Stéphane Poitras

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Aerobic Fitness Exercises in the Management of Fibromyalgia: Part 1

Background and Purpose: The objective of this study was to create guidelines for the use of aerobic fitness exercises in the management of adult patients (>18 years of age) with fibromyalgia, as defined by the 1990 American College of Rheumatology criteria. Methods: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D−). From the rigorous literature search, 13 randomized control trials and 3 controlled clinical trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. Results: There were 24 positive recommendations: 10 grade A, 1 grade B, and 13 grade C+. Of these 24 positive recommendations, only 5 were of clinical benefit. Discussion and Conclusion: The Ottawa Panel recommends aerobic fitness exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

Implementation of a participatory ergonomics program in the rehabilitation of workers suffering from subacute back pain

This paper describes a participatory ergonomics program aimed at early return to regular work of workers suffering from subacute occupational back pain and assesses the perceptions of the participants on the implementation of ergonomic solutions in the workplace. The participatory ergonomics program was used in the rehabilitation of workers suffering from subacute back pain for more than 6 weeks, a program that was associated with an increased rate of return to work. The perceptions of the participatory ergonomics participants were assessed 6 months after completion of the ergonomic intervention through a questionnaire sent to employer representatives, union representatives and injured workers of participating workplaces. About half of the ergonomic solutions were implemented according to the perception of the participants, with a substantial agreement between respondents.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Strengthening Exercises in the Management of Fibromyalgia: Part 2

Background and Purpose: The objective of this study was to create guidelines for the use of strengthening exercises in the management of adult patients (>18 years of age) with fibromyalgia (FM), as defined by the 1990 American College of Rheumatology criteria. Methods: Following Cochrane Collaboration methods, the Ottawa Methods Group found and synthesized evidence from comparative controlled trials and formed the Ottawa Panel, with nominated experts from key stakeholder organizations. The Ottawa Panel then developed criteria for grading the recommendations based on experimental design (I for randomized controlled trials, II for nonrandomized studies) and strength of evidence (A, B, C+, C, D+, D, or D−). From the rigorous literature search, 5 randomized controlled trials were selected. Statistical analysis was based on Cochrane Collaboration methods. Continuous data were calculated with weighted mean differences between the intervention and control groups, and dichotomous data were analyzed with relative risks. Clinical improvement was calculated using absolute benefit and relative difference in change from baseline. Clinical significance was attained when an improvement of 15% relative to a control was found. Results: There were 5 positive recommendations: 2 grade A and 3 grade C+. All 5 were of clinical benefit. Discussion and Conclusion: The Ottawa Panel recommends strengthening exercises for the management of fibromyalgia as a result of the emerging evidence (grades A, B, and C+, although most trials were rated low quality) shown in the literature.

Evidence-informed management of chronic low back pain with transcutaneous electrical nerve stimulation, interferential current, electrical muscle stimulation, ultrasound, and thermotherapy

The management of chronic low back pain (CLBP) has proven to be very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Ottawa Panel evidence-based clinical practice guidelines for the management of osteoarthritis in adults who are obese or overweight.

Background and Purpose The objective of this review was to construct an updated evidence-based clinical practice guideline on the use of physical activity and diet for the management of osteoarthritis (OA) in adults (>18 years of age) who are obese or overweight (body mass index ≥25 kg/m2). Data Sources Articles were extracted from the following databases: MEDLINE, EMBASE (Current Contents), SPORTDiscus, SUM, Scopus, CINAHL, AMED, BIOMED, PubMed, ERIC, the Cochrane Controlled Trials, and PEDro. Study Selection The Ottawa Panel and research assistance team strictly applied the inclusion and exclusion criteria from previous Ottawa Panel publications. Data Extraction An a priori literature search was conducted for articles related to obesity and OA of the lower extremities that were published from January 1, 1966, to November 30, 2010. Inclusion criteria and the methods to grade the recommendations were created by the Ottawa Panel. Data Synthesis Recommendations were graded based on the strength of evidence (A, B, C, C+, D, D+, or D−) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies). In agreement with previous Ottawa Panel methods, Cochrane Collaboration methods were utilized for statistical analysis. Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group. There were a total of 79 recommendations from 9 articles. From these recommendations, there were 36 positive recommendations: 21 grade A and 15 grade C+. There were no grade B recommendations, and all recommendations were of clinical benefit. Limitations Further research is needed, as more than half of the trials were of low methodological quality. Conclusions This review suggests that physical activity and diet programs are beneficial, specifically for pain relief (9 grade A recommendations) and improved functional status (6 grade A and 7 grade C+ recommendations), for adults with OA who are obese or overweight. The Ottawa Panel was able to demonstrate that when comparing physical activity alone, diet alone, physical activity combined with diet, and control groups, the intervention including physical activity and diet produced the most beneficial results.

