Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis

Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis.

Objective

To conduct a systematic review and meta-analysis on the prognosis of acute idiopathic neck pain and disability.

Data Sources

EMBASE, CINAHL, Medline, AMED, PEDro, and CENTRAL were searched from inception to July 2009, limited to human studies. Reference lists of relevant systematic reviews were searched by hand. Search terms included: neck pain, prognosis, inception, cohort, longitudinal, observational, or prospective study and randomized controlled trial.

Study Selection

Eligible studies were longitudinal cohort studies and randomized controlled trials with a no treatment or minimal treatment arm that recruited an inception cohort of acute idiopathic neck pain and reported pain or disability outcomes. Eligibility was determined by 2 authors independently. Seven of 20,085 references were included.

Data Extraction

Pain and disability data were extracted independently by 2 authors. Risk of bias was assessed independently by 2 authors.

Data Synthesis

Statistical pooling showed a weighted mean pain score (0–100) of 64 (95% confidence interval [CI], 61–67) at onset and 35 (95% CI, 32–38) at 6.5 weeks. At 12 months, neck pain severity remained high at 42 (95% CI, 39–45). Disability reduced from a pooled weighted mean score (0–100) at onset of 30 (95% CI, 28–32) to 17 (95% CI, 15–19) by 6.5 weeks, without further improvement at 12 months. Studies varied in length of follow-up, design, and sample size.

Conclusions

This review provides Level I evidence that the prognosis of acute idiopathic neck pain is worse than currently recognized. This evidence can guide primary care clinicians when providing prognostic information to patients. Further research to identify prognostic factors and long-term outcomes from inception cohorts would be valuable.     

The effects of stretching in spasticity: a systematic review

Bovend'Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: a systematic review.

Objectives

To investigate the general effect of stretching on spasticity and to explore the complexity of stretching in patients with spasticity.

Data Sources

Two researchers independently performed a systematic literature search using the databases: Medline, PEDro, Cochrane library, Web of Science, CINAHL, and Allied and Complementary Medicine.

Study Selection

Studies on adults receiving a stretching technique to reduce spasticity were included.

Data Extraction

Randomized controlled trials (RCTs) were assessed on the PEDro scale for methodologic quality. Thirteen items from the CONSORT list and the Critical Appraisal Skills Program guideline were used to assess the methodologic quality of the other studies.

Data Synthesis

RCTs (n=10) and other clinical trials (n=11) were included. The methodologic quality of the RCTs was low, varying between 4 and 8 on the PEDro scale. All studies show great diversity at the levels of methodology, population, intervention, and outcome measures making a meta-analysis not feasible. Both manual and mechanical stretching methods were studied. Stretching protocols were generally inadequately described and poorly standardized. The outcome measures used often assessed impairments such as available range of motion but were unable to distinguish between neural and nonneural components of spasticity. Associated functional benefits were not usually investigated. Although there is some positive evidence supporting the immediate effects of 1 stretching session, it remains unclear how long these effects abide and its long-term consequences.

Conclusions

There is a wide diversity in studies investigating the effects of stretching on spasticity, and the available evidence on its clinical benefit is overall inconclusive. We recognize the need for consensus on a paradigm for stretching and for good-quality studies. Future research should address this issue and should investigate the clinical importance of the short- and long-term effects.     

The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery

Friedly J, Nishio I, Bishop MJ, Maynard C. The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery.

Objectives

To evaluate whether the use of epidural steroid injections (ESIs) is associated with decreased subsequent opioid use in patients in the Department of Veteran's Affairs (VA) and to determine whether treatment with multiple injections are associated with decreased opioid use and lumbar surgery after ESIs.

Design

VA patients undergoing ESIs during the study period for specific low back pain (LBP) diagnoses were identified, and lumbar surgery and opioid use were examined for 6 months before and after ESI.

Setting

National VA administrative data.

Participants

U.S. veterans (retrospective data analysis).

Interventions

Not applicable.

Main Outcome Measures

Opioid use and lumbar surgery after ESIs.

Results

During the 2-year study period, 13,741 different VA patients underwent an ESI for LBP. The majority of patients were using opioids before their ESIs (64%), as were the majority after their ESIs (67%). Of patients not on opioids before the ESIs, 38% were prescribed opioids afterward, whereas only 16% of people on opioids before the ESIs stopped using opioids afterward. Patients who received more than 3 injections were more likely than patients receiving fewer injections to start taking opioids after ESIs (19% vs 13%, P<.001) and to undergo lumbar surgery after ESIs (8.7% vs 6.3%, P=.003).

