Secular trends in gabapentinoid dispensing by compensated workers with low back pain: a retrospective cohort study.

OBJECTIVES: The increase in gabapentinoid prescribing is paralleling the increase in serious harms. To describe the low back pain workers compensation population whose management included a gabapentinoid between 2010 and 2017, and determine secular trends in, and factors associated with gabapentinoid use. METHODS: We analysed claim-level and service-level data from the Victorian workers' compensation programme between 1 January 2010 and 31 December 2017 for workers with an accepted claim for a low back pain injury and who had programme-funded gabapentinoid dispensing. Secular trends were calculated as a proportion of gabapentinoid dispensings per year. Poisson, negative binomial and Cox hazards models were used to examine changes over time in incidence and time to first dispensing. RESULTS: Of the 17 689 low back pain claimants, one in seven (14.7%) were dispensed at least one gabapentinoid during the first 2 years (n=2608). The proportion of workers who were dispensed a gabapentinoid significantly increased over time (7.9% in 2010 to 18.7% in 2017), despite a reduction in the number of claimants dispensed pain-related medicines. Gabapentinoid dispensing was significantly associated with an opioid analgesic or anti-depressant dispensing claim, but not claimant-level characteristics. The time to first gabapentinoid dispensing significantly decreased over time from 311.9 days (SD 200.7) in 2010 to 148.2 days (SD 183.1) in 2017. CONCLUSIONS: The proportion of claimants dispensed a gabapentinoid more than doubled in the period 2010-2017; and the time to first dispensing halved during this period.

Clinical care standards for the management of low back pain: a scoping review.

The objective of this study is to compare and contrast the quality statements and quality indicators across clinical care standards for low back pain. Searches were performed in Medline, guideline databases, and Google searches to identify clinical care standards for the management of low back pain targeting a multidisciplinary audience. Two independent reviewers reviewed the search results and extracted relevant information from the clinical care standards. We compared the quality statements and indicators of the clinical care standards to identify the consistent messages and the discrepancies between them. Three national clinical care standards from Australia, Canada, and the United Kingdom were included. They provided from 6 to 8 quality statements and from 12 to 18 quality indicators. The three standards provide consistent recommendations in the quality statements related to imaging, and patient education/advice and self-management. In addition, the Canadian and Australian standards also provide consistent recommendations regarding comprehensive assessment, psychological support, and review and patient referral. However, the three clinical care standards differ in the statements related to psychological assessment, opioid analgesics, non-opioid analgesics, and non-pharmacological therapies. The three national clinical care standards provide consistent recommendations on imaging and patient education/advice, self-management of the condition, and two standards (Canadian and Australian) agree on recommendations regarding comprehensive assessment, psychological support, and review and patient referral. The standards differ in the quality statements related to psychological assessment, opioid prescription, non-opioid analgesics, and non-pharmacological therapies.

Clinical indicators to monitor health care in low back pain: a scoping review.

Clinical care indicators for low back pain can be used to monitor healthcare practices and consequently be used to evaluate success of strategies to improve care quality. The aim of this study was to identify the clinical care indicators that have been used to measure appropriateness of health care for patients with low back pain. We conducted a systematic search of five electronic databases and Google to identify clinical care indicators that have been used to measure any aspect of care for people with low back pain. Care indicators were narratively described according to their type (i.e. structure, process, or outcomes) and categorized by their purpose (e.g. to measure aspects related to assessment, imaging requests, treatment/prevention, and outcomes). A total of 3562 and 2180 records were retrieved from electronic databases and Google searches, respectively. We identified 280 indicators related to low back pain care from 40 documents and publications. Most quality indicators were process indicators (n = 213, 76%), followed by structure (n = 41, 15%) and outcome indicators (n = 26, 9%). The most common indicators were related to imaging requests (n = 41, 15%), referral to healthcare providers (n = 30, 11%), and shared decision-making (n = 21, 7%). Our review identified a range of clinical care indicators that have been used to measure the quality of health care for people with low back pain. Our findings will support a Delphi study to reach international consensus on what would be the most important and feasible indicators for a minimum dataset to be collected globally.

Prioritisation of clinical trial learning needs of musculoskeletal researchers: an inter-disciplinary modified Delphi study by the Australia & New Zealand musculoskeletal clinical trials network.

