Daniel Paul Kerr

Effectiveness of Acupuncture for Low Back Pain: A Systematic Review

Study Design. A systematic review of randomized controlled trials (RCTs). Objective. To explore the evidence for the effectiveness of acupuncture for nonspecific low back pain (LBP). Summary of Background Data. Since the most recent systematic reviews on RCTs on acupuncture for LBP, 6 RCTs have been published, which may impact on the previous conclusions. Methods. Searches were completed for RCTs on all types of acupuncture for patients with nonspecific LBP published in English. Methodologic quality was scored using the Van Tulder scale. Trials were deemed to be high quality if they scored more than 6/11 on the Van Tulder scale, carried out appropriate statistical analysis, with at least 40 patients per group, and did not exceed 20% and 30% dropouts at short/intermediate and long-term follow-up, respectively. High quality trials were given more weight when conducting the best evidence synthesis. Studies were grouped according to the control interventions, i.e., no treatment, sham intervention, conventional therapy, acupuncture in addition to conventional therapy. Treatment effect size and clinical significance were also determined. The adequacy of acupuncture treatment was judged by comparison of recommendations made in textbooks, surveys, and reviews. Results. Twenty-three trials (n = 6359) were included and classified into 5 types of comparisons, 6 of which were of high quality. There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief. There is strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific LBP, but the effectiveness of acupuncture compared with other forms of conventional therapies still requires further investigation. Conclusion. Acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic LBP.

The Effectiveness of Physiotherapy Exercises in Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVE To evaluate the effectiveness of exercise in the treatment of people with subacromial impingement syndrome (SAIS). METHODS A systematic review and meta-analysis were conducted. Ten electronic databases were searched from the dates of their inception until August 2010. Included studies were randomized controlled trials investigating exercise in the management of SAIS. Outcomes were pain, strength, function, and quality of life. Data were summarized qualitatively using a best evidence synthesis. Treatment effect size and variance of individual studies were used to give an overall summary effect and data were converted to standardized mean difference with 95% confidence intervals (standardized mean difference (SMD) (CI)). RESULTS Sixteen studies were included (n = 1162). There was strong evidence that exercise decreases pain and improves function at short-term follow-up. There was also moderate evidence that exercise results in short-term improvement in mental well-being and a long-term improvement in function for those with SAIS. The most common risk of bias across the studies was inadequately concealed treatment allocation. Six studies in the review were suitable for meta-analysis. Exercise had a small positive effect on strength of the rotator cuff in the short term (SMD -0.46 (-0.76, 0.16); P = 0.003) and a small positive effect on long-term function (SMD -0.31 (-0.57, 0.04); P = 0.02). CONCLUSIONS Physiotherapy exercises are effective in the management of SAIS. However, heterogeneity of the exercise interventions, coupled with poor reporting of exercise protocols, prevented conclusions being drawn about which specific components of the exercise protocols (ie, type, intensity, frequency and duration) are associated with best outcomes.

Acupuncture in the management of chronic low back pain: a blinded randomized controlled trial.

Objective: To assess the efficacy of acupuncture in the treatment of chronic low back pain. Methods: Patients (n = 60) with chronic low back pain were recruited and randomly allocated to either Acupuncture therapy or Placebo transcutaneous electrical nerve stimulation (TENS) groups. Patients were treated weekly for 6 weeks, and blinded assessments were carried out pre- and post-treatment using the McGill Pain Questionnaire (MPQ) and visual analog scales (VAS) for pain, the Short-form 36 quality-of-life questionnaire, and a simple range of motion measurement. A total of 46 patients completed the trial and were followed up at 6 months. Results: Analysis of results using t tests showed that in both groups there were significant pre-post improvements for all scores, except for MPQ scores in the Placebo-TENS group. There was no significant difference between the 2 groups for any of the outcome measures at the end of treatment. Results from the 6-month follow-up would suggest that the response was better in the acupuncture group. Discussion: Further research is necessary to fully assess the efficacy of this treatment in combating chronic low back pain using larger sample sizes or alternative control groups.

