Gd Baxter

A randomized clinical trial of manipulative therapy and interferential therapy for acute low back pain

Study Design. A multicenter assessor-blinded randomized clinical trial was conducted. Objectives. To investigate the difference in effectiveness of manipulative therapy and interferential therapy for patients with acute low back pain when used as sole treatments and in combination. Summary of Background Data. Both manipulative therapy and interferential therapy are commonly used treatments for low back pain. Evidence for the effectiveness of manipulative therapy is available only for the short-term. There is limited evidence for interferential therapy, and no study has investigated the effectiveness of manipulative therapy combined with interferential therapy. Methods. Consenting subjects (n = 240) recruited following referral by physicians to physiotherapy departments in the (government-funded) National Health Service in Northern Ireland were randomly assigned to receive a copy of the Back Book and either manipulative therapy (MT; n = 80), interferential therapy (IFT; n = 80), or a combination of manipulative therapy and interferential therapy (CT; n = 80). The primary outcome was a change in functional disability on the Roland Morris Disability Questionnaire. Follow-up questionnaires were posted at discharge and at 6 and 12 months. Results. The groups were balanced at baseline for low back pain and demographic characteristics. At discharge all interventions significantly reduced functional disability (Roland Morris scale, MT: −4.53; 95% CI, −5.7 to −3.3 vs. IFT: −3.56; 95% CI, −4.8 to −2.4 vs. CT: −4.65; 95% CI, −5.8 to −3.5; P = 0.38) and pain (McGill questionnaire, MT: −5.12; 95% CI, −7.7 to −2.5 vs. IFT: −5.87; 95% CI, −8.5 to −3.3 vs. CT: −6.64; 95% CI, −9.2 to −4.1; P = 0.72) and increased quality of life (SF-36 Role-Physical, MT: 28.6; 95% CI, 18.3 to 38.9 vs. IFT: 31.4; 95% CI, 21.2 to 41.5 vs. CT: 30; 95% CI, 19.9 to 40; P = 0.93) to the same degree and maintained these improvements at 6 and 12 months. No significant differences were found between groups for reported LBP recurrence, work absenteeism, medication consumption, exercise participation, or healthcare use at 12 months (P > 0.05). Conclusions. For acute low back pain, there was no difference between the effects of a combined manipulative therapy and interferential therapy package and either manipulative therapy or interferential therapy alone.

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.

Walking Exercise for Chronic Musculoskeletal Pain: Systematic Review and Meta-Analysis

OBJECTIVE To systematically review the evidence examining effects of walking interventions on pain and self-reported function in individuals with chronic musculoskeletal pain. DATA SOURCES Six electronic databases (MEDLINE, CINAHL, PsychINFO, PEDro, Sport Discus, and the Cochrane Central Register of Controlled Trials) were searched from January 1980 to March 2014. STUDY SELECTION Randomized and quasi-randomized controlled trials in adults with chronic low back pain, osteoarthritis, or fibromyalgia comparing walking interventions to a nonexercise or nonwalking exercise control group. DATA EXTRACTION Data were independently extracted using a standardized form. Methodological quality was assessed using the U.S. Preventive Services Task Force system. DATA SYNTHESIS Twenty-six studies (2384 participants) were included, and suitable data from 17 studies were pooled for meta-analysis, with a random effects model used to calculate between-group mean differences and 95% confidence intervals (CIs). Data were analyzed according to the duration of follow-up (short-term, ≤8wk postrandomization; medium-term, >2mo to 12mo; long-term, >12mo). Interventions were associated with small to moderate improvements in pain at short-term (mean difference , -5.31; 95% CI, -8.06 to -2.56) and medium-term (mean difference, -7.92; 95% CI, -12.37 to -3.48) follow-up. Improvements in function were observed at short-term (mean difference, -6.47; 95% CI, -12.00 to -0.95), medium-term (mean difference, -9.31; 95% CI, -14.00 to -4.61), and long-term (mean difference, -5.22; 95% CI, -7.21 to -3.23) follow-up. CONCLUSIONS Evidence of fair methodological quality suggests that walking is associated with significant improvements in outcome compared with control interventions but longer-term effectiveness is uncertain. With the use of the U.S. Preventive Services Task Force system, walking can be recommended as an effective form of exercise or activity for individuals with chronic musculoskeletal pain but should be supplemented with strategies aimed at maintaining participation. Further work is required for examining effects on important health-related outcomes in this population in robustly designed studies.

