The association between physical activity and neck and low back pain: a systematic review

The effect of physical activity on neck and low back pain is still controversial. No systematic review has been conducted on the association between daily physical activity and neck and low back pain. The objective of this study was to evaluate the association between physical activity and the incidence/prevalence of neck and low back pain. Publications were systematically searched from 1980 to June 2009 in several databases. The following key words were used: neck pain, back pain, physical activity, leisure time activity, daily activity, everyday activity, lifestyle activity, sedentary, and physical inactivity. A hand search of relevant journals was also carried out. Relevant studies were retrieved and assessed for methodological quality by two independent reviewers. The strength of the evidence was based on methodological quality and consistency of the results. Seventeen studies were included in this review, of which 13 were rated as high-quality studies. Of high-quality studies, there was limited evidence for no association between physical activity and neck pain in workers and strong evidence for no association in school children. Conflicting evidence was found for the association between physical activity and low back pain in both general population and school children. Literature with respect to the effect of physical activity on neck and low back pain was too heterogeneous and more research is needed before any final conclusion can be reached.     

Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review

Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.     

The effectiveness of walking as an intervention for low back pain: a systematic review

As current low back pain (LBP) guidelines do not specifically advocate walking as an intervention, this review has explored for the effectiveness of walking in managing acute and chronic LBP. CINAHL, Medline, AMED, EMBASE, PubMed, Cochrane and Scopus databases, as well as a hand search of reference lists of retrieved articles, were searched. The search was restricted to studies in the English language. Studies were included when walking was identified as an intervention. Four studies met inclusion criteria, and were assessed with a quality checklist. Three lower ranked studies reported a reduction in LBP from a walking intervention, while the highest ranked study observed no effect. Heterogeneity of study design made it difficult to draw comparisons between studies. There is only low–moderate evidence for walking as an effective intervention strategy for LBP. Further investigation is required to investigate the strength of effect for walking as a primary intervention in the management of acute and chronic LBP.     

Cost-effectiveness of general practice care for low back pain: a systematic review

Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves.     

Imperfect placebos are common in low back pain trials: a systematic review of the literature

The placebo is an important tool to blind patients to treatment allocation and therefore minimise some sources of bias in clinical trials. However, placebos that are improperly designed or implemented may introduce bias into trials. The purpose of this systematic review was to evaluate the adequacy of placebo interventions used in low back pain trials. Electronic databases were searched systematically for randomised placebo-controlled trials of conservative interventions for low back pain. Trial selection and data extraction were performed by two reviewers independently. A total of 126 trials using over 25 different placebo interventions were included. The strategy most commonly used to enhance blinding was the provision of structurally equivalent placebos. Adequacy of blinding was assessed in only 13% of trials. In 20% of trials the placebo intervention was a potentially genuine treatment. Most trials that assessed patients’ expectations showed that the placebo generated lower expectations than the experimental intervention. Taken together, these results demonstrate that imperfect placebos are common in low back pain trials; a result suggesting that many trials provide potentially biased estimates of treatment efficacy. This finding has implications for the interpretation of published trials and the design of future trials. Implementation of strategies to facilitate blinding and balance expectations in randomised groups need a higher priority in low back pain research. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain

BACKGROUND CONTEXT

The STarT Back Screening Tool (SBST) categorizes risk of future disability in patients with low back pain (LBP). Previous studies evaluating the use of SBST in physical therapy (PT) populations do not reflect the ethnic and socioeconomic diversity occurring in clinical practice and lack statistical power to evaluate factors associated with outcomes within each SBST risk category.

Effectiveness of psychological interventions delivered by non-psychologists on low back pain and disability: a qualitative systematic review

Background Context

Psychological treatments delivered by non-psychologists have been proposed as a way to increase access to care to address important psychological barriers to recovery in people with low back pain (LBP).

Acupuncture therapy for chronic lower back pain: a systematic review

INTRODUCTION

Chronic low back pain is a common condition affecting a significant proportion of the population and has large economic implications on the society. Acupuncture has grown in popularity as an alternative therapy for chronic low back pain. Recent National Institute for Health and Clinical Excellence (NICE) guidelines on low back pain offer a course of acupuncture as a baseline treatment option according to patient preference. The aim of this systematic review was to evaluate if this treatment option is justified in view of recent evidence available on the efficacy of acupuncture.

MATERIALS AND METHODS

Studies included were identified by a PubMed search for relevant, randomised, controlled trials on the 23 July 2009. A systematic review was performed.

RESULTS

Fifteen randomised controlled trials were identified. Of these, four met the eligibility criteria and were critically appraised. These trials suggest acupuncture can be superior to usual care in treating chronic low back pain, especially, when patients have positive expectations about acupuncture.