Acupuncture for acute non-specific low back pain: A pilot randomised non-penetrating sham controlled trial

OBJECTIVE A pilot study to assess the feasibility of a trial to investigate the efficacy of acupuncture compared to placebo needling for the treatment of acute low back pain (LBP). As part of this, the study was designed to establish the credibility of the placebo control, and to provide data to inform a power analysis to determine numbers for a future trial. STUDY DESIGN A pilot patient and assessor blinded randomized controlled trial. SETTING Primary care health centre facility, South and East Belfast Trust, Northern Ireland. PATIENTS Patients from the physiotherapy waiting list (n=48) with LBP of less than 12 weeks duration. OUTCOME MEASURES Roland and Morris Disability Questionnaire (RMDQ), Visual Analogue Scale (VAS), medication use and an exit questionnaire were completed at baseline, end of treatment, and at 3 months follow up. RESULTS Ninety-four percent (45/48) of patients completed assigned treatment, 83% (40/48) completed 3 months follow-up. The sham needle used here proved to be credible: 91.7% in the placebo group believed they had received acupuncture, compared to 95.8% in the verum acupuncture group. Differences in baseline characteristics were accounted for using ANCOVA. There was no significant difference between groups on the RMDQ over time. For pain, the only statistically significant difference was at the 3 months follow up (worst VAS, point estimate, 18.7, 95% CI 1.5-36.0, p=0.034). The majority of patients were taking some form of analgesic medication for LBP at the start of treatment (n=44; 92%), and at the end of treatment the verum acupuncture group were taking significantly fewer tablets of pain control medication (mean (S.D.): 1.0+/-0.3) than the placebo group (mean (S.D.): 4.2+/-0.6, p<0.05). Based upon these data, power analysis (power=90%, alpha=0.05, minimal clinically important difference (MCID) for RMDQ=2.5 points) indicated that 120 participants (60 per group) would be needed to complete an adequately powered randomized controlled trial. CONCLUSIONS This study has demonstrated the feasibility of a randomized controlled trial of penetrating needle acupuncture compared to a non-penetrating sham for the treatment of acute LBP in primary care; 120 participants would be required in a fully powered trial. The placebo needle used in this study proved to be a credible form of control.

Pedometer-driven walking for chronic low back pain A feasibility randomized controlled trial

Objectives:To evaluate the feasibility of an RCT of a pedometer-driven walking program and education/advice to remain active compared with education/advice only for treatment of chronic low back pain (CLBP). Methods:Fifty-seven participants with CLBP recruited from primary care were randomly allocated to either: (1) education/advice (E, n=17) or (2) education/advice plus an 8-week pedometer-driven walking program (EWP, n=40). Step targets, actual daily step counts, and adverse events were recorded in a walking diary over the 8 weeks of intervention for the EWP group only. All other outcomes (eg, functional disability using the Oswestry Disability Questionnaire (ODQ), pain scores, physical activity (PA) measurement etc.) were recorded at baseline, week 9 (immediately post-intervention), and 6 months in both groups. Results:The recruitment rate was 22% and the dropout rate was lower than anticipated (13% to 18% at 6 mo). Adherence with the EWP was high, 93% (n=37/40) walked for ≥6 weeks, and increased their steps/day (mean absolute increase in steps/d, 2776, 95% confidence interval [CI], 1996-3557) by 59% (95% CI, 40.73%-76.25%) from baseline. Mean percentage adherence with weekly step targets was 70% (95% CI, 62%-77%). Eight (20%) minor-related adverse events were observed in 13% (5/40) of the participants. The EWP group participants demonstrated an 8.2% point improvement (95% CI, −13 to −3.4) on the ODQ at 6 months compared with 1.6% points (95% CI, –9.3 to 6.1) for the E group (between group d=0.44). There was also a larger mean improvement in pain (d=0.4) and a larger increase in PA (d=0.59) at 6 months in EWP. Discussion:This preliminary study demonstrated that a main RCT is feasible. EWP was safe and produced a real increase in walking; CLBP function and pain improved, and participants perceived a greater improvement in their PA levels. These improvements require confirmation in a fully powered RCT.

