Differences in Patient Characteristics, Number of Treatments, and Recovery Rates Between Referred and Self-referred Patients With Nonspecific Neck Pain in Manual Therapy: A Secondary Analysis.

OBJECTIVE: In various countries, patients can visit a physiotherapist via self-referral. The aims of this study were to evaluate whether there are differences between individuals with nonspecific neck pain who consult a manual therapist via self-referral and those who do so via referral by a physician concerning patient characteristics, number of treatments, and recovery; and whether (self-)referral is associated with recovery. METHODS: This study is part of a prospective cohort study with posttreatment and 12-month follow-up in a Dutch manual-therapy setting. Adult patients with nonspecific neck pain were eligible for participation. Baseline measurements included demographic data and data concerning neck pain. At follow-up, number of treatments, recovery, and satisfaction were assessed. To evaluate differences between the groups, we used the χ2 test and the independent t test. A logistic regression analysis was used to evaluate the association between referral status and recovery. RESULTS: In total, 272 manual therapists participated and 1311 patients were included. Of 831 patients whose referral data are available, about half patients consulted a manual therapist by self-referral. The mean number of treatments was 5.4, which did not differ between the 2 groups. We found no differences between the groups concerning age, sex, pain intensity at baseline, or recovery rate. Patients in the self-referral group experienced acute neck pain more frequently, had recurrent complaints more often, and reported less disability compared to the referred group. Referral status was not associated with recovery. CONCLUSION: We found several small differences between self-referred and referred patients.

Prospective Cohort Study of Patients With Neck Pain in a Manual Therapy Setting: Design and Baseline Measures.

OBJECTIVES: The purpose of this study was to describe the design and baseline measurements of a prospective multicenter cohort study in patients with neck pain treated by Dutch manual therapists. Objectives of the study were to determine which patients seek help from a manual therapist, to describe usual care manual therapy in patients with neck pain, to examine the occurrence of nonserious adverse events after treatment, to describe predictors of adverse events, and to determine whether the occurrence of nonserious adverse events affect outcome after manual therapy care. METHODS: During a 3-month inclusion period, consecutive patients aged between 18 and 80 years presenting with neck pain in manual therapy practices in The Netherlands were included in the study. Baseline questionnaires included the Numeric Rating Scale, Neck Disability Index (NDI), Neck Bournemouth Questionnaire, Fear Avoidance Beliefs Questionnaire (FABQ), and Patient Expectancy List. Within the treatment episode, manual therapist clinical reasoning and applied interventions were registered and patients reported on adverse events. At the end of the treatment episode and at 12-month follow-up, pain intensity (Numeric Rating Scale), functional outcomes (NDI, Neck Bournemouth Questionnaire), personal factors (FABQ), and global perceived effect were measured. RESULTS: During the 3-month inclusion period, 263 participating manual therapists collected data on 1193 patients with neck pain. Most patients (69.4%) were female. The mean age was 44.7 (±13.7) years. The NDI showed overall mild disability (mean score 26%). Mean scores in pain intensity were moderate (4.8), and there was low risk of prolonged disability owing to personal factors (FABQ). CONCLUSION: This study provides information on baseline characteristics of patients visiting manual therapists for neck pain. In The Netherlands, patients seeking care of manual therapists are comparable to patients in other countries regarding demographics and neck pain characteristics.

Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review.

