Marienke van Middelkoop

Exercise therapy for chronic nonspecific low-back pain

Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. During the past 5 years, many additional trials have been published on chronic low back pain. This articles aims to give an overview on the effectiveness of exercise therapy in patients with low back pain. For this overview, existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria, and the search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. Studies were included if they fulfilled the following criteria: (1) randomised controlled trials,(2) adult (> or =18 years) population with chronic (> or =12 weeks) nonspecific low back pain and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias and outcomes at short-term, intermediate and long-term follow-up. The GRADE approach (GRADE, Grading of Recommendations Assessment, Development and Evaluation) was used to determine the quality of evidence. In total, 37 randomised controlled trials met the inclusion criteria and were included in this overview. Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.

Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review

Study Design. Systematic review of interventions. Objective. To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain. Summary of Background Data. SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention. Methods. Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. The primary outcomes were pain, functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence. Results. We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief (mean difference −4.16, 95% confidence interval −6.97 to −1.36) and functional status (standardized mean difference −0.22, 95% confidence interval −0.36 to −0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT. Conclusions. High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority.

Difference between parental perception and actual weight status of children: a systematic review

An increasing number of children worldwide are overweight, and the first step in treating obesity is to identify overweight. However, do parents recognise overweight in their child and which factors influence parental perception? The aim of the present review is to systematically study differences between parental perception and the actual weight status of children. Medline, EMbase, CINAHL and PsychINFO were searched. After screening 2497 abstracts and 106 full texts, two reviewers independently scored the methodological quality of 51 articles (covering 35 103 children), which fulfilled the inclusion criteria. The primary outcome parameters were sensitivity and specificity of parental perception for actual weight status of their child. The methodological quality of the studies ranged from poor to excellent. Pooled results showed that according to objective criteria 11 530 children were overweight; of these, 7191 (62.4%) were incorrectly perceived as having normal weight by their parents. The misperception of overweight children is higher in parents with children aged 2-6 years compared with parents of older children. Sensitivity (correct perception of overweight) of the studies ranged from 0.04 to 0.89, while specificity (correct perception of normal weight) ranged from 0.86 to 1.00. There were no significant differences in sensitivity or specificity for different cut-off points for overweight, or between newer and older studies. Therefore we can conclude that parents are likely to misperceive the weight status of their overweight child, especially in children aged 2-6 years. Because appropriate treatment starts with the correct perception of overweight, health care professionals should be aware of the frequent parental misperception of the overweight status of their children.

Carpal Tunnel Syndrome. Part I: Effectiveness of Nonsurgical Treatments–A Systematic Review

OBJECTIVE To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found. CONCLUSIONS The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.

Risk Factors for Patellofemoral Pain Syndrome: A Systematic Review

STUDY DESIGN Systematic review. OBJECTIVES To systematically outline the risk factors for patellofemoral pain syndrome (PFPS). BACKGROUND PFPS is the most commonly diagnosed condition in young individuals with knee complaints. High incidence among athletes suggests a possibility of prevention. The first step toward prevention is identification of possible risk factors. METHODS Prospective studies that included 20 or more patients with PFPS and examined at least 1 possible risk factor for PFPS were included. An assessment list was applied to evaluate the quality of the studies. A meta-analysis was conducted using a random-effects model. Significant differences were based on calculated mean differences, with matching 95% confidence intervals (CIs). For dichotomous data, odds ratios or relative risks were calculated. RESULTS Of the 3845 potentially relevant articles, 7 were included in this review. These studies examined a total of 135 variables, and pooling was possible for 13 potential risk factors. The pooled data showed that knee extension peak torques were significantly lower in the PFPS group than in controls. Mean differences in torque, with negative differences reflecting lower means in the PFPS group, were as follows: (a) standardized relative to body weight at 60°/s, -0.24 Nm (95% CI: -0.39, -0.09); (b) standardized relative to body weight at 240°/s, -0.11 Nm (95% CI: -0.17, -0.05); (c) standardized relative to body mass index at 60°/s, -0.84 Nm (95% CI: -1.23, -0.44); (d) standardized relative to body mass index at 240°/s, -0.32 Nm (95% CI: -0.52, -0.12); (e) nonstandardized in a concentric mode at 60°/s, -17.54 Nm (95% CI: -25.53, -9.54); (f) nonstandardized in a concentric mode at 240°/s, -7.72 Nm (95% CI: -12.67, -2.77). CONCLUSION Weaker knee extension strength, expressed by peak torque, appears to be a risk factor for PFPS, based on meta-analyses of pooled results from multiple studies. Because several other risk factors for PFPS were described only in single studies, these additional risk factors, as well as those with conflicting evidence, need to be confirmed in future studies. LEVEL OF EVIDENCE Prognosis, level 1a-.