Conclusions

Opioid use did not decrease in the 6 months after ESIs. In this population, patients who received multiple injections were more likely to start taking opioids and to undergo lumbar surgery within the 6 months after treatment with ESIs. These findings are concerning because our data suggest that ESIs are not reducing opioid use in this VA population.     

A systematic review of instruments assessing participation: challenges in defining participation

Eyssen IC, Steultjens MP, Dekker J, Terwee CB. A systematic review of instruments assessing participation: challenges in defining participation.

Objectives

To evaluate: (1) whether instruments which intend to measure participation actually do and (2) how frequently specific aspects and domains of participation are addressed.

Data Sources

A systematic search was performed in PubMed.

Study Selection

Included were patient-reported instruments that primarily aim to measure participation.

Data Extraction

The full-text instruments were extracted from the articles or obtained from the authors. Two reviewers independently rated each item of the included instruments as measuring participation (yes, no, or undetermined). For each item, the specific aspect and domain of participation were categorized.

Data Synthesis

Included were 103 instruments (2445 items). Of the included items, 619 items concerned participation and 217 concerned undetermined items. In total, 68 instruments contained at least 1 (sub)scale with 50% or more participation or undetermined items. The participation items referred to the participation aspects: participation problems (53%), participation accomplishment (31%), and satisfaction with participation (9%). The domains of the participation items concerned: work/study (27%), social life (27%), general participation (19%), and home (11%). The undetermined items mainly referred to domains about leisure (43%), transport (26%), and shopping (12%).

Conclusions

According to our working definition of participation, most instruments that aim to measure participation do so only to a limited extent. These instruments mainly assess aspects of participation problems and participation accomplishment. The domains of participation covered by these instruments primarily include work/study, social life, general participation, home, leisure, transport, and shopping.     

Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review

Prvu Bettger JA, Stineman MG. Effectiveness of multidisciplinary rehabilitation services in postacute care: state-of-the-science. A review.

Objectives

To summarize the efficacy of postacute rehabilitation and to outline future research strategies for increasing knowledge of its effectiveness.

Data Sources

English-language systematic reviews that examined multidisciplinary therapy-based rehabilitation services for adults, published in the last 25 years and available through Cochrane, Medline, or CINAHL databases. We excluded multidisciplinary biopsychosocial rehabilitation programs and mental health services.

Study Selection

Using the search term rehabilitation, 167 records were identified in the Cochrane database, 1163 meta-analyses and reviews were identified in Medline, and 226 in CINAHL. The Medline and CINAHL search was further refined with 3 additional search terms: therapy, multidisciplinary, and interdisciplinary. In summary, we used 12 reviews to summarize the efficacy of multidisciplinary, therapy-based postacute rehabilitation; the 12 covered only 5 populations.

Data Extraction

Two reviewers extracted information about study populations, sample sizes, study designs, the settings and timing of rehabilitation, interventions, and findings.

Data Synthesis

Based on systematic reviews, the evidence for efficacy of postacute rehabilitation services across the continuum was strongest for stroke. There was also strong evidence supporting multidisciplinary inpatient rehabilitation for patients with rheumatoid arthritis, moderate to severe acquired brain injury, including traumatic etiologies, and for older adults. Heterogeneity limited our ability to conclude a benefit or a lack of a benefit for rehabilitation in other postacute settings for the other conditions in which systematic reviews had been completed. The efficacy of multidisciplinary rehabilitation services has not been systematically reviewed for many of the diagnostic conditions treated in rehabilitation. We did not complete a summary of findings from individual studies.

Conclusions

Given the limitations and paucity of systematic reviews, information from carefully designed nonrandomized studies could be used to complement randomized controlled trials in the study of the effectiveness of postacute rehabilitation. Consequently, a stronger evidence base would become available with which to inform policy decisions, guide the use of services, and improve patient access and outcomes.     

Adaptation strategies of the lower extremities of patients with a transtibial or transfemoral amputation during level walking: a systematic review

Prinsen EC, Nederhand MJ, Rietman JS. Adaptation strategies of the lower extremities of patients with a transtibial or transfemoral amputation during level walking: a systematic review.

Objective

To describe adaptation strategies in terms of joint power or work in the amputated and intact leg of patients with a transtibial (TT) or transfemoral (TF) amputation.

Data Sources

MEDLINE, CINAHL, Physiotherapy Evidence Database, Embase, and the Cochrane Register of Controlled Trials were searched. Studies were collected up to November 1, 2010. Reference lists were additionally scrutinized.

