Daniel Steffens

Prevention of Low Back Pain: A Systematic Review and Meta-analysis

IMPORTANCE Existing guidelines and systematic reviews lack clear recommendations for prevention of low back pain (LBP). OBJECTIVE To investigate the effectiveness of interventions for prevention of LBP. DATA SOURCES MEDLINE, EMBASE, Physiotherapy Evidence Database Scale, and Cochrane Central Register of Controlled Trials from inception to November 22, 2014. STUDY SELECTION Randomized clinical trials of prevention strategies for nonspecific LBP. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed the risk of bias. The Physiotherapy Evidence Database Scale was used to evaluate the risk-of-bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to describe the quality of evidence. MAIN OUTCOMES AND MEASURES The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP. We calculated relative risks (RRs) and 95% CIs using random-effects models. RESULTS The literature search identified 6133 potentially eligible studies; of these, 23 published reports (on 21 different randomized clinical trials including 30,850 unique participants) met the inclusion criteria. With results presented as RRs (95% CIs), there was moderate-quality evidence that exercise combined with education reduces the risk of an episode of LBP (0.55 [0.41-0.74]) and low-quality evidence of no effect on sick leave (0.74 [0.44-1.26]). Low- to very low-quality evidence suggested that exercise alone may reduce the risk of both an LBP episode (0.65 [0.50-0.86]) and use of sick leave (0.22 [0.06-0.76]). For education alone, there was moderate- to very low-quality evidence of no effect on LBP (1.03 [0.83-1.27]) or sick leave (0.87 [0.47-1.60]). There was low- to very low-quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71-1.44]) or sick leave (0.87 [0.47-1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74-1.40]). CONCLUSION AND RELEVANCE The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low.

Does magnetic resonance imaging predict future low back pain? A systematic review

Magnetic resonance imaging (MRI) has the potential to identify pathology responsible for low back pain (LBP). However, the importance of findings on MRI remains controversial. We aimed to systematically review whether MRI findings of the lumbar spine predict future LBP in different samples with and without LBP.

What Triggers an Episode of Acute Low Back Pain? A Case–Crossover Study

To investigate a range of transient risk factors for an episode of sudden‐onset, acute low back pain (LBP).

Risk factors for a recurrence of low back pain

BACKGROUND CONTEXT The clinical importance of lumbar pathology identified on magnetic resonance imaging (MRI) remains unclear. It is plausible that pathology seen on MRI is a risk factor for a recurrence of low back pain (LBP); however, to our knowledge, this has not been investigated by previous studies. PURPOSE The aim was to investigate whether lumbar pathology, identifiable on MRI, increases the risk of a recurrence of LBP. STUDY DESIGN This was a prospective inception cohort study with 1-year follow-up. PATIENT SAMPLE Seventy-six people who had recovered from an episode of LBP within the previous 3 months were included. OUTCOME MEASURES The primary outcome was time to recurrence of LBP, which was determined by contacting participants at 2-month intervals for 12 months. METHODS All participants underwent a baseline assessment including MRI scan and completion of a questionnaire, which assessed a range of potential risk factors for recurrence. Magnetic resonance imaging scans were reported for the presence of a range of MRI findings. The primary analysis investigated the predictive value of two clinical features (age and number of previous episodes) and six MRI findings (disc degeneration, high intensity zone, Modic changes, disc herniation, facet joint arthrosis, and spondylolisthesis) in a multivariate Cox regression model. We decided a priori that dichotomous predictors with hazard ratios (HRs) of greater than 1.5 or less than 0.67 would be considered potentially clinically important and justify further investigation. RESULTS Of the eight predictors entered into the primary multivariate model, three (disc degeneration, high intensity zone, and number of previous episodes) met our a priori threshold for potential importance. Participants with disc degeneration score greater than or equal to 3 (Pfirrmann scale) had a HR of 1.89 (95% confidence interval [CI] 0.42-8.53) compared with those without. Patients with high intensity zone had an HR of 1.84 (95% CI 0.94-3.59) compared with those without. For every additional previous episode, participants had an HR of 1.04 (95% CI 1.02-1.07). CONCLUSIONS We identified promising risk factors for a recurrence of LBP, which should be further investigated in larger trials. The findings suggest that pathology seen on MRI plays a potentially important role in recurrence of LBP.

Triggers for an episode of sudden onset low back pain: study protocol

BackgroundMost research on risk factors for low back pain has focused on long term exposures rather than factors immediately preceding the onset of low back pain. The aim of this study is to quantify the transient increase in risk of a sudden episode of low back pain associated with acute exposure to a range of common physical and psychological factors.Methods/designThis study uses a case-crossover design. One thousand adults with a sudden onset of low back pain presenting to primary care clinicians will be recruited. Basic demographic and clinical information including exposure to putative triggers will be collected using a questionnaire. These triggers include exposure to hazardous manual tasks, physical activity, a slip/trip or fall, consumption of alcohol, sexual activity, being distracted, and being fatigued or tired. Exposures in the case window (0-2 hours from the time when participants first notice their back pain) will be compared to exposures in two control time-windows (one 24-26 hours and another 48-50 hours before the case window).DiscussionThe completion of this study will provide the first-research based estimates of the increase in risk of a sudden episode of acute low back pain associated with transient exposure to a range of common factors thought to trigger low back pain.