Course and predicting factors of lower-extremity injuries after running a marathon.

Objective:Following the Second International Conference on Concussion in Sport in 2005, a summary agreement statement was published that introduced new terminology for sport-related concussions. This new classification system is binary (ie, “simple” versus “complex” concussions). Athletes who are slow to recover (ie, >10 days) are classified as having complex concussions. The purpose of this study was to determine if high school football players, retrospectively classified as having a simple or a complex concussion, could be differentiated in the first 48 after injury on the basis of symptom reporting or neuropsychological testing. Design:Case-control study. Setting:Pennsylvania high school football programs. Participants:The total sample consisted of 114 concussed high school football players who were identified through a 3 year prospective cohort study. Interventions:All completed a computerized neuropsychological screening evaluation within 72 hours of injury. They were followed clinically until they recovered and were cleared to return to play. They were classified retrospectively as having a simple (n = 55) or complex (n = 59) concussion based on their recovery times. Main Outcome Measurements:Neurocognitive test performance and symptom ratings. Results:Within 72 hours after injury, athletes with complex concussions performed more poorly on neuropsychological testing and reported more symptoms than those with simple concussions. Athletes with complex concussions who were slow to recover were 18 times more likely to have 3 unusually low neuropsychological test scores than those with simple concussions (95% CI = 2.3-144.9). Athletes with previous concussions did not recover more slowly. Conclusions:This study provides evidence that supports and refutes the clinical usefulness of the new simple-complex concussion classification system.

Factors associated with patellofemoral pain syndrome: a systematic review

This review systematically summarises factors associated with patellofemoral pain syndrome (PFPS). A systematic literature search was conducted. Studies including ≥20 patients with PFPS that examined ≥1 possible factor associated with PFPS were included. A meta-analysis was performed, clinical heterogeneous data were analysed descriptively. The 47 included studies examined 523 variables, eight were pooled. Pooled data showed a larger Q-angle, sulcus angle and patellar tilt angle (weighted mean differences (WMD) 2.08; 95% CI 0.64, 3.63 and 1.66; 95% CI 0.44, 2.77 and 4.34; 95% CI 1.16 to 7.52, respectively), less hip abduction strength, lower knee extension peak torque and less hip external rotation strength (WMD –3.30; 95% CI –5.60, –1.00 and –37.47; 95% CI –71.75, –3.20 and –1.43; 95% CI –2.71 to –0.16, respectively) in PFPS patients compared to controls. Foot arch height index and congruence angle were not associated with PFPS. Six out of eight pooled variables are associated with PFPS, other factors associated with PFPS were based on single studies. Further research is required.

A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain.