CONCLUSIONS

NICE guidelines of a course of acupuncture, offered according to patient preference as a treatment option for chronic low back pain, are justified.     

Computed tomography for the diagnosis of lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review

Aim  

In low back pain if serious pathology is suspected diagnostic imaging could be performed. One of the imaging techniques available for this purpose is computed tomography (CT), however, insight in the diagnostic performance of CT is unclear.     

Risk factors for low back pain and sciatica: an umbrella review

Background

Low back pain (LBP) is a highly prevalent condition and it is associated with significant disability and work absenteeism worldwide. A variety of environmental and individual characteristics have been reported to increase the risk of LBP. To our knowledge, there has been no previous attempt to summarize the evidence from existing systematic reviews of risk factors for LBP or sciatica.

Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain

Clinical practice guidelines state that the tissue source of low back pain cannot be specified in the majority of patients. However, there has been no systematic review of the accuracy of diagnostic tests used to identify the source of low back pain. The aim of this systematic review was therefore to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint or sacroiliac joint (SIJ) as the source of low back pain. MEDLINE, EMBASE and CINAHL were searched up to February 2006 with citation tracking of eligible studies. Eligible studies compared index tests with an appropriate reference test (discography, facet joint or SIJ blocks or medial branch blocks) in patients with low back pain. Positive likelihood ratios (+LR) > 2 or negative likelihood ratios (-LR) < 0.5 were considered informative. Forty-one studies of moderate quality were included; 28 investigated the disc, 8 the facet joint and 7 the SIJ. Various features observed on MRI (high intensity zone, endplate changes and disc degeneration) produced informative +LR (> 2) in the majority of studies increasing the probability of the disc being the low back pain source. However, heterogeneity of the data prevented pooling. +LR ranged from 1.5 to 5.9, 1.6 to 4.0, and 0.6 to 5.9 for high intensity zone, disc degeneration and endplate changes, respectively. Centralisation was the only clinical feature found to increase the likelihood of the disc as the source of pain: +LR = 2.8 (95%CI 1.4–5.3). Absence of degeneration on MRI was the only test found to reduce the likelihood of the disc as the source of pain: −LR = 0.21 (95%CI 0.12–0.35). While single manual tests of the SIJ were uninformative, their use in combination was informative with +LR of 3.2 (95%CI 2.3–4.4) and −LR of 0.29 (95%CI 0.12–0.35). None of the tests for facet joint pain were found to be informative. The results of this review demonstrate that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. However, the changes in probability are usually small and at best moderate. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review

Purpose  

In about 5% of all cases LBP is associated with serious underlying pathology requiring diagnostic confirmation and directed treatment. Magnetic resonance imaging (MRI) is often used for this diagnostic purpose yet its role remains controversial. Consequently, this review aimed to summarize the available evidence on the diagnostic accuracy of MRI for identifying lumbar spinal pathology in adult low back pain (LPB) or sciatica patients.     

Manipulation and mobilization for treating chronic low back pain: a systematic review and meta-analysis

Background Context

Mobilization and manipulation therapies are widely used to benefit patients with chronic low back pain. However, questions remain about their efficacy, dosing, safety, and how these approaches compare with other therapies.

The association between pro-inflammatory biomarkers and nonspecific low back pain: a systematic review

BACKGROUND CONTEXT

About 85% of the patients with low back pain seeking medical care have nonspecific low back pain (NsLBP), implying that no definitive cause can be identified. Nonspecific low back pain is defined as low back pain and disability which cannot be linked to an underlying pathology, such as cancer, spinal osteomyelitis, fracture, spinal stenosis, cauda equine, ankylosing spondylitis, and visceral-referred pain. Many pain conditions are linked with elevated serum levels of pro-inflammatory biomarkers. Outcomes of interest are NsLBP and the level of pro-inflammatory biomarkers.

Physical fitness, rather than self-reported physical activities, is more strongly associated with low back pain: evidence from a working population

Introduction

Physical activity is suggested to be important for low back pain (LBP) but a major problem is the limited validity of the measurement of physical activities, which is usually based on questionnaires. Physical fitness can be viewed as a more objective measurement and our question was how physical activity based on self-reports and objective measured levels of physical fitness were associated with LBP.

Materials and methods

We analyzed cross-sectional data of 1,723 police employees. Physical activity was assessed by questionnaire (SQUASH) measuring type of activity, intensity, and time spent on these activities. Physical fitness was based on muscular dynamic endurance capacity and peak oxygen uptake (VO₂ peak). Severe LBP, interfering with functioning, was defined by pain ratings ≥4 on a scale of 0–10.

