Andrew J. Hahne

Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review

Study Design. A systematic review of randomized controlled trials. Objective. To determine the efficacy and adverse effects of conservative treatments for people who have lumbar disc herniation with associated radiculopathy (LDHR). Summary of Background Data. Although conservative management is commonly used for people who have LDHR, the efficacy and adverse effects of conservative treatments for this condition are unclear. Methods. We searched 10 computer databases for trials published in English between 1971 and 2008. Trials focusing on people with referred leg symptoms and radiologic confirmation of a lumbar disc herniation were included if at least 1 group received a conservative and noninjection treatment. Results. Eighteen trials involving 1671 participants were included. Seven (39%) trials were considered of high quality. Meta-analysis on 2 high-quality trials revealed that advice is less effective than microdiscectomy surgery at short-term follow-up, but equally effective at long-term follow-up. Individual high-quality trials provided moderate evidence that stabilization exercises are more effective than no treatment, that manipulation is more effective than sham manipulation for people with acute symptoms and an intact anulus, and that no difference exists among traction, laser, and ultrasound. One trial showed some additional benefit from adding mechanical traction to medication and electrotherapy methods. Adverse events were associated with traction (pain, anxiety, lower limb weakness, and fainting) and ibuprofen (gastrointestinal events). Conclusion. Advice is less effective than microdiscectomy in the short term but equally effective in the long term for people who have LDHR. Moderate evidence favors stabilization exercises over no treatment, manipulation over sham manipulation, and the addition of mechanical traction to medication and electrotherapy. There was no difference among traction, laser, and ultrasound. Adverse events were associated with traction and ibuprofen. Additional high-quality trials would allow firmer conclusions regarding adverse effects and efficacy.

Do within-session changes in pain intensity and range of motion predict between-session changes in patients with low back pain?

Physiotherapists commonly use post-treatment changes in a patients pain intensity and range of motion to guide treatment selection and predict possible longer-term outcomes. This study tested the validity of this practice by evaluating the predictive value of within-session changes in pain intensity and range of motion in 53 patients with low back pain. Pain intensity and range of motion measurements of spinal flexion, extension, lateral flexion, and straight-leg-raise were taken by the patients therapist before and after one treatment session, and were repeated by a blinded therapist at the beginning of the patients subsequent treatment session. Regression analysis revealed that the strength of association between within-session and between-session changes ranged from r = 0.35 to r = 0.80 for range of motion measurements, and from r = 0.24 to r = 0.47 for pain intensity. Odds ratios for pain and range of motion ranged from 3.5 (95% CI 0.9 to 14.6) to 37.0 (95% CI 4.1 to 330), indicating greater odds of improving between-session if improvement was obtained within-session. These results provide preliminary support for the practice of using within-session changes in pain intensity and range of motion to guide treatment selection when treating impairments in patients with low back pain.

The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: A systematic review and meta-analysis

OBJECTIVES To systematically summarise the evidence on the effectiveness of proprioceptive training in reducing the incidence and recurrence rates of ankle sprains in the sporting population. DESIGN A systematic review and meta-analysis of randomised controlled trials. METHODS A computer-based literature search of MEDLINE, EMBASE, CINAHL, SPORTDiscus and PEDro (to October 2013) was conducted. Methodological quality of individual studies was assessed using the PEDro scale. Meta-analysis was performed on eligible studies to produce a pooled estimate of the effectiveness of the intervention. RESULTS Seven moderate-to-high quality randomised controlled trials involving 3726 participants were included. Results of the meta-analysis combining all participants, irrespective of ankle injury history status, revealed a significant reduction of ankle sprain incidence when proprioceptive training was performed compared to a range of control interventions (relative risk=0.65, 95% CI 0.55-0.77). Results favouring the intervention remained significant for participants with a history of ankle sprain (relative risk=0.64, 95% CI 0.51-0.81). Results looking exclusively at primary prevention in those without a history were also statistically significant (relative risk=0.57, 95% CI 0.34 to 0.97), although the pooled effect was obtained from two non-significant trials. CONCLUSIONS Proprioceptive training programmes are effective at reducing the rate of ankle sprains in sporting participants, particularly those with a history of ankle sprain. Current evidence remains inconclusive on the benefits for primary prevention of ankle sprains.

The effectiveness of sub-group specific manual therapy for low back pain : a systematic review.

BACKGROUND Manual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond. OBJECTIVES To determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy. DATA SOURCES A systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL). TRIAL ELIGIBILITY CRITERIA: RCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included. TRIAL APPRAISAL AND SYNTHESIS METHODS: Identified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity. RESULTS Seven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low. CONCLUSIONS This review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required.

