Clinical practice guidelines on interventional management of low back pain: A synthesis of recommendations.

OBJECTIVE: To summarize the recommendations on the interventional management of subacute and chronic nonradicular low back pain (LBP) from the 21 quality-appraised clinical practice guidelines (CPGs) identified in a previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review." By disseminating this information, we aimed to facilitate the implementation of these recommendations into clinical practice. TYPE: Systematic Review LITERATURE SURVEY: Electronic bibliographic databases, guideline databases, and gray literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria. METHODOLOGY: A total of 21 CPGs were quality appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections, radiofrequency procedures (RF), facet injections, sacroiliac injections, and prolotherapy. Within each treatment category, the recommendations were organized based on two factors: quality of CPG and strength of recommendation. SYNTHESIS: Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly for. The second, third, and fourth most common strength of recommendations were inconclusive, weakly against, and strongly against, respectively, and the least common was strongly for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation was weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive. CONCLUSIONS: Most of the interventional management recommendations for management of nonradicular LBP in the 21 CPGs appraised in this review were either weakly for, weakly against, or inconclusive, with several recommendations within each treatment category contradicting each other. Appraisal of Guidelines for Research & Evaluation Instrument quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation.

The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. OBJECTIVE: To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. METHODS: In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. RESULTS: A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. CONCLUSIONS: Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.