Discriminative and predictive validity assessment of the Quebec Task Force Classification

Study Design. A prospective cohort study of workers with low back pain who had been absent from work for more than 4 weeks was conducted. Objective. To assess the discriminative and predictive validity of the Quebec Task Force Classification for workers during the subacute phase of disability from back pain. Summary of Background Data. The Quebec Task Force Classification was designed for clinical decision making, prognosis establishment, quality of care evaluation, and scientific research in low back pain. Methods. For this study, 104 workers absent from work because of back pain were classified according to the first four categories of the Quebec Task Force Classification 4 weeks after their first day of work absence. They then were randomized into four treatment groups: standard care (control), clinical–rehabilitation intervention, occupational intervention, and the Sherbrooke model (a combination of the clinical–rehabilitation and occupational interventions). Functional status, pain level, and work status were assessed at baseline and after 1 year. Duration of full compensation and back-related costs were calculated over a mean follow-up period of 6.5 years. The discriminative validity of the Quebec Task Force Classification was evaluated using Kendall tau correlation coefficients. Predictive validity was evaluated using logistic regression analyses. Age, gender, comorbidities, body mass index, and treatment group were considered as potential confounders. Results. Significant but low correlation coefficients were found between Quebec Task Force Classification categories and functional status scores at baseline. Subjects classified as having distal radiating pain (categories 3 and 4) at baseline were more likely to have a lower functional status, higher pain level, and no return to regular work at the 1-year follow-up evaluation. They also were more likely to accumulate more days of full compensation and to cost more after a mean follow-up period of 6.5 years. Conclusion. The Quebec Task Force Classification demonstrated good predictive ability by discriminating between subjects with and those without distal radiating pain.

Physiotherapists and Use of Low Back Pain Guidelines: A Qualitative Study of the Barriers and Facilitators

Introduction A new set of clinical practice guidelines (CPGs) for the management of low back pain (LBP) and prevention of persistent disability entitled “Clinic on Low back pain in Interdisciplinary Practice” (CLIP) was developed in the province of Quebec, Canada. The literature shows that simply disseminating CPGs does not necessarily lead to their adoption by clinicians. To improve adherence to CPGs among healthcare professionals, the literature suggests that there is a need to identify and address the factors impeding or facilitating their use. The aim of this study was therefore to identify the barriers to and facilitators of CLIP CPG use, as perceived by physiotherapists (PTs). Methods A descriptive study using a qualitative method was conducted with a sample of 16 PTs from a variety of professional backgrounds. Each participant used the CPGs over a 6-week period with two patients suffering from LBP, and then participated in a semi-structured interview in which he or she was asked to identify the barriers and facilitators experienced. Results The participating PTs identified many barriers and facilitators pertaining to the guidelines themselves, the users and the environment. Four key nodes emerged from these barriers and facilitators during data analysis. It appears that the clinicians’ understanding of the CPGs, the level of compatibility between their practices and the CLIP CPG recommendations, the level of CPG relevance as perceived by the clinicians, and their level of agreement with the CPGs, all affected their use of the guidelines. Conclusions In order to increase CLIP CPG use, the implementation strategy to be developed should take into account the barriers and facilitators that were identified in this study.

