Evaluation of methodological and reporting quality of systematic reviews on conservative non-pharmacological musculoskeletal pain management in children and adolescents: A methodological analysis.

BACKGROUND: There are no studies investigating the methodological and report quality of systematic reviews of non-pharmacological interventions for musculoskeletal pain management among children and adolescents. OBJECTIVE: To evaluate the methodological and reporting quality of systematic reviews on conservative non-pharmacological pain management in children and adolescents with musculoskeletal pain. METHODS: Searches were conducted on the Cochrane Database of Systematic Reviews, Medline, Embase, and three other databases. Two pairs of reviewers independently assessed each article according to the predetermined selection criteria. We assessed the methodological quality of systematic reviews, using the AMSTAR 2 checklist and the quality of reporting, using PRISMA checklist. Descriptive analysis was used to summarise the characteristics of all included systematic reviews. The percentage of systematic reviews achieving each item from the AMSTAR 2, PRISMA checklist and the overall confidence in the results were described. RESULTS: We included 17 systematic reviews of conservative non-pharmacological pain management for musculoskeletal pain in children and adolescents. Of the 17 systematic reviews included, nine (53%) were rated as "critically low", seven (41%) were rated as "low", and one (6%) was rated as "high" methodological quality by AMSTAR-2. The reporting quality by items from PRISMA range from 17.6% (95% CI 6.2 to 41) to 100% (95% CI 81.6 to 100). CONCLUSION: This systematic review of physical interventions in children and adolescents showed overall 'very low' to 'high' methodological quality and usually poor reporting quality.

One step at a time. Shaping consensus on research priorities and terminology in telehealth in musculoskeletal pain: an international modified e-Delphi study.

BACKGROUND: Telehealth has emerged as an alternative model for treatment delivery and has become an important component of health service delivery. However, there is inconsistency in the use of terminologies and a lack of research priorities in telehealth in musculoskeletal pain. The purpose of this international, multidisciplinary expert panel assembled in a modified three-round e-Delphi survey is to achieve a consensus on research priorities and for the standard terminology for musculoskeletal pain telehealth practice. METHODS: In this international modified e-Delphi survey, we invited an expert panel consisting of researchers, clinicians, consumer representatives, industry partners, healthcare managers, and policymakers to participate in a three-round e-Delphi. Expert panels were identified through the Expertscape website, PubMed database, social media, and a snowball approach. In Round 1, potential research priorities and terminologies were presented to panel members. Panel members rated the agreement of each research priority on a 5-point Likert scale and an 11-point numerical scale, and each terminology on a 5-point Likert scale for the "telehealth in musculoskeletal pain " field over rounds. At least 80% of the panel members were required to agree to be deemed a consensus. We analyzed the data descriptively and assessed the stability of the results using the Wilcoxon matched-pairs signed rank test. RESULTS: We performed an international e-Delphi survey from February to August 2022. Of 694 invited people, 160 panel members participated in the first round, 133 in the second round (83% retention), and 134 in the third round (84% retention). Most of the panel members were researchers 76 (47%), clinicians 57 (36%), and consumer representatives 9 (6%) of both genders especially from Brazil 31 (19%), India 22 (14%), and Australia 19 (12%) in the first round. The panel identified fourteen telehealth research priorities spanned topics including the development of strategies using information and communication technology, telehealth implementation services, the effectiveness and cost-effectiveness of telehealth interventions, equity of telehealth interventions, qualitative research and eHealth literacy in musculoskeletal pain conditions from an initial list of 20 research priorities. The consensus was reached for "digital health" and "telehealth" as standard terminologies from an initial list of 37 terminologies. CONCLUSION: An international, multidisciplinary expert consensus recommends that future research should consider the 14 research priorities for telehealth musculoskeletal pain reached. Additionally, the terms digital health and telehealth as the most appropriate terminologies to be used in musculoskeletal telehealth research. REGISTER: Open Science Framework ( https://osf.io/tqmz2/ ).

