Survey to assess the feasibility of establishing an international network for evidence synthesis in occupational safety and health.

BACKGROUND: Evidence synthesis in the field of occupational safety and health (OSH) has been continuously growing over the last two decades. With over 100 systematic reviews now published, the Cochrane Work Review group has played an important role in this development and the Cochrane Thematic Group 'Work & Health & Social Security' was established recently to combine evidence from both the OSH and insurance medicine fields. Worldwide, many organizations produce and synthesize evidence in OSH that can complement and support each other. We believe that a global network including Cochrane and others can collaborate on methods development and in the production, synthesis, use and dissemination of different types of evidence even more effectively. AIMS: To determine if establishing a global network for evidence synthesis in OSH is feasible. METHODS: We conducted a survey of international and national institutions between November 2022 and January 2023 using LimeSurvey. Participants included representatives of affiliated and sustaining members of the International Commission on Occupational Health, national institutes for OSH, academia and other international organizations. RESULTS: From 151 invitations, we received responses from 57 representatives of 54 organizations. Representatives reported that their organization will contribute financially on an annual basis (n = 1) or provide in-kind support (n = 10), and will probably be able to provide financial or in-kind support (n = 25). CONCLUSIONS: The feasibility criterion was met and an international network is being established.

The Dutch Multidisciplinary Occupational Health Guideline to Enhance Work Participation Among Low Back Pain and Lumbosacral Radicular Syndrome Patients.

Purpose Based on current scientific evidence and best practice, the first Dutch multidisciplinary practice guideline for occupational health professionals was developed to stimulate prevention and enhance work participation in patients with low back pain (LBP) and lumbosacral radicular syndrome (LRS). Methods A multidisciplinary working group with health care professionals, a patient representative and researchers developed the recommendations after systematic review of evidence about (1) Risk factors, (2) Prevention, (3) Prognostic factors and (4) Interventions. Certainty of the evidence was rated with GRADE and the Evidence to Decision (EtD) framework was used to formulate recommendations. High or moderate certainty resulted in a recommendation "to advise", low to very low in a recommendation "to consider", unless other factors in the framework decided differently. Results An inventory of risk factors should be considered and an assessment of prognostic factors is advised. For prevention, physical exercises and education are advised, besides application of the evidence-based practical guidelines "lifting" and "whole body vibration". The stepped-care approach to enhance work participation starts with the advice to stay active, facilitated by informing the worker, reducing workload, an action plan and a time-contingent increase of work participation for a defined amount of hours and tasks. If work participation has not improved within 6 weeks, additional treatments should be considered based on the present risk and prognostic factors: (1) physiotherapy or exercise therapy; (2) an intensive workplace-oriented program; or (3) cognitive behavioural therapy. After 12 weeks, multi-disciplinary (occupational) rehabilitation therapy need to be considered. Conclusions Based on systematic reviews and expert consensus, the good practice recommendations in this guideline focus on enhancing work participation among workers with LBP and LRS using a stepped-care approach to complement existing guidelines focusing on recovery and daily functioning.

Value of work for employees with a chronic disease.

Background: Most people with a chronic disease value participation in work. Knowledge is limited, however, as to what extent employees with a chronic disease value participating in work, and the main reasons for this. Limited research is available on which specific factors contribute to the perceived value of work. Aims: To evaluate main reasons for, and the extent to which employees with a chronic disease value participation in work, and factors which motivate or demotivate employees in work. Methods: A survey of members of three large patient federations was performed. Respondents had a chronic disease and were of working age. The extent and reasons for valuing work were analysed using descriptive statistics; (de)motivating aspects were qualitatively analysed using specific software. Results: The 1683 respondents valued work with an average of 8 on a scale from 1 to 10 (1: 'work is not at all important to me' and 10: 'work is extremely important to me'). Most frequent reported reasons for valuing work were the provision of income, social contact and the ability to contribute to society. Motivational aspects for work were being financially independent, having positive social contact with colleagues or clients and having the ability to contribute to society. In contrast, negative social contact, performing useless work and having little autonomy demotivated people. Conclusions: Employed people with a chronic disease generally value work, mainly because it makes them financially independent, provides social contact and enables them to contribute to society.