Study Selection

Studies were included when they presented joint power or work and compared (1) the amputated and intact legs, (2) the amputated leg and a referent leg, or (3) the intact leg and a referent leg. Eligibility was independently assessed by 2 reviewers. A total of 13 articles were identified.

Data Extraction

Data extraction was performed using standardized forms of the Cochrane Collaboration. Methodologic quality was independently assessed using the Downs and Black instrument by 2 reviewers. The possibility of data pooling was examined. Significant differences found in studies that could not be pooled are also presented.

Data Synthesis

Significant results (P<.05). For work TT, for the concentric work total stance phase knee, the amputated was less than the intact/referent side, and the referent was less than the intact side. For the eccentric knee extensor (K1) phase, the amputated was less than the intact side, and the intact was greater than the referent side. For the concentric knee extensor (K2) phase, the amputated/referent was less than the intact side. For the concentric work total stance phase hip, the amputated/intact was greater than the referent side. For the concentric hip extensor (H1) phase, the amputated/intact was greater than the referent side. For power TT, for the peak power generation stance phase knee, the amputated was less than the referent side. For peak power generation swing phase knee, the amputated was less than the referent side. For the eccentric knee flexor (K4) phase, the amputated was less than the intact side. For the eccentric hip flexor (H2) phase, the amputated was greater than the intact side. For work TF, for the concentric plantar flexor (A2) phase, the referent was less than the intact side. For the H1 phase, the referent was less than the intact side. For the H2 phase, the amputated was greater than the intact/referent side, and the referent was greater than the intact side. For power TF, for the K2 phase, the referent was less than the intact side. Sensitivity analysis did not alter the conclusions.

Conclusions

Adaptations were seen in the amputated and intact legs. TT and TF use remarkably similar adaptation strategies at the level of the hip to compensate for the loss of plantar flexion power and facilitate forward progression. At the knee level, adaptations differed between TT and TF.     

Evidenced-based cognitive rehabilitation for persons with multiple sclerosis: a review of the literature

O’Brien AR, Chiaravalloti N, Goverover Y, DeLuca J. Evidenced-based cognitive rehabilitation for persons with multiple sclerosis: a review of the literature.

Objectives

To conduct evidence-based review of cognitive rehabilitation intervention research conducted in persons with multiple sclerosis (MS), to classify level of evidence, and to generate recommendations for interventions in this area.

Data Sources

An open (no year limits set) search of Medline, PsychInfo, and CINAHL (eliminating repetitions) using combinations of the following terms: attention, awareness, cognition, cognitive, communication, executive, executive function, language, learning, memory, perception, problem solving, reasoning, rehabilitation, remediation, training, and working memory. Reference sections of articles found through the sites were also searched.

Study Selection

Studies were chosen based on criteria from previous evidence-based reviews such that articles are excluded from the review if (1) the study was not an intervention, (2) it was a theoretic article, (3) it was a review article, (4) detail was lacking to fully evaluate the intervention, (5) it was not MS-specific, (6) it included a pediatric sample, (7) it was a case report without empirical data to evaluate outcomes, (8) it was not peer-reviewed (also excludes book chapters), (9) it was a pharmacologic intervention, or (10) it was not available for review in English.

Data Extraction

Articles were categorized into interventions for attention, learning and memory, executive functioning, or nonspecified/combined cognitive domains. There were 4 reviewers in the current study. All articles were reviewed independently by at least 2 persons and abstracted according to predetermined criteria. There was a final total of 16 articles, which underwent a full review and classification of a level of evidence based on previously published peer-reviewed methodology used for evidence-based reviews.

Data Synthesis

The current review yielded 16 studies of cognitive rehabilitation for persons with MS, including 4 class I studies, 5 class II studies, 2 class III studies, and 5 class IV studies. Two intervention methodologies in the area of verbal learning and memory received support for a practice guideline and practice option, respectively.

Conclusions

Cognitive rehabilitation in MS is in its relative infancy. More methodologically rigorous research is needed to determine the effectiveness and efficacy of various cognitive rehabilitation interventions. Specific recommendations for future research are given.     