Attitudes and beliefs of Brazilian physical therapists about chronic nonspecific low back pain and its impact on clinical decision-making: An Online Survey Study.

INTRODUCTION: Recent clinical practice guidelines recognize the importance of the biopsychosocial model in the management of patients with chronic nonspecific low back pain, and the attitudes and beliefs of physical therapists are believed to directly influence clinical decision-making. OBJECTIVE: To investigate factors associated to biomedical and biopsychosocial approaches and its impact on attitudes and beliefs to treat patients with chronic nonspecific low back pain. METHOD: This was a cross-sectional study conducted online with 302 Brazilian physiotherapists who treat patients with nonspecific chronic low back pain. The HC-PAIRS and PABS-PT were used to investigate attitudes and beliefs low back pain. Descriptive statistics and bivariate analyses were performed for association tests, comparing the scores on the scales between groups. In addition, multiple linear regression analyses were also used. RESULTS: The overall mean score of HC-PAIRS was 54.0 (9.0), and the biomedical and biopsychosocial factors of PABS-PT were 29.7 (9.0) and 36.2 (5.3), respectively. Significant associations were identified between gender (p = 0.04) and level of academic training (p < 0.00) and both scales, HC-PAIRS and PABSPT, respectively. CONCLUSION: Sociodemographic characteristics were associated with the beliefs of physical therapists; a higher score for treatment options for chronic low back pain based on the biomedical mode, was observed in female physiotherapist and in physios with higher education level. Variables such as age and length of professional experience indicated that the lower the age and/or length of professional experience of Brazilian physical therapists, the stronger the belief in the relationship between low back pain and tissue damage.

Implementation of an online pain science education for chronic musculoskeletal pain in Brazilian public health system: protocol for a hybrid type III randomised controlled trial with economic evaluation.

BACKGROUND: Although clinical practice guidelines recommend pain education as the first-line option for the management of chronic musculoskeletal pain, there is a lack of pain education programmes in healthcare. Thus, digital health programmes can be an effective tool for implementing pain education strategies for public health. This trial will aim to analyse the implementation and effectiveness outcomes of three online pain science education strategies in the Brazilian public health system (SUS) for individuals with chronic musculoskeletal pain. METHODS: We will conduct a hybrid type III effectiveness-implementation randomised controlled trial with economic evaluation. We will include adult individuals with chronic musculoskeletal pain, recruited from primary healthcare in the city of Guarapuava, Brazil. Individuals will be randomised to three implementation groups receiving a pain science education intervention (EducaDor) but delivered in different modalities: group 1) synchronous online; group 2) asynchronous videos; and group 3) interactive e-book only. Implementation outcomes will include acceptability, appropriateness, feasibility, adoption, fidelity, penetration, sustainability, and costs. We will also assess effectiveness outcomes, such as pain, function, quality of life, sleep, self-efficacy, and adverse effects. Cost-effectiveness and cost-utility analyses will be conducted from the SUS and societal perspectives. The evaluations will be done at baseline, post-intervention (10 weeks), and 6 months. DISCUSSION: This study will develop and implement a collaborative intervention model involving primary healthcare professionals, secondary-level healthcare providers, and patients to enhance self-management of chronic pain. In addition to promoting better pain management, this study will also contribute to the field of implementation science in public health by generating important insights and recommendations for future interventions. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05302180; 03/29/2022).

Translation, cross-cultural adaptation and measurement properties of three implementation measures into Brazilian-Portuguese.

