Psychometric properties of health-related quality of life instruments in patients undergoing palmar fasciectomy for dupuytren's disease: a prospective study.

BACKGROUND: The traditional outcome measured following treatment of Dupuytren's Disease (DD) has been digital range of motion; specifically the gain in digital extension. The outcomes research movement in the last three decades however has been advocating the measurement of outcomes from the patient's perspective using Health-Related Quality of Life questionnaires (HRQOL). Although several generic and region-specific HRQOL questionnaires exist, there is no guidance as to which one is the most appropriate for this population. The objective of this study is to evaluate the psychometric properties of three self-reported HRQOL outcome measures in patients with DD. METHODS: Patients with DD were enrolled from the practices of three plastic surgeons. Test-retest reliability, concurrent validity and responsiveness of three HRQOL questionnaires were compared in a prospective study design. The HRQOL measures included Health Utilities Index Mark 3 (HUI3), Short Form-36 (SF-36), and the Michigan Hand Questionnaire (MHQ). RESULTS: All three measures demonstrated good test-retest reliability (ICC = 0.77-0.85). Concurrent validity was found between the HUI3 pain and dexterity attributes and SF-36 physical summary score. The sensitivity of the MHQ to detect changes in the status of the patient was found to be high (effect size = 1.14) whereas that of the SF-36 was trivial. CONCLUSIONS: The HUI3 and the MHQ seem to be reliable and valid tools to assess the HRQOL in patients with Dupuytren's Disease.

Health-related quality of life in patients undergoing palmar fasciectomy for Dupuytren's disease.

BACKGROUND: The present study was undertaken to assess the health-related quality of life in patients with Dupuytren's disease who undergo palmar fasciectomy. METHODS: A prospective cohort of patients with Dupuytren's disease undergoing palmar and/or digital fasciectomy was recruited from the practice of three plastic surgeons in Hamilton, Ontario, Canada. After written informed consent was obtained, participants were asked to complete three health-related quality-of-life questionnaires (i.e., Short Form-36, Michigan Hand Outcomes Questionnaire, and Health Utility Index Mark 3) at five time points: at 1 week and 1 day preoperatively, and at 1, 3, 6, and 12 months postoperatively. Ranges of motion and grip strength measurement were also recorded. RESULTS: For the 26 patients in the study, the multiattribute scores of the Health Utility Index Mark 3 improved from 0.80 before surgery to 0.83 at 12 months postoperatively (p > 0.05). There was no difference in the Short Form-36 scores, but the Michigan Hand Outcomes Questionnaire scores improved from 74 at 1 week preoperatively to 90 at the 12-month postoperative visit (p < 0.001). CONCLUSIONS: Patients who undergo palmar fasciectomy for Dupuytren's disease experience a substantial improvement in their health-related quality of life 12 months after surgery. In the authors' study population, a benefit of 0.85 quality-adjusted life-year within 12 months was observed. This can be translated as follows: the average patient who undergoes palmar fasciectomy gains the equivalent of approximately 14.4 days (0.48 months) in perfect health by undergoing palmar fasciectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Physician-delivered injection therapies for mechanical neck disorders: a systematic review update (non-oral, non-intravenous pharmacological interventions for neck pain).

BACKGROUND: Controversy persists regarding medicinal injections for mechanical neck disorders (MNDs). OBJECTIVES: To determine the effectiveness of physician-delivered injections on pain, function/disability, quality of life, global perceived effect and patient satisfaction for adults with MNDs. SEARCH METHODS: We updated our previous searches of CENTRAL, MEDLINE and EMBASE from December 2006 through to March 2012. SELECTION CRITERIA: We included randomized controlled trials of adults with neck disorders treated by physician-delivered injection therapies. DATA COLLECTION AND ANALYSIS: Two authors independently selected articles, abstracted data and assessed methodological quality. When clinical heterogeneity was absent, we combined studies using random-effects models. RESULTS: We included 12 trials (667 participants). No high or moderate quality studies were found with evidence of benefit over control. Moderate quality evidence suggests little or no difference in pain or function/disability between nerve block injection of steroid and bupivacaine vs bupivacaine alone at short, intermediate and long-term for chronic neck pain. We found limited very low quality evidence of an effect on pain with intramuscular lidocaine vs control for chronic myofascial neck pain. Two low quality studies showed an effect on pain with anaesthetic nerve block vs saline immediately post treatment and in the short-term. All other studies were of low or very low quality with no evidence of benefit over controls. AUTHORS' CONCLUSIONS: Current evidence does not confirm the effectiveness of IM-lidocaine injection for chronic mechanical neck pain nor anaesthetic nerve block for cervicogenic headache. There is moderate evidence of no benefit for steroid blocks vs controls for mechanical neck pain.

