Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Primary Low Back Pain in Adults.

PURPOSE: To evaluate benefits and harms of transcutaneous electrical nerve stimulation (TENS) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: We searched for randomized controlled trials (RCTs) from various electronic databases from July 1, 2007 to March 9, 2022. Eligible RCTs targeted TENS compared to placebo/sham, usual care, no intervention, or interventions with isolated TENS effects (i.e., combined TENS with treatment B versus treatment B alone) in adults with CPLBP. We extracted outcomes requested by the WHO Guideline Development Group, appraised the risk of bias, conducted meta-analyses where appropriate, and graded the certainty of evidence using GRADE. RESULTS: Seventeen RCTs (adults, n = 1027; adults ≥ 60 years, n = 28) out of 2010 records and 89 full text RCTs screened were included. The evidence suggested that TENS resulted in a marginal reduction in pain compared to sham (9 RCTs) in the immediate term (2 weeks) (mean difference (MD) = -0.90, 95% confidence interval -1.54 to -0.26), and a reduction in pain catastrophizing in the short term (3 months) with TENS versus no intervention or interventions with TENS specific effects (1 RCT) (MD = -11.20, 95% CI -17.88 to -3.52). For other outcomes, little or no difference was found between TENS and the comparison interventions. The certainty of the evidence for all outcomes was very low. CONCLUSIONS: Based on very low certainty evidence, TENS resulted in brief and marginal reductions in pain (not deemed clinically important) and a short-term reduction in pain catastrophizing in adults with CPLBP, while little to no differences were found for other outcomes.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Needling Therapies for Chronic Primary Low Back Pain in Adults.

PURPOSE: Evaluate benefits and harms of needling therapies (NT) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: Electronic databases were searched for randomized controlled trials (RCTs) assessing NT compared with placebo/sham, usual care, or no intervention (comparing interventions where the attributable effect could be isolated). We conducted meta-analyses where indicated and graded the certainty of evidence. RESULTS: We screened 1831 citations and 109 full text RCTs, yeilding 37 RCTs. The certainty of evidence was low or very low across all included outcomes. There was little or no difference between NT and comparisons across most outcomes; there may be some benefits for certain outcomes. Compared with sham, NT improved health-related quality of life (HRQoL) (physical) (2 RCTs; SMD = 0.20, 95%CI 0.07; 0.32) at 6 months. Compared with no intervention, NT reduced pain at 2 weeks (21 RCTs; MD = - 1.21, 95%CI - 1.50; - 0.92) and 3 months (9 RCTs; MD = - 1.56, 95%CI - 2.80; - 0.95); and reduced functional limitations at 2 weeks (19 RCTs; SMD = - 1.39, 95%CI - 2.00; - 0.77) and 3 months (8 RCTs; SMD = - 0.57, 95%CI - 0.92; - 0.22). In older adults, NT reduced functional limitations at 2 weeks (SMD = - 1.10, 95%CI - 1.71; - 0.48) and 3 months (SMD = - 1.04, 95%CI - 1.66; - 0.43). Compared with usual care, NT reduced pain (MD = - 1.35, 95%CI - 1.86; - 0.84) and functional limitations (MD = - 2.55, 95%CI - 3.70; - 1.40) at 3 months. CONCLUSION: Based on low to very low certainty evidence, adults with CPLBP experienced some benefits in pain, functioning, or HRQoL with NT; however, evidence showed little to no differences for other outcomes.

Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Structured and Standardized Education or Advice for Chronic Primary low back pain in Adults.

PURPOSE: Evaluate benefits and harms of education/advice for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. METHODS: Electronic databases were searched for randomized controlled trials (RCTs) assessing education/advice compared with placebo/sham, usual care, or no intervention (including comparison interventions where the attributable effect of education/advice could be isolated). We conducted meta-analyses and graded the certainty of evidence. RESULTS: We screened 2514 citations and 86 full text RCTs and included 15 RCTs. Most outcomes were assessed 3 to 6 months post-intervention. Compared with no intervention, education/advice improved pain (10 RCTs, MD = -1.1, 95% CI -1.63 to -0.56), function (10 RCTs, SMD = -0.51, 95% CI -0.89 to -0.12), physical health-related quality of life (HRQoL) (2 RCTs, MD = 24.27, 95% CI 12.93 to 35.61), fear avoidance (5 RCTs, SMD = -1.4, 95% CI -2.51 to -0.29), depression (1 RCT; MD = 2.10, 95% CI 1.05 to 3.15), and self-efficacy (1 RCT; MD = 4.4, 95% CI 2.77 to 6.03). Education/advice conferred less benefit than sham Kinesio taping for improving fear avoidance regarding physical activity (1 RCT, MD = 5.41, 95% CI 0.28 to 10.54). Compared with usual care, education/advice improved pain (1 RCT, MD = -2.10, 95% CI -3.13 to -1.07) and function (1 RCT, MD = -7.80, 95% CI -14.28 to -1.32). There was little or no difference between education/advice and comparisons for other outcomes. For all outcomes, the certainty of evidence was very low. CONCLUSION: Education/advice in adults with CPLBP was associated with improvements in pain, function, HRQoL, and psychological outcomes, but with very low certainty.

