Stephen May

Reliability of procedures used in the physical examination of non-specific low back pain: A systematic review

The purpose of this systematic review was to determine the quality of the research and to assess the reliability of different types of physical examination procedures used in the assessment of patients with non-specific low back pain. A search of electronic databases (MEDLINE, PEDro, AMED, EMBASE, Cochrane, and CINAHL) up to August 2005 identified 48 relevant studies which were analysed for quality and reliability. Pre-established criteria were used to judge the quality of the studies and satisfactory reliability, and conclusions emphasised high quality studies (> or = 60% methods score). The mean quality score of the studies was 52% (range 0 to 88%), indicating weak to moderate methodology. Based on the upper threshold used (kappa/ICC > 0.85) most procedures demonstrated either conflicting evidence or moderate to strong evidence of low reliability. When the lower threshold was used (kappa/ICC > 0.70) evidence about pain response to repeated movements changed from contradictory to moderate evidence for high reliability. Most procedures commonly used by clinicians in the examination of patients with back pain demonstrate low reliability.

Risk factors for the onset of non-specific neck pain: a systematic review

Objective Neck pain is a common musculoskeletal disorder, but little is known about which individuals develop neck pain. This systematic review investigated factors that constitute a risk for the onset of non-specific neck pain. Design and setting A range of electronic databases and reference sections of relevant articles were searched to identify appropriate articles. Studies investigating risk factors for the onset of non-specific neck pain in asymptomatic populations were included. All studies were prospective with at least 1 year follow-up. Main results 14 independent cohort studies met the inclusion criteria for the review. Thirteen studies were assessed as high quality. Female gender, older age, high job demands, low social/work support, being an ex-smoker, a history of low back disorders and a history of neck disorders were linked to the development of non-specific neck pain. Conclusions Various clinical and sociodemographic risk factors were identified that have implications for occupational health and health policy. However, there was a lack of good-quality research investigating the predictive nature of many other variables.

Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review

BACKGROUND Shoulder pain is a common clinical problem, and numerous tests are used to diagnose structural pathology. OBJECTIVES To systematically review the reliability of physical examination procedures used in the clinical examination of patients with shoulder pain. DATA SOURCES MEDLINE, PEDro, AMED, PsychInfo, Cochrane Library (2009) and CINAHL were searched from the earliest record on the database to June 2009. STUDY ELIGIBILITY CRITERIA Reliability studies that included any patients with shoulder pain were analysed for their quality and reliability results. STUDY APPRAISAL AND SYNTHESIS METHODS Pre-established criteria were used to judge the quality of the studies (high quality >60% methods score) and satisfactory levels of reliability (kappa or intraclass correlation coefficient > or =0.85, sensitivity analysis 0.70). A qualitative synthesis was performed based on levels of evidence. RESULTS Thirty-six studies were included with a mean methods score of 57%. Seventeen studies were deemed to be of high quality; high-quality studies were less likely to meet the pre-agreed level of reliability. The majority of studies indicated poor reliability for all procedures investigated. LIMITATIONS Overall, the evidence regarding reliability was contradictory. CONCLUSIONS AND IMPLICATIONS There is no consistent evidence that any examination procedure used in shoulder assessments has acceptable levels of reliability. Alternate methods of classification which are reliable should be used to classify patients with shoulder problems.

Exercise for rotator cuff tendinopathy: a systematic review

BACKGROUND Shoulder pain due to rotator cuff tendinopathy is a common problem. Exercise is one intervention used to address this problem but conclusions from previous reviews have been mixed. OBJECTIVE To systematically review the effectiveness of exercise, incorporating loaded exercise (against gravity or resistance), for rotator cuff tendinopathy. DATA SOURCES An electronic search of AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to November 2010 and supplemented by hand searching related articles and contact with topic experts. STUDY ELIGIBILITY CRITERIA Randomised controlled trials evaluating the effectiveness of exercise, incorporating loaded exercise, in participants with rotator cuff tendinopathy. STUDY APPRAISAL AND SYNTHESIS METHODS Included studies were appraised for risk of bias using the tool developed by the Cochrane Back review Group. Due to heterogeneity of studies, a narrative synthesis was undertaken based upon levels of evidence. RESULTS Five articles detailing four studies were included, all of which were regarded as presenting a low risk of bias. Overall, the literature was supportive of the use of exercise in terms of pain and functional disability. LIMITATIONS The results should be regarded with some degree of caution due to limitations associated with the studies including lack of blinding, no intervention control groups and limitations of the outcome measures used. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The available literature is supportive of the use of exercise but due to the paucity of research and associated limitations further study is indicated.

Self-management of chronic low back pain and osteoarthritis.

Chronic low back pain and osteoarthritis are two musculoskeletal problems that are highly prevalent in the general population, are frequently episodic and persistent, and are associated with high costs to society, both direct and indirect. This epidemiological picture provides the background that justifies the use of self-management strategies in managing these problems. For this Review, relevant systematic reviews were included that related to effectiveness; other study designs were included that addressed other aspects of the topic. The accepted definition of self-management includes liaison between health professionals and individuals with these problems, as well as independent health-promotion activities. Independent self-management strategies, such as exercise and self-medication, are practiced by individuals in the general population. Consistent evidence shows that self-management programs for osteoarthritis are effective in addressing pain and function, but effect sizes are small and might be clinically negligible. Educational programs for patients with back pain are effective in an occupational setting and if combined with an exercise program. Exercise is an effective strategy in the management of both chronic low back pain and osteoarthritis, although it is unclear what the optimum exercise is. Exercise, supported by advice and education, should be at the core of self-management strategies for chronic low back pain and osteoarthritis.

