 12%.

CONCLUSIONS

Women identified by active osteoporosis case finding stated to be prepared to take preventive drugs, even if side effects were expected and some out-of-pocket contribution was required.

Non-steroidal anti-inflammatory drugs for low back pain

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed medications worldwide and are widely used for patients with low-back pain. Selective COX-2 inhibitors are currently available and used for patients with low-back pain.

OBJECTIVES

The objective was to assess the effects of NSAIDs and COX-2 inhibitors in the treatment of non-specific low-back pain and to assess which type of NSAID is most effective.

SEARCH STRATEGY

We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials up to and including June 2007 if reported in English, Dutch or German. We also screened references given in relevant reviews and identified trials.

SELECTION CRITERIA

Randomised trials and double-blind controlled trials of NSAIDs in non-specific low-back pain with or without sciatica were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed methodological quality. All studies were also assessed on clinical relevance, from which no further interpretations or conclusions were drawn. If data were considered clinically homogeneous, a meta-analysis was performed. If data were lacking for clinically homogeneous trials, a qualitative analysis was performed using a rating system with four levels of evidence (strong, moderate, limited, no evidence).

MAIN RESULTS

In total, 65 trials (total number of patients = 11,237) were included in this review. Twenty-eight trials (42%) were considered high quality. Statistically significant effects were found in favour of NSAIDs compared to placebo, but at the cost of statistically significant more side effects. There is moderate evidence that NSAIDs are not more effective than paracetamol for acute low-back pain, but paracetamol had fewer side effects. There is moderate evidence that NSAIDs are not more effective than other drugs for acute low-back pain. There is strong evidence that various types of NSAIDs, including COX-2 NSAIDs, are equally effective for acute low-back pain. COX-2 NSAIDs had statistically significantly fewer side-effects than traditional NSAIDs.

AUTHORS' CONCLUSIONS

The evidence from the 65 trials included in this review suggests that NSAIDs are effective for short-term symptomatic relief in patients with acute and chronic low-back pain without sciatica. However, effect sizes are small. Furthermore, there does not seem to be a specific type of NSAID which is clearly more effective than others. The selective COX-2 inhibitors showed fewer side effects compared to traditional NSAIDs in the RCTs included in this review. However, recent studies have shown that COX-2 inhibitors are associated with increased cardiovascular risks in specific patient populations.

Lysholm scale and WOMAC index were responsive in prospective cohort of young general practice patients

OBJECTIVE

To determine the construct validity and responsiveness of the Lysholm knee scoring scale and the WOMAC osteoarthritis index in adolescents and young adults with knee complaints in general practice.

STUDY DESIGN AND SETTING

In the framework of a prospective cohort study with 1-year follow-up, we included 314 patients aged 12-35 years consulting the general practitioner for incident knee complaints. Subgroup analyses of traumatic and nontraumatic knee complaints and of adolescents and adults were performed.

RESULTS

Construct validity was adequate for both questionnaires both in traumatic and nontraumatic patients (aged 12-35) and in adolescents (12-17) and young adults (18-35). Effect size (ES) and standardized response mean (SRM) for both Lysholm and WOMAC global scores were moderate in nontraumatic patients and high in traumatic patients. Guyatt's responsiveness statistic was high in both subpopulations. Adolescents showed high responsiveness with all measures on the Lysholm scale, and moderate (Guyatt's statistic) to high responsiveness (ES and SRM) on the WOMAC index. Young adults showed high responsiveness with all measures on both instruments.

CONCLUSION

Although neither of the scales was developed for use in adolescents and young adults in general practice, both scales show adequate responsiveness, content, and construct validity in this population.

[Early surgery or a wait-and-see policy in lumbosacral radicular syndrome: a randomized study]

OBJECTIVE

To compare early surgery with expectative policy and later surgery if necessary in patients with sciatica that did not resolve within 6 weeks.

DESIGN

Randomized multicentre clinical trial (ISRCTN 26872154).