E-health to improve work functioning in employees with rheumatoid arthritis in rheumatology practice: a feasibility study.

OBJECTIVES: To evaluate the feasibility of an e-health intervention in rheumatology practice for employees with rheumatoid arthritis (RA) who experience problems with work functioning. METHOD: Twenty-three out of 90 patients with RA from a hospital rheumatology department, invited by letter, participated in a feasibility study. The 3-month internet e-health programme consisted of a self-management programme using a three-step problem-solving strategy: (step 1) analyse your work problems and opportunities; (step 3) identify solutions; and (step 3) work out a strategy (action plan). Support and personal feedback was provided by a rheumatology nurse. Patients completed assignments, received information, and actively worked on their goals. The main feasibility outcome included satisfaction with the programme. Other feasibility outcomes included usefulness, suitability, website use, and work functioning measured at baseline and/or 3 months using questionnaires, semi-structured interviews, and website data. RESULTS: In total, 95% of the participants were satisfied with the programme, and 96% thought the programme was useful for working RA patients and would recommend the programme to other working RA patients (91%). On the website, all patients at least partially completed the assignments in step 1 and 12 patients completed at least one assignment in step 3. Patients judged the website as well arranged with clear tasks. Patients worked on a range of (individual) goals, resolving work challenges using different strategies and actions. CONCLUSIONS: The e-health intervention is a feasible intervention for rheumatology practice justifying further effectiveness evaluation while allowing for further improvements in the selection of RA patients and shaping the intervention.

Work ability: a new outcome measure in rheumatoid arthritis?

OBJECTIVES: To assess the relationship between disease activity and work ability, quality of life (QoL), and fatigue in patients with RA during a 12-month course of the tumour necrosis factor (TNF)-blocking agent adalimumab. METHODS: RA patients in the working age category who started treatment with adalimumab were included consecutively and followed up for 12 months. Generalized estimating equation (GEE) analyses were used to study relationships between disease activity and the outcome variables work ability, QoL, and fatigue at baseline, 6 months, and 12 months. Disease activity was measured using the 28-joint Disease Activity Score (DAS28), quality of life was assessed with the Rheumatoid Arthritis-specific Quality of Life instrument (RAQoL), and fatigue was assessed using the Checklist Individual Strength (CIS) questionnaire and the Need for Recovery scale (NFR). RESULTS: After 1 year, markedly improvement was seen not only in the DAS28 (from 5.2 +/- 1.2 to 3.1 +/- 1.6) but also in work ability, RAQoL, and work-related fatigue, which improved by 50, 29, and 34%, respectively. At all three time points strong significant associations were observed between DAS28 and work ability, RAQoL, and work-related fatigue and this relationship remained strong after adjustment for confounders. CONCLUSIONS: Disease activity was associated with QoL, work-related fatigue, and work ability in a group of RA patients treated with adalimumab for 1 year. As improvement in these factors influences work participation positively and work ability measures more than health status, the current results suggest that simple tools such as work ability should be used more frequently as outcome measures in trials with RA patients.

Illness perceptions and work participation: a systematic review.

PURPOSE: Self-regulatory processes play an important role in mediating between the disease and the health outcomes, and potentially also work outcomes. This systematic review aims to explore the relationship between illness perceptions and work participation in patients with somatic diseases and complaints. METHODS: The bibliographic databases Medline, PsycINFO and Embase were searched from inception to March 2008. Included were cross-sectional or longitudinal studies, patients with somatic diseases or complaints, illness perceptions based on at least four dimensions of the common sense model of self-regulation, and work participation. RESULTS: Two longitudinal and two cross-sectional studies selected for this review report statistically significant findings for one or more illness perception dimensions in patients with various complaints and illnesses, although some dimensions are significant in one study but not in another. Overall, non-working patients perceived more serious consequences, expected their illness to last a longer time, and reported more symptoms and more emotional responses as a result of their illness. Alternatively, working patients had a stronger belief in the controllability of their condition and a better understanding of their disease. CONCLUSIONS: The limited number of studies in this review suggests that illness perceptions play a role in the work participation of patients with somatic diseases or complaints, although it is not clear how strong this relationship is and which illness perception dimensions are most useful. Identifying individuals with maladaptive illness perceptions and targeting interventions toward changing these perceptions are promising developments in improving work participation.

