Luciana Gazzi Macedo

An updated overview of clinical guidelines for the management of non-specific low back pain in primary care

The aim of this study was to present and compare the content of (inter)national clinical guidelines for the management of low back pain. To rationalise the management of low back pain, evidence-based clinical guidelines have been issued in many countries. Given that the available scientific evidence is the same, irrespective of the country, one would expect these guidelines to include more or less similar recommendations regarding diagnosis and treatment. We updated a previous review that included clinical guidelines published up to and including the year 2000. Guidelines were included that met the following criteria: the target group consisted mainly of primary health care professionals, and the guideline was published in English, German, Finnish, Spanish, Norwegian, or Dutch. Only one guideline per country was included: the one most recently published. This updated review includes national clinical guidelines from 13 countries and 2 international clinical guidelines from Europe published from 2000 until 2008. The content of the guidelines appeared to be quite similar regarding the diagnostic classification (diagnostic triage) and the use of diagnostic and therapeutic interventions. Consistent features for acute low back pain were the early and gradual activation of patients, the discouragement of prescribed bed rest and the recognition of psychosocial factors as risk factors for chronicity. For chronic low back pain, consistent features included supervised exercises, cognitive behavioural therapy and multidisciplinary treatment. However, there are some discrepancies for recommendations regarding spinal manipulation and drug treatment for acute and chronic low back pain. The comparison of international clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations are generally similar. There are also some differences which may be due to a lack of strong evidence regarding these topics or due to differences in local health care systems. The implementation of these clinical guidelines remains a challenge for clinical practice and research.

Scales to Assess the Quality of Randomized Controlled Trials: A Systematic Review

Background and Purpose: The methodological quality of randomized controlled trials (RCTs) is commonly evaluated in order to assess the risk of biased estimates of treatment effects. The purpose of this systematic review was to identify scales used to evaluate the methodological quality of RCTs in health care research and summarize the content, construction, development, and psychometric properties of these scales. Methods: Extensive electronic database searches, along with a manual search, were performed. Results: One hundred five relevant studies were identified. They accounted for 21 scales and their modifications. The majority of scales had not been rigorously developed or tested for validity and reliability. The Jadad Scale presented the best validity and reliability evidence; however, its validity for physical therapy trials has not been supported. Discussion and Conclusion: Many scales are used to evaluate the methodological quality of RCTs, but most of these scales have not been adequately developed and have not been adequately tested for validity and reliability. A valid and reliable scale for the assessment of the methodological quality of physical therapy trials needs to be developed.

Motor Control Exercise for Persistent, Nonspecific Low Back Pain: A Systematic Review

Background: Previous systematic reviews have concluded that the effectiveness of motor control exercise for persistent low back pain has not been clearly established. Objective: The objective of this study was to systematically review randomized controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain. Methods: Electronic databases were searched to June 2008. Pain, disability, and quality-of-life outcomes were extracted and converted to a common 0 to 100 scale. Where possible, trials were pooled using Revman 4.2. Results: Fourteen trials were included. Seven trials compared motor control exercise with minimal intervention or evaluated it as a supplement to another treatment. Four trials compared motor control exercise with manual therapy. Five trials compared motor control exercise with another form of exercise. One trial compared motor control exercise with lumbar fusion surgery. The pooling revealed that motor control exercise was better than minimal intervention in reducing pain at short-term follow-up (weighted mean difference=−14.3 points, 95% confidence interval [CI]=−20.4 to −8.1), at intermediate follow-up (weighted mean difference=−13.6 points, 95% CI=−22.4 to −4.1), and at long-term follow-up (weighted mean difference=−14.4 points, 95% CI=−23.1 to −5.7) and in reducing disability at long-term follow-up (weighted mean difference=−10.8 points, 95% CI=−18.7 to −2.8). Motor control exercise was better than manual therapy for pain (weighted mean difference=−5.7 points, 95% CI=−10.7 to −0.8), disability (weighted mean difference=−4.0 points, 95% CI=−7.6 to −0.4), and quality-of-life outcomes (weighted mean difference=−6.0 points, 95% CI=−11.2 to −0.8) at intermediate follow-up and better than other forms of exercise in reducing disability at short-term follow-up (weighted mean difference=−5.1 points, 95% CI=−8.7 to −1.4). Conclusions: Motor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise.