METHODS

Patients who had had severe sciatica for 6 to 12 weeks were randomized to early surgery or to prolonged conservative treatment with later surgery if necessary. The primary outcomes were the Roland Disability Questionnaire score, the visual-analogue scale for leg pain score, and the patient's report of their perceived recovery over the first year after randomization. Repeated measures analysis according to the intention-to-treat principle was used to analyse the outcome curves for both groups.

RESULTS

A total of 283 patients were included and randomized. Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiscectomy after a mean of 2.2 weeks. Of 142 patients assigned to conservative treatment, 55 (39%) still had to undergo surgical treatment after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (p = 0.13). Leg pain lessened more quickly in patients assigned to early surgery (p < 0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio (HR): 1.97; 95% CI: 1.72-2.22; p < 0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.

CONCLUSIONS

The 1-year outcomes were similar for patients assigned to early surgery and those assigned to extended conservative treatment with later surgery if necessary but the rates of reduction of leg pain and of perceived recovery were faster in those assigned to early surgery.

Tragedy of conducting a clinical trial; generic alert system needed

Stopping a clinical trial without reaching the final objective is not the ideal outcome any researcher wants; sometimes ceasing is inevitable. Due to marginal inclusion of patients we were forced to cease our randomized clinical trial on the effectiveness of proprioceptive training on the development of chronic whiplash complaints a year after the start. Although incidence figures demonstrate that recruitment of the planned number of whiplash patients would be easily feasible, we were unable to enroll the amount of subjects. Several motives can be proposed that would have prevented this obliged halting from happening. Other studies also report impracticability of the planned number of whiplash injury patients.

Reported incidence and treatment of dermatophytosis in children in general practice: a comparison between 1987 and 2001

INTRODUCTION

Dermatophytosis is a common skin infection in children. Although the epidemiology is relatively unknown it is becoming a major health problem in some countries. We determine the incidence and management of dermatophytosis in Dutch general practice in 1987 and 2001.

METHODS

We used data of all children aged 0-17 years derived from two national surveys performed in Dutch general practice in 1987 and 2001 respectively. All diagnoses, prescriptions and referrals were registered over a 12 months period by the participating general practitioners (GPs), 161 and 195 respectively. Data were stratified for socio-demographic characteristics.

RESULTS

Compared to 1987, in 2001 the total reported incidence rate of dermatophytosis in children in general practice increased from 20.8 [95%CI 18.9-22.8] to 24.6 [95%CI 23.5-25.7] per 1,000 person years. Infants (<1 year), girls, children in rural areas and children of non-western immigrants more often consulted the GP for dermatophytosis in 2001. In both surveys GPs treated the majority of children with dermatophytosis with topical drugs, especially with azoles.

CONCLUSIONS

The reported incidence rate of dermatophytosis in children in general practice increased; however it is unclear whether this is a consequence of an increasing prevalence in the population or a changing help seeking behaviour. GPs generally follow the national guideline for the treatment of dermatophytosis in children.

Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. A Cochrane systematic review

BACKGROUND

Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS). Objectives. This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults. Search strategy. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied. Selection criteria. We included randomised controlled trials and concurrent controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS. Data collection and analysis. Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence.

MAIN RESULTS

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

CONCLUSIONS

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

Incidence of non-traumatic complaints of arm, neck and shoulder in general practice