Different frequencies of acupuncture treatment for chronic low back pain: An assessor-blinded pilot randomised controlled trial

OBJECTIVES To examine the feasibility of a main RCT to compare the effectiveness of two frequencies (2 versus 5 times/week) of acupuncture treatment for chronic low back pain (LBP). METHODS Participants (n=30) with chronic LBP were randomised into two groups to receive 10 acupuncture treatments: Low Frequency Group, 2 times/week for five weeks (n=15); High Frequency Group, 5 times/week for two weeks (n=15). The following outcomes were measured blindly at baseline, 2 weeks, 5 weeks, 3 months and 1 year: pain on a VAS, functional disability using the RMDQ, quality of life using the Measure Yourself Medical Outcome Profile (MYMOP-2), psychological impact with the Coping Strategies Questionnaire (CSQ) and Pain Locus of Control (PLC) questionnaire. Two objective outcomes, the Shuttle Walk Test (SWT) and Lateral Trunk Flexibility (LTF), were also measured. RESULTS The compliance rate was 100% for each group. Some of the measurements were shown to be sensitive (VAS, RMDQ, MYMOP-2 Wellbeing). 66-330 participants would be required for a fully powered non-inferiority trial. The groups were balanced at baseline for LBP and demographic characteristics. There were no significant differences between the groups in terms of any of the outcomes, at each follow-up time point. It was notable however that the clinically important improvement in terms of pain, functional disability, quality of life, and SWT in both groups was achieved within the first two weeks, which was maintained at one year follow-up. CONCLUSIONS It is feasible to conduct a main RCT, to compare different frequencies of acupuncture for LBP, using sensitive measurements. Also the trend for early clinically important improvement within a minimum of four measurements is worthy of further study.

Factors that influence low back pain in people with a stoma.

Purpose: People with a stoma believe that there is a link between their surgery and low back pain (LBP). Aim: To explore factors relating to (i) core stability in people with a stoma and LBP and (ii) biopsychosocial factors related to LBP. Methods: Adults with an ileostomy and LBP (n = 17) completed (i) a range of standardised instruments, (ii) clinical tests and (iii) an ultrasound scan of right and left transversus abdominis (TrA). Results: The findings showed moderate pain and disability: RMDQ: median = 12 (IQR: 9.5–13), EQ-5D health state: mean = 6.9 (±1.75), BPI pain severity: median = 4.5 (IQR: 2.87–5.4). The TrA contraction was less on the operated than the unoperated side and this was linked to less control for BKFO to the operated side, and the presence of a parastomal hernia. Co-morbidities were associated with greater balance problems during the stork test (p < 0.05). Men had more fear avoidance (p < 0.05) on the FABQ regarding physical activity. Discussion: Abdominal function may be altered after stoma surgery leading to reduced ability to perform functional tasks and a possible increased risk of back pain. These results should be viewed with caution due to the small sample size. Implications for Rehabilitation Back pain in people with a stoma is a complex problem including both physical and psychological issues. The ability of transversus abdominis (TrA) to contract efficiently is unclear; however, those with a thinner TrA had poorer balance and core stability (as measured by bent knee fall out). The psychological factors of fear avoidance must be addressed alongside any physical interventions for motor control, muscle strengthening and rehabilitation of function after surgery. This research needs to be repeated with a larger sample due to the small numbers in this exploratory study (n = 17).

Low back pain in people with a stoma: a postal survey.

Purpose. To investigate whether low back pain (LBP) is a problem for people with a stoma. Method. Following ethical approval, a postal questionnaire was sent to the Ileostomy Association of Northern Ireland (n = 402). Results. The response rate was 81.6%. Two hundred ninety three (72.8%) were included in the analysis. The participants fell into three groups: those who never had LBP (n = 102, 34.8%), those who had LBP but not within the last 6 months (n = 26, 8.9%) and those who had LBP within the last 6 months (n = 165, 56.3%). Participants with LBP (n = 165) compared the ease with which they could carry out everyday tasks: ‘before’ and ‘since’ surgery. There was a mean increased difficulty of between 1.75 and 2.26 points across all tasks. The Roland Morris Disability Questionnaire scores ranged from 0 to 24 with 50% having a score of 8/24 or higher. Some participants (n = 76, 46.1%) believed that the stoma surgery was the reason for their back pain, followed by 27.9% (n = 46) blaming weak muscles. Others (53.3%) thought their back pain was worsening. There was a significant rise in the incidence of first episode back pain within a year of surgery. Conclusions. These results suggest that LBP is a problem for people with a stoma.