A critical appraisal of guidelines for the management of knee osteoarthritis using Appraisal of Guidelines Research and Evaluation criteria

Clinical practice guidelines have been elaborated to summarize evidence related to the management of knee osteoarthritis and to facilitate uptake of evidence-based knowledge by clinicians. The objectives of the present review were summarizing the recommendations of existing guidelines on knee osteoarthritis, and assessing the quality of the guidelines using a standardized and validated instrument – the Appraisal of Guidelines Research and Evaluation (AGREE) tool. Internet medical literature databases from 2001 to 2006 were searched for guidelines, with six guidelines being identified. Thirteen clinician researchers participated in the review. Each reviewer was trained in the AGREE instrument. The guidelines were distributed to four groups of three or four reviewers, each group reviewing one guideline with the exception of one group that reviewed two guidelines. One independent evaluator reviewed all guidelines. All guidelines effectively addressed only a minority of AGREE domains. Clarity/presentation was effectively addressed in three out of six guidelines, scope/purpose and rigour of development in two guidelines, editorial independence in one guideline, and stakeholder involvement and applicability in none. The clinical management recommendation tended to be similar among guidelines, although interventions addressed varied. Acetaminophen was recommended for initial pain treatment, combined with exercise and education. Nonsteroidal anti-inflammatory drugs were recommended if acetaminophen failed to control pain, but cautiously because of gastrointestinal risks. Surgery was recommended in the presence of persistent pain and disability. Education and activity management interventions were superficially addressed in most guidelines. Guideline creators should use the AGREE criteria when developing guidelines. Innovative and effective methods of knowledge translation to health professionals are needed.

A systematic critical appraisal for non-pharmacological management of osteoarthritis using the appraisal of guidelines research and evaluation II instrument.

Clinical practice CPGs (CPGs) have been developed to summarize evidence related to the management of osteoarthritis (OA). CPGs facilitate uptake of evidence-based knowledge by consumers, health professionals, health administrators and policy makers. The objectives of the present review were: 1) to assess the quality of the CPGs on non-pharmacological management of OA; using a standardized and validated instrument - the Appraisal of Guidelines Research and Evaluation (AGREE II) tool - by three pairs of trained appraisers; and 2) to summarize the recommendations based on only high-quality existing CPGs. Scientific literature databases from 2001 to 2013 were systematically searched for the state of evidence, with 17 CPGs for OA being identified. Most CPGs effectively addressed only a minority of AGREE II domains. Scope and purpose was effectively addressed in 10 CPGs on the management of OA, stakeholder involvement in 12 CPGs, rigour of development in 10 CPGs, clarity/presentation in 17 CPGs, editorial independence in 2 CPGs, and applicability in none of the OA CPGs. The overall quality of the included CPGs, according to the 7-point AGREE II scoring system, is 4.8±0.41 for OA. Therapeutic exercises, patient education, transcutaneous electrical nerve stimulation, acupuncture, orthoses and insoles, heat and cryotherapy, patellar tapping, and weight control are commonly recommended for the non-pharmacological management of OA by the high-quality CPGs. The general clinical management recommendations tended to be similar among high-quality CPGs, although interventions addressed varied. Non-pharmacological management interventions were superficially addressed in more than half of the selected CPGs. For CPGs to be standardized uniform creators should use the AGREE II criteria when developing CPGs. Innovative and effective methods of CPG implementation to users are needed to ultimately enhance the quality of life of arthritic individuals.

Ottawa panel evidence-based clinical practice guidelines on therapeutic massage for neck pain

OBJECTIVE To update evidence-based clinical practice guideline (EBCPG) on the use of massage compared to a control or other treatments for adults (>18 years) suffering from sub-acute and chronic neck pain. METHODS A literature search was performed from January 1, 1948 to December 31, 2010 for relevant articles. The Ottawa Panel created inclusion criteria focusing on high methodological quality and grading methods. Recommendations were assigned a grade (A, B, C, C+, D, D+, D-) based on strength of evidence. RESULTS A total of 45 recommendations from ten articles were developed including 8 positive recommendations (6 grade A and 2 grade C+) and 23 neutral recommendations (12 grade C and 11 grade D). DISCUSSION Therapeutic massage can decrease pain, tenderness, and improve range of motion for sub-acute and chronic neck pain. CONCLUSION The Ottawa Panel was able to demonstrate that the massage interventions are effective for relieving immediate post-treatment neck pain symptoms, but data is insufficient for long-term effects.