Return to work of breast cancer survivors: a systematic review of intervention studies.

BACKGROUND: Breast cancer management has improved dramatically in the past three decades and as a result, a population of working age women is breast cancer survivor. Interventions for breast cancer survivors have shown improvements in quality of life and in physical and psychological states. In contrast, efforts aimed at stimulating re-employment and return-to-work interventions for breast cancer survivors have not kept pace. The objective of this review was to study the effects and characteristics of intervention studies on breast cancer survivors in which the outcome was return to work. METHODS: The Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2006), Medline, Ovid, EMBASE and PsychInfo were systematically searched for studies conducted between 1970 to February 2007. Intervention studies for female breast cancer survivors that were focused on return to work were included. RESULTS: Our search strategy identified 5219 studies. Four studies out of 100 potentially relevant abstracts were selected and included 46-317 employed women who had had mastectomy, adjuvant therapy and rehabilitation, with the outcome return to work. The intervention programs focused on improvement of physical, psychological and social recovery. Although a substantial percentage (between 75% to 85%) of patients included in these studies returned to work after rehabilitation, it is not clear whether this proportion would have been lower for patients without counseling or exercise, or any other interventions, as three out of four studies did not include a comparison group. CONCLUSION: The most important finding of this review is the lack of methodologically sound intervention studies on breast cancer survivors with the outcome return to work. Using evidence from qualitative and observational studies on cancer and the good results of intervention studies on return to work programs and vocational rehabilitation, return to work interventions for breast cancer survivors should be further developed and evaluated.

Perceived work ability, quality of life, and fatigue in patients with rheumatoid arthritis after a 6-month course of TNF inhibitors: prospective intervention study and partial economic evaluation.

OBJECTIVE: The objective of this exploratory study was to evaluate the effects and costs of a 6-month course of tumour necrosis factor (TNF) inhibitors on work ability, quality of life, and fatigue in patients with rheumatoid arthritis (RA). METHODS: In this prospective single-arm intervention study 59 consecutive patients of working age with established RA were recruited from an outpatient clinic in Amsterdam, the Netherlands. All patients received fortnightly subcutaneous injections of 40 mg adalimumab. The three outcomes at baseline and 6 months were: perceived work ability [Work Ability Index (WAI)], quality of life [Rheumatoid Arthritis Quality of Life instrument (RAQoL)], and fatigue [Checklist Individual Strength (CIS), Need for Recovery (NFR) scale]. Cost data of the preceding 6 months were collected using a self-administered patient questionnaire at baseline and follow-up. RESULTS: At 6 months, all outcomes showed a statistically significant improvement in mean scores from baseline, ranging from 10.0% (WAI), to 11.7% (RAQoL), to 15% (NFR) (subgroup paid work, n = 26). The total mean costs showed a twofold increase in mean costs per week per patient [difference EUR 169, 95% confidence interval (CI) EUR 113-226]. CONCLUSIONS: In this short-term exploratory evaluation, a 6-month course of TNF inhibitors improved work ability and quality of life, and reduced fatigue in patients with established RA. These effects are associated with an increase in total healthcare costs, attributable to the costs of TNF inhibitors. Randomized controlled trials with a longer follow-up are needed to show a long-term effect on work disability and the potential cost-effectiveness of TNF inhibitors.

Mortality and cancer incidence in workers in two Australian prebake aluminium smelters.

