Vinicius C. Oliveira

Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis

BACKGROUND Existing guidelines and systematic reviews provide inconsistent recommendations on epidural corticosteroid injections for sciatica. Key limitations of existing reviews are the inclusion of trials with active controls of unknown efficacy and failure to provide an estimate of the size of the treatment effect. PURPOSE To determine the efficacy of epidural corticosteroid injections for sciatica compared with placebo. DATA SOURCES International Pharmaceutical Abstracts, PsycINFO, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL. STUDY SELECTION Randomized, placebo-controlled trials assessing the efficacy of epidural corticosteroid injections in participants with sciatica. DATA EXTRACTION Two independent reviewers extracted data and assessed risk of bias. Leg pain, back pain, and disability were converted to common scales from 0 (no pain or disability) to 100 (worst possible pain or disability). Thresholds for clinically important change in the range of 10 to 30 have been proposed for these outcomes. Effects were calculated for short-term (>2 weeks but ≤3 months) and long-term (≥12 months) follow-up. DATA SYNTHESIS Data were pooled with a random-effects model, and the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used in summary conclusions. Twenty-five published reports (23 trials) were included. The pooled results showed a significant, although small, effect of epidural corticosteroid injections compared with placebo for leg pain in the short term (mean difference, -6.2 [95% CI, -9.4 to -3.0]) and also for disability in the short term (mean difference, -3.1 [CI, -5.0 to -1.2]). The long-term pooled effects were smaller and not statistically significant. The overall quality of evidence according to the GRADE classification was rated as high. LIMITATION The review included only English-language trials and could not incorporate dichotomous outcome measures into the analysis. CONCLUSION The available evidence suggests that epidural corticosteroid injections offer only short-term relief of leg pain and disability for patients with sciatica. The small size of the treatment effects, however, raises questions about the clinical utility of this procedure in the target population. PRIMARY FUNDING SOURCE None.

Patient-centred communication is associated with positive therapeutic alliance: a systematic review

QUESTION During the patient-therapist encounter, which communication factors correlate with constructs of therapeutic alliance? DESIGN Systematic review. PARTICIPANTS Clinicians and patients in primary, secondary or tertiary care settings. MEASURES Studies had to investigate the association between communication factors (interaction styles, verbal factors or non-verbal factors) and constructs of the therapeutic alliance (collaboration, affective bond, agreement, trust, or empathy), measured during encounters between health practitioners and patients. RESULTS Among the twelve studies that met the inclusion criteria, 67 communication factors were identified (36 interaction styles, 17 verbal factors and 14 non-verbal factors). The constructs of therapeutic alliance in the included studies were rapport, trust, communicative success and agreement. Interaction styles that showed positive large correlations with therapeutic alliance were those factors that help clinicians to engage more with patients by listening to what they have to say, asking questions and showing sensitivity to their emotional concerns. Studies of verbal and non-verbal factors were scarce and inconclusive. CONCLUSIONS The limited evidence suggests patient-centred interaction styles related to the provision of emotional support and allowing patient involvement in the consultation process enhance the therapeutic alliance. Clinicians can use this evidence to adjust their interactions with patients to include communication strategies that strengthen the therapeutic alliance.

Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis

Objective To investigate the efficacy and tolerability of analgesic and adjuvant pain drugs typically administered in primary care for the management of patients with sciatica. Design Systematic review. Data source International Pharmaceutical Abstracts, PsycINFO, Medline, Embase, Cochrane Central Register of Clinical Trials (CENTRAL), CINAHL, and LILACS. Study selection Randomised controlled trials assessing the efficacy and tolerability of drugs versus placebo or other treatment for sciatica. Data extraction Two independent reviewers extracted data and assessed methodological quality using the PEDro scale. Pain and disability outcomes were converted to a common 0 to 100 scale. Data were pooled with a random effects model, and the GRADE approach was used in summary conclusions. Results Twenty three published reports met the inclusion criteria. The evidence to judge the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and opioid analgesics ranged from moderate to low quality. Most of the pooled estimates did not favour the active treatment over placebo. The pooled results of two trials of corticosteroids (mean difference in overall and leg pain −12.2, 95% confidence interval −20.9 to −3.4) and a single trial of the anticonvulsant gabapentin for chronic sciatica (mean difference in overall pain relief −26.6, −38.3 to −14.9) showed some benefits but only in the short term. The median rate of adverse events was 17% (interquartile range 10-30%) for the active drugs and 11% (3-23%) for placebo. Trial limitations included failure to use validated outcome measures, lack of long term follow-up, and small sample size. Conclusions As the existing evidence from clinical trials is of low quality, the efficacy and tolerability of drugs commonly prescribed for the management of sciatica in primary care is unclear.

