M.W. van Tulder

Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions.

Study Design. A systematic review of randomized controlled trials. Objectives. To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain. Summary of Background Data. Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy. Methods. A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results. Results. The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100‐point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti‐inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short‐term effects. Conclusions. The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain.

Clinical Guidelines for the Management of Low Back Pain in Primary Care : An International Comparison

Study Design. Descriptive study. Objectives. To compare national clinical guidelines on low back pain. Summary of Background Data. To rationalize the management of low back pain, clinical guidelines have been issued in various countries around the world. 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. Methods. Guidelines were included that met the following criteria: the target group consisted of primary care health professionals, and the guideline was published in English, German, or Dutch. Only one guideline per country was included: the one most recently published. Results. Clinical guidelines from 11 different countries published from 1994 until 2000 were included in this review. 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 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. However, there were discrepancies for recommendations regarding exercise therapy, spinal manipulation, muscle relaxants, and patient information. Conclusion. The comparison of clinical guidelines for the management of low back pain showed that diagnostic and therapeutic recommendations were generally similar. Updates of the guidelines are planned in most countries, although so far produced only in the United Kingdom. However, new evidence may lead to stronger conclusions and enable future guidelines to become even more concordant.

Diagnosis and treatment of low back pain

Low back pain is a considerable health problem in all developed countries and is most commonly treated in primary healthcare settings. It is usually defined as pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica). The most important symptoms of non-specific low back pain are pain and disability. The diagnostic and therapeutic management of patients with low back pain has long been characterised by considerable variation within and between countries among general practitioners, medical specialists, and other healthcare professionals.1 2 w1 Recently, a large number of randomised clinical trials have been done, systematic reviews have been written, and clinical guidelines have become available. The outlook for evidence based management of low back pain has greatly improved. This review presents the current state of science regarding the diagnosis and treatment of low back pain. We used the Cochrane Library to identify relevant systematic reviews that evaluate the effectiveness of conservative, complementary, and surgical interventions. Medline searches were used to find other relevant systematic reviews on diagnosis and treatment of low back pain, with the keywords “low back pain”, “systematic review”, “meta-analysis”, “diagnosis”, and “treatment”. Our personal files were used for additional references. We also checked available clinical guidelines and used Clinical Evidence as source for clinically relevant information on benefits and harms of treatments.3 4 Most of us will experience at least one episode of low back pain during our life. Reported lifetime prevalence varies from 49% to 70% and point prevalences from 12% to 30% are reported in Western countries.w2 w3 The diagnostic process is mainly focused on the triage of patients with specific or non-specific low back pain. Specific low back pain is defined as symptoms caused by a specific pathophysiological mechanism, such …

Spinal radiographic findings and nonspecific low back pain - A systematic review of observational studies

Study Design. A systematic review of published observational studies. Objectives. To examine the causal relationship between radiographic findings and nonspecific low back pain. Summary of Background Data. The causal relationship between radiographic findings and nonspecific low back pain still is controversial. Methods. Two reviewers independently scored the methodologic quality of all relevant, available studies using a standardized set of criteria. The association between radiographic findings and nonspecific low back pain was expressed as an odds ratio with a corresponding 95% confidence interval. Results. Degeneration, defined by the presence of disc space narrowing, osteophytes, and sclerosis, turned out to be associated with nonspecific low back pain with odds ratios ranging from 1.2 to 3.3. Spondylolysis and spondylolisthesis, spina bifida, transitional vertebrae, spondylosis, and Scheuermanns disease did not appear to be associated with low back pain. The validity scores of the observational studies ranged from 0% to 91% of the maximum score. Only two studies used a prospective design, and most studies lacked control for confounding, an appropriate test for nonspecific low back pain, and blinded assessment of radiographs and low back pain status. Conclusions. There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain.

Diagnosis and treatment of sciatica

Sciatica affects many people. The most important symptoms are radiating leg pain and related disabilities. Patients are commonly treated in primary care but a small proportion is referred to secondary care and may eventually have surgery. Many synonyms for sciatica appear in the literature, such as lumbosacral radicular syndrome, ischias, nerve root pain, and nerve root entrapment. #### Summary points In about 90% of cases sciatica is caused by a herniated disc with nerve root compression, but lumbar stenoses and (less often) tumours are possible causes. The diagnosis of sciatica and its management varies considerably within and between countries—for example, the surgery rates for lumbar discectomy vary widely between countries.w1 A recent publication confirmed this large variation in disc surgery, even within countries.1 This may in part be caused by a paucity of evidence on the value of diagnostic and therapeutic interventions and a lack of clear clinical guidelines or reflect differences in healthcare and insurance systems. This review presents the current state of science for the diagnosis and treatment of sciatica. #### Sources and selection criteria We identified systematic reviews in the Cochrane Library evaluating the effectiveness of conservative and surgical interventions for sciatica. Medline searches up to December 2006 were carried out to find other relevant systematic reviews on the diagnosis …

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.