BACKGROUND: Exposures in the aluminium production industry have been declining and this study aimed to investigate cancer and mortality in two Australian prebake aluminium smelters. METHODS: The cohort included 4396 males who had worked in a prebake smelter for at least 3 months. They were matched against the National Death Index and the National Cancer Statistics Clearing House to obtain cause of death and type of cancer. Standardised Mortality Ratios (SMRs) and Standardised Incidence Ratios (SIRs) were calculated for the whole cohort, for production or maintenance work categories and for duration of employment categories. RESULTS: The SMRs for all causes, circulatory, respiratory and injury deaths were at or below expected. Mesothelioma was the only significantly increased cause of death (SMR 3.52, 95% CI 1.47 to 8.46). Death from prostate cancer in production workers was elevated (SMR 2.39, 95% CI 1.29 to 4.44) and in those who had worked for more than 20 years in production or maintenance jobs (SMR 3.67, 95% CI 1.53 to 8.81). There were statistically significant excesses of incident stomach cancer, mesothelioma, and kidney cancer cases, while the SIR for melanoma was significantly reduced. There was no significant trend for duration of exposure for any type of incident cancer. CONCLUSIONS: This study found no overall excess of mortality or cancer, but incident mesothelioma and kidney cancer risks were elevated. The lack of excess risk for lung or bladder cancer or deaths from respiratory disease may be related to the different level and pattern of exposure between Søderberg and prebake smelters.

Relationships between alumina and bauxite dust exposure and cancer, respiratory and circulatory disease.

OBJECTIVES: To examine the associations between alumina and bauxite dust exposure and cancer incidence and circulatory and respiratory disease mortality among bauxite miners and alumina refinery workers. METHODS: This cohort of 5770 males has previously been linked to national mortality and national and state cancer incidence registries (1983-2002). In this paper, Poisson regression was used to undertake internal comparisons within the cohort based on subgroups of cumulative exposure to inhalable bauxite and alumina dust. Exposure was estimated using job histories and historical air monitoring data. RESULTS: There was no association between ever bauxite exposure and any of the outcomes. There was a borderline significant association between ever alumina exposure and cerebrovascular disease mortality (10 deaths, RR 3.8, 95% CI 1.1 to 13). There was some evidence of an exposure-response relationship between cumulative bauxite exposure and non-malignant respiratory disease mortality (seven deaths, trend p value: 0.01) and between cumulative alumina exposure and cerebrovascular disease mortality (trend p value: 0.04). These associations were based on very few cases and for non-malignant respiratory disease the deaths represented a heterogeneous mixture of causes. There was no evidence of an excess risk for any cancer type with bauxite or alumina exposure. CONCLUSIONS: These preliminary findings, based on very few cases, suggest that cumulative inhalable bauxite exposure may be associated with an excess risk of death from non-malignant respiratory disease and that cumulative inhalable alumina dust exposure may be associated with an excess risk of death from cerebrovascular disease. Neither exposure appears to increase the risk of incident cancers.

Factors associated with long-term sick leave in sick-listed employees: a systematic review.

OBJECTIVE: The objective of this systematic review was to investigate which factors are associated with continued sick leave among workers on sick leave for at least 6 weeks. METHODS: A systematic literature search was performed in Medline, EMBASE and PsycINFO, based on combinations of MeSH terms and free text words. Only cohort studies of workers on sick leave for more than 6 weeks at baseline were included. Outcome was measured in terms of factors related to long-term sick leave. The factors were classified first as predisposing, precipitating or perpetuating factors, and then as individual or work-related factors. Methodological quality was assessed for all studies and the strength of the evidence for each factor was assessed using the levels of evidence rating system. RESULTS: Five cohort studies fulfilled all inclusion criteria and 77 factors were investigated. Of these, 16 different significant factors associated with long-term sick leave were identified and were all classified as predisposing factors. Evidence was found for 14 individual factors and two work-related factors. The level of evidence was found to be insufficient for all factors except older age and history of sick leave, which were found to have weak evidence. CONCLUSIONS: Based on this review, there is weak evidence that older age and history of sickness absence are factors associated with long-term sick leave in sick-listed employees. There is insufficient evidence for an effect of other individual or work-related factors on long-term sick leave. There are no published studies on perpetuating factors related to long-term sick leave.

Antidepressants for non-specific low back pain.

