Arianne P. Verhagen

The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus.

Most systematic reviews rely substantially on the assessment of the methodological quality of the individual trials. The aim of this study was to obtain consensus among experts about a set of generic core items for quality assessment of randomized clinical trials (RCTs). The invited participants were experts in the field of quality assessment of RCTs. The initial item pool contained all items from existing criteria lists. Subsequently, we reduced the number of items by using the Delphi consensus technique. Each Delphi round comprised a questionnaire, an analysis, and a feedback report. The feedback report included staff team decisions made on the basis of the analysis and their justification. A total of 33 international experts agreed to participate, of whom 21 completed all questionnaires. The initial item pool of 206 items was reduced to 9 items in three Delphi rounds. The final criteria list (the Delphi list) was satisfactory to all participants. It is a starting point on the way to a minimum reference standard for RCTs on many different research topics. This list is not intended to replace, but rather to be used alongside, existing criteria lists.

Prevalence and incidence of shoulder pain in the general population; a systematic review.

Objective: To investigate the incidence and prevalence of shoulder complaints in the general population. Method: A systematic review of the literature was conducted. Medline, Embase, and Cinahl were searched for relevant studies. Results: Eighteen studies on prevalence and one study on incidence met the inclusion criteria. Incidence figures of 0.9–2.5% were found for different age groups. Prevalence figures differed from 6.9 to 26% for point prevalence, 18.6–31% for 1‐month prevalence, 4.7–46.7% for 1‐year prevalence and 6.7–66.7% for lifetime prevalence. Prevalence rates decreased when the case definition was restricted, in terms of duration of pain or the presence of limited movements, and increased when the location for pain was enlarged. Conclusion: The reported prevalence figures on shoulder complaints diverged strongly. Health professionals and policymakers who estimate the amount of medical care needed and related costs should be aware of the variations in prevalence rate and the underlying reasons for these differences.

Prognostic factors of whiplash-associated disorders: a systematic review of prospective cohort studies

&NA; We present a systematic review of prospective cohort studies. Our aim was to assess prognostic factors associated with functional recovery of patients with whiplash injuries. The failure of some patients to recover following whiplash injury has been linked to a number of prognostic factors. However, there is some inconsistency in the literature and there have been no systematic attempts to analyze the level of evidence for prognostic factors in whiplash recovery. Studies were selected for inclusion following a comprehensive search of MEDLINE, EMBASE, CINAHL, the database of the Dutch Institute of Allied Health Professions up until April 2002 and hand searches of the reference lists of retrieved articles. Studies were selected if the objective was to assess prognostic factors associated with recovery; the design was a prospective cohort study; the study population included at least an identifiable subgroup of patients suffering from a whiplash injury; and the paper was a full report published in English, German, French or Dutch. The methodological quality was independently assessed by two reviewers. A study was considered to be of ‘high quality’ if it satisfied at least 50% of the maximum available quality score. Two independent reviewers extracted data and the association between prognostic factors and functional recovery was calculated in terms of risk estimates. Fifty papers reporting on twenty‐nine cohorts were included in the review. Twelve cohorts were considered to be of ‘high quality’. Because of the heterogeneity of patient selection, type of prognostic factors and outcome measures, no statistical pooling was able to be performed. Strong evidence was found for high initial pain intensity being an adverse prognostic factor. There was strong evidence that for older age, female gender, high acute psychological response, angular deformity of the neck, rear‐end collision, and compensation not being associated with an adverse prognosis. Several physical (e.g. restricted range of motion, high number of complaints), psychosocial (previous psychological problems), neuropsychosocial factors (nervousness), crash related (e.g. accident on highway) and treatment related factors (need to resume physiotherapy) showed limited prognostic value for functional recovery. High initial pain intensity is an important predictor for delayed functional recovery for patients with whiplash injury. Often mentioned factors like age, gender and compensation do not seem to be of prognostic value. Scientific information about prognostic factors can guide physicians or other care providers to direct treatment and to probably prevent chronicity.

Effectiveness of exercise therapy: A best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinsons disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

Exercise therapy for chronic nonspecific low-back pain

Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. During the past 5 years, many additional trials have been published on chronic low back pain. This articles aims to give an overview on the effectiveness of exercise therapy in patients with low back pain. For this overview, existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria, and the search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. Studies were included if they fulfilled the following criteria: (1) randomised controlled trials,(2) adult (> or =18 years) population with chronic (> or =12 weeks) nonspecific low back pain and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias and outcomes at short-term, intermediate and long-term follow-up. The GRADE approach (GRADE, Grading of Recommendations Assessment, Development and Evaluation) was used to determine the quality of evidence. In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

Does neuromuscular electrical stimulation strengthen the quadriceps femoris? A systematic review of randomised controlled trials

AbstractDevices for neuromuscular electrical stimulation (NMES) are increasingly used by individuals without specific injuries and are standard equipment in most physical therapy practices. The most often stimulated muscle group is the quadriceps femoris. We designed a systematic review and meta-analysis of randomised controlled trials to determine whether NMES is an effective modality for strength augmentation of the quadriceps femoris.A full content search for randomised controlled trials was performed in Medline, Embase, Cinahl, the Cochrane Controlled Trials Register and the Physical Therapy Evidence Database. Maximum volitional isometric or isokinetic muscle torque in Nm was used as main outcome measure.Thirty-five trials were included and evaluated. A fundamental distinction was made between the trials using subjects with unimpaired quadriceps femoris muscles and the trials using post-injury or post-operative subjects. In the unimpaired quadriceps subgroup, meta-analyses were performed for the comparisons ‘NMES versus no exercises’ and ‘NMES versus volitional exercises’. All other comparisons were evaluated descriptively. The included trials were generally of poor quality and meta-analytic data indicate that publication bias may be present. The evaluated data suggest that, both for the unimpaired and impaired quadriceps, NMES makes sense compared with doing no exercises but volitional exercises appear to be more effective in most situations.Based on the available evidence, NMES may only be preferred over volitional training for within-cast muscle training and perhaps in specific situations where volitional training does not receive sufficient patient compliance. Further research should be directed toward identifying the clinical impact at activity and participation levels and the optimal stimulation parameters of this modality.

