R.A. de Bie

Effectiveness of exercise therapy: A best-evidence summary of systematic reviews

The purpose of this project was to summarise the available evidence on the effectiveness of exercise therapy for patients with disorders of the musculoskeletal, nervous, respiratory, and cardiovascular systems. Systematic reviews were identified by means of a comprehensive search strategy in 11 bibliographic databases (08/2002), in combination with reference tracking. Reviews that included (i) at least one randomised controlled trial investigating the effectiveness of exercise therapy, (ii) clinically relevant outcome measures, and (iii) full text written in English, German or Dutch, were selected by two reviewers. Thirteen independent and blinded reviewers participated in the selection, quality assessment and data-extraction of the systematic reviews. Conclusions about the effectiveness of exercise therapy were based on the results presented in reasonable or good quality systematic reviews (quality score > or = 60 out of 100 points). A total of 104 systematic reviews were selected, 45 of which were of reasonable or good quality. Exercise therapy is effective for patients with knee osteoarthritis, sub-acute (6 to 12 weeks) and chronic (> or = 12 weeks) low back pain, cystic fibrosis, chronic obstructive pulmonary disease, and intermittent claudication. Furthermore, there are indications that exercise therapy is effective for patients with ankylosing spondylitis, hip osteoarthritis, Parkinsons disease, and for patients who have suffered a stroke. There is insufficient evidence to support or refute the effectiveness of exercise therapy for patients with neck pain, shoulder pain, repetitive strain injury, rheumatoid arthritis, asthma, and bronchiectasis. Exercise therapy is not effective for patients with acute low back pain. It is concluded that exercise therapy is effective for a wide range of chronic disorders.

EXERCISE REDUCES SICK LEAVE IN PATIENTS WITH NON-ACUTE NON-SPECIFIC LOW BACK PAIN: A META-ANALYSIS

OBJECTIVESnTo investigate whether exercise alone or as a part of a multidisciplinary treatment reduces sick leave in patients with non-specific non-acute low back pain.nnnMETHODSnA meta-analysis of randomized controlled trials was performed. A qualitative analysis of the sick leave results was performed applying pre-defined levels of evidence. In studies comparing exercise with usual care, pooled effect sizes were computed.nnnRESULTSnFourteen trials were identified allowing 22 comparisons between treatments. The qualitative and the quantitative analysis showed strong evidence that exercise reduces sick days during the first follow-up year, the effect size (95% confidence interval) was -0.24 ( -0.36, -0.11). In a subgroup of studies on the treatment of severely disabled patients (> 90 sick days under usual care) the effect size was -0.30 (-0.42, -0.17). The effect size of the number of patients receiving a disability allowance was small and not significant.nnnCONCLUSIONnThe reviewed trials provide strong evidence that exercise significantly reduces sick days during the first follow-up year.

Impact of quality items on study outcome. Treatments in acute lateral ankle sprains.

OBJECTIVEnThis study investigates the influence of different aspects of methodologic quality on the conclusions of a systematic review concerning treatments of acute lateral ankle sprain.nnnMETHODnA data set of a systematic review of 44 trials was used, of which 22 trials could be included in this study. Quality assessment of the individual studies was performed using the Delphi list. We calculated effect sizes of the main outcome measure in each study in order to evaluate the relationship between overall quality scores and outcome. Next, we investigated the impact of design attributes on pooled effect sizes by subgroup analysis.nnnRESULTSnThe quality of most studies (82%) was low; only 4 of 22 trials were of high quality. Studies with proper randomization and blinding procedure produce a slightly higher (not statistically significant) effect estimate compared to the other studies.nnnCONCLUSIONnPrevious research has suggested that methodologically poorly designed studies tend to over-estimate the effect estimate. Our study does not confirm these conclusions.

Paratonia: a Delphi procedure for consensus definition.

Background and Purpose: Paratonia is a motor problem that develops during the course of dementia. Definitions of paratonia used in the literature differ considerably, which has clinical implications and may lead to an undesirable heterogeneity in study populations. For this reason, we initiated a Delphi procedure with known experts in the field to establish an operational consensus definition of paratonia. Methods: The Delphi procedure involved an anonymous and multistage approach presented as a questionnaire, with each stage building on the results of the previous one in order to reach consensus on the definition of paratonia. Results: Eight of 17 experts agreed to participate in the study. After 4 rounds, the participants reached consensus on the following definition: paratonia is a form of hypertonia with an involuntary variable resistance during passive movement. The nature of paratonia may change with progression of dementia (eg, from active assistance (aka Mitgehen) to active resistance). The degree of resistance depends on the speed of movement (eg, slow→ low resistance, fast → high resistance). The degree of paratonia is proportional to the amount of force applied and increases with progression of dementia. The resistance to passive movement is in any direction and there is no clasp‐knife phenomenon. Conclusion: The Delphi procedure resulted in a comprehensive, operational definition of paratonia. Future research should focus on the reliability and validity of this definition.