Back schools for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group

Study Design. A systematic review within the Cochrane Collaboration Back Review Group. Objectives. To assess the effectiveness of back schools for patients with nonspecific low back pain (LBP). Summary of Background Data. Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating patients with LBP. However, the content of back schools has changed and appears to vary widely today. Methods. We searched the MEDLINE and EMBASE databases and the Cochrane Central Register of Controlled Trials to November 2004 for relevant trials reported in English, Dutch, French, or German. We also screened references from relevant reviews and included trials. Randomized controlled trials that reported on any type of back school for nonspecific LBP were included. Four reviewers, blinded to authors, institution, and journal, independently extracted the data and assessed the quality of the trials. We set the high-quality level, a priori, at a trial meeting six or more of 11 internal validity criteria. Because data were clinically and statistically too heterogeneous to perform a meta-analysis, we used a qualitative review (best evidence synthesis) to summarize the results. The evidence was classified into four levels (strong, moderate, limited, or no evidence), taking into account the methodologic quality of the studies. We also evaluated the clinical relevance of the studies. Results. Nineteen randomized controlled trials (3,584 patients) were included in this updated review. Overall, the methodologic quality was low, with only six trials considered to be high-quality. It was not possible to perform relevant subgroup analyses for LBP with radiation versus LBP without radiation. The results indicate that there is moderate evidence suggesting that back schools have better short- and intermediate-term effects on pain and functional status than other treatments for patients with recurrent and chronic LBP. There is moderate evidence suggesting that back schools for chronic LBP in an occupational setting are more effective than other treatments and placebo or waiting list controls on pain, functional status, and return to work during short- and intermediate-term follow-up. In general, the clinical relevance of the studies was rated as insufficient. Conclusion. There is moderate evidence suggesting that back schools, in an occupational setting, reduce pain and improve function and return-to-work status, in the short- and intermediate-term, compared with exercises, manipulation, myofascial therapy, advice, placebo, or waiting list controls, for patients with chronic and recurrent LBP. However, future trials should improve methodologic quality and clinical relevance and evaluate the cost-effectiveness of back schools.

Effect sizes of non-surgical treatments of non-specific low-back pain.

Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.

An economic evaluation of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball

Objectives: To evaluate the cost effectiveness of a proprioceptive balance board training programme for the prevention of ankle sprains in volleyball. Methods: A total of 116 volleyball teams participated in this study which was carried out during the 2001–2002 volleyball season. Teams were randomly allotted to an intervention group (66 teams, 628 players) or a control group (52 teams, 494 players). Intervention teams followed a prescribed balance board training programme as part of their warm up. Control teams followed their normal training routine. An ankle sprain was recorded if it occurred as a result of volleyball and caused the subject to stop volleyball activity. The injured player completed a cost diary for the duration of the ankle sprain. Analyses were performed according to the intention to treat principle. Mean direct, indirect, and total costs were calculated and were compared between the two groups. Results: The total costs per player (including the intervention material) were significantly higher in the intervention group (€36.99 (93.87)) than in the control group (€18.94 (147.09)). The cost of preventing one ankle sprain was approximately €444.03. Sensitivity analysis showed that a proprioceptive balance board training programme aimed only at players with previous ankle sprains could be cost effective over a longer period of time. Conclusions: Positive effects of the balance board programme could only be achieved at certain costs. However, if broadly implemented, costs associated with the balance board programme would probably be lower.

Occupational health guidelines for the management of low back pain: an international comparison

Background: The enormous socioeconomic burden of low back pain emphasises the need for effective management of this problem, especially in an occupational context. To address this, occupational guidelines have been issued in various countries. Aims: To compare available international guidelines dealing with the management of low back pain in an occupational health care setting. Methods: The guidelines were compared regarding generally accepted quality criteria using the AGREE instrument, and also summarised regarding the guideline committee, the presentation, the target group, and assessment and management recommendations (that is, advice, return to work strategy, and treatment). Results and Conclusions: The results show that the quality criteria were variously met by the guidelines. Common flaws concerned the absence of proper external reviewing in the development process, lack of attention to organisational barriers and cost implications, and lack of information on the extent to which editors and developers were independent. There was general agreement on numerous issues fundamental to occupational health management of back pain. The assessment recommendations consisted of diagnostic triage, screening for “red flags” and neurological problems, and the identification of potential psychosocial and workplace barriers for recovery. The guidelines also agreed on advice that low back pain is a self limiting condition and, importantly, that remaining at work or an early (gradual) return to work, if necessary with modified duties, should be encouraged and supported.