Prognostic factors for poor recovery in acute whiplash patients

&NA; The objective of our prospective inception cohort study was to identify prognostic factors for poor recovery in patients with whiplash‐associated disorders grade 1 or 2 who still had neck pain and accompanying complaints 2 weeks after the accident. The study was carried out in a primary health care setting in The Netherlands and included 125 patients. The primary outcome measure was functional recovery defined in terms of neck pain intensity or work disability without medication use. The secondary outcome measures included neck pain intensity, work disability and sick leave. The outcomes were assessed at 4, 12 and 52 weeks after the accident. Prognostic factors were identified by logistic regression analyses. One year after the injury, 64% of the patients were recovered. Factors related to poor recovery were female gender, a low level of education, high initial neck pain, more severe disability, higher levels of somatisation and sleep difficulties. Neck pain intensity and work disability proved to be the most consistent predictors for poor recovery. The accuracy of the predictions of the prognostic models was high, meaning that the models adequately distinguished patients with poor recovery from those regarded as recovered. These findings add to the growing body of evidence, indicating that socio‐demographic, physical and psychological factors affect short‐ and long‐term outcome after whiplash injury. Our findings also indicate that care providers can easily identify patients at risk for poor recovery with a visual analogue scale for initial pain intensity and work‐related activities.

Spinal mechanical load as a risk factor for low back pain: a systematic review of prospective cohort studies.

Study Design. Systematic review. Objective. To review and critically evaluate the past literature for spinal mechanical load as risk factor for low back pain (LBP). Summary of Background Data. LBP is a costly health problem worldwide, and treatments are often unsuccessful. Therefore, prevention might be more beneficial in the management of LBP. With respect to prevention, the knowledge of risk factors is essential. From the literature, exposures involving spinal mechanical load is frequently discussed as a potential risk factor for LBP. For a better understanding of this risk factor, we performed a systematic review of the literature. Additionally, we evaluated exposures of spinal mechanical load for possible dose-response relations with LBP. Methods. We systematically searched Medline, Embase, PsycINFO, and CINAHL databases (without language restriction) for full-report publications of prospective cohort studies, evaluating spinal mechanical load during work and/or leisure time activities as risk factors for nonspecific LBP in patients (>18 years of age) free of LBP at baseline. We assessed the methodology of each article and extracted information on population, response rates, characteristics of LBP, exposures, and estimated association(s), using standardized forms. We performed a best evidence synthesis of the obtained information. Results. In total, 18 studies were eligible (all rated as high methodologic quality) reporting on 24,315 subjects. Conclusion. We found strong evidence that leisure time sport or exercises, sitting, and prolonged standing/walking are not associated with LBP. Evidence for associations in leisure time activities (e.g., do-it-yourself home repair, gardening), whole-body vibration, nursing tasks, heavy physical work, and working with ones trunk in a bent and/or twisted position and LBP was conflicting. We found no studies, thus no evidence, for an association between sleeping or sporting on a professional level and LBP.

Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review

Patients with a lumbosacral radicular syndrome are mostly treated conservatively first. The effect of the conservative treatments remains controversial. To assess the effectiveness of conservative treatments of the lumbosacral radicular syndrome (sciatica). Relevant electronic databases and the reference lists of articles up to May 2004 were searched. Randomised clinical trials of all types of conservative treatments for patients with the lumbosacral radicular syndrome selected by two reviewers. Two reviewers independently assessed the methodological quality and the clinical relevance. Because the trials were considered heterogeneous we decided not to perform a meta-analysis but to summarise the results using the rating system of levels of evidence. Thirty trials were included that evaluated injections, traction, physical therapy, bed rest, manipulation, medication, and acupuncture as treatment for the lumbosacral radicular syndrome. Because several trials indicated no evidence of an effect it is not recommended to use corticosteroid injections and traction as treatment option. Whether clinicians should prescribe physical therapy, bed rest, manipulation or medication could not be concluded from this review. At present there is no evidence that one type of treatment is clearly superior to others, including no treatment, for patients with a lumbosacral radicular syndrome.

Measurement properties of disease-specific questionnaires in patients with neck pain: a systematic review

PurposeTo critically appraise and compare the measurement properties of the original versions of neck-specific questionnaires.MethodsBibliographic databases were searched for articles concerning the development or evaluation of the measurement properties of an original version of a self-reported questionnaire, evaluating pain and/or disability, which was specifically developed or adapted for patients with neck pain. The methodological quality of the selected studies and the results of the measurement properties were critically appraised and rated using a checklist, specifically designed for evaluating studies on measurement properties.ResultsThe search strategy resulted in a total of 3,641 unique hits, of which 25 articles, evaluating 8 different questionnaires, were included in our study. The Neck Disability Index is the most frequently evaluated questionnaire and shows positive results for internal consistency, content validity, structural validity, hypothesis testing, and responsiveness, but a negative result for reliability. The other questionnaires show positive results, but the evidence for each measurement property is mostly limited, and at least 50% of the information on measurement properties per questionnaire is lacking.ConclusionsOur findings imply that studies of high methodological quality are needed to properly assess the measurement properties of the currently available questionnaires. Until high quality studies are available, we recommend using these questionnaires with caution. There is no need for the development of new neck-specific questionnaires until the current questionnaires have been adequately assessed.