Background: Headache is the most common neurological symptoms worldwide, as over 90% of people have noted at least one headache during their lifetime. Tension-type headaches, cervicogenic headaches, and migraines are common types of headache which can have a significant impact on social, physical, and occupational functioning. Therapeutic management of headaches mainly includes physical therapy and pharmacological interventions. Dry needling is a relatively new therapeutic approach that uses a thin filiform needle without injectate to penetrate the skin and stimulate underlying tissues for the management of neuromusculoskeletal pain and movement impairments.The main objective of this systematic review and meta-analysis is to evaluate the effectiveness of dry needling in comparison to other interventions on pain and disability in patients with tension-type headache, cervicogenic headache, and migraine. Methods/design: We will focus on clinical trials with concurrent control group(s) and comparative observational studies assessing the effect of dry needling in patients with tension-type headache, cervicogenic headache, and migraine. Electronic databases from relevant fields of research (PubMed/ Medline, Scopus, Embase®, PEDro, Web of Science, Ovid, AMED, CENTRAL, and Google Scholar) will be searched from inception to June 2019 using defined search terms. No restrictions for language of publication or geographic location will be applied. Moreover, grey literature, citation tracking, and reference lists scanning of the selected studies will be searched manually. Primary outcomes of this study are pain intensity and disability, and secondary outcomes are cervical spine ROM, frequency of headaches, health-related quality of life, and TrPs tenderness. Studies will be selected by three independent reviewers based on prespecified eligibility criteria. Three reviewers will independently extract data in each eligible study using a pre-piloted Microsoft Excel data extraction form. The assessment of risk of bias will be implemented using the Cochrane Back and Neck Review Group 13-item criteria and NOS. Direct meta-analysis will be performed using a fixed or random effects model to estimate effect size such as standardized mean difference (Morris's dppc ) and 95% confidence intervals. Statistical heterogeneity will also be evaluated using the I2 statistic and the χ2 test. All meta-analyses will be performed using Stata V.11 and V.14 softwares. The overall quality of the evidence for the primary outcomes will be assessed using GRADE. Discussion: All analyses in this study will be based on the previous published papers. Therefore, ethical approval and patient consent are not required. The findings of this study will provide important information on the value of dry needling for the management of tension-type headache, cervicogenic headache, and migraine. Trial registration: PROSPERO registration number: CRD42019124125.

Does the outcome of diagnostic ultrasound influence the treatment modalities and recovery in patients with shoulder pain in physiotherapy practice? Results from a prospective cohort study.

STUDY DESIGN: Prospective cohort study including patients with shoulder pain in primary care physiotherapy. BACKGROUND: There is an increased tendency to use diagnostic ultrasound to aid the diagnostic strategy and target treatment. It is a relatively cheap and accessible imaging technique but the implications for practice and patients are unknown. OBJECTIVES: To study the influence of diagnostic ultrasound (DUS) on diagnostic work-up, treatment modalities and recovery. METHODS: Participants (n = 389) with a new episode of shoulder pain were assessed at baseline and followed for 6, 12 and 26 weeks. Diagnostic work-up, including the use of DUS, and treatment strategies were reported by the therapists at 3, 6 and 12 weeks. RESULTS: Most patients (41%) were diagnosed with subacromial impingement/pain syndrome after physical examination or DUS. DUS was used in 31% of the participants. Tendinopathy was the most found abnormality in this sub-population. Patients who underwent DUS were more frequently treated using exercise therapy. Patients that not had DUS were more likely to receive massage therapy, trigger point therapy or mobilisation techniques. Logistic regression analyses did not show a significant association between DUS and recovery after 26 weeks (0.88, 95%CI:0.50-1.57). Correcting for the therapist as a confounder using a multilevel binary logistic regression did not show a significant cluster effect. CONCLUSION: Diagnostic US as a work-up component does not seem to influence diagnosis or recovery but does influence the choice of treatment modality. Conclusions are limited to observational data. High quality randomized trials should study the effect of DUS on recovery.

Prevention and treatment of low back pain: evidence, challenges, and promising directions.

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Carpal Tunnel Syndrome: Effectiveness of Physical Therapy and Electrophysical Modalities. An Updated Systematic Review of Randomized Controlled Trials.

OBJECTIVE: To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS). DATA SOURCES: The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database. STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential eligible studies. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool. DATA SYNTHESIS: A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint, continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be identified. CONCLUSIONS: Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for CTS.

Effectiveness of Surgical and Postsurgical Interventions for Carpal Tunnel Syndrome-A Systematic Review.