The Mckenzie Method for Low Back Pain: A Systematic Review of the Literature With a Meta-analysis Approach

Study Design and Objectives. Meta-analysis of randomized controlled trials to evaluate the effectiveness of the McKenzie method for low back pain (LBP). Summary of Background Data. The McKenzie method is a popular classification-based treatment for LBP. The faulty equation of McKenzie to extension exercises (generic McKenzie) is common in randomized trials. Methods. MEDLINE, EMBASE, PEDro, and LILACS were searched up to August 2003. Two independent reviewers extracted the data and assessed methodologic quality. Pooled effects were calculated among homogeneous trials using the random effects model. A sensitivity analysis excluded trials reporting on generic McKenzie. Results. Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, −4.16 points; 95% confidence interval, −7.12 to −1.20) and disability (WMD on a 0- to 100-point scale, −5.22 points; 95% confidence interval, −8.28 to −2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up. Heterogeneity prevented pooling of studies on chronic LBP as well as pooling of studies included in the sensitivity analysis. Conclusions. There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects. There is limited evidence for the use of McKenzie method in chronic LBP. The effectiveness of classification-based McKenzie is yet to be established.

There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials

OBJECTIVE To evaluate the convergent and construct validity of the Physiotherapy Evidence Database (PEDro) scale used to rate the methodological quality of randomized trials in physiotherapy. STUDY DESIGN AND SETTING PEDro total scores and individual-item scores were extracted from 9,456 physiotherapy trials indexed on PEDro. Convergent validity was tested by comparing PEDro total scores with three other quality scales. Construct validity was tested by regressing the PEDro score and individual-item scores with the Institute for Scientific Information Web of Knowledge impact factors (IF) and SCImago journal rankings (SJR) for the journals in which the trials were published. RESULTS Testing of convergent validity revealed correlations with the other quality scales ranging from 0.31 to 0.69. The PEDro total score was weakly but significantly associated with IF and SJR (P < 0.0001). Eight of the 10 individual scale items that contribute to the PEDro total score were significantly associated with IF. CONCLUSION This study provides preliminary evidence of the convergent and construct validity of the PEDro total score and the construct validity of eight individual scale items.

Relationship between physical activity and disability in low back pain: A systematic review and meta-analysis

&NA; It is often assumed that patients with pain‐related disability due to low back pain (LBP) will have reduced physical activity levels, but recent studies have provided results that challenge this assumption. The aim of our systematic review was to examine the relationship between physical activity and disability in LBP. The literature search included 6 electronic databases and the reference list of relevant systematic reviews and studies to May 2010. To be included, studies had to measure both disability (eg, with the Roland Morris Disability Questionnaire) and physical activity (eg, by accelerometry) in patients with non‐specific LBP. Two independent reviewers screened search results and extracted data, and authors were contacted for additional data. Correlation coefficients were pooled using the random‐effects model. The search identified 3213 records and 18 studies were eligible for inclusion. The pooled results showed a weak relationship between physical activity and disability in acute or subacute (<3 months) LBP (r = −0.08, 95% confidence interval = −0.17 to 0.002), and a moderate and negative relationship in chronic (>3 months) LBP (r = −0.33, 95% confidence interval = −0.51 to −0.15). That is, persons with acute or subacute LBP appear to vary in the levels of physical activity independent of their pain‐related disability. Persons with chronic LBP with high levels of disability are also likely to have low levels of physical activity. Persons with acute or subacute back pain appear to vary in the levels of physical activity independent of disability. Persons with chronic back pain with high levels of disability will likely have low levels of physical activity.