BACKGROUND: There is a need to increase the capacity and capability of musculoskeletal researchers to design, conduct, and report high-quality clinical trials. The objective of this study was to identify and prioritise clinical trial learning needs of musculoskeletal researchers in Australia and Aotearoa New Zealand. Findings will be used to inform development of an e-learning musculoskeletal clinical trials course. METHODS: A two-round online modified Delphi study was conducted with an inter-disciplinary panel of musculoskeletal researchers from Australia and Aotearoa New Zealand, representing various career stages and roles, including clinician researchers and consumers with lived experience of musculoskeletal conditions. Round 1 involved panellists nominating 3-10 topics about musculoskeletal trial design and conduct that they believe would be important to include in an e-learning course about musculoskeletal clinical trials. Topics were synthesised and refined. Round 2 asked panellists to rate the importance of all topics (very important, important, not important), as well as select and rank their top 10 most important topics. A rank score was calculated whereby higher scores reflect higher rankings by panellists. RESULTS: Round 1 was completed by 121 panellists and generated 555 individual topics describing their musculoskeletal trial learning needs. These statements were grouped into 37 unique topics for Round 2, which was completed by 104 panellists. The topics ranked as most important were: (1) defining a meaningful research question (rank score 560, 74% of panellists rated topic as very important); (2) choosing the most appropriate trial design (rank score 410, 73% rated as very important); (3) involving consumers in trial design through to dissemination (rank score 302, 62% rated as very important); (4) bias in musculoskeletal trials and how to minimise it (rank score 299, 70% rated as very important); and (5) choosing the most appropriate control/comparator group (rank score 265, 65% rated as very important). CONCLUSIONS: This modified Delphi study generated a ranked list of clinical trial learning needs of musculoskeletal researchers. Findings can inform training courses and professional development to improve researcher capabilities and enhance the quality and conduct of musculoskeletal clinical trials.

1,4-Diaryl-1,2,3-triazole neolignan-celecoxib hybrids inhibit experimental arthritis induced by zymosan.

Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes cartilage damage. Anti-inflammatories are widely used in the management of RA, but they can have side effects such as gastrointestinal and/or cardiovascular disorders. Studies published by our group showed that the synthesis of hybrid triazole analogs neolignan-celecoxib containing the substituent groups sulfonamide (L15) or carboxylic acid (L18) exhibited anti-inflammatory activity in an acute model of inflammation, inhibited expression of P-selectin related to platelet activation and did not induce gastric ulcer, minimizing the related side effects. In continuation, the present study evaluated the anti-inflammatory effects of these analogs in an experimental model of arthritis and on the functions of one of the important cells in this process, macrophages. Mechanical hyperalgesia, joint edema, leukocyte recruitment to the joint and damage to cartilage in experimental arthritis and cytotoxicity, spread of disease, phagocytic activity and nitric oxide (NO) and hydrogen peroxide production by macrophages were evaluated. Pre-treatment with L15 and L18 reduced mechanical hyperalgesia, joint edema and the influx of leukocytes into the joint cavity after different periods of the stimulus. The histological evaluation of the joint showed that L15 and L18 reduced cartilage damage and there was no formation of rheumatoid pannus. Furthermore, L15 and L18 were non-cytotoxic. The analogs inhibited the spreading, the production of NO and hydrogen peroxide. L15 decreased the phagocytosis. Therefore, L15 and L18 may be potential therapeutic prototypes to treat chronic inflammatory diseases such as RA.

Efficacy, safety, and dose-dependence of the analgesic effects of opioid therapy for people with osteoarthritis: systematic review and meta-analysis.

OBJECTIVE: To evaluate the efficacy and safety of opioids for analgesic therapy for people with osteoarthritis. STUDY DESIGN: Systematic review and meta-analysis of randomised, placebo-controlled trials of opioid therapies for treating the pain of osteoarthritis. The primary outcome was medium term pain relief (six weeks to less than 12 months). Quality of evidence was assessed with GRADE criteria. DATA SOURCES: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, CINAHL, PsycINFO, AMED, and the WHO International Clinical Trials Registry; trials published to 31 October 2020. DATA SYNTHESIS: We extracted pain, disability, health-related quality of life, and adverse events data for 36 eligible trials (overall dose range: 10-210 oral morphine milligram equivalents [MME] per day). Continuous pain and disability outcomes were converted to common 0-100-point scales; changes of less than ten points were deemed to be very small effects. Differences in dichotomous outcomes were expressed as risk ratios. Data were pooled for meta-analysis in random effects models. The evidence from 19 trials (8965 participants; dose range, 10-126 MME/day) for very small medium term pain relief (mean difference [MD], -4.59 points; 95% CI, -7.17 to -2.02 points) was low quality, as was that from 16 trials (6882 participants; dose range, 10-126 MME/day) for a very small effect on disability (MD, -4.15 points; 95% CI, -6.94 to -1.35 points). Opioid dose was not statistically significantly associated with either degree of pain relief or incidence of adverse events in a meta-regression analysis. Evidence that opioid therapy increased the risk of adverse events (risk ratio, 1.43; 95% CI, 1.29-1.59) was of very low quality. CONCLUSIONS: Opioid medications may provide very small pain and disability benefits for people with osteoarthritis, but may also increase the risk of adverse events. PROSPERO REGISTRATION: CRD42019142813 (prospective).