OBJECTIVE: To present an evidence-based overview of the effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome (CTS). DATA SOURCES: The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016. STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS: A best-evidence synthesis was performed to summarize the results. Four systematic reviews and 33 RCTs were included. Surgery versus nonsurgical interventions, timing of surgery, and various surgical techniques and postoperative interventions were studied. Corticosteroid injection was more effective than surgery (strong evidence, short-term). Surgery was more effective than splinting or anti-inflammatory drugs plus hand therapy (moderate evidence, midterm and long-term). Manual therapy was more effective than surgical treatment (moderate evidence, short-term and midterm). Within surgery, corticosteroid irrigation of the median nerve before skin closure as additive to CTS release or the direct vision plus tunneling technique was more effective than standard open CTS release (moderate evidence, short-term). Furthermore, short was more effective than long bulky dressings, and a sensory retraining program was more effective than no program after surgery (moderate evidence, short-term). For all other interventions only conflicting, limited, or no evidence was found. CONCLUSIONS: Surgical treatment seems to be more effective than splinting or anti-inflammatory drugs plus hand therapy in the short-term, midterm, and/or long-term to treat CTS. However there is strong evidence that a local corticosteroid injection is more effective than surgery in the short-term, and moderate evidence that manual therapy is more effective than surgery in the short-term and midterm. There is no unequivocal evidence that suggests one surgical treatment is more effective than the other. Postsurgical, a short- (2-3 days) favored a long-duration (9-14 days) bulky dressing and a sensory retraining program seems to be more effective than no program in short-term. More research regarding the optimal timing of surgery for CTS is needed.

Do Patients With Carpal Tunnel Syndrome Benefit From Low-Level Laser Therapy? A Systematic Review of Randomized Controlled Trials.

OBJECTIVE: To systematically review the literature on the effectiveness of low-level laser therapy for patients with carpal tunnel syndrome. DATA SOURCES: The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database were searched for relevant systematic reviews and randomized controlled trials (RCTs) up to April 8, 2016. STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS: A best-evidence synthesis was performed to summarize the results of the 2 systematic reviews and 17 RCTs that were included. Strong evidence was found for the effectiveness of low-level laser therapy compared with placebo treatment in the very short term (0 to ≤5wk). After 5 weeks, the positive effects of low-level laser therapy on pain, function, or recovery diminished over time (moderate and conflicting evidence were found at 7- and 12-wk follow-up, respectively). CONCLUSIONS: In the very short term, low-level laser therapy is more effective as a single intervention than placebo low-level laser therapy in patients with carpal tunnel syndrome, after which the positive effects of low-level laser therapy tend to subside. Evidence in the midterm and long term is sparse.

Back schools for acute and subacute non-specific low-back pain.

BACKGROUND: Since the introduction of the Swedish back school in 1969, back schools have frequently been used for treating people with low-back pain (LBP). However, the content of back schools has changed and appears to vary widely today. In this review we defined back school as a therapeutic programme given to groups of people, which includes both education and exercise. This is an update of a Cochrane review first published in 1999, and updated in 2004. For this review update, we split the review into two distinct reviews which separated acute from chronic LBP. OBJECTIVES: To assess the effectiveness of back schools on pain and disability for people with acute or subacute non-specific LBP. We also examined the effect on work status and adverse events. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, PubMed and two clinical trials registers up to 4 August 2015. We also checked the reference lists of articles and contacted experts in the field of research on LBP. SELECTION CRITERIA: We included randomised controlled trials (RCTs) or quasi-RCTs that reported on back school for acute or subacute non-specific LBP. The primary outcomes were pain and disability. The secondary outcomes were work status and adverse events. Back school had to be compared with another treatment, a placebo (or sham or attention control) or no treatment. DATA COLLECTION AND ANALYSIS: We used the 2009 updated method guidelines for this Cochrane review. Two review authors independently screened the references, assessed the quality of the trials and extracted the data. We set the threshold for low risk of bias, a priori, as six or more of 13 internal validity criteria and no serious flaws (e.g. large drop-out rate). We classified the quality of the evidence into one of four levels (high, moderate, low or very low) using the adapted Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We contacted study authors for additional information. We collected adverse effects information from the trials. MAIN RESULTS: The search update identified 273 new references, of which none fulfilled our inclusion criteria. We included four studies (643 participants) in this updated review, which were all included in the previous (2004) update. The quality of the evidence was very low for all outcomes. As data were too clinically heterogeneous to be pooled, we described individual trial results. The results indicate that there is very low quality evidence that back schools are no more effective than a placebo (or sham or attention control) or another treatment (physical therapies, myofascial therapy, joint manipulations, advice) on pain, disability, work status and adverse events at short-term, intermediate-term and long-term follow-up. There is very low quality evidence that shows a statistically significant difference between back schools and a placebo (or sham or attention control) for return to work at short-term follow-up in favour of back school. Very low quality evidence suggests that back school added to a back care programme is more effective than a back care programme alone for disability at short-term follow-up. Very low quality evidence also indicates that there is no difference in terms of adverse events between back school and myofascial therapy, joint manipulation and combined myofascial therapy and joint manipulation. AUTHORS' CONCLUSIONS: It is uncertain if back schools are effective for acute and subacute non-specific LBP as there is only very low quality evidence available. While large well-conducted studies will likely provide more conclusive findings, back schools are not widely used interventions for acute and subacute LBP and further research into this area may not be a priority.