Electrotherapy for neck pain.

BACKGROUND: Neck pain is common, disabling and costly. The effectiveness of electrotherapy as a physiotherapeutic option remains unclear. This is an update of a Cochrane review first published in 2005 and previously updated in 2009. OBJECTIVES: This systematic review assessed the short, intermediate and long-term effects of electrotherapy on pain, function, disability, patient satisfaction, global perceived effect, and quality of life in adults with neck pain with and without radiculopathy or cervicogenic headache. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, without language restrictions, from their beginning to August 2012; handsearched relevant conference proceedings; and consulted content experts. SELECTION CRITERIA: Randomized controlled trials (RCTs), in any language, investigating the effects of electrotherapy used primarily as unimodal treatment for neck pain. Quasi-RCTs and controlled clinical trials were excluded. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. We were unable to statistically pool any of the results, but we assessed the quality of the evidence using an adapted GRADE approach. MAIN RESULTS: Twenty small trials (1239 people with neck pain) containing 38 comparisons were included. Analysis was limited by trials of varied quality, heterogeneous treatment subtypes and conflicting results. The main findings for reduction of neck pain by treatment with electrotherapeutic modalities were as follows.Very low quality evidence determined that pulsed electromagnetic field therapy (PEMF) and repetitive magnetic stimulation (rMS) were more effective than placebo, while transcutaneous electrical nerve stimulation (TENS) showed inconsistent results.Very low quality evidence determined that PEMF, rMS and TENS were more effective than placebo.Low quality evidence (1 trial, 52 participants) determined that permanent magnets (necklace) were no more effective than placebo (standardized mean difference (SMD) 0.27, 95% CI -0.27 to 0.82, random-effects model).Very low quality evidence showed that modulated galvanic current, iontophoresis and electric muscle stimulation (EMS) were not more effective than placebo.There were four trials that reported on other outcomes such as function and global perceived effects, but none of the effects were of clinical importance. When TENS, iontophoresis and PEMF were compared to another treatment, very low quality evidence prevented us from suggesting any recommendations. No adverse side effects were reported in any of the included studies. AUTHORS' CONCLUSIONS: We cannot make any definite statements on the efficacy and clinical usefulness of electrotherapy modalities for neck pain. Since the evidence is of low or very low quality, we are uncertain about the estimate of the effect. Further research is very likely to change both the estimate of effect and our confidence in the results. Current evidence for PEMF, rMS, and TENS shows that these modalities might be more effective than placebo. When compared to other interventions the quality of evidence was very low thus preventing further recommendations.Funding bias should be considered, especially in PEMF studies. Galvanic current, iontophoresis, EMS, and a static magnetic field did not reduce pain or disability. Future trials on these interventions should have larger patient samples, include more precise standardization, and detail treatment characteristics.

Increasing sharp safety device use in healthcare: a semi-structured interview study.

The use of sharp safety devices in healthcare is considered the most important means of preventing occupational percutaneous injuries and has been mandated for use in most hospitals in industrialized countries including in Canada. However, clinical personnel's perceptions on the use of safety devices needs further characterization to improve compliance. This study's objective was to identify healthcare provider perspectives on different aspects of sharp safety device use and on how use could be increased. Using a constant comparison approach, data from semi-structured interviews with 39 nurses, physicians and phlebotomists providing direct patient care, and six nurses acting as the interface between clinical personnel and purchasing departments, were analyzed. Study participants were from three of the six health authorities in British Columbia. The four major categories that emerged from the data were: selection processes; identification and replacement; training; and multi-level barriers and facilitators. Findings highlighted the importance of including personnel regularly using safety devices at each stage of their selection including when they are being considered for replacement with superior devices, as well as the need for appropriate initial and refresher training, and how practices at the hospital, ward and individual level facilitate safety device use.

Inconsistent definitions for intention-to-treat in relation to missing outcome data: systematic review of the methods literature.