BACKGROUND: To translate and cross-culturally adapt into Brazilian-Portuguese, and to test the measurement properties of the following items of implementation outcome measures: Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). METHODS: This was a measurement properties study in accordance with the Consensus-based Standards for the selection of health status Measurement Instruments (COSMIN). We conducted a translation and cross-cultural adaptation of three implementation measures according to guidelines for translation and cross-cultural adaptation, then we collected information from patients who had participated in remotely delivered physical therapy treatment for musculoskeletal condition. The patients answered the translated versions of the implementation outcome measures. The measurement properties of the three implementation outcome measures were collected in a test-retest assessment, with an interval of 7 to 14 days.. The measurement properties evaluated in this study were interpretability, measured using Ceiling and Floor Effects, reliability in test-retest evaluation, measured using Cronbach's Alpha Coefficient, internal consistency, measured using Intraclass Correlation Coefficient and construct validity, measured using Pearson Correlation. RESULTS: We included 104 participants (76 female). The average age of the sample was 56.8 (SD 14.8) years old. The items of implementation outcome measures (AIM, IAM, and FIM) showed 66.39%, 63.11%, and 63.93% of ceiling effects. The items of implementation outcome measures showed adequate internal consistency measured using Cronbach's Alpha Coefficient (AIM: 0.89, IAM: 0.91, FIM: 0.93) and values of Standard Error of Measurement between 5 and 10%, showing good measurement error. The results of AIM and IAM was classified as moderate reliability and the FIM as substantial reliability. In a total 96 correlations, > 75% of correlations met our prior hypothesis. CONCLUSION: The three Brazilian-Portuguese versions of items of implementation outcome measures had adequate internal consistency, measurement error and construct validity. The three implementation outcome measures showed moderate to substantial reliability values. The Ceiling Effect was observed in the three measures, showing maximum values ​​in more than 15% of the evaluations.

The state of the art in telerehabilitation for musculoskeletal conditions.

BACKGROUND: Given the rapid advances in communication technology and the need that emerged from the COVID-19 pandemic, telehealth initiatives have been widely used worldwide. This masterclass aims to provide an overview of telerehabilitation for musculoskeletal conditions, synthesizing the different terminologies used to describe telehealth and telerehabilitation, its effectiveness and how to use it in clinical practice, barriers and facilitators for the implementation in health services, and discuss the need of a curriculum education for the near future. MAIN BODY: Telerehabilitation refers to the use of information and communication technologies provided by any healthcare professionals for rehabilitation services. Telerehabilitation is a safe and effective option in the management of musculoskeletal conditions in different models of delivery. There are many technologies, with different costs and benefits, synchronous and asynchronous, that can be used for telerehabilitation: telephone, email, mobile health, messaging, web-based systems and videoconferences applications. To ensure a better practice of telerehabilitation, the clinician should certify safety and access, and appropriateness of environment, communication, technology, assessment, and therapeutic prescription. Despite the positive effect of telerehabilitation in musculoskeletal disorders, a suboptimal telerehabilitation implementation may have happened due to the COVID-19 pandemic, especially in countries where telehealth was not a reality, and clinicians lacked training and guidance. This emphasizes the need to identify the necessary curriculum content to guide future clinicians in their skills and knowledge for telerehabilitation. There are some challenges and barriers that must be carefully accounted for to contribute to a health service that is inclusive and relevant to health professionals and end users. CONCLUSIONS: Telerehabilitation can promote patient engagement in health care and plays an important role in improving health outcomes in patients with musculoskeletal conditions. Digital health technologies can also offer new opportunities to educate patients and facilitate the process of behavior change to a healthy lifestyle. Currently, the main needs in telerehabilitation are the inclusion of it in health curriculums in higher education and the development of cost-effectiveness and implementation trials, especially in low- and middle-income countries where access, investments and digital health literacy are limited.

Physical therapists and public perceptions of telerehabilitation: An online open survey on acceptability, preferences, and needs.