Public and patient perceptions of diagnostic labels for non-specific low back pain: a content analysis.

PURPOSE: An online randomised experiment found that the labels lumbar sprain, non-specific low back pain (LBP), and episode of back pain reduced perceived need for imaging, surgery and second opinions compared to disc bulge, degeneration, and arthritis among 1447 participants with and without LBP. They also reduced perceived seriousness of LBP and increased recovery expectations. METHODS: In this study we report the results of a content analysis of free-text data collected in our experiment. We used two questions: 1. When you hear the term [one of the six labels], what words or feelings does this make you think of? and 2. What treatment (s) (if any) do you think a person with [one of the six labels] needs? Two independent reviewers analysed 2546 responses. RESULTS: Ten themes emerged for Question1. Poor prognosis emerged for disc bulge, degeneration, and arthritis, while good prognosis emerged for lumbar sprain, non-specific LBP, and episode of back pain. Thoughts of tissue damage were less common for non-specific LBP and episode of back pain. Feelings of uncertainty frequently emerged for non-specific LBP. Twenty-eight treatments emerged for Question2. Surgery emerged for disc bulge, degeneration, and arthritis compared to lumbar sprain, non-specific LBP, and episode of back pain. Surgery did not emerge for non-specific LBP and episode of back pain. CONCLUSION: Our results suggest that clinicians should consider avoiding the labels disc bulge, degeneration and arthritis and opt for labels that are associated with positive beliefs and less preference for surgery, when communicating with patients with LBP.

Hospital variation in admissions for low back pain following an emergency department presentation: a retrospective study.

BACKGROUND: One in 6 patients with low back pain (LBP) presenting to emergency departments (EDs) are subsequently admitted to hospital each year, making LBP the ninth most common reason for hospital admission in Australia. No studies have investigated and quantified the extent of clinical variation in hospital admission following an ED presentation for LBP. METHODS: We used routinely collected ED data from public hospitals within the state of New South Wales, Australia, to identify presentations of patients aged between 18 and 111 with a discharge diagnosis of LBP. We fitted a series of random effects multilevel logistic regression models adjusted by case-mix and hospital variables. The main outcome was the hospital-adjusted admission rate (HAAR). Data were presented as funnel plots with 95% and 99.8% confidence limits. Hospitals with a HAAR outside the 95% confidence limit were considered to have a HAAR significantly different to the state average. RESULTS: We identified 176,729 LBP presentations across 177 public hospital EDs and 44,549 hospital admissions (25.2%). The mean (SD) age was 51.8 (19.5) and 52% were female. Hospital factors explained 10% of the variation (ICC = 0.10), and the median odds ratio (MOR) was 2.03. We identified marked variation across hospitals, with HAAR ranging from 6.9 to 65.9%. After adjusting for hospital variables, there was still marked variation between hospitals with similar characteristics. CONCLUSION: We found substantial variation in hospital admissions following a presentation to the ED due to LBP even after controlling by case-mix and hospital characteristics. Given the substantial costs associated with these admissions, our findings indicate the need to investigate sources of variation and to determine instances where the observed variation is warranted or unwarranted.

Second opinions for spinal surgery: a scoping review.