BACKGROUND: Authors of randomized trial reports seem to hold a variety of views regarding the relationship between missing outcome data (MOD) and intention to treat (ITT). The objectives of this study were to systematically investigate how authors of methodology articles define ITT in the presence of MOD, how they recommend handling MOD under ITT, and to make a proposal for potential improvement in the definition and use of ITT in relation to MOD. METHODS AND FINDINGS: We systematically searched MEDLINE in February 2009 for methodological articles written in English that devoted at least one paragraph to ITT and two other paragraphs to either ITT or MOD. We excluded original trial reports, observational studies, and clinical systematic reviews. Working in teams of two, we independently extracted relevant information from each eligible article. Of 1007 titles and abstracts reviewed, 66 articles met eligibility criteria. Five (8%) did not provide a definition of ITT; 25 (38%) mentioned MOD but did not discuss its relationship to ITT; and 36 (55%) discussed the relationship of MOD with ITT. These 36 articles described one or more of three statements: complete follow-up is required for ITT (58%); ITT and MOD are separate issues (17%); and ITT requires a specific strategy for handling MOD (78%); 17 (47%) endorsed more than one relationship. The most frequently mentioned strategies for handling MOD within ITT were: using the last outcome carried forward (50%); sensitivity analysis (50%); and use of available data to impute missing data (46%). CONCLUSION: We found that there is no consensus on the definition of ITT in relation to MOD. For conceptual clarity, we suggest that both reports of randomized trials and systematic reviews separately consider and describe how they deal with participants with complete data and those with MOD.

Choosing a survey sample when data on the population are limited: a method using Global Positioning Systems and aerial and satellite photographs.

BACKGROUND: Various methods have been proposed for sampling when data on the population are limited. However, these methods are often biased. We propose a new method to draw a population sample using Global Positioning Systems and aerial or satellite photographs. RESULTS: We randomly sampled Global Positioning System locations in designated areas. A circle was drawn around each location with radius representing 20 m. Buildings in the circle were identified from satellite photographs; one was randomly chosen. Interviewers selected one household from the building, and interviews were conducted with eligible household members. CONCLUSIONS: Participants had known selection probabilities, allowing proper estimation of parameters of interest and their variances. The approach was made possible by recent technological developments and access to satellite photographs.

Patient education for neck pain.

BACKGROUND: Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear. OBJECTIVES: To assess the short- to long-term effects of therapeutic patient education (TPE) strategies on pain, function, disability, quality of life, global perceived effect, patient satisfaction, knowledge transfer, or behaviour change in adults with neck pain associated with whiplash or non-specific and specific mechanical neck pain with or without radiculopathy or cervicogenic headache. SEARCH METHODS: We searched computerised bibliographic databases (inception to 11 July 2010). SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCT) investigating the effectiveness of TPE for acute to chronic neck pain. DATA COLLECTION AND ANALYSIS: Paired independent review authors conducted selection, data abstraction, and 'Risk of bias' assessment. We calculated risk ratio (RR) and standardised mean differences (SMD). Heterogeneity was assessed; no studies were pooled. MAIN RESULTS: Of the 15 selected trials, three were rated low risk of bias. Three TPE themes emerged.Advice focusing on activation: There is moderate quality evidence (one trial, 348 participants) that an educational video of advice focusing on activation was more beneficial for acute whiplash-related pain when compared with no treatment at intermediate-term [RR 0.79 (95% confidence interval (CI) 0.59 to 1.06)] but not long-term follow-up [0.89 (95% CI, 0.65 to 1.21)]. There is low quality evidence (one trial, 102 participants) that a whiplash pamphlet on advice focusing on activation is less beneficial for pain reduction, or no different in improving function and global perceived improvement from generic information given out in emergency care (control) for acute whiplash at short- or intermediate-term follow-up. Low to very low quality evidence (nine trials using diverse educational approaches) showed either no evidence of benefit or difference for varied outcomes. Advice focusing on pain & stress coping skills and workplace ergonomics: Very low quality evidence (three trials, 243 participants) favoured other treatment or showed no difference spanning numerous follow-up periods and disorder subtypes.  Low quality evidence (one trial, 192 participants) favoured specific exercise training for chronic neck pain at short-term follow-up.Self-care strategies: Very low quality evidence (one trial, 58 participants) indicated that self-care strategies did not relieve pain for acute to chronic neck pain at short-term follow-up. AUTHORS' CONCLUSIONS: With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.