Post-Concussion Symptoms and Disability in Adults With Mild Traumatic Brain Injury: A Systematic Review and Meta-Analysis.

Studies investigating long-term symptoms and disability after mild traumatic brain injury (mTBI) have yielded mixed results. This systematic review and meta-analysis aimed to determine the prevalence of self-reported post-concussion symptoms (PCS) and disability following mTBI. We systematically searched MEDLINE, Embase, CINAHL, CENTRAL, and PsycInfo to identify inception cohort studies of adults with mTBI. Paired reviewers independently extracted data and assessed risk of bias with the Scottish Intercollegiate Guidelines Network criteria. We identified 43 eligible studies for the systematic review; 41 were rated as high risk of bias, primarily due to high attrition (> 20%). Twenty-one studies (49%) were included in the meta-analyses (five studies were narratively synthesized; 17 studies were duplicate reports). At 3-6 months post-injury, the estimated prevalence of PCS from random-effects meta-analyses was 31.3% (95% confidence interval [CI] = 25.4-38.4) using a lenient definition of PCS (2-4 mild severity PCS) and 18.3% (95% CI = 13.6-24.0) using a more stringent definition. The estimated prevalence of disability was 54.0% (95% CI = 49.4-58.6) and 29.6% (95% CI = 27.8-31.5) when defined as Glasgow Outcome Scale-Extended <8 and <7, respectively. The prevalence of symptoms similar to PCS was higher in adults with mTBI versus orthopedic injury (prevalence ratio = 1.57, 95% CI = 1.22-2.02). In a meta-regression, attrition rate was the only study-related factor significantly associated with higher estimated prevalence of PCS. Setting attrition to 0%, the estimated prevalence of PCS (lenient definition) was 16.1%. We conclude that nearly one in three adults who present to an emergency department or trauma center with mTBI report at least mild severity PCS 3-6 months later, but controlling for attrition bias, the true prevalence may be one in six. Studies with representative samples and high retention rates are needed.

Changes in Manipulative Peak Force Modulation and Time to Peak Thrust among First-Year Chiropractic Students Following a 12-Week Detraining Period.

OBJECTIVE: The purpose of this study was to analyze differences in peak force modulation and time-to-peak thrust in posterior-to-anterior (PA) high-velocity-low-amplitude (HVLA) manipulations in first-year chiropractic students prior to and following a 12-week detraining period. METHODS: Chiropractic students (n=125) performed 2 thrusts prior to and following a 12-week detraining period: total peak force targets were 400 and 600 N, on a force-sensing table using a PA hand contact of the participant's choice (bilateral hypothenar, bilateral thenar, or cross bilateral). Force modulation was compared to defined target total peak force values of 600 and 400 N, and time-to-peak thrust was compared between data sets using 2-tailed paired t-tests. RESULTS: Total peak force for the 600 N intensity varied by 124.11 + 65.77 N during the pre-test and 123.29 + 61.43 N during the post-test compared to the defined target of 600 N (P = .90); total peak force for the 400 N intensity varied by 44.91 + 34.67 N during the pre-test and 44.60 + 32.63 N during the post-test compared to the defined target of 400 N (P = .57). Time-to-peak thrust for the 400 N total peak force was 137.094 + 42.47 milliseconds during the pre-test and 125.385 + 37.46 milliseconds during the post-test (P = .0004); time-to-peak thrust for the 600 N total peak force was 136.835 + 40.48 milliseconds during the pre-test and 125.385 + 33.78 milliseconds during the post-test (P = .03). CONCLUSIONS: The results indicate no drop-off in the ability to modulate force for either thrust intensity, but did indicate a statistically significant change in time-to-peak thrust for the 400 N total peak force thrust intensity in first-year chiropractic students following a 12-week detraining period.