Evidence for the effectiveness of electrophysical modalities for treatment of medial and lateral epicondylitis: a systematic review.

BACKGROUND: Several treatments are available to treat epicondylitis. Among these are instrumental electrophysical modalities, ranging from ultrasound, extracorporeal shock wave therapy (ESWT), transcutaneous electrical nerve stimulation (TENS) to laser therapy, commonly used to treat epicondylitis. OBJECTIVES: To present an evidence-based overview of the effectiveness of electrophysical modality treatments for both medial and lateral epicondylitis (LE). METHODS: Searches in PubMed, EMBASE, CINAHL and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results. RESULTS: A total of 2 reviews and 20 RCTs were included, all of which concerned LE. Different electrophysical regimes were evaluated: ultrasound, laser, electrotherapy, ESWT, TENS and pulsed electromagnetic field therapy. Moderate evidence was found for the effectiveness of ultrasound versus placebo on mid-term follow-up. Ultrasound plus friction massage showed moderate evidence of effectiveness versus laser therapy on short-term follow-up. On the contrary, moderate evidence was found in favour of laser therapy over plyometric exercises on short-term follow-up. For all other modalities only limited/conflicting evidence for effectiveness or evidence of no difference in effect was found. CONCLUSIONS: Potential effectiveness of ultrasound and laser for the management of LE was found. To draw more definite conclusions high-quality RCTs examining different intensities are needed as well as studies focusing on long-term follow-up results.

Subacromial impingement syndrome--effectiveness of physiotherapy and manual therapy.

BACKGROUND: The subacromial impingement syndrome (SIS) includes the rotator cuff syndrome, tendonitis and bursitis of the shoulder. Treatment includes surgical and non-surgical modalities. Non-surgical treatment is used to reduce pain, to decrease the subacromial inflammation, to heal the compromised rotator cuff and to restore satisfactory function of the shoulder. To select the most appropriate non-surgical intervention and to identify gaps in scientific knowledge, we explored the effectiveness of the interventions used, concentrating on the effectiveness of physiotherapy and manual therapy. METHODS: The Cochrane Library, PubMed, EMBASE, PEDro and CINAHL were searched for relevant systematic reviews and randomised clinical trials (RCTs). Two reviewers independently extracted data and assessed the methodological quality. A best-evidence synthesis was used to summarise the results. RESULTS: Two reviews and 10 RCTs were included. One RCT studied manual therapy as an add-on therapy to self-training. All other studies studied the effect of physiotherapy: effectiveness of exercise therapy, mobilisation as an add-on therapy to exercises, ultrasound, laser and pulsed electromagnetic field. Moderate evidence was found for the effectiveness of hyperthermia compared to exercise therapy or ultrasound in the short term. Hyperthermia and exercise therapy were more effective in comparison to controls or placebo in the short term (moderate evidence). For the effectiveness of hyperthermia, no midterm or long-term results were studied. In the midterm, exercise therapy gave the best results (moderate evidence) compared to placebo or controls. For other interventions, conflicting, limited or no evidence was found. CONCLUSIONS: Some physiotherapeutic treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults.