Reliability of 3 assessment tools used to evaluate randomized controlled trials for treatment of neck pain.

STUDY DESIGN: Pragmatic, cross-sectional study. OBJECTIVE: To assess the interrater reliability of 3 tools used by the Cervical Overview Group (COG) for the assessment of the internal validity of randomized controlled trials (RCTs): Jadad, van Tulder, and risk of bias (RoB). SUMMARY OF BACKGROUND DATA: For clinicians to implement evidence-based practice, they need to critically appraise health care literature. Checklists, scales, and domain-based criteria exist to evaluate the internal validity of RCTs for rehabilitation studies, but there is a lack of research reporting the reliability of existing assessment tools. METHODS: Four members of the COG with multiprofessional and methodological background independently evaluated the internal validity of 54 RCTs using prepiloted Jadad and van Tulder reporting forms, and 18 RCTs using RoB, from June 2003 to May 2009. The κ statistic was calculated for each combination of raters and assessment tools. Standard agreement categorizations were used. RESULTS: For Jadad, 4 of 7 items demonstrated mean κ statistic ranges from moderate to substantial agreement (mean values, 0.42-0.78), as did 8 of 11 items on the van Tulder tool (mean values, 0.44-0.77). The RoB demonstrated moderate to substantial (mean values, 0.56-0.76) agreement on 3 of 12 items. Consistent substantial agreement was found across all assessment tools for the domain "allocation concealment": Jadad 0.69 (mean range, 0.60-0.77); van Tulder 0.77 (mean range, 0.73-0.81); RoB 0.76 (mean range, 0.65-0.88); and moderate to substantial across 2 tools for the domain "sequence generation": van Tulder 0.53 (mean range, 0.37-0.66) and RoB 0.66 (mean range, 0.45-0.88). Other domains demonstrated slight or fair agreement. CONCLUSION: Consistent interrater agreement was found across the 3 assessment tools for allocation concealment and for 2 tools for sequence generation. However, users should acknowledge that moderate variation exists within other items requiring more judgment. When evaluating rehabilitation RCTs, clinicians should consider limitations of rating certain items within the selected assessment tool.

Feasibility of a provincial voluntary reporting system for work-related asthma in Ontario.

OBJECTIVE: The Ontario Work-Related Asthma Surveillance System: Physician Reporting (OWRAS) Network was established in 2007 to estimate the prevalence of work-related asthma (WRA) in Ontario, and to test the feasibility of collecting data for cases of WRA from physicians voluntarily. METHODS: More than 300 respirologists, occupational medicine physicians, allergists and primary care providers in Ontario were invited to participate in monthly reporting of WRA cases by telephone, postal service or e-mail. RESULTS: Since 2007, 49 physicians have registered with the OWRAS Network and, to date, have reported 34 cases of occupational asthma and 49 cases of work-exacerbated asthma. Highly reactive chemicals were the most frequently reported suspected causative agent of the 108 suspected exposures reported. CONCLUSION: Despite the challenge of enlisting a representative sample of physicians in Ontario willing to report, the OWRAS Network has shown that it is feasible to implement a voluntary reporting system for WRA; however, its long-term sustainability is currently unknown.

Complexity of food preparation and food security status in low-income young women.

PURPOSE: This study was conducted to explore whether preparing more complex meals was associated with higher food security status. METHODS: This mixed-methods, community-based study involved the use of semistructured interviews to examine the cooking practices of a group of young, low-income women in Montreal. Fifty participants aged 18 to 35 were recruited at 10 locations in five low-income neighbourhoods. Food security status was the main outcome measure and the main exposure variable, "complex food preparation," combined the preparation of three specific food types (soups, sauces, and baked goods) using basic ingredients. RESULTS: Low-income women preparing a variety of meals using basic ingredients at least three times a week were more than twice as likely to be food secure as were women preparing more complex meals less frequently. CONCLUSIONS: Women who prepared more complex meals more frequently had higher food security. Whether this means that preparing more complex foods results in greater food security remains unclear, as this was an exploratory study.

Botulinum toxin for subacute/chronic neck pain.