BACKGROUND: Second opinions have the goal of clarifying uncertainties around diagnosis or management, particularly when healthcare decisions are complex, unpleasant, and carry considerable risks. Second opinions might be particularly useful for people recommended surgery for their back pain as surgery has at best a limited role in the management of back pain. METHODS: We conducted a scoping review. Two independent researchers screened PubMed, EMBASE, Cochrane CENTRAL and CINAHL from inception to May 6th, 2021. Studies of any design published in any language were eligible provided they described a second opinion intervention for people with spinal pain (low back or neck pain with or without radicular pain) either considering surgery or to whom surgery had been recommended. We assessed the methodological quality with the Downs & Black scale. Outcomes were: i) characteristics of second opinion services for people considering or who have been recommended spinal surgery, ii) agreement between first and second opinions in terms of diagnoses, need for surgery and type of surgery, iii) whether they reduce surgery and improve patient outcomes; and iv) the costs and healthcare use associated with these services. Outcomes were presented descriptively. RESULTS: We screened 6341 records, read 27 full-texts, and included 12 studies (all observational; 11 had poor methodological quality; one had fair). Studies described patient, doctor, and insurance-initiated second opinion services. Diagnostic agreement between first and second opinions varied from 53 to 96%. Agreement for need for surgery between first and second opinions ranged from 0 to 83%. Second opinion services may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. Second opinion services may reduce costs and healthcare use (e.g. imaging), but might increase others (e.g. injections). CONCLUSIONS: Second opinion services typically recommend less surgical treatments compared to first opinions and may reduce surgery rates in the short-term, but it is unclear whether these reductions are sustained in the long-term or if patients only delay surgery. There is a need for high-quality randomised trials to determine the value of second opinion services for reducing spinal surgery.

Reporting characteristics of journal infographics: a cross-sectional study.

BACKGROUND: Infographics have become an increasingly popular method to present research findings and increase the attention research receives. As many scientific journals now use infographics to boost the visibility and uptake of the research they publish, infographics have become an important tool for medical education. It is unknown whether such infographics convey the key characteristics that are needed to make useful interpretations of the data such as an adequate description of the study population, interventions, comparators and outcomes; methodological limitations; and numerical estimates of benefits and harms. This study described whether infographics published in peer-reviewed health and medical research journals contain key characteristics that are needed to make useful interpretations of clinical research. METHODS: In this cross-sectional study, we identified peer-reviewed journals listed in the top quintile of 35 unique fields of medicine and health research listed in the Journal Citation Reports database. Two researchers screened journals for the presence of infographics. We defined an infographic as a graphical visual representation of research findings. We extracted data from a sample of two of the most recent infographics from each journal. Outcomes were the proportion of infographics that reported key characteristics such as study population, interventions, comparators and outcomes, benefits, harms, effect estimates with measures of precision, between-group differences and conflicts of interest; acknowledged risk of bias, certainty of evidence and study limitations; and based their conclusions on the study's primary outcome. RESULTS: We included 129 infographics from 69 journals. Most infographics described the population (81%), intervention (96%), comparator (91%) and outcomes (94%), but fewer contained enough information on the population (26%), intervention (45%), comparator (20%) and outcomes (55%) for those components of the study to be understood without referring to the main paper. Risk of bias was acknowledged in only 2% of infographics, and none of the 69 studies that had declared a conflict of interest disclosed it in the infographics. CONCLUSIONS: Most infographics do not report sufficient information to allow readers to interpret study findings, including the study characteristics, results, and sources of bias. Our results can inform initiatives to improve the quality of the information presented in infographics.

How do people use and view infographics that summarise health and medical research? A cross-sectional survey.

BACKGROUND: Understanding how people use infographics and their opinion on them has important implications for the design of infographics but has not been investigated. The aim of this study was to describe people's use of and opinions about infographics summarising health and medical research, preferences for information to include in infographics, and barriers to reading full-text articles. METHODS: We conducted an online cross-sectional survey of consumers of infographics that summarise health or medical research. Demographic and outcome data were collected and summarised using descriptive statistics. A sensitivity analysis explored whether being a researcher/academic influenced the findings. RESULTS: Two hundred fifty-four participants completed the survey (88% completion rate). Participants included health professionals (66%), researchers (34%), academics (24%), and patients/the public (13%). Most used Twitter (67%) and smartphones (89%) to access and view infographics, and thought infographics were useful tools to communicate research (92%) and increase the attention research receives (95%). Although most participants were somewhat/extremely likely (76%) to read the full-text article after viewing an infographic, some used infographics as a substitute for the full text at least half of the time (41%), thought infographics should be detailed enough so they do not have to read the full text (55%), and viewed infographics as tools to reduce the time burden of reading the full text (64%). Researchers/academics were less likely to report behaviours/beliefs suggesting infographics can reduce the need to read the full-text article. CONCLUSIONS: Given many people use infographics as a substitute for reading the full-text article and want infographics to be detailed enough so they don't have to read the full text, a checklist to facilitate clear, transparent, and sufficiently detailed infographics summarising some types of health and medical research may be useful.