BACKGROUND: Antidepressants are commonly used in the management of low-back pain. However, their use is controversial. OBJECTIVES: The aim of this review was to determine whether antidepressants are more effective than placebo for the treatment of non-specific low-back pain. SEARCH STRATEGY: Randomised controlled trials were identified from MEDLINE and EMBASE (to September 2007), PsycINFO to June 2006, the Cochrane Central Register of Controlled Trials 2006, issue 2, and previous systematic reviews. SELECTION CRITERIA: We included randomised controlled trials that compared antidepressant medication and placebo for patients with non-specific low-back pain, and used at least one clinically relevant outcome measure. DATA COLLECTION AND ANALYSIS: Two blinded review authors independently extracted data and assessed the methodological quality of the trials. Meta-analyses were used to examine the effect of antidepressants on pain, depression and function, and the effect of antidepressant type on pain. To account for studies that could not be pooled, additional qualitative analyses were performed using the levels of evidence recommended by the Cochrane Back Review Group. MAIN RESULTS: Ten trials that compared antidepressants with placebo were included in this review. The pooled analyses showed no difference in pain relief (six trials; standardized mean difference (SMD) -0.06 (95% confidence interval (CI) -0.28 to 0.16)) or depression (two trials; SMD 0.06 (95% CI -0.29 to 0.40)) between antidepressant and placebo treatments. The qualitative analyses found conflicting evidence on the effect of antidepressants on pain intensity in chronic low-back pain, and no clear evidence that antidepressants reduce depression in chronic low-back pain patients. Two pooled analyses showed no difference in pain relief between different types of antidepressants and placebo. Our findings were not altered by the sensitivity analyses which varied the level of methodological quality required for inclusion in the meta-analyses to allow data from additional trials to be examined. Two additional trials were identified in September 2007 and await assessment. AUTHORS' CONCLUSIONS: There is no clear evidence that antidepressants are more effective than placebo in the management of patients with chronic low-back pain. These findings do not imply that severely depressed patients with back pain should not be treated with antidepressants; furthermore, there is evidence for their use in other forms of chronic pain.

[Guideline 'The chronically ill and work']. / Richtlijn 'Chronisch zieken en werk'.

- The guideline 'The chronically ill and work' gives insight into disease-overarching factors and interventions that can promote or impede the participation in the work process of workers and those looking for work who have a chronic condition. - In particular, the guideline focuses on the role taken on by workers or those looking for work themselves during the process of keeping or resuming work. - The guideline gives recommendations for the daily practice of healthcare providers which are based on knowledge from disease-specific guidelines, the international literature and the experiences of healthcare providers, and workers and those looking for work with a chronic condition.

Exercises for mechanical neck disorders: A Cochrane review update.

BACKGROUND: Neck pain (NP) is disabling and costly. OBJECTIVES: To assess the effectiveness of exercise on pain, disability, function, patient satisfaction, quality of life (QoL) and global perceived effect (GPE) in adults with NP. METHODS: We searched computerised databases up to May 2014 for randomized controlled trials (RCTs) comparing exercise to a control in adults with NP with/without cervicogenic headache (CGH) or radiculopathy. Two reviewers independently conducted selection, data abstraction and assessed risk of bias. Meta-analyses were performed to establish pooled standardised mean differences (SMDp). The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) was used to summarise the body of evidence. MAIN RESULTS: The following exercises (27 trials) were supported by 'Moderate GRADE' evidence: For chronic NP, 1) cervico-scapulothoracic and upper extremity (UE) strengthening for moderate to large pain reduction immediately post treatment (IP) and at short-term (ST) follow-up; 2) scapulothoracic and UE endurance training for a small pain reduction (IP/ST); 3) cervical, shoulder and scapulothoracic strengthening and stretching exercise for a small to large pain reduction in the long-term (LT) (SMDp -0.45 [95%CI: -0.72 to -0.18]) and function improvement; 4) cervico-scapulothoracic strengthening/stabilisation exercises for pain and function at intermediate-term (IT) (SMDp -14.90 [95%CI: -22.40 to -7.39]). 5) mindfulness exercises (Qigong) for minor improved function but not GPE (ST). For chronic CGH, cervico-scapulothoracic strengthening and endurance exercises including pressure biofeedback for small/moderate improvement of pain, function and GPE (IP/LT). AUTHORS' CONCLUSIONS: Specific strengthening exercises of the neck, scapulothoracic and shoulder for chronic NP and chronic CGH are beneficial. Future research should explore optimal dosage.