Results

Higher levels of physical fitness, both muscular and aerobic, were associated with less LBP (OR: 0.54; 95% CI: 0.34–0.86, respectively, 0.59: 95%CI: 0.35–0.99). For self-reported physical activity, both a low and a high level of the total physical activity pattern were associated with an increase of LBP (OR: 1.52; 95%CI: 1.00–2.31, respectively, 1.60; 95%CI: 1.05–2.44).

Conclusion

These findings suggest that physical activity of an intensity that improves physical fitness may be important in the prevention of LBP.     

Screening for malignancy in low back pain patients: a systematic review

To describe the accuracy of clinical features and tests used to screen for malignancy in patients with low back pain. A systematic review was performed on all available records on MEDLINE, EMBASE, and CINAHL electronic databases. Studies were considered eligible if they investigated a cohort of low back pain patients, used an appropriate reference standard, and reported sufficient data on the diagnostic accuracy of tests. Two authors independently assessed methodological quality and extracted data to calculate positive (LR+) and negative (LR−) likelihood ratios. Six studies evaluating 22 different clinical features and tests were identified. The prevalence of malignancy ranged from 0.1 to 3.5%. A previous history of cancer (LR+ = 23.7), elevated ESR (LR+ = 18.0), reduced hematocrit (LR+ = 18.2), and overall clinician judgement (LR+ = 12.1) increased the probability of malignancy when present. A combination of age ≥50 years, a previous history of cancer, unexplained weight loss, and failure to improve after 1 month had a reported sensitivity of 100%. Overall, there was poor reporting of methodological quality items, and very few studies were performed in community primary care settings. Malignancy is rare as a cause of low back pain. The most useful features and tests are a previous history of cancer, elevated ESR, reduced hematocrit, and clinician judgement.     

NASS Contemporary Concepts in Spine Care: Spinal manipulation therapy for acute low back pain

Background context

Low back pain (LBP) continues to be a very prevalent, disabling, and costly spinal disorder. Numerous interventions are routinely used for symptoms of acute LBP. One of the most common approaches is spinal manipulation therapy (SMT).

Purpose

To assess the current scientific literature related to SMT for acute LBP.

Patient sample

Not applicable.

Outcome measures

Not applicable.

Design

Systematic review (SR).

Methods

Literature was identified by searching MEDLINE using indexed and free text terms. Studies were included if they were randomized controlled trials (RCTs) published in English, and SMT was administered to a group of patients with LBP of less than 3 months. RCTs included in two previous SRs were also screened, as were reference lists of included studies. Combined search results were screened for relevance by two reviewers. Data related to methods, risk of bias, harms, and results were abstracted independently by two reviewers.

Results

The MEDLINE search returned 699 studies, of which six were included; an additional eight studies were identified from two previous SRs. There were 2,027 participants in the 14 included RCTs, which combined SMT with education (n=5), mobilization (MOB) (n=4), exercise (n=3), modalities (n=3), or medication (n=2). The groups that received SMT were most commonly compared with those receiving physical modalities (n=7), education (n=6), medication (n=5), exercise (n=5), MOB (n=3), or sham SMT (n=2). The most common providers of SMT were chiropractors (n=5) and physical therapists (n=5). Most studies (n=6) administered 5 to 10 sessions of SMT over 2 to 4 weeks for acute LBP. Outcomes measured included pain (n=10), function (n=10), health-care utilization (n=6), and global effect (n=5). Studies had a follow-up of less than 1 month (n=7), 3 months (n=1), 6 months (n=3), 1 year (n=2), or 2 years (n=1). When compared with various control groups, results for improvement in pain in the SMT groups were superior in three RCTs and equivalent in three RCTs in the short term, equivalent in four RCTs in the intermediate term, and equivalent in two RCTs in the long term. For improvement in function, results from the SMT groups were superior in one RCT and equivalent in four RCTs in the short term, superior in one RCT and equivalent in one RCT in the intermediate term, and equivalent in one RCT and inferior in one RCT in the long term. No harms related to SMT were reported in these RCTs.

Conclusions

Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.     

The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis

Background Context

Clinicians regard lumbar lordotic curvature (LLC) with respect to low back pain (LBP) in a contradictory fashion. The time-honored point of view is that LLC itself, or its increment, causes LBP. On the other hand, recently, the biomechanical role of LLC has been emphasized, and loss of lordosis is considered a possible cause of LBP. The relationship between LLC and LBP has immense clinical significance, because it serves as the basis of therapeutic exercises for treating and preventing LBP.