Sidney M. Rubinstein

A systematic review of the risk factors for cervical artery dissection

Background and Purpose— Cervical artery dissection (CAD) is a recognized cause of ischemic stroke among young and middle-aged individuals. The pathogenesis of dissections is unknown, although numerous constitutional and environmental risk factors have been postulated. To better understand the quality and nature of the research on the pathogenesis of CAD, we performed a systematic review of its risk factors. Methods— PubMed [MEDLINE (1966 to February 22, 2005)] and Embase (1980 to February 22, 2005) were searched to identify studies fulfilling the inclusion criteria. Two reviewers independently assessed methodological quality of the primary studies. Relevant data were extracted, including the risk factor(s) investigated, characteristics of the study population, and strength of the association(s). Results— Thirty-one case-control studies were included for analysis. Selection bias, lack of control for confounding, and inadequate method of data analysis were the most common identified methodological shortcomings. Strong associations were reported from individual studies for the following risk factors: aortic root diameter >34 mm (odds ratio [OR=14.2; 95% confidence interval [CI], 3.2 to 63.6), migraine (ORadj, 3.6; 95% CI, 1.5 to 8.6), relative diameter change (>11.8%) during the cardiac cycle of the common carotid artery (ORadj, 10.0; 95% CI, 1.8 to 54.2), and trivial trauma (in the form of manipulative therapy of the neck) (ORadj, 3.8; 95% CI, 1.3 to 11). A weak association was found for homocysteine (2 studies: ORcrude, unknown; 95% CI, 1.05 to 1.52; ORcrude, 1.3; 95% CI, 1.0 to 1.7), and recent infection (ORadj, 1.60; 95% CI, 0.67 to 3.80). Two studies had conflicting findings for low levels of α1-antitrypsin, with the methodologically stronger study suggesting no association with CAD. Conclusions— CAD is a multi-factorial disease. Many of the reviewed studies contained 2 or more major sources of bias commonly found in case-control studies. Only one study (of homocysteine) used healthy controls, a robust sample size, and had a low risk of biased results. The relationship between atherosclerosis and CAD has been insufficiently examined.

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.

A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy

Clinical provocative tests of the neck, which position the neck and arm inorder to aggravate or relieve arm symptoms, are commonly used in clinical practice in patients with a suspected cervical radiculopathy. Their diagnostic accuracy, however, has never been examined in a systematic review. A comprehensive search was conducted in order to identify all possible studies fulfilling the inclusion criteria. A study was included if: (1) any provocative test of the neck for diagnosing cervical radiculopathy was identified; (2) any reference standard was used; (3) sensitivity and specificity were reported or could be (re-)calculated; and, (4) the publication was a full report. Two reviewers independently selected studies, and assessed methodological quality. Only six studies met the inclusion criteria, which evaluated five provocative tests. In general, Spurling’s test demonstrated low to moderate sensitivity and high specificity, as did traction/neck distraction, and Valsalva’s maneuver. The upper limb tension test (ULTT) demonstrated high sensitivity and low specificity, while the shoulder abduction test demonstrated low to moderate sensitivity and moderate to high specificity. Common methodological flaws included lack of an optimal reference standard, disease progression bias, spectrum bias, and review bias. Limitations include few primary studies, substantial heterogeneity, and numerous methodological flaws among the studies; therefore, a meta-analysis was not conducted. This review suggests that, when consistent with the history and other physical findings, a positive Spurling’s, traction/neck distraction, and Valsalva’s might be indicative of a cervical radiculopathy, while a negative ULTT might be used to rule it out. However, the lack of evidence precludes any firm conclusions regarding their diagnostic value, especially when used in primary care. More high quality studies are necessary in order to resolve this issue.