BACKGROUND: During the COVID-19 pandemic, telerehabilitation allowed the continuation of physical therapy care in parallel with public health measures to prevent the virus spread. However, in low- and middle-income countries including Brazil, telerehabilitation was unfamiliar to most of the population. OBJECTIVE: To investigate acceptability, preferences, and needs in telerehabilitation by Brazilian physical therapists and the general population. METHODS: We conducted an observational cross-sectional study with an online survey consisting of 13 multiple-choice items. Items were distributed among acceptability, preferences, and needs sections, and encompassed confidence in delivering or receiving telerehabilitation, its perceived efficacy and costs, and suitable content. RESULTS: A total of 1107 responses were registered, 717 from physical therapists. Half of them self-reported confidence in conducting telerehabilitation through the internet (synchronous or asynchronous). The same proportion disagreed that telerehabilitation is as effective as in-person interventions. Physical therapists agreed telerehabilitation should contain educational, self-management strategies, and exercises information, but the general population endorsed the provision of technical advice on exercise execution. The general population mostly reported that telerehabilitation could help their specific health condition (86%), but only 14% of respondents would pay the same as they pay for in-person consultations. Participants reported an overall preference for synchronous communication and concern about the lack of a hands-on approach. CONCLUSION: Physical therapists and the general population appear to demonstrate apprehension towards telerehabilitation. Insufficient preparation or inadequate knowledge might influence participants' acceptance, preferences, and needs.

Can you be a manual therapist without using your hands?

BACKGROUND: To align with current best practices, manual therapists have refined their treatment options to include exercise and pain education for people with chronic musculoskeletal pain. In this commentary, we suggest that manual therapists should also add telehealth to their toolbox. Thus, we aim to discuss the use of telehealth by manual therapists caring for patients with musculoskeletal disorders. MAIN BODY: Telehealth can be delivered to the patient in different modes, such as real-time clinical contact or asynchronously. Platforms vary from websites and smartphone apps to virtual reality systems. Telehealth may be an effective approach, especially for improving pain and function in people with musculoskeletal pain, and it has the potential to reduce the individual and socioeconomic burden of musculoskeletal conditions. However, the certainty of evidence reported in systematic reviews is often low. Factors such as convenience, flexibility, undivided attention from the clinician, user-friendly platforms, goal setting, and use of evidence-based information are all enablers for telehealth use and improving patients' knowledge, self-efficacy, and self-management. Barriers to widening the use of telehealth in musculoskeletal care include the reliability of technology, data privacy issues, difficult to build therapeutic alliance, one-size-fits-all approaches, digital health literacy, and payment models. CONCLUSION: We suggest that practitioners of manual medicine make telehealth part of their clinical toolbox where it makes sense and where there is evidence that it is beneficial for people who seek their care.

Three in Every 10 School-aged Children in Brazil Report Back Pain in Any Given Year: 12-Month Prospective Cohort Study of Prevalence, Incidence, and Prognosis.

OBJECTIVE: To estimate the prevalence, incidence, and prognosis of back pain in children and adolescents. DESIGN: Prospective cohort study. METHODS: We followed children and adolescents between the ages of 8 and 18 years with and without back pain over 12 months (3, 6, and 12 months) from public and private schools. At baseline, parents (or guardians) answered questionnaires including sociodemographic characteristics and perception of sleep quality of their children and adolescents. Children and adolescents answered questionnaires including sociodemographic characteristics, presence of back pain, pain intensity, quality of life, and psychosomatic symptoms. At follow-up, children and adolescents answered questions about the presence of back pain. RESULTS: Six hundred fifteen children and adolescents were included, 163 of whom had back pain and 452 of whom had no back pain at baseline. The mean age of participants was 11.6 years (SD = 2.5), and the majority were female (n = 362; 59%). The 1-month prevalence of back pain was 26% (95% confidence interval: 23%-30%). The incidence rate of back pain was 35% (31%-40%) over 12 months. Of the 163 participants who had back pain at baseline, 83% had recovered by 12 months. Of those who recovered within 6 months, 31% had a recurrence of back pain at the 12-month follow-up. CONCLUSION: Two to 3 in every 10 children and adolescents reported back pain in the last month. New cases of back pain were reported by 3-4 in every 10 children and adolescents for a period of 12 months. Nearly all children recover within 12 months, but recurrence seems to be common. J Orthop Sports Phys Ther 2022;52(8):554-562. Epub: 19 June 2022. doi:10.2519/jospt.2022.10819.