Do people with an ileostomy have a different back pain experience to those with a colostomy? A postal survey in Northern Ireland

Background. The abdominal muscles play a vital role in lumbar stability. The stoma surgery creates a permanent flaw in the abdominal wall and this may increase the risk of low back pain for people with a stoma. Purpose. To determine whether there was a difference in back pain experience between the two stoma groups: ileostomy and colostomy. Method. A postal questionnaire sent to people in Northern Ireland with an ileostomy or colostomy. Results. Over half (56.7%, n = 417) had back pain in the last 6 months and the primary perceived cause was the stoma surgery. There was a statistically significant deterioration in functional activities in those with back pain when ‘today’ was compared with ‘before surgery’. Those with a colostomy had generally poorer outcomes in respect of pain and disability, than those with an ileostomy. Conclusion. Low back pain in people with a stoma is a real and complex issue, especially as there are significant differences between those with an ileostomy when compared with people with a colostomy. Many factors are likely to contribute to a person developing low back pain, not least, the underlying reason for the surgery and the surgical procedure itself.

FRI0462-HPR The effectiveness of physiotherapy exercises in subacromial impingement syndrome: A systematic review and meta-analysis

Background Exercise is a fundamental part of the management of subacromial impingement syndrome (SAIS), yet there has been relatively little examination of exercise interventions for this condition. Previous reviews in this area contain few randomized controlled trials (RCTs), have significant weaknesses, and none have conducted a rigorous meta-analysis of the data specifically related to exercise intervention. Questions remain regarding the overall effectiveness of exercise intervention in SAIS for example; which muscles should be targeted; and what is the optimal strengthening approach. The inconsistency of treatment and lack of guidelines may be reflected in the poor long-term outcome of conservative management of SAIS.1,2 Objectives To evaluate the effectiveness of exercise in the treatment of people with SAIS. Methods A systematic review and meta-analysis was conducted. Ten electronic databases were searched from the dates of their inception until August 2010. Included studies were RCTs investigating exercise in the management of SAIS. Outcomes were pain, strength, function, and quality of life. Data were summarised qualitatively using a best evidence synthesis. Treatment effect size and variance of individual studies were used to give an overall summary effect and data were converted to standardised mean difference with 95% confidence intervals (SMD (CI)). Results Sixteen studies were included (total number of study participants=1162). There was strong evidence that exercise decreases pain and improves function at short term follow-up. There was also moderate evidence that exercise results in short term improvement in mental well-being and a long-term improvement in function, for those with SAIS. There was limited evidence that exercise reduced pain at long term follow-up. It was not possible to comment on the effect of exercise on long-term quality of life due to insufficient evidence. The most common risk of bias across the studies was inadequately concealed treatment allocation. Six studies in the review were suitable for meta-analysis. Exercise had a small positive effect on strength of the rotator cuff in the short term (SMD -0.46 (-0.76, 0.16); p=0.003), and a small positive effect on long-term function (SMD -0.31 (-0.57, 0.04); p=0.020). There was no statistically significant effect of exercise on short-term function. Conclusions Physiotherapy exercises are effective in the management of SAIS. However, heterogeneity of the exercise interventions, coupled with poor reporting of exercise protocols, prevented conclusions being drawn about which specific components of the exercise protocols (i.e. type, intensity, frequency and duration) were associated with best outcomes. References Desmeules F, Côté CH, Frémont P. Therapeutic exercise and orthopaedic manual therapy for impingement syndrome: a systematic review. Clin J Sports Med. 2003;13:176–182. Reilingh ML, Kuijpers T, Tanja-Hafterkamp AM, van der Windt DA. Course and prognosis of shoulder symptoms in general practice. Rheumatology. 2008;47:724–730. Disclosure of Interest None Declared