Efficacy of Directional Preference Management for Low Back Pain: A Systematic Review

Background Providing specific treatment based on symptom response for people with low back pain (LBP) and a directional preference (DP) is a widely used treatment approach. The efficacy of treatment using the principles of directional preference management (DPM) for LBP is unclear. Objective The purpose of this study was to determine the efficacy of treatment using the principles of DPM for people with LBP and a DP. Methods Computer databases were searched for randomized controlled trials (RCTs) published in English up to January 2010. Only RCTs investigating DPM for people with LBP and a DP were included. Outcomes for pain, back specific function, and work participation were extracted. Results Six RCTs were included in this review. Five were considered high quality. Clinical heterogeneity of the included trials prevented meta-analysis. GRADE quality assessment revealed mixed results; however, moderate evidence was identified that DPM was significantly more effective than a number of comparison treatments for pain, function, and work participation at short-term, intermediate-term, and long-term follow-ups. No trials found that DPM was significantly less effective than comparison treatments. Conclusions Although this systematic review showed mixed results, some evidence was found supporting the effectiveness of DPM when applied to participants with a DP, particularly at short-term and intermediate-term follow-ups. Further high-quality RCTs are warranted to evaluate the effect of DPM applied to people with LBP and a DP.

Individualised physiotherapy as an adjunct to guideline-based advice for low back disorders in primary care: a randomised controlled trial

Background Many patients with low-back disorders persisting beyond 6 weeks do not recover. This study investigates whether individualised physiotherapy plus guideline-based advice results in superior outcomes to advice alone in participants with low-back disorders. Methods This prospective parallel group multicentre randomised controlled trial was set in 16 primary care physiotherapy practices in Melbourne, Australia. Random assignment resulted in 156 participants receiving 10 sessions of physiotherapy that was individualised based on pathoanatomical, psychosocial and neurophysiological barriers to recovery combined with guideline-based advice, and 144 participants receiving 2 sessions of physiotherapist-delivered advice alone. Primary outcomes were activity limitation (Oswestry Disability Index) and numerical rating scales for back and leg pain at 5, 10, 26 and 52 weeks postbaseline. Analyses were by intention-to-treat using linear mixed models. Results Between-group differences showed significant effects favouring individualised physiotherapy for back and leg pain at 10 weeks (back: 1.3, 95% CI 0.8 to 1.8; leg: 1.1, 95% CI 0.5 to 1.7) and 26 weeks (back: 0.9, 95% CI 0.4 to 1.4; leg: 1.0, 95% CI 0.4 to 1.6). Oswestry favoured individualised physiotherapy at 10 weeks (4.7; 95% CI 2.0 to 7.5), 26 weeks (5.4; 95% CI 2.6 to 8.2) and 52 weeks (4.3; 95% CI 1.4 to 7.1). Responder analysis at 52 weeks showed participants receiving individualised physiotherapy were more likely to improve by a clinically important amount of 50% from baseline for Oswestry (relative risk (RR=1.3) 1.5; 95% CI 1.2 to 1.8) and back pain (RR 1.3; 95% CI 1.2 to 1.8) than participants receiving advice alone. Conclusions 10 sessions of individualised physiotherapy was more effective than 2 sessions of advice alone in participants with low-back disorders of ≥6 weeks and ≤6 months duration. Between-group changes were sustained at 12 months for activity limitation and 6 months for back and leg pain and were likely to be clinically significant. Clinical trial registration ACTRN12609000834257.

A classification and treatment protocol for low back disorders: Part 1 - specific manual therapy

Abstract Background: It has been widely recommended that clinical trials involving people with low back disorders should identify subgroups and provide specific treatment in order to increase the likelihood of clinically meaningful effects being demonstrated. The Maitland approach to providing manual therapy is an appropriate and widely used clinical method in providing specific treatment. However, few clinical trials have described a detailed clinical protocol that allows replication in clinical and research practice. Objectives: This paper presents a detailed classification and treatment protocol for people with clinical features indicating a likely positive response to specific manual therapy. Conclusion: The presented protocol will be used in the Specific Treatment for Problems of the Spine trials comparing specific physiotherapy to evidence-based advice.

Specific treatment of problems of the spine (STOPS): design of a randomised controlled trial comparing specific physiotherapy versus advice for people with subacute low back disorders