Centralization and directional preference: A systematic review

Centralization is a symptom response to repeated movements that can be used to classify patients into sub-groups, determine appropriate management strategies, and prognosis. The aim of this study was to systematically review the literature relating to centralization and directional preference, and specifically report on prevalence, prognostic validity, reliability, loading strategies, and diagnostic implications. Search was conducted to June 2011; multiple study designs were considered. 62 studies were included in the review; 54 related to centralization and 8 to directional preference. The prevalence of centralization was 44.4% (range 11%-89%) in 4745 patients with back and neck pain in 29 studies; it was more prevalent in acute (74%) than sub-acute or chronic (42%) symptoms. The prevalence of directional preference was 70% (range 60%-78%) in 2368 patients with back or neck pain in 5 studies. Twenty-one of 23 studies supported the prognostic validity of centralization, including 3 high quality studies and 4 of moderate quality; whereas 2 moderate quality studies showed evidence that did not support the prognostic validity of centralization. Data on the prognostic validity of directional preference was limited to one study. Centralization and directional preference appear to be useful treatment effect modifiers in 7 out of 8 studies. Levels of reliability were very variable (kappa 0.15-0.9) in 5 studies. Findings of centralization or directional preference at baseline would appear to be useful indicators of management strategies and prognosis, and therefore warrant further investigation.

Centralization: its prognostic value in patients with referred symptoms and sciatica.

Study Design. Prospective, comparative cohort study. Objective. To investigate the prognostic significance of centralization in patients with subacute sciatica and referred symptoms. Summary of Background Data. Previous studies have shown that centralization occurs commonly in the nonspecific low back population, and its occurrence is associated with a good prognosis. The phenomenon has never been evaluated in a population with sciatica and referred symptoms. Methods. The sample pool was 104 consecutive patients referred for investigation of possible disc herniation. Of these patients, 60 were recruited into the study and underwent a standardized mechanical evaluation using repeated end-range movements, while symptom response was monitored to expose 2 groups: centralization group (CG) and noncentralization group (NCG). All patients were treated in the same way and were followed for one year. If patients did not have improvement surgery was considered. Outcomes included back and leg pain, disability, Nottingham Health Profile, and surgical outcome. Results. There were 25 patients who were classified in the CG, 35 in the NCG, and other baseline characteristics were similar between groups. At 1, 2, and 3 months, the CG had significantly better outcomes than the NCG. At 2 months, the CG had more improvements in leg pain (P = 0.007), disability (P = <0.001), and Nottingham Health Profile (P = 0.001). After 1 year, disability was less in the CG (P = 0.029). In the CG, 3 patients underwent surgery, in the NCG, 16 (P = 0.01). The odds ratio for surgery in the NCG was 6.2. Conclusion. Patients with sciatica and suspected disc herniation who have a centralization response to a mechanical evaluation will have significantly better outcomes. Patients who do not have centralization will be 6 times more likely to undergo surgery.

Evidence-informed management of chronic low back pain with the McKenzie method.

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.

Expert therapists use specific clinical reasoning processes in the assessment and management of patients with shoulder pain: a qualitative study

QUESTION What are the key items in the clinical reasoning process which expert clinicians identify as being relevant to the assessment and management of patients with shoulder pain? DESIGN Qualitative study using a three-round Delphi procedure. PARTICIPANTS Twenty-six experts in the UK consented to be involved and were contactable, of whom 20 contributed, with 12, 15, and 15 contributing to the different rounds. RESULTS Clinical reasoning was mostly about diagnostic reasoning, but also involved narrative reasoning. Diagnostic reasoning involved both pattern recognition and hypothetico-deductive reasoning. Diagnostic reasoning emphasised general history items, a constellation of signs and symptoms to identify specific diagnostic categories, and standard physical examination procedures. Narrative reasoning was highlighted by the communication involved in expert history taking, seeing patients in their functional and psychological context, and collaborative reasoning with the patient regarding management. CONCLUSIONS These expert clinicians demonstrated the use of diagnostic pattern recognition, and hypothetico-deductive and narrative clinical reasoning processes. The emphasis was on the history and basic physical examination procedures to make clinical decisions.

Prescriptive Clinical Prediction Rules in Back Pain Research: A Systematic Review

Abstract Prescriptive clinical prediction rules (CPRs) are a way of using a small selection of clinical findings to match patients to optimal interventions. A number of CPRs have been developed for use with back pain patients, but these have not been systematically reviewed. The purpose of this review was to evaluate existing CPRs against established criteria to determine the quality of the studies and the overall development of the CPR against a set number of stages. Medline was searched up until June 2008, and 16 studies were reviewed that related to 9 different CPRs. These studies investigated and attempted to find clinical characteristics for responders to manipulation, stabilization exercise, physical therapy, chiropractic, traction, rehabilitation, usual care, and zygapophyseal joint injections. Eleven of these studies related to the derivation stage and five to the validation stage. The manipulation and stabilization CPRs had been the most studied. The derivation studies were mostly high quality, whereas none of the validation studies were. Some of the validation studies did not provide evidence that validated the CPR. Most of these CPRs need further evaluation before they can be applied clinically; most did not pass the lowest level of evidence hierarchy. As regards the manipulation CPR, evidence to date for its clinical utility is limited and contradictory. For the stabilization CPR, there was limited evidence that it may be considered but only with caution and in similar patients. Overall, there is limited evidence to support the general application of spinal CPRs.