Abstract 3: Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: An evaluation of long-term efficacy

Objective: To assess the efficacy of fluoroscopically guided caudal epidural steroid injections (ESIs) in the management of lumbar spinal stenosis. Design: Retrospective chart review and follow-up study. Setting: Academic-affiliated outpatient physiatry practice. Participants: Patients with low back and/or leg pain of at least 3 months in duration with clinical and radiographic evidence of moderate to severe lumbar spinal stenosis who received caudal ES’s between 1995 and 2002. Patients who had undergone prior lumbar spinal surgery were excluded. Intervention: Fluoroscopically guided caudal ESIs. Main Outcome Measures: Visual Numeric Scale (VNS), Roland-Morris Disability Questionnaire (RMDQ), North American Spine Society Patient Satisfaction Index (PSI), and subsequent surgery. Results: Of 3153 charts reviewed, 95 patients met inclusion criterion. 79 (83%) completed the follow-up questionnaire by mail or telephone interview. The mean patient age was 70 years, mean duration of symptoms was 39 months, and average follow-up time was 31 months. Patients underwent an average of 1.5 caudal ESIs. 9 patients subsequently underwent surgery; 1 had an intradiskal electrothermal therapy procedure. A VNS improvement of 50% or greater was seen in 37% of patients. With respect to patient satisfaction, 44% reported that the procedure either fully met their expectations or that they would undergo it again for the same outcome. A functional improvement of 2 points or greater was seen on the RMDQ in 40% of patients. The concurrent presence of degenerative spondylolisthesis was the only variable that had a significant positive correlation with successful outcomes (P<.003). Conclusions: Caudally placed, fluoroscopically guided ESIs offer a safe, minimally invasive option for managing pain caused by lumbar spinal stenosis. Many patients in this study derived long-term benefit from a single caudal ESI. The concurrent presence of degenerative spondylolisthesis appears to be a positive prognostic factor for successful response.     

A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance

Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance.

Objective

To determine the reproducibility of manual palpation in identifying trigger points based on a systematic review of available literature.

Data Sources

Medline (1965-2007), CINHAL (1982-2007), ISI Web of Science (1945-2007), and MANTIS (1966-2007) databases and reference lists of articles.

Study Selection

Reproducibility studies relating to identification and diagnosis of trigger points through palpation. Acceptable studies were required to specifically consider either inter- or intrarater reliability of trigger point identification through manual palpation and include κ statistics as part of their statistical assessment.

Data Extraction

Three independent reviewers considered the studies for inclusion and rated their methodologic quality based on the Standards for Reporting of Diagnostic Accuracy guidelines for the reporting of diagnostic studies.

Data Synthesis

Eleven studies were initially included; however, 5 were subsequently excluded based on the inclusion and exclusion criteria. Only 2 studies were judged to be of high quality, and the level of evidence criteria suggested that, at best, moderate evidence could be found from which to make pronouncements on the literature. Only local tenderness of the trapezius (κ range, .15-.62) and pain referral of the gluteus medius (κ range, .298-.487) and quadratus lumborum (κ range, .36-.501) were found to be reproducible.

Conclusions

The methodologic quality of the majority of studies for the purpose of establishing trigger point reproducibility is generally poor. More high-quality studies are needed to comment on this procedure. Clinicians and scientists are urged to move toward simpler, global assessments of patient status.     

Postherpetic neuralgia involving the right C5 dermatome treated with a cervical transforaminal epidural steroid injection: a case report

A 66-year-old woman presented with 2 weeks of debilitating right upper-limb pain with a vesicular rash over the right C5 dermatome secondary to herpes zoster. Her pain failed to improve with: oral narcotics, divalproex, gabapentin, pregabalin, and topical 2% lidocaine cream. Six weeks postonset, a right C5 transforaminal epidural steroid injection (TESI) under fluoroscopic guidance was performed. Prior to the injection, her numeric pain intensity was rated as 9 to 10/10, and 15 minutes after the injection, it was reduced to 3/10. At 2 weeks, her pain had maintained an intensity of 3/10 and over another 2 weeks had resolved. She remained pain-free 3 months later. In this case, the use of a cervical TESI provided dramatic results in the treatment of debilitating postherpetic neuralgia (PHN). Further investigation is needed to determine the efficacy of TESI in the early management of PHN.     

Disordered eating, menstrual disturbances, and low bone mineral density in dancers: a systematic review

Hincapié CA, Cassidy JD. Disordered eating, menstrual disturbances, and low bone mineral density in dancers: a systematic review.

Objective

To assemble and synthesize the best evidence on the epidemiology, diagnosis, prognosis, treatment, and prevention of disordered eating, menstrual disturbances, and low bone mineral density in dancers.