BackgroundLow back disorders are a common and costly cause of pain and activity limitation in adults. Few treatment options have demonstrated clinically meaningful benefits apart from advice which is recommended in all international guidelines. Clinical heterogeneity of participants in clinical trials is hypothesised as reducing the likelihood of demonstrating treatment effects, and sampling of more homogenous subgroups is recommended. We propose five subgroups that allow the delivery of specific physiotherapy treatment targeting the pathoanatomical, neurophysiological and psychosocial components of low back disorders. The aim of this article is to describe the methodology of a randomised controlled trial comparing specific physiotherapy treatment to advice for people classified into five subacute low back disorder subgroups.Methods/DesignA multi-centre parallel group randomised controlled trial is proposed. A minimum of 250 participants with subacute (6 weeks to 6 months) low back pain and/or referred leg pain will be classified into one of five subgroups and then randomly allocated to receive either physiotherapy advice (2 sessions over 10 weeks) or specific physiotherapy treatment (10 sessions over 10 weeks) tailored according to the subgroup of the participant. Outcomes will be assessed at 5 weeks, 10 weeks, 6 months and 12 months following randomisation. Primary outcomes will be activity limitation measured with a modified Oswestry Disability Index as well as leg and back pain intensity measured on separate 0-10 Numerical Rating Scales. Secondary outcomes will include a 7-point global rating of change scale, satisfaction with physiotherapy treatment, satisfaction with treatment results, the Sciatica Frequency and Bothersomeness Scale, quality of life (EuroQol-5D), interference with work, and psychosocial risk factors (Orebro Musculoskeletal Pain Questionnaire). Adverse events and co-interventions will also be measured. Data will be analysed according to intention to treat principles, using linear mixed models for continuous outcomes, Mann Whitney U tests for ordinal outcomes, and Chi-square, risk ratios and risk differences for dichotomous outcomes.DiscussionThis trial will determine the difference in outcomes between specific physiotherapy treatment tailored to each of the five subgroups versus advice which is recommended in guidelines as a suitable treatment for most people with a low back disorder.Trial registrationAustralia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000834257.

Mindfulness Training for Health Profession Students—The Effect of Mindfulness Training on Psychological Well-Being, Learning and Clinical Performance of Health Professional Students: A Systematic Review of Randomized and Non-randomized Controlled Trials

Background: High levels of stress have been identified in medical students and increasingly in other health profession student population groups. As stress can affect psychological well‐being and interfere with learning and clinical performance, there is a clear argument for universities to include health professional student well‐being as an outcome in core curriculum. Mindfulness training is a potential construct to manage stress and enhance academic success. Objectives: The aims of this systematic review were to assess the effectiveness of mindfulness training in medical and other health professional student population groups and to compare the effectiveness of the different mindfulness‐based programs. Data Sources: A literature search was completed using The Cochrane library, Medline, Cinahl, Embase, Psychinfo, and ERIC (proquest) electronic databases from inception to June 2016. Randomized and non‐randomized controlled trials were included. Of the potential 5355 articles, 19 met the inclusion criteria. Study Selection Participants and Interventions: Studies focused on medical (n = 10), nursing (n = 4), social work (n = 1), psychology (n = 1), and medical plus other health (n = 3) students. Interventions were based on mindfulness. Data Extraction: The 19 studies included 1815 participants. Meta‐analysis was performed evaluating the effect of mindfulness training on mindfulness, anxiety, depression, stress, mood, self‐efficacy, and empathy. The effect of mindfulness on academic performance was discussed. Data Synthesis and Conclusions: Mindfulness‐based interventions decrease stress, anxiety, and depression and improve mindfulness, mood, self‐efficacy, and empathy in health profession students. Due to the range of presentation options, mindfulness training can be relatively easily adapted and integrated into health professional training programs.

The effectiveness of physiotherapy functional restoration for post-acute low back pain: A systematic review

BACKGROUND The effectiveness of multidisciplinary treatment for post-acute (>6 weeks) low back pain (LBP) has been established. Physiotherapists have sufficient training to conduct less intensive functional restoration. The effectiveness of physiotherapy functional restoration (PFR) has not been evaluated using current systematic review methodology. OBJECTIVES To determine the effects of PFR for post-acute LBP. DATA SOURCES Electronic databases searched include: MEDLINE, EMBASE, CINAHL, PsycINFO, PEDro and Cochrane CENTRAL. TRIAL ELIGIBILITY CRITERIA: Randomised controlled trials of physiotherapy treatment for post-acute LBP combining exercise and cognitive-behavioural intervention compared with other intervention, no intervention or placebo. TRIAL APPRAISAL AND SYNTHESIS METHODS: Two authors independently extracted data. Risk of bias was assessed using the PEDro scale and overall quality of the body of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Treatment effect sizes and 95% confidence intervals were calculated for pain, function and sick leave. RESULTS Sixteen trials were included. Heterogeneity prevented meta-analysis for most comparisons. Meta-analyses showed moderate to high quality evidence of significant but small effects favouring PFR compared with advice for intermediate term function and intermediate and long term pain. There was however low to moderate quality evidence that PFR was no more effective than a range of other treatment types. Heterogeneous trials frequently contributed to very low quality evidence. CONCLUSIONS Moderate to high quality evidence was found of small effects favouring PFR compared with advice. Preliminary evidence suggested PFR is not different to other treatment types. Further high quality research is required replicating existing trial protocols.