Jaime Guzman

Multidisciplinary rehabilitation for chronic low back pain: systematic review.

Abstract Objective: To assess the effect of multidisciplinary biopsychosocial rehabilitation on clinically relevant outcomes in patients with chronic low back pain. Design: Systematic literature review of randomised controlled trials. Participants: A total of 1964 patients with disabling low back pain for more than three months. Main outcome measures: Pain, function, employment, quality of life, and global assessments. Results: Ten trials reported on a total of 12 randomised comparisons of multidisciplinary treatment and a control condition. There was strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary biopsychosocial intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psychophysical treatments did not improve pain, function, or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments. Conclusions: The reviewed trials provide evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain. Less intensive interventions did not show improvements in clinically relevant outcomes. What is already known on this topic Disabling chronic pain is regarded as the result of interrelating physical, psychological, and social or occupational factors requiring multidisciplinary intervention Two previous systematic reviews of multidisciplinary rehabilitation for chronic pain were open to bias and did not include any of the randomised controlled trials now available What this study adds Intensive, daily biopsychosocial rehabilitation with a functional restoration approach improves pain and function in chronic low back pain Less intensive interventions did not show improvements in clinically relevant outcomes It is unclear whether the improvements are worth the cost of these intensive treatments

Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

Study Design. Best evidence synthesis. Objective. To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in Grades I–III whiplash-associated disorders (WAD). Summary of Background Data. Knowledge of the course of recovery of WAD guides expectations for recovery. Identifying prognostic factors assists in planning management and intervention strategies and effective compensation policies to decrease the burden of WAD. Methods. The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis. Results. We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD. Conclusion. The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for WAD. Recovery of WAD seems to be multifactorial.

Course and prognostic factors for neck pain in the general population: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

Study Design. Best evidence synthesis. Objective. To undertake a best evidence synthesis on course and prognosis of neck pain and its associated disorders in the general population. Summary of Background Data. Knowing the course of neck pain guides expectations for recovery. Identifying prognostic factors assists in planning public policies, formulating interventions, and promoting lifestyle changes to decrease the burden of neck pain. Methods. The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Findings from studies meeting criteria for scientific validity were abstracted into evidence tables and included in a best evidence synthesis. Results. We found 226 articles on the course and prognostic factors in neck pain and its associated disorders. After critical review, 70 (31%) of these were accepted on scientific merit. Six studies related to course and 7 to prognostic factors in the general population. Between half and three quarters of persons in these populations with current neck pain will report neck pain again 1 to 5 years later. Younger age predicted better outcome. General exercise was unassociated with outcome, although regular bicycling predicted poor outcome in 1 study. Psychosocial factors, including psychologic health, coping patterns, and need to socialize, were the strongest prognostic factors. Several potential prognostic factors have not been well studied, including degenerative changes, genetic factors, and compensation policies. Conclusion. The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for this symptom. General exercise was not prognostic of better outcome; however, several psychosocial factors were prognostic of outcome.

Course and Prognostic Factors for Neck Pain in Whiplash-Associated Disorders (WAD)

STUDY DESIGN Best evidence synthesis. OBJECTIVE To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in Grades I-III whiplash-associated disorders (WAD). SUMMARY OF BACKGROUND DATA Knowledge of the course of recovery of WAD guides expectations for recovery. Identifying prognostic factors assists in planning management and intervention strategies and effective compensation policies to decrease the burden of WAD. METHODS The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis. RESULTS We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 47 of these studies related to course and prognostic factors in WAD. The evidence suggests that approximately 50% of those with WAD will report neck pain symptoms 1 year after their injuries. Greater initial pain, more symptoms, and greater initial disability predicted slower recovery. Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, postinjury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery. There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD. CONCLUSION The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for WAD. Recovery of WAD seems to be multifactorial.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis.

Objective To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. Design Systematic review and random effects meta-analysis of randomised controlled trials. Data sources Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials. Study selection criteria Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention. Results Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, −0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery. Conclusions Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care.

Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations.

Study Design. Best evidence synthesis. Objective. To provide evidence-based guidance to primary care clinicians about how to best assess and treat patients with neck pain. Summary of Background Data. There is a need to translate the results of clinical and epidemiologic studies into meaningful and practical information for clinicians. Methods. Based on best evidence syntheses of published studies on the risk, prognosis, assessment, and management of people with neck pain and its associated disorders, plus additional research projects and focused literature reviews reported in this supplement, the 12-member multidisciplinary Scientific Secretariat of the Neck Pain Task Force followed a 4-step approach to develop practical guidance for clinicians. Results. The Neck Pain Task Force recommends that people seeking care for neck pain should be triaged into 4 groups: Grade I neck pain with no signs of major pathology and no or little interference with daily activities; Grade II neck pain with no signs of major pathology, but interference with daily activities; Grade III neck pain with neurologic signs of nerve compression; Grade IV neck pain with signs of major pathology. In the emergency room after blunt trauma to the neck, triage should be based on the NEXUS criteria or the Canadian C-spine rule. Those with a high risk of fracture should be further investigated with plain radiographs and/or CT-scan. In ambulatory primary care, triage should be based on history and physical examination alone, including screening for red flags and neurologic examination for signs of radiculopathy. Exercises and mobilization have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain after a motor vehicle collision. Exercises, mobilization, manipulation, analgesics, acupuncture, and low-level laser have been shown to provide some degree of short-term relief of Grade I or Grade II neck pain without trauma. Those with confirmed Grade III and severe persistent radicular symptoms might benefit from corticosteroid injections or surgery. Those with confirmed Grade IV neck pain require management specific to the diagnosed pathology. Conclusion. The best available evidence suggests initial assessment for neck pain should focus on triage into 4 grades, and those with common neck pain (Grade I and Grade II) might be offered the listed noninvasive treatments if short-term relief is desired.

Treatment of Neck Pain : Injections and Surgical Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

Study Design. Best evidence synthesis. Objective. To identify, critically appraise, and synthesize literature from 1980 through 2006 on surgical interventions for neck pain alone or with radicular pain in the absence of serious pathologic disease. Summary of Background Data. There have been no comprehensive systematic literature or evidence-based reviews published on this topic. Methods. We systematically searched Medline for literature published from 1980 to 2006 on percutaneous and open surgical interventions for neck pain. Publications on the topic were also solicited from experts in the field. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our Best Evidence Synthesis. Results. Of the 31,878 articles screened, 1203 studies were relevant to the Neck Pain Task Force mandate and of these, 31 regarding treatment by surgery or injections were accepted as scientifically admissible. Radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported by current evidence. We found there is support for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids. It is not clear from the evidence that long-term outcomes are improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures. However, relatively rapid and substantial symptomatic relief after surgical treatment seems to be reliably achieved. It is not evident that one open surgical technique is clearly superior to others for radiculopathy. Cervical foramenal or epidural injections are associated with relatively frequent minor adverse events (5%–20%); however, serious adverse events are very uncommon (<1%). After open surgical procedures on the cervical spine, potentially serious acute complications are seen in approximately 4% of patients. Conclusion. Surgical treatment and limited injection procedures for cervical radicular symptoms may be reasonably considered in patients with severe impairments. Percutaneous and open surgical treatment for neck pain alone, without radicular symptoms or clear serious pathology, seems to lack scientific support.

Course and prognostic factors for neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.