Data Sources

Medline, CINAHL, PsycINFO, Embase, and other electronic databases were searched from 1966 to 2010 using key words such as “dance,” “dancer,” “dancing,” “eating disorders,” “menstruation disturbances,” and “bone density.” In addition, the reference lists of relevant studies were examined, specialized journals were hand-searched, and the websites of major dance associations were scanned for relevant information.

Study Selection

Citations were screened for relevance using a priori criteria, and relevant studies were critically reviewed for scientific merit by the best evidence synthesis method. After 2748 abstracts were screened, 124 articles were reviewed, and 23 (18.5%) of these were accepted as scientifically admissible (representing 19 unique studies).

Data Extraction

Data from accepted studies were abstracted into evidence tables relating to prevalence and associated factors; incidence and risk factors; diagnosis; and prevention of disordered eating, menstrual disturbances, and/or low bone mineral density in dancers.

Data Synthesis

The scientifically admissible studies consisted of 13 (68%) cross-sectional studies and 6 (32%) cohort studies. Disordered eating and menstrual disturbances are common in dancers. The lifetime prevalence of any eating disorder was 50% in professional dancers, while the point prevalence ranged between 13.6% and 26.5% in young student dancers. In their first year of intensive dance training, 32% of university-level dancers developed a menstrual disturbance. The incidence of disordered eating and low bone mineral density in dancers is unknown. Several potential risk factors are suggested by the literature, but there is little compelling evidence for any of these. There is preliminary evidence that multifaceted sociocultural prevention strategies may help decrease the incidence of disordered eating.

Conclusions

The dance medicine literature is heterogeneous. The best available evidence suggests that disordered eating, menstrual disturbances, and low bone mineral density are important health issues for dancers at all skill levels. Future research would benefit from clear and relevant research questions being addressed with appropriate study designs and better reporting of studies in line with current scientific standards.     

Aerobic exercise to improve cognitive function in adults with neurological disorders: a systematic review

McDonnell MN, Smith AE, Mackintosh SF. Aerobic exercise to improve cognitive function in adults with neurological disorders: a systematic review.

Objective

To evaluate whether aerobic exercise improves cognition in adults diagnosed with neurologic disorders.

Data Sources

The Cochrane Central Register of Controlled Clinical Trials, MEDLINE, CINAHL, PubMed, EMBASE, PEDro, AMED, SPORTDiscus, PsycINFO, ERIC, and Google Scholar, with the last search performed in December 2010.

Study Selection

We included controlled clinical trials and randomized controlled trials with adults diagnosed with a neurologic disorder. Studies were included if they compared a control group with a group involved in an aerobic exercise program to improve cardiorespiratory fitness and if they measured cognition as an outcome.

Data Extraction

Two reviewers independently extracted data and methodologic quality of the included trials.

Data Synthesis

From the 67 trials reviewed, a total of 7 trials, involving 249 participants, were included. Two trials compared the effectiveness of yoga and aerobic exercise in adults with multiple sclerosis. Two trials evaluated the effect of exercise on patients with dementia, and 2 trials evaluated the effectiveness of exercise to improve cognition after traumatic brain injury. One trial studied the effect of a cycling program in people with chronic stroke. Lack of commonality between measures of cognition limited meta-analyses. Results from individual studies show that aerobic exercise improved cognition in people with dementia, improved attention and cognitive flexibility in patients with traumatic brain injury, improved choice reaction time in people with multiple sclerosis, and enhanced motor learning in people with chronic stroke.

Conclusions

There is limited evidence to support the use of aerobic exercise to improve cognition in adults with neurologic disorders. Of the 67 studies retrieved, less than half included cognition as an outcome, and few studies continued the aerobic exercise program long enough to be considered effective. Further studies investigating the effect of aerobic exercise interventions on cognition in people with neurologic conditions are required.     

Epidural steroid injections are useful for the treatment of low back pain and radicular symptoms: Pro

Epidural steroid injection has been used to treat low back pain for many decades. Numerous randomized trials have examined the efficacy of this approach. This review details the findings of older systematic reviews, newer randomized controlled trials, and two recent systematic reviews that examine the effectiveness of this treatment. Collectively, studies in acute radicular pain due to herniated nucleus pulposus have failed to show that epidural steroid injection reduces long-term pain or obviates the need for surgery. Similarly, there is scant evidence that epidural steroids have any beneficial effect in those with acute low back pain without leg pain or in those with chronic low back or leg pain. However, most studies have demonstrated more rapid resolution of leg pain in those who received epidural steroid injections versus those who did not. The role of epidural steroid injections in the management of acute radicular pain due to herniated nucleus pulposus is simply to provide earlier pain relief.