A best-evidence review of diagnostic procedures for neck and low-back pain

This chapter aims to present an overview of the best available evidence on diagnostic procedures for neck and low-back pain. Relatively little is known about the accuracy of such procedures. Although most spinal conditions are benign and self-limiting, the real challenge to the clinician is to distinguish serious spinal pathology or nerve-root pain from non-specific neck and low-back pain. The use of valid procedures can assist the clinician in this aim. A search was conducted in PubMed to identify relevant systematic reviews and primary studies on diagnostic procedures for the neck and low back. A systematic review was included if at least two independent reviewers were used; a systematic procedure was followed for identifying the literature; and a methodological assessment was conducted. In the absence of systematic reviews, primary studies are reported. Systematic reviews were identified which evaluated evidence for diagnostic procedures in the following categories: history, physical examination, and special studies, including diagnostic imaging, diagnostic blocks, and facet and sacroiliac joint injections. In general, there is much more evidence on diagnostic procedures for the low back than there is for the neck. With regard to the history, a number of factors can be identified which can assist the clinician in identifying sciatica due to disc herniation or serious pathology. With regard to the physical examination, the straight-leg raise is the only sign consistently reported to be sensitive for sciatica due to disc herniation, but is limited by its low specificity. The diagnostic accuracy of other neurological signs and tests is unclear. Orthopaedic tests of the neck, such as Spurlings or the upper-limb tension test, are useful to rule a radiculopathy in or rule out, respectively. In patients 50 years of age or older, plain spinal radiography together with standard laboratory tests are highly accurate in identifying underlying systemic disease; however, plain spinal radiography is not a valuable tool for non-specific neck or low-back pain. There is strong evidence for the diagnostic accuracy of facet joint blocks in evaluating spinal pain, and moderate evidence for transforaminal epidural injections, as well as sacroiliac joint injections for diagnostic purposes. In conclusion, during the history, the clinician can accurately identify sciatica due to disc herniation, as well as serious pathology. There is sufficient evidence regarding the accuracy of specific tests for identifying sciatica or radiculopathy (such as the straight-leg raise) or certain orthopaedic tests of the neck. Plain spinal radiography in combination with standard laboratory tests is useful for identifying pathology, but is not advisable for non-specific neck or low-back pain.

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.

Cauda equina syndrome in patients undergoing manipulation of the lumbar spine.

Cauda equina syndrome has been implicated as a potential complication of spinal manipulation. A review of the literature from 1911 to 1989 revealed ten reported cases of cauda equine syndrome in patients undergoing manipulation without anesthesia. This article presents three new cases where a temporal association was found between the onset of cauda equine symptoms and lumbar manipulation. The type of manipulation administered and the relationship between the treatment and symptoms is reviewed. In each of these cases both the chiropractic practitioner and the emergency room physician failed to comprehend the nature of the problem and take appropriate action. As a consequence, the patients went untreated for several days. This may have led to residual symptomatology. It is concluded that patients who present with bowel or bladder disturbances, leg weakness, or rectal and genital sensory changes after manipulation, be recognized as experiencing as experiencing a cauda equina syndrome.

Spinal manipulative therapy for acute low back pain: an update of the cochrane review

Study Design. Systematic review of interventions. Objective. To assess the effects of spinal manipulative therapy (SMT) for acute low back pain. Summary of Background Data. SMT is one of many therapies for the treatment of low back pain, which is a worldwide, extensively practiced intervention. Methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to March 13, 2011. RCTs that examined manipulation or mobilization in adults with acute low back pain (<6-week duration) were included. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life. Two authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE (grading of recommendations assessment, development, and evaluation) was used to assess the quality of the evidence. The effects were examined for SMT versus (1) inert interventions, (2) sham SMT, (3) other interventions, and (4) SMT as adjunct therapy. Results. We identified 20 RCTs (total participants = 2674), 12 (60%) of which were not included in the previous review. In total, 6 trials (30% of all included studies) had a low risk of bias. In general, for the outcomes of pain and functional status, there is low- to very low-quality evidence suggesting no difference in effect for SMT when compared with inert interventions, sham SMT or as adjunct therapy. There was varying quality of evidence (from very low to moderate) suggesting no difference in effect for SMT when compared with other interventions. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT. Conclusion. SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation.

Injection therapy and denervation procedures for chronic low-back pain: a systematic review

Injection therapy and denervation procedures are commonly used in the management of chronic low-back pain (LBP) despite uncertainty regarding their effectiveness and safety. To provide an evaluation of the current evidence associated with the use of these procedures, a systematic review was performed. Existing systematic reviews were screened, and the Cochrane Back Review Group trial register was searched for randomized controlled trials (RCTs) fulfilling the inclusion criteria. Studies were included if they recruited adults with chronic LBP, evaluated the use of injection therapy or denervation procedures and measured at least one clinically relevant outcome (such as pain or functional status). Two review authors independently assessed studies for eligibility and risk of bias (RoB). A meta-analysis was performed with clinically homogeneous studies, and the GRADE approach was used to determine the quality of evidence. In total, 27 RCTs were included, 14 on injection therapy and 13 on denervation procedures. 18 (66%) of the studies were determined to have a low RoB. Because of clinical heterogeneity, only two comparisons could be pooled. Overall, there is only low to very low quality evidence to support the use of injection therapy and denervation procedures over placebo or other treatments for patients with chronic LBP. However, it cannot be ruled out that in carefully selected patients, some injection therapy or denervation procedures may be of benefit.

Adverse events following chiropractic care for subjects with neck or low-back pain: Do the benefits outweigh the risks?

This synopsis provides an overview of the benign and serious risks associated with chiropractic care for subjects with neck or low-back pain. Most adverse events associated with spinal manipulation are benign and self-limiting. The incidence of severe complications following chiropractic care and manipulation is extremely low. The best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.