Effect of Motor Control Exercises Versus Graded Activity in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial

Background Motor control exercises to improve control and coordination of trunk muscles and graded activity under the principles of cognitive-behavioral therapy are 2 commonly used exercise therapies, yet there is little evidence to support the use of one intervention over the other. Objective The objective of this study was to compare the effectiveness of motor control exercises and graded activity for patients with chronic nonspecific low back pain. Design This study was a prospectively registered randomized controlled trial with outcome assessment and statistical analyses conducted blind to group. Setting The study was conducted in primary care settings. Patients The participants were 172 patients with chronic (>12 weeks) nonspecific low back pain. Interventions Patients were randomly assigned to receive either motor control exercises or graded activity. There was no attempt to subclassify patients to match them to a treatment. Patients in both groups received 14 sessions of individualized, supervised exercise therapy. Measurements Primary outcomes were average pain over the previous week (numeric rating scale) and function (Patient-Specific Functional Scale); secondary outcomes were disability (24-item Roland-Morris Disability Questionnaire), global impression of change (Global Perceived Effect Scale), and quality of life (36-Item Short-Form Health Survey questionnaire [SF-36]). Outcome measures were collected at baseline and at 2, 6, and 12 months after intervention. Results A linear mixed models analysis showed that there were no significant differences between treatment groups at any of the time points for any of the outcomes studied. For example, the effect for pain at 2 months was 0.0 (−0.7 to 0.8). Limitations Clinicians could not be blinded to the interventions. Conclusion The results of this study suggest that motor control exercises and graded activity have similar effects for patients with chronic nonspecific low back pain.

Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review

Background Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood. Purpose The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain. Data Sources Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0–10). Study Selection Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study. Data Extraction Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews. Results are presented as weighted mean differences with 95% confidence intervals. Data Synthesis Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3–9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were −6.2 (−9.4 to −3.0), −5.5 (−9.9 to −1.0), −6.5 (−10.1 to −3.0), and −3.9 (−7.4 to −0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant. Limitations Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies. Conclusions The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.

Multifidus and Paraspinal Muscle Group Cross-Sectional Areas of Patients With Low Back Pain and Control Patients: A Systematic Review With a Focus on Blinding

Background Several studies have investigated differences in paraspinal muscle morphology between patients with low back pain (LBP) and control patients. However, inconsistencies in the results of some of these studies may limit generalizations. Objective The purpose of this study was to systematically review studies evaluating paraspinal muscle morphology in patients with LBP and control patients, with a focus on the effects of blinding. Data Sources An electronic search was performed with the use of relevant databases. Study quality was evaluated by means of the Newcastle-Ottawa Quality Assessment Scale. Study Selection Case-control studies investigating paraspinal muscle size between patients with LBP and control patients who were healthy were included. Studies that compared paraspinal muscle size between symptomatic and asymptomatic sides of patients with unilateral LBP also were included. Data Extraction Studies investigating the same outcome—at the same spinal level and for the same muscle and population—were pooled. Mean differences with 95% confidence interval were calculated for each study. Data Synthesis Eleven studies were included. With 1 exception, all pooled results were significantly different statistically between groups, suggesting that paraspinal muscles are smaller in patients with chronic LBP than in control patients and on the symptomatic side of patients with chronic unilateral LBP. In patients with acute unilateral LBP, there was no significant difference between sides. A qualitative examination demonstrated a trend toward an increased effect size when outcome assessors were unblinded. Limitations Limitations of this review include the small number of studies included and their small sample size. Misclassification of blinding status may have occurred when the study did not report blinding status. Conclusions Evidence suggests that paraspinal muscles are significantly smaller in patients with chronic LBP than in control patients. Although no definite conclusion could be taken as to the effects of blinding, future imaging studies should consider the use of blinded outcome assessors.

Differences in Range of Motion Between Dominant and Nondominant Sides of Upper and Lower Extremities

OBJECTIVE The objective of this study was to compare ranges of motion (ROM) between dominant and nondominant sides for the joints of the upper and lower extremities. METHODS Ninety healthy white women from 18 to 59 years of age were measured in this study. Active and passive ROM were measured for the ankle, knee, hip, shoulder, elbow, and wrist using a standard goniometer. The order of the joints, motion, sides, and active or passive motion testing was randomly selected. A paired t test was used for the comparison between sides. RESULTS The results of this study showed a statistically significant difference between dominant and nondominant sides for 34 of the 60 ROM measured. The maximum mean difference between sides for all ROM measured was 7.5 degrees . CONCLUSION The results of this show that some ROM are different between body sides and that when these differences exist they are minimal and may not be clinically insignificant. These results support the practice of using the opposite side of the body as an indicator of preinjury or normal extremity ROM.