Effect of weather on back pain: results from a case-crossover study

To investigate the influence of various weather conditions on risk of low back pain.

Activity level predicts 6-minute walk distance in healthy older females: an observational study

BACKGROUND The 6-minute walk test (6MWT) is widely used in clinical practice and research. Few studies have investigated activity level as a predictor of 6-minute walk distance (6MWD), and existing predictive models do not allow for activity level. OBJECTIVES To evaluate if knowledge of the level of physical activity enhanced the ability to predict 6MWD, and if the inclusion of activity level added to the predictive accuracy of existing models for the 6MWT in healthy older women; and to validate existent predictive models for 6MWD in a new sample. DESIGN Cross-sectional, observational study. SETTING Four elderly communities. PARTICIPANTS A convenience sample of healthy active and sedentary older non-smoking females with no musculoskeletal or lung disorders. MAIN OUTCOME MEASURES Age, height, weight, spirometric values and 6MWD. RESULTS Seventy-seven out of 154 females met the inclusion criteria [mean age 66 (standard deviation 6.5) years]: 46 were active and composed the active group and 31 were sedentary and composed the sedentary group. The active group had significantly greater 6MWD than the sedentary group (mean 44m; 95% confidence interval 14 to 73m; P<0.01). Previous published models that did not allow for activity level either over or underestimated the 6MWD in this sample. The activity level was shown to be an important independent predictor of 6MWD. CONCLUSION This study demonstrates the importance of considering the level of physical activity when predicting 6MWD in older women.

Robotic Surgery in Uro-oncology: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Robotic surgery represents a new horizon in minimally invasive urologic surgery. This systematic review of the literature and meta-analysis examines the effectiveness of robotic surgery compared with laparoscopic or open surgery for major uro-oncological procedures. Twenty-five articles reported findings from 8 trials of prostatectomy (4 trials) and cystectomy (4 trials) including 1033 participants. Robotic surgery is comparable with laparoscopic or open surgery for oncological outcomes and overall complications, and provides somewhat better functional outcome when compared with laparoscopic and open surgery.

Patients' and Physiotherapists' Views on Triggers for Low Back Pain

Study Design. A cross-sectional survey. Objective. The aim of this study was to compare patients’ and physiotherapists’ views on triggers for low back pain (LBP) and to identify any novel factors not previously reported. Summary of Background Data. Most research on risk factors for LBP is guided by the views of clinicians and researchers, not patients. Consequently, potentially valuable information about risk factors for LBP is not available from those suffering the condition. This study aimed to compare patients’ and physiotherapists’ views on triggers for LBP and to identify any novel factors not previously reported. Methods. One hundred two physiotherapists and 999 patients with a sudden, acute episode of LBP participated in this study. Participating physiotherapists were asked to nominate the most likely short-term risk factors to trigger a LBP episode. Similarly, patients were asked what they thought had triggered their onset of LBP. Responses were coded into risk factor categories and subcategories by 2 independent researchers. Endorsement of each category was compared using the Pearson Chi-square statistic. Results. Both patients and physiotherapists endorsed biomechanical risk factors as the most important risk factor category (87.7% and 89.4%, respectively) and had similar levels of endorsement for 3 of the top 5 subcategories (lifting, bending, and prolonged sitting). There were significant differences in endorsement of awkward postures (13.4% vs 1.2%; P < 0.001) sports injuries (15.9% vs 4.7%; P < 0.001), physical trauma (3.4% vs 9.2%; P < 0.001), and unaccustomed activity (2.3% vs 7.3%; P < 0.001) by patients and physiotherapists, respectively. Conclusion. Overall, patients’ and physiotherapists’ views were remarkably similar. Both patients and physiotherapists endorsed lifting as the most important trigger for LBP and agreed on 3 of the top 5 (lifting, bending, and prolonged sitting). No new risk factors were suggested by patients. Level of Evidence: 2

Do MRI findings identify patients with low back pain or sciatica who respond better to particular interventions? A systematic review

PurposeMagnetic resonance imaging (MRI) can reveal a range of degenerative findings and anatomical abnormalities; however, the clinical importance of these remains uncertain and controversial. We aimed to investigate if the presence of MRI findings identifies patients with low back pain (LBP) or sciatica who respond better to particular interventions.MethodsMEDLINE, EMBASE and CENTRAL databases were searched. We included RCTs investigating MRI findings as treatment effect modifiers for patients with LBP or sciatica. We excluded studies with specific diseases as the cause of LBP. Risk of bias was assessed using the criteria of the Cochrane Back Review Group. Each MRI finding was examined for its individual capacity for effect modification.ResultsEight published trials met the inclusion criteria. The methodological quality of trials was inconsistent. Substantial variability in MRI findings, treatments and outcomes across the eight trials prevented pooling of data. Patients with Modic type 1 when compared with patients with Modic type 2 had greater improvements in function when treated by Diprospan (steroid) injection, compared with saline. Patients with central disc herniation when compared with patients without central disc herniation had greater improvements in pain when treated by surgery, compared with rehabilitation.ConclusionsAlthough individual trials suggested that some MRI findings might be effect modifiers for specific interventions, none of these interactions were investigated in more than a single trial. High quality, adequately powered trials investigating MRI findings as effect modifiers are essential to determine the clinical importance of MRI findings in LBP and sciatica (PROSPERO: CRD42013006571).