BACKGROUND: Neck disorders are common, disabling and costly. Botulinum toxin (BoNT) intramuscular injections are often used with the intention of treating neck pain. OBJECTIVES: To systematically evaluate the literature on the treatment effectiveness of BoNT for neck pain, disability, global perceived effect and quality of life in adults with neck pain with or without associated cervicogenic headache, but excluding cervical radiculopathy and whiplash associated disorder. SEARCH STRATEGY: We searched CENTRAL, MEDLINE, AMED, Index to Chiropractic Literature, CINAHL, LILACS, and EMBASE from their origin to 20 September 2010. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials in which BoNT injections were used to treat subacute or chronic neck pain. DATA COLLECTION AND ANALYSIS: A minimum of two review authors independently selected articles, abstracted data, and assessed risk of bias, using the Cochrane Back Review Group criteria. In the absence of clinical heterogeneity, we calculated standardized mean differences (SMD) and relative risks, and performed meta-analyses using a random-effects model. The quality of the evidence and the strength of recommendations were assigned an overall grade for each outcome. MAIN RESULTS: We included nine trials (503 participants). Only BoNT type A (BoNT-A) was used in these studies.High quality evidence suggests there was little or no difference in pain between BoNT-A and saline injections at four weeks (five trials; 252 participants; SMD pooled -0.07 (95% confidence intervals (CI) -0.36 to 0.21)) and six months for chronic neck pain. Very low quality evidence indicated little or no difference in pain between BoNT-A combined with physiotherapeutic exercise and analgesics and saline injection with physiotherapeutic exercise and analgesics for patients with chronic neck pain at four weeks (two trials; 95 participants; SMD pooled 0.09 (95% CI -0.55 to 0.73)) and six months (one trial; 24 participants; SMD -0.56 (95% CI -1.39 to 0.27)). Very low quality evidence from one trial (32 participants) showed little or no difference between BoNT-A and placebo at four weeks (SMD 0.16 (95% CI -0.53 to 0.86)) and six months (SMD 0.00 (95% CI -0.69 to 0.69)) for chronic cervicogenic headache. Very low quality evidence from one trial (31 participants), showed a difference in global perceived effect favouring BoNT-A in chronic neck pain at four weeks (SMD -1.12 (95% CI: -1.89 to -0.36)). AUTHORS' CONCLUSIONS: Current evidence fails to confirm either a clinically important or a statistically significant benefit of BoNT-A injection for chronic neck pain associated with or without associated cervicogenic headache. Likewise, there was no benefit seen for disability and quality of life at four week and six months.

Conventional and sharp safety devices in 6 hospitals in British Columbia, Canada.

BACKGROUND: Reengineered sharp safety devices have been recommended to reduce occupational percutaneous injury risk in health care facilities. We conducted this study just over 1 year after passage of legislation requiring the use of sharp safety medical devices to assess the frequency of safety and conventional sharp device use and whether safety features were being activated to cover sharp points after safety devices were used and before disposal. METHODS: Approximately equal numbers of sharps disposal containers from various wards in 6 nonprofit adult and pediatric British Columbia hospitals were audited by paired research assistants, wearing protective clothing. RESULTS: In the 699 audited sharps containers, 7% (1,690/25,910) of all devices were conventional devices, specifically 2% (96/4,702) of all phlebotomy devices, 7% (1,240/17,705) of all syringes, and 10% (354/3,503) of all intravenous catheters. In addition, 94% (4,344/4,602) of all safety phlebotomy devices, 95% (2,955/3,119) of all safety intravenous devices, and 80% (13,050/16,420) of all safety syringes had been activated before disposal. CONCLUSION: More than 1 year after legislation was passed mandating the use of sharp safety devices in British Columbia hospitals, the risk from sharps remains excessive because of the ongoing use of conventional sharp devices and nonactivation of safety devices.

Ongoing use of conventional devices and safety device activation rates in hospitals in Ontario, Canada.