Prevention of Low Back Pain: A Systematic Review and Meta-analysis

IMPORTANCE Existing guidelines and systematic reviews lack clear recommendations for prevention of low back pain (LBP). OBJECTIVE To investigate the effectiveness of interventions for prevention of LBP. DATA SOURCES MEDLINE, EMBASE, Physiotherapy Evidence Database Scale, and Cochrane Central Register of Controlled Trials from inception to November 22, 2014. STUDY SELECTION Randomized clinical trials of prevention strategies for nonspecific LBP. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data and assessed the risk of bias. The Physiotherapy Evidence Database Scale was used to evaluate the risk-of-bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to describe the quality of evidence. MAIN OUTCOMES AND MEASURES The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP. We calculated relative risks (RRs) and 95% CIs using random-effects models. RESULTS The literature search identified 6133 potentially eligible studies; of these, 23 published reports (on 21 different randomized clinical trials including 30,850 unique participants) met the inclusion criteria. With results presented as RRs (95% CIs), there was moderate-quality evidence that exercise combined with education reduces the risk of an episode of LBP (0.55 [0.41-0.74]) and low-quality evidence of no effect on sick leave (0.74 [0.44-1.26]). Low- to very low-quality evidence suggested that exercise alone may reduce the risk of both an LBP episode (0.65 [0.50-0.86]) and use of sick leave (0.22 [0.06-0.76]). For education alone, there was moderate- to very low-quality evidence of no effect on LBP (1.03 [0.83-1.27]) or sick leave (0.87 [0.47-1.60]). There was low- to very low-quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71-1.44]) or sick leave (0.87 [0.47-1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74-1.40]). CONCLUSION AND RELEVANCE The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low.

Effectiveness of self‐management of low back pain: Systematic review with meta‐analysis

To determine the effectiveness of self‐management for nonspecific low back pain (LBP).

Communication that values patient autonomy is associated with satisfaction with care: a systematic review

QUESTION Which communication factors used by clinicians during patient-clinician interactions are associated with satisfaction with care? DESIGN Systematic review with meta-analysis of studies investigating the association of verbal or nonverbal factors or interaction styles used by clinicians with patient satisfaction during an encounter between clinician and patient. PARTICIPANTS : Clinicians interacting with patients in primary care or rehabilitation settings. RESULTS Twenty seven studies investigated 129 verbal, nonverbal, and interaction style factors. Of these, 38 factors were consistently associated with satisfaction. Verbal factors concerning clinicians involving, facilitating, and supporting patients were associated with satisfaction with care. Most communication factors presented a fair correlation (r≥0.21 but <0.41) with satisfaction with care. Nonverbal factors such as time spent discussing prevention and time spent reading patient charts had a fair association with satisfaction with care (correlations range from 0.21 to 0.40). A moderate association was found between interaction styles such as caring (pooled r=0.51, 95% CI 0.42 to 0.60) and satisfaction with care. Over half (58%) of the 129 identified factors never associated with satisfaction with care and the remainder associated inconsistently. CONCLUSION The number of potential modifiable communication factors associated with satisfaction with care and the magnitude of their association partially support interventions to train clinicians in communication skills that value patient autonomy.

Health locus of control questionnaire for patients with chronic low back pain: psychometric properties of the Brazilian–Portuguese version