Study Design. Best-evidence synthesis. Objective. To perform a best evidence synthesis on the course and prognostic factors for neck pain and its associated disorders in workers. Summary of Background Data. Knowledge of the course of neck pain in workers guides expectations for recovery. Identifying prognostic factors assists in planning effective workplace policies, formulating interventions and promoting lifestyle changes to decrease the frequency and burden of neck pain in the workplace. Methods. The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of the literature published between 1980 and 2006 to assemble the best evidence on neck pain and its associated disorders. Studies meeting criteria for scientific validity were included in a best evidence synthesis. Results. We found 226 articles related to course and prognostic factors in neck pain and its associated disorders. After a critical review, 70 (31%) were accepted on scientific merit; 14 of these studies related to course and prognostic factors in working populations. Between 60% and 80% of workers with neck pain reported neck pain 1 year later. Few workplace or physical job demands were identified as being linked to recovery from neck pain. However, workers with little influence on their own work situation had a slightly poorer prognosis, and white-collar workers had a better prognosis than blue-collar workers. General exercise was associated with better prognosis; prior neck pain and prior sick leave were associated with poorer prognosis. Conclusion. The Neck Pain Task Force presents a report of current best evidence on course and prognosis for neck pain. Few modifiable prognostic factors were identified; however, having some influence over ones own job and being physically active seem to hold promise as prognostic factors.

Course and Prognostic Factors for Neck Pain in the General Population: Results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN Best evidence synthesis. OBJECTIVE To undertake a best evidence synthesis on course and prognosis of neck pain and its associated disorders in the general population. SUMMARY OF BACKGROUND DATA Knowing the course of neck pain guides expectations for recovery. Identifying prognostic factors assists in planning public policies, formulating interventions, and promoting lifestyle changes to decrease the burden of neck pain. METHODS The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) conducted a critical review of literature published between 1980 and 2006 to assemble the best evidence on neck pain. Findings from studies meeting criteria for scientific validity were abstracted into evidence tables and included in a best evidence synthesis. RESULTS We found 226 articles on the course and prognostic factors in neck pain and its associated disorders. After critical review, 70 (31%) of these were accepted on scientific merit. Six studies related to course and 7 to prognostic factors in the general population. Between half and three quarters of persons in these populations with current neck pain will report neck pain again 1 to 5 years later. Younger age predicted better outcome. General exercise was unassociated with outcome, although regular bicycling predicted poor outcome in 1 study. Psychosocial factors, including psychologic health, coping patterns, and need to socialize, were the strongest prognostic factors. Several potential prognostic factors have not been well studied, including degenerative changes, genetic factors, and compensation policies. CONCLUSION The Neck Pain Task Force undertook a best evidence synthesis to establish a baseline of the current best evidence on the course and prognosis for this symptom. General exercise was not prognostic of better outcome; however, several psychosocial factors were prognostic of outcome.

Surfing for Back Pain Patients : The Nature and Quality of Back Pain Information on the Internet

Study Design. A prospective, systematic review of web sites related to back pain. Objective. To assess the nature and quality of back pain-related information on the World Wide Web during a 2-year period. Summary of Background Data. The Internet has become a rich source of medical information. Limited knowledge is available, however, about the quality of online resources. Although previous systematic reviews on medical-related web sites found problems in varying degrees with the credibility of information, no such review was conducted to assess the back pain-related sites. Methods. A search of web sites was conducted in November 1996 using five search engines (AltaVista, Infoseek, Lycos, Yahoo, and Magellan) and two key terms (“back pain” and “back problems”). A sample of sites was evaluated by two independent reviewers. Each site was described by the type and nature of the sponsor, target audience, and content. Overall quality was assessed in terms of evidence-based information available. Results. Seventy-four web sites were reviewed in 1996, and nine of them (12.2%) were identified as high-quality sites. Advertising was the focus of 80.8% of the sites. Eleven sites (14.9%) were found to be discontinued 1 year later, and 20 (27.0%) were not accessible by the reviewers at the 2-year follow-up evaluation. Of the remaining 54 sites, 44.4% were produced by for-profit companies, and most sites targeted people with back pain (63.0%). Only seven out of the nine high-quality sites held their ratings at the 2-year follow-up evaluation. Conclusion. Most back pain-related web sites can be classified as advertising. The quality varied considerably, resulting in difficulties for patients to find useful information in this field. The increasing number of people seeking medical information on the Web creates a need for more high quality sites. Further, systematic review of web sites should be encouraged to monitor the accuracy of Internet publication.