Eccentric exercise protocols for chronic non-insertional Achilles tendinopathy: how much is enough?

Eccentric exercises for the calf muscles have been shown to be effective for chronic non‐insertional Achilles tendinopathy (AT). However, the relative effectiveness of various dosages is unknown. A systematic review of randomized‐controlled trials (RCTs) was designed to determine whether an optimum dose of eccentric exercises could be recommended. Three selected RCTs showed positive effects of very similar eccentric exercise protocols for chronic non‐insertional AT. Owing to insufficient reported compliance data, a conclusion on the relative effectiveness of various compliances was not feasible. According to our review, the relative effectiveness of various dosages of eccentric exercises for AT is still unclear. However, it appears that highly variable compliance rates result in similar positive outcomes; these findings, therefore, highlight the need for further investigations.

Reflexology in the management of low back pain: A pilot randomised controlled trial

OBJECTIVE The current study was designed as a pilot study for a randomised controlled trial to investigate the effectiveness of reflexology in the management of low back pain (LBP). MATERIALS AND METHODS Participants suffering non-specific LBP were recruited and randomised into either a reflexology or a sham group. Patients and outcome assessor were blinded to group allocation. Each patient received either a 40 min reflexology treatment or sham treatment (according to group allocation) once per week for six consecutive weeks. The primary outcome measure was pain (visual analogue scale), secondary outcome measures were the McGill pain questionnaire, Roland-Morris disability questionnaire, and SF-36 health survey. Outcome measures were performed at baseline, week 6, week 12 and week 18. RESULTS VAS scores for pain reduced in the treatment group by a median value of 2.5 cm, with minimal change in the sham group (0.2 cm). Secondary outcome measures produced an improvement in both groups (McGill pain questionnaire: 18 points in the reflexology group and 11.5 points in the sham group). Results indicate that reflexology may have a positive effect on LBP. CONCLUSION Reflexology appears to offer promise as a treatment in the management of LBP; however, an adequately powered trial is required before any more definitive pronouncements are possible.

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.

Exercise and Auricular Acupuncture for Chronic Low-back Pain: A Feasibility Randomized-controlled Trial.

Objectives:To evaluate the feasibility of a randomized-controlled trial (RCT) investigating the effects of adding auricular acupuncture (AA) to exercise for participants with chronic low-back pain (CLBP). Methods:Participants with CLBP were recruited from primary care and a university population and were randomly allocated (n=51) to 1 of 2 groups: (1) “Exercise Alone (E)”—12-week program consisting of 6 weeks of supervised exercise followed by 6 weeks unsupervised exercise (n=27); or (2) “Exercise and AA (EAA)”—12-week exercise program and AA (n=24). Outcome measures were recorded at baseline, week 8, week 13, and 6 months. The primary outcome measure was the Oswestry Disability Questionnaire. Results:Participants in the EAA group demonstrated a greater mean improvement of 10.7% points (95% confidence interval, –15.3,−5.7) (effect size=1.20) in the Oswestry Disability Questionnaire at 6 months compared with 6.7% points (95% confidence interval, −11.4,−1.9) in the E group (effect size=0.58). There was also a trend towards a greater mean improvement in quality of life, LBP intensity and bothersomeness, and fear-avoidance beliefs in the EAA group. The dropout rate for this trial was lower than anticipated (15% at 6 mo), adherence with exercise was similar (72% E; 65% EAA). Adverse effects for AA ranged from 1% to 14% of participants. Discussion:Findings of this study showed that a main RCT is feasible and that 56 participants per group would need to be recruited, using multiple recruitment approaches. AA was safe and demonstrated additional benefits when combined with exercise for people with CLBP, which requires confirmation in a fully powered RCT.