BACKGROUND: Work-related upper limb disorder (WRULD), repetitive strain injury (RSI), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as those associated with operating vibrating tools. Work-related CANS, which is the term we use in this review, severely hampers the working population. OBJECTIVES: To assess the effects of conservative interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work-related outcomes. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 31 May 2013), MEDLINE (1950 to 31 May 2013), EMBASE (1988 to 31 May 2013), CINAHL (1982 to 31 May 2013), AMED (1985 to 31 May 2013), PsycINFO (1806 to 31 May 2013), the Physiotherapy Evidence Database (PEDro; inception to 31 May 2013) and the Occupational Therapy Systematic Evaluation of Evidence Database (OTseeker; inception to 31 May 2013). We did not apply any language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-randomised controlled trials evaluating conservative interventions for work-related complaints of the arm, neck or shoulder in adults. We excluded trials undertaken to test injections and surgery. We included studies that evaluated effects on pain, functional status or work ability. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included studies. When studies were sufficiently similar, we performed statistical pooling of reported results. MAIN RESULTS: We included 44 studies (62 publications) with 6,580 participants that evaluated 25 different interventions. We categorised these interventions according to their working mechanisms into exercises, ergonomics, behavioural and other interventions.Overall, we judged 35 studies as having a high risk of bias mainly because of an unknown randomisation procedure, lack of a concealed allocation procedure, unblinded trial participants or lack of an intention-to-treat analysis.We found very low-quality evidence showing that exercises did not improve pain in comparison with no treatment (five studies, standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -1.08 to 0.03), or minor intervention controls (three studies, SMD -0.25, 95% CI -0.87 to 0.37) or when provided as additional treatment (two studies, inconsistent results) at short-term follow-up or at long-term follow-up. Results were similar for recovery, disability and sick leave. Specific exercises led to increased pain at short-term follow-up when compared with general exercises (four studies, SMD 0.45, 95% CI 0.14 to 0.75)We found very low-quality evidence indicating that ergonomic interventions did not lead to a decrease in pain when compared with no intervention at short-term follow-up (three studies, SMD -0.07, 95% CI -0.36 to 0.22) but did decrease pain at long-term follow-up (four studies, SMD -0.76, 95% CI -1.35 to -0.16). There was no effect on disability but sick leave decreased in two studies (risk ratio (RR) 0.48, 95% CI 0.32 to 0.76). None of the ergonomic interventions was more beneficial for any outcome measures when compared with another treatment or with no treatment or with placebo.Behavioural interventions had inconsistent effects on pain and disability, with some subgroups showing benefit and others showing no significant improvement when compared with no treatment, minor intervention controls or other behavioural interventions.In the eight studies that evaluated various other interventions, there was no evidence of a clear beneficial effect of any of the interventions provided. AUTHORS' CONCLUSIONS: We found very low-quality evidence indicating that pain, recovery, disability and sick leave are similar after exercises when compared with no treatment, with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm, neck or shoulder. Low-quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up. There was no evidence of an effect on other outcomes. For behavioural and other interventions, there was no evidence of a consistent effect on any of the outcomes.Studies are needed that include more participants, that are clear about the diagnosis of work-relatedness and that report findings according to current guidelines.

Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review.

BACKGROUND: Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and mobilisation are considered for its treatment. OBJECTIVE: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis. METHODS: Searches in PubMed, Embase, Cinahl and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. RESULTS: One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and mid-term effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found. CONCLUSIONS: Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis.

Subacromial impingement syndrome: effectiveness of pharmaceutical interventions-nonsteroidal anti-inflammatory drugs, corticosteroid, or other injections: a systematic review.