This study assessed voluntary compliance with the use of sharp safety devices in lieu of conventional ones and the activation status of these safety devices: VanishPoint syringes, Terumo Surshield butterflies, and Insyte Autoguard IV catheters. Sharps disposal containers from various wards in three private, not-for profit, university-affiliated Ontario hospitals were audited during 9 days in August 2007. In the 149 audited sharps containers, 55% of all syringes found were conventional compared with 45% that were safety syringes. In the three hospitals, the percentages of conventional (non-safety) vs. safety syringes found in used sharps containers were as follows, respectively: (i) 72% conventional and 28% safety, (ii) 55% conventional and 45% safety, and (iii) 65% conventional and 35% safety. In addition, it was found that 77% of 2131 Terumo butterflies, 97% of 1117 Insyte Autoguard IV catheters, and 87% of 4897 VanishPoint syringes in the containers had been activated. This study, carried out approximately 1 year before it was legally required to use safety instead of sharp conventional devices, found that most devices in use were conventional ones. It was also found that only the activation rate for the safety IV device was acceptable.

Surgeons' and residents' double-gloving practices at 2 teaching hospitals in Ontario.

BACKGROUND: Surgeons and residents are at increased risk of exposure to blood-borne pathogens owing to percutaneous injury (PI) and contamination. One method known to reduce risk is double-gloving (DG) during surgery. METHODS: All surgeons and residents affiliated with the University of Western Ontario (UWO) and McMaster University in 2005 were asked to participate in a Web-based survey. The survey asked respondents their specialty, the number of operations they participated in per week, their age and sex, the proportion of surgeries in which they double-gloved (DG in ≥75% surgeries was considered to be routine), and the average number of PIs they sustained per year and whether or not they reported them to an employee health service. RESULTS: In total, 155 of 331 (47%) eligible surgeons and residents responded; response rates for UWO and McMaster surgeons were 50% and 39%, respectively, and for UWO and McMaster residents, they were 52% and 47%, respectively. A total of 43% of surgeons and residents reported routine DG; 50% from McMaster and 36% from UWO. Using logistic regression to simultaneously adjust for participant characteristics, we confirmed that DG was more frequent at McMaster than at UWO, with an odds ratio of 3.32 (95% confidence interval 1.35-8.17). Surgeons and residents reported an average of 3.3 surgical PIs per year (2.2 among McMaster participants and 4.5 among UWO participants). Of the 77% who reported at least 1 injury/year, 67% stated that they had not reported it to an employee health service. CONCLUSION: Percutaneous injuries occur frequently during surgery, yet routine DG, an effective means of reducing risk, was carried out by less than half of the surgeons and residents participating in this study. This highlights the need for a more concerted and broad-based approach to increase the use of a measure that is effective, inexpensive and easily carried out.

Botulinum toxin intramuscular injections for neck pain: a systematic review and metaanalysis.

OBJECTIVE: To assess the effect of intramuscular botulinum toxin type A (BoNT-A) injections on pain, function/disability, global perceived effect, and quality of life (QOL) in adults with neck pain (NP). METHODS: We searched Central, Medline, and Embase databases up to June 2010. A minimum of 2 authors independently selected articles, abstracted data, and assessed risk of bias and clinical applicability. We estimated standard mean differences (SMD) with 95% CI, relative risks (RR), and performed metaanalyses (SMD(p)) using a random-effects model for nonheterogeneous data. The approach of the Grading of Recommendations Assessment, Development, and Evaluation working group summarizes the quality of evidence. RESULTS: We selected 14 trials. High-quality evidence suggested BoNT-A was no better than saline at 4 weeks [4 trials/183 participants; SMD(p) -0.21 (95% CI -0.50 to 0.07)] and 6 months for chronic NP. Moderate-quality evidence showed a similar effect for subacute/chronic whiplash-associated disorder (WAD) on pain [4 trials/122 participants; SMD(p) -0.21 (95% CI -0.57 to 0.15)], disability, and QOL. Very low-quality evidence indicated BoNT-A combined with exercise and analgesics was not significant for chronic NP reduction at 4 weeks [3 trials/114 participants; SMD(p) -0.08 (95% CI -0.45 to 0.29)] but was at 6 months [2 trials/43 participants; SMD(p) -0.66 (95% CI -1.29 to -0.04)]. CONCLUSION: Current evidence does not confirm a clinically or statistically significant benefit of BoNT-A used alone on chronic NP in the short term or on subacute/chronic WAD pain, disability, and QOL. Larger trials, subgroups, and predictors of responses defined a priori (to facilitate selection of patients most likely to benefit) and factorial designs to explore BoNT as an adjunct treatment to physiotherapeutic exercise and analgesics are needed.