Incidence densities in primary care are often based on disease or region-specific code registration (e.g. 'epicondylitis', 'shoulder symptom') according to the International Classification of Primary Care (ICPC). Few estimates are available on arm, neck and shoulder complaints. Unknown, is the proportion missed due to registration with a non-region-specific code (e.g. 'muscle pain'). Therefore, we estimated the incidence in non-traumatic arm, neck and shoulder complaints in the age-group 18-64 years, and determined the contribution of non-specific codes to the total figure. In this prospective registration study, 21 general practitioners (GPs) from 13 Dutch general practices classified and registered patient's symptoms and diagnoses according to ICPC at each consultation during 12 consecutive months. Incidence densities were calculated. The incidence density was 97.4/1000 person-years (95% CI: 91.2-103.7). This results in 147 (95% CI: 138-157) incident cases/year for an average-sized GP-practice (2350 patients). Main contributors were: shoulder (L92, L08) and neck complaints (L01, L83). Of all incident consultations, 23% were registered with non-region-specific codes, mainly 'other musculoskeletal disease' (L99). Non-traumatic complaints of arm, neck and shoulder are frequently consulted for in Dutch primary care. When estimating morbidity in primary care, based on diagnostic codes, one should be aware of possible underestimation of morbidity and corresponding workload, when excluding codes not specific for that region or disease.

Social and psychological factors influenced the course of arm, neck and shoulder complaints

OBJECTIVE

To investigate the clinical course and prognostic factors of complaints of arm, neck, and shoulder.

STUDY DESIGN AND SETTING

A prospective cohort study in physical therapy practice. Participating physiotherapists recruited new consulters with musculoskeletal complaints of the neck and/or upper extremities. Participants filled in questionnaires at baseline, 3 months, and 6 months. The main outcome measure was the persistence of complaints over 6-month follow-up. Possible predictors like social and psychological factors, physical factors, and complaint specific factors were tested in univariate and multivariate logistic regression analyses for repeated measurements.

RESULTS

Of the 624 participants at baseline 543 (87%) returned at least one follow-up questionnaire. At 6-month follow-up, 40% had persisting pain and discomfort. Somatization, kinesiophobia, catastrophizing, and a long duration of complaints at baseline were significantly related to the persistence of complaints over 6 months in the total population. In those with paid work (77%), catastrophizing, low decision authority at work, and a long duration of complaints at baseline were significantly related to the persistence of complaints over 6 months.

CONCLUSION

40% of the participants had persisting pain and discomfort after 6 months and mainly social and psychological factors played a role in this course.

WITHDRAWN: Non-steroidal anti-inflammatory drugs for low-back pain

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently prescribed medications worldwide and are widely used for patients with low back pain.

OBJECTIVES

The objective of this systematic review was to assess the effects of NSAIDs in the treatment of non-specific low back pain and to assess which type of NSAID is most effective.

SEARCH STRATEGY

We searched the Medline and Embase databases and the Cochrane Controlled Trials Register (CCTR) up to and including September 1998 if reported in English, Dutch or German. We also screened references given in relevant reviews and identified trials.

SELECTION CRITERIA

Randomised trials and double-blind controlled trials of NSAIDs in non-specific low back pain with or without radiation were included.

DATA COLLECTION AND ANALYSIS

Two authors blinded with respect to authors, institution and journal independently extracted data and assessed methodological quality. A methodological quality score was applied, and studies meeting at least six of 11 specified criteria were considered high quality studies. If data were considered clinically homogeneous, a meta-analysis was performed using a fixed effects model for statistically homogeneous subgroups and a random effects model for statistically heterogeneous subgroups. If data were considered clinically heterogeneous, a qualitative analysis was performed using a rating system with four levels of evidence (strong, moderate, limited, no).

MAIN RESULTS

A total of 51 trials (total number of patients = 6057) were included in this review, of which 46 were published in English and five in German. Sixteen trials (31%) were of high quality. The pooled Relative Risk for global improvement after one week was 1.24 (95% CI 1.10 , 1.41) and for additional analgesic use 1.29 (95% CI 1.05 , 1.57), indicating a statistically significant effect in favour of NSAIDs compared to placebo. The results of the qualitative analysis showed that there is conflicting evidence (level 3) that NSAIDs are more effective than paracetamol for acute low back pain, and that there is moderate evidence (level 2) that NSAIDs are not more effective than other drugs for acute low back pain. There is strong evidence (level 1) that various types of NSAIDs are equally effective for acute low back pain.