OBJECTIVE: To present an evidence-based overview of the effectiveness of pharmaceutical interventions, including nonsteroidal anti-inflammatory drugs, corticosteroid injections, and other injections, used to treat the subacromial impingement syndrome (SIS). An overview can help physicians select the most appropriate pharmaceutical intervention, and it can identify gaps in scientific knowledge. DATA SOURCES: The Cochrane Library, PubMed, Embase, PEDro, and CINAHL databases. STUDY SELECTION: Two reviewers independently selected relevant reviews and randomized clinical trials. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS: A best evidence synthesis was used to summarize the results. Three reviews and 5 randomized clinical trials were included. Although we found limited evidence for effectiveness in favor of 2 sessions with corticosteroid injections versus 1 session, for the effectiveness of corticosteroid injections versus placebo, nonsteroidal anti-inflammatory drugs, or acupuncture, only conflicting and no evidence for effectiveness was found. Moderate evidence was found in favor of immediate release oral ibuprofen compared with sustained-released ibuprofen in the short-term. Also, moderate evidence for effectiveness was found in favor of glyceryltrinitrate patches versus placebo patches in the short-term and mid term. Furthermore, injections with disodium ethylene diamine tetraacetic acid plus ultrasound with ethylene diamine tetraacetic acid gel were more effective (moderate evidence) than was placebo treatment in the short- and long-term. CONCLUSIONS: This article presents an overview of the effectiveness of pharmaceutical interventions for SIS. Some treatments seem to be promising (moderate evidence) to treat SIS, but more research is needed before firm conclusions can be drawn.

Trends over time in the size and quality of randomised controlled trials of interventions for chronic low-back pain.

PURPOSE: Previous reviews of randomised controlled trials (RCTs) for low-back pain (LBP) have failed to identify any positive trend in study quality with more recent years of publication. This study aimed to identify and describe trends over time in the study design characteristics and risk of bias in chronic LBP trials performed over the past 30 years. METHODS: One fifty-seven randomised trials of interventions for chronic LBP were extracted from recently published systematic reviews. The reviews included RCTs on physical and rehabilitation interventions, injection therapy and denervation procedures, complementary and alternative therapies and pharmacological interventions for chronic LBP. Study level data were extracted and analysed for trends associated with year of publication. RESULTS: Overall, the mean sample size in the RCTs was 141 (median 70; range 17-3093). There was a slight increase in the median number of risk of bias criteria fulfilled from trials published prior to 1995 to those published after 1996. The analysis showed that in more recent years RCTs of medical interventions were more likely to be successfully blinded than RCTs of non-medical interventions. CONCLUSIONS: The continuing uncertainty regarding the efficacy of many interventions for chronic LBP again stresses the need for large RCTs with low risk of bias. Further research is needed into specific risks of bias within the RCTs for chronic LBP and the effect they have on the plausibility of the results.

Headache: the placebo effects in the control groups in randomized clinical trials; an analysis of systematic reviews.

OBJECTIVE: The purpose of this study is to describe the effects in the placebo and "no treatment" arms in trials with headache patients. METHOD: This is a secondary analysis of randomized controlled trials from 8 systematic reviews and selected trials with a "no treatment" or placebo control group. The different types of "no treatment" and placebo interventions were assessed and classified into 6 subgroups. The analyses were carried out according to type of outcome variable. RESULTS: In total, 119 studies were included (7119 participants). The mean recovery rate in all control groups was 35.7%. Significantly more participants recovered in control groups of pharmacological studies than in nonpharmacological studies: 38.5% vs 15.0%, respectively. Adults were more likely to recover in nonpharmacological studies and children in pharmacological studies. CONCLUSIONS: The mean recovery rate in the control groups was 36%. The recovery rate varied substantially between type of intervention and patients.

Effectiveness of interventions for secondary Raynaud's phenomenon: a systematic review.

OBJECTIVES: To present an evidence-based overview of the effectiveness of (non)surgical symptomatic interventions to treat secondary Raynaud's phenomenon (RP). DATA SOURCES: The Cochrane Library, PubMed, Embase, PEDro, and CINAHL were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION: Two reviewers independently extracted data and assessed the methodologic quality. DATA SYNTHESIS: If pooling of data was not possible, a best-evidence synthesis was used to summarize the results. Of the 5 reviews and 19 RCTs included, 1 RCT studied acupuncture and another RCT reported on percutaneous radiofrequency thoracic sympathectomy. All others concentrated on the effectiveness of drugs (oral or intravenous [IV]). It appeared that calcium channel blockers significantly reduce the frequency and severity of Raynaud attacks, and are therefore effective in the treatment of secondary RP. Iloprost (oral and IV) was also found to be effective. Limited evidence was found for atorvastatin. For other traditional and more recently discovered interventions, no clear favorable effects were found. CONCLUSIONS: This review shows that there is clear evidence in favor of calcium channel blockers and iloprost (oral and IV) to treat secondary RP. For all other interventions, only limited, conflicting, or no evidence was found. More high-quality, well-designed RCTs are needed in this field, especially for new interventions based on recent knowledge about the pathophysiology of secondary RP.