Acupuncture for Low Back Pain: An Overview of Systematic Reviews

Objective. As evidence of the effectiveness of acupuncture for low back pain (LBP) is inconsistent, we aimed to critically appraise the evidence from relevant systematic reviews. Methods. Systematic reviews of randomized controlled trials (RCTs) concerning acupuncture and LBP were searched in seven databases. Internal validity and external validity of systematic reviews were assessed. Systematic reviews were categorized and high quality reviews assigned greater weightings. Conclusions were generated from a narrative synthesis of the outcomes of subgroup comparisons. Results. Sixteen systematic reviews were appraised. Overall, the methodological quality was low and external validity weak. For acute LBP, evidence that acupuncture has a more favorable effect than sham acupuncture in relieving pain was inconsistent; it had a similar effect on improving function. For chronic LBP, evidence consistently demonstrated that acupuncture provides short-term clinically relevant benefits for pain relief and functional improvement compared with no treatment or acupuncture plus another conventional intervention. Conclusion. Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP. More efforts are needed to improve both internal and external validity of systematic reviews and RCTs in this area.

Laser Acupuncture for Treating Musculoskeletal Pain: A Systematic Review with Meta-analysis

Laser acupuncture has been studied extensively over several decades to establish evidence-based clinical practice. This systematic review aims to evaluate the effects of laser acupuncture on pain and functional outcomes when it is used to treat musculoskeletal disorders and to update existing evidence with data from recent randomized controlled trials (RCTs). A computer-based literature search of the databases MEDLINE, AMED, EMBASE, CINAHL, SPORTSDiscus, Cochrane Library, PubMed, Current Contents Connect, Web of Science, and SCOPUS was used to identify RCTs comparing between laser acupuncture and control interventions. A meta-analysis was performed by calculating the standardized mean differences and 95% confidence intervals, to evaluate the effect of laser acupuncture on pain and functional outcomes. Included studies were assessed in terms of their methodological quality and appropriateness of laser parameters. Forty-nine RCTs met the inclusion criteria. Two-thirds (31/49) of these studies reported positive effects, were of high methodological quality, and reported the dosage adequately. Negative or inconclusive studies commonly failed to demonstrate these features. For all diagnostic subgroups, positive effects for both pain and functional outcomes were more consistently seen at long-term follow-up rather than immediately after treatment. Moderate-quality evidence supports the effectiveness of laser acupuncture in managing musculoskeletal pain when applied in an appropriate treatment dosage; however, the positive effects are seen only at long-term follow-up and not immediately after the cessation of treatment.

Promoting physical activity for individuals with neurological disability: indications for practice.

Purpose: This study explored processes that influenced involvement in recreational exercise for individuals with neurological disability, to identify strategies to promote physical activity for health and well-being in this population. Method: Nineteen participants (11 males and eight females), aged 20–71 years, with a range of neurological conditions and functional limitations, were recruited in one large metropolitan area in New Zealand. Individual semi-structured interviews explored participants’ views, perceptions, and experiences of undertaking recreational exercise. Data were analysed for themes. Results: For some individuals, recreational exercise is undertaken for its physical, psychological, or social benefits, despite the physical activity itself feeling relatively unsatisfactory. In contrast, individuals who are able to undertake their preferred choice of recreational exercise experience intense satisfaction. This motivates self-maintenance of physical activity, even for those individuals who require carer support or assistance to do so. Conclusions: This study has identified that there can be two forms of involvement in recreational exercise that allows individuals with neurological disability to become more physically active. The information could be further developed and tested in intervention studies to provide strategies for health professionals to facilitate engagement in physical activity for people with neurological disability. Implications for Rehabilitation Strategies to encourage physical activity should promote the individual’s own choice of involvement in recreational exercise. Access to an individual’s own choice of recreational exercise leads to self-sufficiency for it to be maintained.