The purpose of this systematic review was to assess the effects of spinal manipulative therapy (SMT), acupuncture and herbal medicine for chronic non-specific LBP. A comprehensive search was conducted by an experienced librarian from the Cochrane Back Review Group (CBRG) in multiple databases up to December 22, 2008. Randomised controlled trials (RCTs) of adults with chronic non-specific LBP, which evaluated at least one clinically relevant, patient-centred outcome measure were included. Two authors working independently from one another assessed the risk of bias using the criteria recommended by the CBRG and extracted the data. The data were pooled when clinically homogeneous and statistically possible or were otherwise qualitatively described. GRADE was used to determine the quality of the evidence. In total, 35 RCTs (8 SMT, 20 acupuncture, 7 herbal medicine), which examined 8,298 patients, fulfilled the inclusion criteria. Approximately half of these (2 SMT, 8 acupuncture, 7 herbal medicine) were thought to have a low risk of bias. In general, the pooled effects for the studied interventions demonstrated short-term relief or improvement only. The lack of studies with a low-risk of bias, especially in regard to SMT precludes any strong conclusions; however, the principal findings, which are based upon low- to very-low-quality evidence, suggest that SMT does not provide a more clinically beneficial effect compared with sham, passive modalities or any other intervention for treatment of chronic low-back pain. There is evidence, however, that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention. Although there are some good results for individual herbal medicines in short-term individual trials, the lack of homogeneity across studies did not allow for a pooled estimate of the effect. In general, these results are in agreement with other recent systematic reviews on SMT, but in contrast with others. These results are also in agreement with recent reviews on acupuncture and herbal medicine. Randomized trials with a low risk of bias and adequate sample sizes are direly needed.

Carpal Tunnel Syndrome. Part II: Effectiveness of Surgical Treatments—A Systematic Review

OBJECTIVE To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions to treat carpal tunnel syndrome (CTS). DATA SOURCES The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 25 RCTs were included. Moderate evidence was found in favor of surgical treatment compared with splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term, and for the effectiveness of corticosteroid irrigation of the median nerve before skin closure as additive to carpal tunnel release in the short term. Limited evidence was found in favor of a double-incision technique compared with the standard incision technique. Also, limited evidence was found in favor of a mini-open technique assisted by a Knifelight instrument compared with a standard open release at 19 months of follow-up. However, in the short term and at 30 months of follow-up, no significant differences were found between the mini-open technique assisted by a Knifelight instrument compared with a standard open release. Many studies compared different surgical interventions, but no evidence was found in favor of any one of them. No RCTs explored the optimal timing strategy for surgery. No evidence was found for the efficacy of various presurgical or postsurgical treatment programs, including splinting. CONCLUSIONS Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the midterm and long term to treat CTS. However, there is no unequivocal evidence that suggests one surgical treatment is more effective than the other. More research is needed to study conservative to surgical treatment in which also should be taken into account the optimal timing of surgery. Future research should also concentrate on optimal presurgical and postsurgical treatment programs.

Prognostic factors for patellofemoral pain: a multicentre observational analysis

Objectives Describe proportions of individuals with patellofemoral pain (PFP) with an unfavourable recovery over 12 months; identify clinical predictors of poor recovery at 3 and 12 months; and determine baseline values of predictors that identify those with poor 12-month prognosis. Methods An observational analysis utilised data from 310 individuals with PFP enrolled in two randomised clinical trials. Thirteen baseline variables (participant, PFP, study characteristics) were investigated for their prognostic ability. Pain, function and global recovery were measured at 3 and 12 months. Multivariate backward stepwise regression analyses (treatment-adjusted, p<0.10) were performed for each follow-up measure. Receiver operator characteristic curves identified cut-points associated with unfavourable recovery at 12 months. Results 55% and 40% of participants had an unfavourable recovery at 3 and 12 months, respectively. Longer baseline pain duration was significantly associated with poor 3-month and 12-month recovery on measures of pain severity (β 11.36 to 24.94), Anterior Knee Pain (AKP) Scale (−4.44 to −11.33) and global recovery (OR: 2.32 to 6.11). Greater baseline pain severity and lower AKP Scale score were significantly associated with poor recovery on multiple measures (p<0.05). Baseline duration >2 months and AKP Scale score <70/100 were associated with unfavourable 12-month recovery. Conclusions A substantial number of individuals with PFP have an unfavourable recovery over 12 months, irrespective of intervention. Knee pain duration >2 months is the most consistent prognostic indicator, followed by AKP Scale score <70. Sports medicine practitioners should utilise interventions with known efficacy in reducing PFP, and promote early intervention to maximise prognosis. Trial registration Australian study: Australian Clinical Trials Registry (ACTRN012605000463673), ClinicalTrials.gov (NCT00118521); Dutch study: International Standard Randomised Controlled Trial Number Register (ISRCTN83938749)