Manipulation and mobilisation for mechanical neck disorders.

BACKGROUND: Neck disorders are common, disabling, and costly. The effectiveness of manipulation and mobilisation remains unclear. OBJECTIVES: To assess whether manipulation and mobilisation, either alone or in combination with other treatments, relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders (MND). SEARCH STRATEGY: Computerised bibliographic databases including CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, were searched without language restrictions from their respective starting dates to March 2002. SELECTION CRITERIA: The studies had to be randomised (RCT) or quasi-randomised and investigate the use of manipulation or mobilisation as a treatment for mechanical neck disorders. DATA COLLECTION AND ANALYSIS: Two independent reviewers conducted citation identification, study selection, data abstraction, and methodological quality assessment. Using a random effects model, relative risk and standardised mean differences were calculated. The reasonableness of combining studies was assessed on clinical and statistical grounds. In the absence of heterogeneity, pooled effect measures were calculated. MAIN RESULTS: Of the 33 selected trials, 42% were high quality trials. Single sessions of manipulation or multiple sessions (3 to 11 weeks) of manipulation or mobilisation, or manipulation and mobilisation showed a nonsignificant benefit in pain relief when assessed against placebo, control groups or other treatments for acute/subacute/chronic MNDs with or without headache. There was strong evidence of benefit favouring multimodal care over a waiting list control for pain reduction [pooled SMD -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [SMD -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. There was moderate evidence of no difference in effect when multimodal care was compared to various other treatments. REVIEWER'S CONCLUSIONS: Multimodal care has short-term and long-term maintained benefits for subacute/chronic MND with or without headache. The common elements in this care strategy were mobilisation and/or manipulation plus exercise. The evidence did not favour manipulation and/or mobilisation done alone or in combination with various other physical medicine agents; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. The added benefit of exercise needs to be further explored. Factorial design would help determine the active treatment agent(s) within a treatment mix. Phase II trials would help identify the most effective treatment characteristics and dosages. Greater attention to methodological quality is needed.

A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain.

STUDY DESIGN: A criteria-based appraisal of review articles on neck pain. OBJECTIVES: To assess the methodologic quality, conclusions, and extent of concordance among reviews on the conservative treatment of neck disorders. SUMMARY OF BACKGROUND DATA: During the past decades there has been an increasing interest in summarizing and analyzing the available evidence on the effectiveness of conservative management of neck pain. Considering the growing number and quality of reviews, consumers may question which reviews to read and believe. METHODS: Computerized bibliographic databases were searched without language restriction. The reviews assessed had been published before January 1998, included neck pain and evaluated conservative therapies, and reported at least one controlled clinical trial. Identification, selection, and quality assessment were performed independently by two investigators. RESULTS: Of the 108 identified articles, 25 review articles were selected, of which 12 were systematic reviews. The reviews differed in their reporting of study population, interventions, and outcomes. Statistical pooling was performed in two high-quality systematic reviews, whereas in other reviews, the investigators explicitly decided not to pool data. The results of the current study show that the concordance among reviews varied. Regarding manipulation and traction, there is inconclusive evidence among reviews. Concordance regarding the effectiveness of other conservative interventions was absent. Many of the reviews displayed major methodologic flaws. CONCLUSIONS: Consumers should consider reports of reviews both carefully and critically, given the wide variety of review methodology, descriptive information, and final conclusions. There is a paucity of evidence from primary studies on neck pain. Therefore, more research is needed to allow systematic reviews to formulate stronger conclusions.

[Systematic reviews in practice. VIII. Searching and assessing systematic reviews]. / De praktijk van systematische reviews. VIII. Zoeken en beoordelen van systematische reviews.