BACKGROUND AND PURPOSE Low back pain is common among Brazilians, especially affecting those who are working. Psychosocial factors, such as the health locus of control, are associated with low back pain prognoses. Although the multidimensional health locus of control questionnaire is widely employed in individuals with low back pain, a Brazilian-Portuguese version is not yet available. The aim of the present study was to translate and adapt the multidimensional health locus of control (MHLC) questionnaire, and to investigate its psychometric properties in a Brazilian population with non-specific chronic low back pain. METHOD Translation and adaptation of the questionnaire was carried out in the first phase of the study. In the second phase it was administered to Brazilians with non-specific chronic low back pain to evaluate its intra-examiner reliability (n=20), concurrent validity, internal consistency (n=40), and floor and ceiling effects. To evaluate concurrent validity the Brazilian-Portuguese version of the Roland-Morris disability questionnaire was used as the comparison. RESULTS The sub-scales demonstrated good to excellent reliability with intra-class coefficient (ICC) values of 0.75 for the external subscale (95% confidence interval (95% CI): 0.46-0.89), 0.87 for the internal sub-scale (95% CI: 0.69-0.94) and 0.90 for the chance sub-scale (95% CI: 0.77-0.96). For concurrent validity, the external and chance sub-scales correlated positively with disability (Pearsons r=0.58; p<0.001 and Pearsons r=0.35; p=0.025), respectively, while the internal sub-scale correlated negatively with disability (Pearsons r= -0.33; p=0.037). The questionnaire had acceptable internal consistency, with a Cronbachs alpha value of 0.65 (95% CI: 0.46-0.80) for external sub-scale, 0.77 (95% CI: 0.64-0.87) for internal sub-scale and 0.83 (95% CI: 0.73-0.90) for chance sub-scale. CONCLUSIONS The Brazilian-Portuguese version of the MHLC questionnaire has acceptable measurement properties similar to that observed with the original English language version.

Prevalence of sarcopenia in older Brazilians: A systematic review and meta-analysis

Sarcopenia is the age‐related loss of muscle mass and function that evolves into disability, loss of independence and death. In Brazil the number of older people is rapidly growing, resulting in an increased prevalence of chronic conditions associated with old age. As prevalence estimates provide essential information to policymakers when developing healthcare strategies, this systematic review and meta‐analysis aimed to estimate the prevalence of sarcopenia in older Brazilians.

Patients in treatment for chronic low back pain have higher externalised beliefs: a cross-sectional study

BACKGROUND People with low back pain (LBP) with higher levels of external locus of control have a poorer prognosis and require greater improvements from active interventions in order to consider these interventions worthwhile. Whether locus of control levels differ between participants with LBP in a patient-health provider relationship and those waiting for treatment is unclear. OBJECTIVE The aim was to investigate if differences in locus of control exist between participants with non-specific chronic LBP being treated (treatment group) and those waiting treatment (control group). METHODS 100 participants (50 per group) with low back symptoms for at least three months for the current episode of LBP and aged between 18 and 60 years were recruited. Multidimensional health locus of control questionnaire (MHLC) was used to collect their beliefs. Multiple linear regression adjusted for disability was used to compare health locus of control between both groups. Differences were described as mean differences and 95% confidence intervals. RESULTS Treatment group scored higher for external locus of control and lower for internal locus of control than control group. Mean differences (95% confidence intervals) were 2.7 points on possible 30-points difference (0.5 to 4.8) for external locus of control and -2.8 points (-5.4 to -0.1) for internal subscale. CONCLUSION Health locus of control was found to be different between treatment and control groups. Participants being treated had higher external locus of control and lower internal locus of control than control group.

People with low back pain who have externalised beliefs need to see greater improvements in symptoms to consider exercises worthwhile: an observational study

QUESTION Does health locus of control predict the smallest worthwhile effect of motor control exercise or spinal manipulative therapy when adjusted for severity of pain? DESIGN Cross-sectional observational study. PARTICIPANTS 86 people with non-specific low back pain who had not yet commenced physiotherapy intervention. OUTCOME MEASURES Predictors were severity of pain measured over the last 7 days using an 11-point scale from 0 to 10, and external and internal health loci of control measured using Form C of the Multidimensional Health Locus of Control scale. The outcome of interest was smallest worthwhile effect which was measured in terms of the percentage perceived change necessary to make two evidence-based physiotherapy interventions for non-specific low back pain (motor control exercise and spinal manipulative therapy) worthwhile. Data were collected before intervention commenced. RESULTS Multivariate analysis showed that when adjusted for pain and internal locus of control, external locus of control predicted the smallest worthwhile effect for motor control exercise (B 0.79; CI 0.10 to 1.48), explaining 0.07 of the variance. None of the predictors significantly predicted the smallest worthwhile effect for spinal manipulative therapy. CONCLUSION Patients with low back pain who have externalised beliefs and agree more strongly with the notion that others are responsible for their condition report higher estimates of smallest worthwhile effect of an active intervention such as motor control exercise than patients who do not have externalised beliefs.