Translation, cross-cultural adaptation, and measurement properties of the psychosomatic questionnaire for children and adolescents with musculoskeletal pain into Brazilian-Portuguese.

BACKGROUND: Psychosomatic symptoms seem to influence both the onset and development of pain. There is lack of Brazilian-Portuguese questionnaires that measure psychosomatic symptoms in children and adolescents. OBJECTIVE: To translate and cross-culturally adapt the Psychosomatic Questionnaire for Children and Adolescents into Brazilian-Portuguese and English and test the measurement properties of the Brazilian-Portuguese version. METHODS: The translation and cross-cultural adaptation (from Dutch to Brazilian-Portuguese and English) followed six steps. Interviews were conducted in 33 Brazilian children and adolescents. We also recruited 107 children and adolescents with musculoskeletal pain from schools to test the measurement properties of the Brazilian-Portuguese version. The questionnaire was completed twice with a 7-day interval. Ceiling and floor effects, missing data, internal consistency, reliability, measurement error and construct validity were assessed. RESULTS: We recruited 140 children and adolescents from public and private schools. During the cross-cultural adaptation process, no major difficulty answering and understanding the questionnaire were reported by children and adolescents. The questionnaire did not show ceiling or floor effects and had minimal missing data (0.37%). Internal consistency by the Cronbach's Alpha was 0.69. Test-retest reliability by the Intraclass Correlation Coefficient was 0.75 (95% CI: 0.64, 0.84). The smallest detectable change was 6.5 points out of 18 points. We observed a moderate correlation of 0.54 (p<0.01) with the Spence Children's Anxiety Scale, consistent with our a-priori hypothesis. CONCLUSION: The Brazilian-Portuguese version of the Psychosomatic Questionnaire for Children and Adolescents has acceptable measurement properties and is a good option for assessing psychosomatic symptoms in clinical practice and research.

The Physiotherapy Evidence Database (PEDro) has better free full-text access than PubMed: An observational study.

BACKGROUND: Access to full-text articles is an essential element of evidence-based practice. OBJECTIVE: Estimate the percentage of articles in the Physiotherapy Evidence Database (PEDro) that have free full-text access and compare free access between PEDro and PubMed. Secondary objectives for access via PEDro: determine if publication year and geographic location impact on free access; determine if adding a link to a portable document format (PDF) locator website would improve free access; and evaluate the association between article characteristics and free access. METHODS: This observational study used a random sample of 200 articles published in 2000-2019 and indexed in PEDro. Data collectors in Australia, Brazil, Nepal, and Spain attempted to access free full text for each article via PEDro. One data collector attempted to access free full text via PubMed. One data collector attempted to access full text via a PDF locator (http://www.pdfsearchengine.net/). The percentage (95% confidence interval [CI]) of articles with free full-text access from PEDro, PubMed, and the PDF locator website were calculated. Logistic regression was used to evaluate the association between free full-text access and article characteristics. RESULTS: Free full text could be accessed via PEDro for 51% of the articles (95% CI: 44, 58). PEDro had 4% higher free access than PubMed (95% CI: 1, 7). Access via PEDro did not vary systematically with time, geographic location, or article characteristics. Access improved by 9% (95% CI: 6, 14) by adding a PDF locator website. CONCLUSIONS: PEDro is a good source of free full-text articles for physical therapists and other rehabilitation professionals. Evidence resources, professional organisations, employers, researchers, and research agencies could all help to increase access to free full text.

At my own pace, space, and place: a systematic review of qualitative studies of enablers and barriers to telehealth interventions for people with chronic pain.