Methodological quality of studies on the measurement properties of neck pain and disability questionnaires: a systematic review.

OBJECTIVE: The aim of this study was to obtain an overview of the methodological quality of studies on the measurement properties of neck pain and disability questionnaires and to describe how well various aspects of the design and statistical analyses of studies on measurement properties are performed. METHODS: A systematic review was performed of published studies on the measurement properties of neck pain and disability questionnaires. Two reviewers independently rated the quality of the studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. This checklist was developed in an international Delphi consensus study. RESULTS: A total of 47 articles were included on the measurement properties of 8 different questionnaires. The methodological quality of the included studies was adequate on some aspects (often, adequate statistical analyses are used for assessing reliability, measurement error, and construct validity) but can be improved on other aspects. The most important methodological aspects that need to be improved are as follows: assessing unidimensionality in internal consistency analysis, stable patients and similar test conditions in studies on reliability and measurement error, and more emphasis on the relevance and comprehensiveness of the items in content validity studies. Furthermore, it is recommended that studies on construct validity and responsiveness should be based on predefined hypotheses and that better statistical methods should be used in responsiveness studies. CONCLUSION: Considering the importance of adequate measurement properties, it is concluded that, in the field of measuring neck pain and disability, there is room for improvement in the methodological quality of studies measurement properties.

Explaining the ineffectiveness of a Tai Chi fall prevention training for community-living older people: a process evaluation alongside a randomized clinical trial (RCT).

The results of a randomized clinical trial (RCT) on the effects of a Tai Chi fall prevention in community-living older people with a high risk of falling in the Netherlands showed no beneficial effects on falls and secondary outcomes (e.g., balance, fear of falling). The aim of this study is to provide insight in process-related factors that may have influenced the effectiveness of the intervention. The intervention consisted of Tai Chi Chuan (TCC) training for 1 h twice a week for 13 weeks. We used self-administered questionnaires and registration forms to collect data from participants and instructors. We analyzed quantitative data by means of descriptive statistics and categorized qualitative data based on the content of the answers given. Of the participants, that started the program 89 (79%) completed the intervention, but a minority of 47% attended 80% of more of the lessons. All participants and instructors were positive about the program and most participants reported benefits from the intervention. Suggestions for improvements mainly relate to adjustments of training aspects. The main process-related factors that may be have influenced the lack of beneficial effects on falls and secondary outcomes are the relatively high withdrawal and the low adherence rates.

Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review.

OBJECTIVE: To review literature systematically concerning effectiveness of nonsurgical interventions for treating carpal tunnel syndrome (CTS). DATA SOURCES: The Cochrane Library, PubMed, EMBASE, CINAHL, and PEDro were searched for relevant systematic reviews and randomized controlled trials (RCTs). STUDY SELECTION: Two reviewers independently applied the inclusion criteria to select potential studies. DATA EXTRACTION: Two reviewers independently extracted the data and assessed the methodologic quality. DATA SYNTHESIS: A best-evidence synthesis was performed to summarize the results of the included studies. Two reviews and 20 RCTs were included. Strong and moderate evidence was found for the effectiveness of oral steroids, steroid injections, ultrasound, electromagnetic field therapy, nocturnal splinting, and the use of ergonomic keyboards compared with a standard keyboard, and traditional cupping versus heat pads in the short term. Also, moderate evidence was found for ultrasound in the midterm. With the exception of oral and steroid injections, no long-term results were reported for any of these treatments. No evidence was found for the effectiveness of oral steroids in long term. Moreover, although higher doses of steroid injections seem to be more effective in the midterm, the benefits of steroids injections were not maintained in the long term. For all other nonsurgical interventions studied, only limited or no evidence was found. CONCLUSIONS: The reviewed evidence supports that a number of nonsurgical interventions benefit CTS in the short term, but there is sparse evidence on the midterm and long-term effectiveness of these interventions. Therefore, future studies should concentrate not only on short-term but also on midterm and long-term results.