AUTHORS' CONCLUSIONS

In conclusion, the evidence from the 51 trials included in this review suggests that NSAIDs are effective for short-term symptomatic relief in patients with acute low back pain. Furthermore, there does not seem to be a specific type of NSAID which is clearly more effective than others. Sufficient evidence on chronic low back pain is still lacking.

Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review

The purpose of this study was to present a systematic overview of published reports on the incidence and associated potential risk factors of lower extremity running injuries in long distance runners. An electronic database search was conducted using the PubMed-Medline database. Two observers independently assessed the quality of the studies and a best evidence synthesis was used to summarise the results. The incidence of lower extremity running injuries ranged from 19.4% to 79.3%. The predominant site of these injuries was the knee. There was strong evidence that a long training distance per week in male runners and a history of previous injuries were risk factors for injuries, and that an increase in training distance per week was a protective factor for knee injuries.

Do metabolic factors add to the effect of overweight on hand osteoarthritis? The Rotterdam Study

BACKGROUND

As hand joints are non-weight bearing, the association between overweight and hand osteoarthritis (HOA) is critical to understanding how overweight may associate with osteoarthritis (OA) apart from axial load. Overweight might be associated with the occurrence of OA through other metabolic factors.

AIM

To evaluate the role of overweight in HOA, cross-sectional data of a population-based study were used (> or =55 years, n = 3585). The role of diabetes, hypertension and total cholesterol:high-density lipoprotein (HDL)-cholesterol ratio on HOA, and whether they play an intermediate role in the association of overweight/HOA was investigated. Furthermore, the prevalence of HOA in the concurrent presence of overweight and other metabolic factors was evaluated.

RESULTS

Independently of other metabolic factors, overweight (body mass index (BMI) >27.4 kg/m(2)) showed a significant association with HOA (OR 1.4, 95% CI 1.2 to 1.7). The association between diabetes and HOA was only present in people aged 55-62 years (OR 1.9, 95% CI 1.0 to 3.8), but was absent in the total population or in other age groups. The association of hypertension with HOA was weak, and disappeared after adjustment for BMI. The total/HDL cholesterol ratio showed no significant association with HOA. The concurrent presence of overweight, diabetes and hypertension resulted in an even higher prevalence of HOA (OR 2.3, 95% CI 1.3 to 3.9) compared with subjects with none of these characteristics; this prevalence increased further in the younger age group (OR 3.2, 95% CI 1.1 to 8.8).

CONCLUSION

No intermediate effect of metabolic factors on the association of overweight with HOA was found. An increase in the prevalence of HOA, however, seems to be present when overweight occurs together with hypertension and diabetes especially at a relatively young age.

Prognostic factors of progression of osteoarthritis of the knee: A systematic review of observational studies

OBJECTIVE

To provide an overview of prognostic factors of knee osteoarthritis (OA) progression.

METHODS

We searched Medline and Embase up to December 2003 according to a specified search strategy (keywords for disease, location, and study design). Studies that fulfilled predefined criteria were assessed for methodologic quality. Study characteristics and associations were extracted and the results were summarized according to a best evidence synthesis.

RESULTS

Of the 1,004 studies found, 37 met the inclusion criteria. Methodologic quality was assessed and only high-quality studies were included (n = 36). The best evidence synthesis yielded strong evidence that hyaluronic acid serum levels and generalized OA are predictive for progression of knee OA. Sex, knee pain, radiologic severity, knee injury, quadriceps strength, and regular sport activities were not predictive. Conflicting evidence for associations was found for several factors including body mass index and age. Limited evidence for an association with progression of knee OA was found for several factors, including the alignment (varus/valgus) of the joint. Limited evidence for no association with progression of OA was also found for several factors, including meniscectomy, several markers of bone or cartilage turnover, and the clinical diagnosis of localized OA.

CONCLUSION

Generalized OA and level of hyaluronic acid seem to be associated with the radiologic progression of knee OA. Knee pain, radiologic severity at baseline, sex, quadriceps strength, knee injury, and regular sport activities seem not to be related. For other factors, the evidence was limited or conflicting.