ABSTRACT: Telehealth is a promising approach to support self-management with the potential to overcome geographical barriers. Understanding patient perspectives will identify practical challenges to delivering self-management strategies by telehealth. The aim of this study was to synthesize the perceptions of people with chronic musculoskeletal pain for engaging in interventions delivered using telehealth. We searched MEDLINE, Embase, CINAHL, LILACS, and PsycINFO databases. We included qualitative studies that explored perceptions or experiences or attitudes of people with chronic musculoskeletal pain engaging with telehealth. We assessed the methodological quality using the Critical Appraisal Skills Programme checklist. Meta-synthesis was guided by a thematic synthesis approach. The level of confidence of review findings was assessed using the Confidence in the Evidence from Reviews of Qualitative Studies (GRADE-CERQual). Twenty-one studies were included (n = 429). Telehealth comprised web-based, videoconference-based, telephone-based, video-based, and smartphone app-based programs delivered solely or combined. Chronic musculoskeletal conditions included people with knee or hip osteoarthritis, chronic low back pain, persistent pain (chronic joint pain or nonspecific chronic musculoskeletal pain), rheumatoid arthritis, and functional fatigue syndrome. The enablers for engaging in telehealth interventions were as follows: (1) "at my own pace, space, and place" and (2) empowered patient. Barriers to engaging in telehealth interventions were as follows: (1) impersonal, (2) technological challenges, (3) irrelevant content, and (4) limited digital (health) literacy. Telehealth interventions with well-designed interactive platforms, flexibility to fit patients' routine, and the broad availability of material may favor better engagement. Encouragement of self-efficacy is linked to successful telehealth-delivered self-management programs.

Choosing what works for whom: towards a better use of mechanistic knowledge in clinical practice.

BACKGROUND: Clinicians commonly try to use mechanism-based knowledge to make sense of the complexity and uncertainty of chronic pain treatments to create a rationale for their clinical decision-making. Although this seems intuitive, there are some problems with this approach. DISCUSSION: The widespread use of mechanism-based knowledge in clinical practice can be a source of confusion for clinicians, especially when complex interventions with different proposed mechanisms of action are equally effective. Although the available mechanistic evidence is still of very poor quality, in choosing from various treatment options for people with chronic pain, an approach that correctly incorporates mechanistic reasoning might aid clinical thinking and practice. CONCLUSION: By explaining that not all evidence of mechanism is the same and by making a proposal to start using mechanism-based knowledge in clinical practice properly, we hope to help clinicians to incorporate mechanistic reasoning to prioritize and start choosing what may best work for whom.

Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis.

QUESTION: What are the effects of specific types of exercise treatments on pain intensity and functional limitation outcomes for adults with chronic low back pain? DESIGN: Systematic review with network meta-analysis of randomised controlled trials. PARTICIPANTS: Adults with non-specific low back pain for ≥ 12 weeks. INTERVENTION: Exercise treatments prescribed or planned by a health professional that involved conducting specific activities, postures and/or movements with a goal to improve low back pain outcomes. OUTCOME MEASURES: Pain intensity (eg, visual analogue scale or numerical rating scale) and back-related functional limitations (eg, Roland Morris Disability Questionnaire or Oswestry Disability Index), each standardised to range from 0 to 100. RESULTS: This review included 217 randomised controlled trials with 20,969 participants and 507 treatment groups. Most exercise types were more effective than minimal treatment for pain and functional limitation outcomes. Network meta-analysis results were compatible with moderate to clinically important treatment effects for Pilates, McKenzie therapy, and functional restoration (pain only) and flexibility exercises (function only) compared with minimal treatment, other effective treatments and other exercise types. The estimated mean differences for these exercise types compared with minimal treatment ranged from -15 to -19 for pain and from -10 to -12 for functional limitation. CONCLUSION: This review found evidence that Pilates, McKenzie therapy and functional restoration were more effective than other types of exercise treatment for reducing pain intensity and functional limitations. Nevertheless, people with chronic low back pain should be encouraged to perform the exercise that they enjoy to promote adherence. REGISTRATION: DOI:10.1002/14651858.CD009790.