In a systematic review (SR) the information from the original studies is searched, selected, extracted, appraised and summarised in a transparent, valid and reproducible manner. SRs are therefore an efficient and reliable source of information for the clinician, health policy maker and researcher. SRs can be identified in various sources. The search strategy is determined by the desired comprehensiveness, the availability of various sources and the need for additional comments on the SR by a referee. In Medline a sensitive filter is available for searching SRs. An SR should be based on a carefully formulated clinical question that can be answered on the basis of data from the original studies. SRs should be thoroughly assessed as they can differ substantially in terms of quality. In such an appraisal the following aspects should be considered: question, search strategy, selection of studies, quality assessment, data extraction and data presentation, (statistical) summary of the data, statistical and clinical heterogeneity, results and conclusion. Various assessment lists are available. Differences in conclusions between SRs on the same subject can be analysed in a systematic manner and can often be resolved.

Short course prednisolone for adhesive capsulitis (frozen shoulder or stiff painful shoulder): a randomised, double blind, placebo controlled trial.

OBJECTIVE: To determine whether a short course of prednisolone is superior to placebo for improving pain, function, and range of motion in adhesive capsulitis. DESIGN: Double blind, randomised, placebo controlled trial. SETTING: Community based rheumatology practice in Australia. PARTICIPANTS: 50 participants (24 active, 26 placebo); 46 completed the 12 week protocol. Entry criteria were age > or =18 years, pain and stiffness in predominantly one shoulder for > or =3 weeks, and restriction of passive motion by >30 degrees in two or more planes. INTERVENTIONS: 30 mg oral prednisolone/day for three weeks or placebo. MAIN OUTCOME MEASURES: Overall, night, and activity related pain, SPADI, Croft shoulder disability questionnaire, DASH, HAQ, SF-36, participant rated improvement, and range of active motion measured at baseline and at 3, 6, and 12 weeks. RESULTS: At 3 weeks, there was greater improvement in overall pain in the prednisolone group than in the placebo group (mean (SD) change from baseline, 4.1 (2.3) v 1.4 (2.3); adjusted difference in mean change between the two groups, 2.4 (95% CI, 1.1 to 3.8)). There was also greater improvement in disability, range of active motion, and participant rated improvement (marked or moderate overall improvement in 22/23 v 11/23; RR = 2 (1.3 to 3.1), p = 0.001). At 6 weeks the analysis favoured the prednisolone group for most outcomes but none of the differences was significant. At 12 weeks, the analysis tended to favour the placebo group. CONCLUSIONS: A three week course of 30 mg prednisolone daily is of significant short term benefit in adhesive capsulitis but benefits are not maintained beyond six weeks.

How reliably do rheumatologists measure shoulder movement?

OBJECTIVE: To assess the intrarater and interrater reliability among rheumatologists of a standardised protocol for measurement of shoulder movements using a gravity inclinometer. METHODS: After instruction, six rheumatologists independently assessed eight movements of the shoulder, including total and glenohumeral flexion, total and glenohumeral abduction, external rotation in neutral and in abduction, internal rotation in abduction and hand behind back, in random order in six patients with shoulder pain and stiffness according to a 6x6 Latin square design using a standardised protocol. These assessments were then repeated. Analysis of variance was used to partition total variability into components of variance in order to calculate intraclass correlation coefficients (ICCs). RESULTS: The intrarater and interrater reliability of different shoulder movements varied widely. The movement of hand behind back and total shoulder flexion yielded the highest ICC scores for both intrarater reliability (0.91 and 0.83, respectively) and interrater reliability (0.80 and 0.72, respectively). Low ICC scores were found for the movements of glenohumeral abduction, external rotation in abduction, and internal rotation in abduction (intrarater ICCs 0.35, 0.43, and 0.32, respectively), and external rotation in neutral, external rotation in abduction, and internal rotation in abduction (interrater ICCs 0.29, 0.11, and 0.06, respectively). CONCLUSIONS: The measurement of shoulder movements using a standardised protocol by rheumatologists produced variable intrarater and interrater reliability. Reasonable reliability was obtained only for the movement of hand behind back and total shoulder flexion.