Self-Guided Web-Based Pain Education for People With Musculoskeletal Pain: A Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study was to investigate the effectiveness of web-based pain education programs without clinical support in patients with musculoskeletal pain. METHODS: PubMed, Scopus, CINAHL, Web of Science, Cochrane Library, and PsycINFO were searched from inception to February 2020. Included studies were randomized clinical trials in which people with musculoskeletal pain were allocated to an experimental group that received web-based pain education as a standalone approach. Three review authors performed data extraction. The PEDro (Physiotherapy Evidence Database) scale was used to assess the methodological quality of the studies. The primary outcomes were pain intensity and disability. RESULTS: Six trials with a total of 1664 participants were included. There is moderate-quality evidence with a small effect size that web-based pain education programs, as a standalone approach, are better than minimal intervention (no intervention or booklets) for pain intensity (standardized mean difference [SMD] = -0.23; 95% CI = -0.43 to -0.04) in the short term and intermediate term (SMD = -0.26; 95% CI = -0.42 to -0.10). Regarding disability, there is low-quality evidence that web-based pain education programs are better than minimal intervention (SMD = -0.36; 95% CI = -0.64 to -0.07) in the short term. Web-based pain education added to usual care was no better than usual care alone in the intermediate or long term for primary outcomes. CONCLUSIONS: Web-based pain education for adults with musculoskeletal pain, as a standalone approach, was better than minimal intervention for pain intensity and disability in the short term, and for pain intensity in the intermediate term. Web-based pain education added to usual care did not provide additional benefits for primary outcomes in the intermediate or long term. IMPACT: Web-based pain education as a standalone intervention provided small improvements in pain intensity and disability in patients with chronic musculoskeletal pain. Poorly resourced settings and overburdened health systems should consider this delivery method in the management of chronic musculoskeletal pain. LAY SUMMARY: If you have chronic musculoskeletal pain, your physical therapist might recommend web-based pain education as treatment to help you reduce pain intensity and disability.

Dry cupping therapy is not superior to sham cupping to improve clinical outcomes in people with non-specific chronic low back pain: a randomised trial.

QUESTION: What are the effects of dry cupping on pain intensity, physical function, functional mobility, trunk range of motion, perceived overall effect, quality of life, psychological symptoms and medication use in individuals with chronic non-specific low back pain? DESIGN: Randomised controlled trial with concealed allocation, intention-to-treat analysis and blinding of participants and assessors. PARTICIPANTS: Ninety participants with chronic non-specific low back pain. INTERVENTIONS: The experimental group (n = 45) received dry cupping therapy, with cups bilaterally positioned parallel to the L1 to L5 vertebrae. The control group (n = 45) received sham cupping therapy. The interventions were applied once a week for 8 weeks. OUTCOME MEASURES: Participants were assessed before and after the first treatment session, and after 4 and 8 weeks of intervention. The primary outcome was pain intensity, measured with the numerical pain scale at rest, during fast walking and during trunk flexion. Secondary outcomes were physical function, functional mobility, trunk range of motion, perceived overall effect, quality of life, psychological symptoms and medication use. RESULTS: On a 0-to-10 scale, the between-group difference in pain severity at rest was negligible: MD 0.0 (95% CI -0.9 to 1.0) immediately after the first treatment, 0.4 (95% CI -0.5 to 1.5) at 4 weeks and 0.6 (95% CI -0.4 to 1.6) at 8 weeks. Similar negligible effects were observed on pain severity during fast walking or trunk flexion. Negligible effects were also found on physical function, functional mobility and perceived overall effect, where mean estimates and their confidence intervals all excluded worthwhile effects. No worthwhile benefits could be confirmed for any of the remaining secondary outcomes. CONCLUSION: Dry cupping therapy was not superior to sham cupping for improving pain, physical function, mobility, quality of life, psychological symptoms or medication use in people with non-specific chronic low back pain. PROTOCOL REGISTRATION NUMBER: NCT03909672.