Are musculoskeletal conditions neglected in national health surveys?

OBJECTIVE: To describe the proportion of national health surveys that contain questions on the prevalence and consequences of musculoskeletal conditions. METHODS: We used a comprehensive search strategy to obtain national health surveys from the 218 countries listed by the World Bank. Two authors independently extracted information from each national health survey. Outcomes were the proportion of surveys that contained questions on the prevalence of musculoskeletal conditions using the Global Burden of Disease categorization of RA, OA, low back pain, neck pain, gout and other and contained condition-specific questions about activity limitation, severity of pain and work absence. We also measured how frequently the prevalence of low back pain was measured using a consensus-based standard definition for low back pain prevalence studies. RESULTS: We identified national health surveys from 170 countries. Sixty-two (36.4%), the majority from high-income countries (n = 43), measured the prevalence of at least one musculoskeletal condition. OA [53 (85.4%)], low back pain [39 (62.9%)] and neck pain [37 (59.7%)] were most commonly measured, while RA and gout prevalence were only measured in 10 (5.9%) and 3 (1.8%) surveys, respectively. A minority of surveys assessed condition-specific activity limitations [6 (3.6%)], pain severity [5 (2.9%)] and work absence [1 (0.6%)]. Only one survey used the consensus-based standard definition for low back pain. CONCLUSION: Musculoskeletal conditions are neglected in the majority of national health surveys. Monitoring musculoskeletal conditions through ongoing surveys is crucial for the development and evaluation of health policies to reduce their burden.

The efficacy and safety of paracetamol for pain relief: an overview of systematic reviews.

OBJECTIVE: To evaluate the efficacy and safety of paracetamol as an analgesic medication in a range of painful conditions. STUDY DESIGN: Systematic review of systematic reviews of the analgesic effects of paracetamol in randomised, placebo-controlled trials. Conduct of systematic reviews was assessed with AMSTAR-2; confidence in effect estimates (quality of evidence) was assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. DATA SOURCES: MEDLINE, EMBASE, PsycINFO, Cochrane Database of Systematic Reviews; systematic reviews published 1 January 2010 - 30 April 2020. DATA SYNTHESIS: We extracted pain and adverse events outcomes from 36 systematic reviews that assessed the efficacy of paracetamol in 44 painful conditions. Continuous pain outcomes were expressed as mean differences (MDs; standardised 0-10-point scale); dichotomous outcomes were expressed as risk ratios (RRs). There is high quality evidence that paracetamol provides modest pain relief for people with knee or hip osteoarthritis (MD, -0.3 points; 95% CI, -0.6 to -0.1 points) and after craniotomy (MD, -0.8 points; 95% CI, -1.4 to -0.2 points); there is moderate quality evidence for its efficacy in tension-type headache (pain-free at 2 hours: RR, 1.3; 95% CI, 1.1-1.4) and perineal pain soon after childbirth (patients experiencing 50% pain relief: RR, 2.4; 95% CI, 1.5-3.8). There is high quality evidence that paracetamol is not effective for relieving acute low back pain (MD, 0.2 points; 95% CI, -0.1 to 0.4 points). Evidence regarding efficacy in other conditions was of low or very low quality. Frequency of adverse events was generally similar for people receiving placebo or paracetamol, except that transient elevation of blood liver enzyme levels was more frequent during repeated administration of paracetamol to patients with spinal pain (RR, 3.8; 95% CI, 1.9-7.4). CONCLUSIONS: For most conditions, evidence regarding the effectiveness of paracetamol is insufficient for drawing firm conclusions. Evidence for its efficacy in four conditions was moderate to strong, and there is strong evidence that paracetamol is not effective for reducing acute low back pain. Investigations that evaluate more typical dosing regimens are required. PROSPERO REGISTRATION: CRD42015029282 (prospective).

Online Information About the Effectiveness of Shoulder Surgery Is Not Based on the Best Available Evidence: A Content Analysis.

OBJECTIVE: To summarize the proportion of consumer webpages on subacromial decompression and rotator cuff repair surgery that make an accurate portrayal of the evidence for these operations (primary outcome), mention the benefits and harms of surgery, outline alternatives to surgery, and make various surgical recommendations. DESIGN: Content analysis. SETTING: Online consumer information about subacromial decompression and rotator cuff repair surgery. Webpages were identified through (1) Google searches using terms synonymous with "shoulder pain" and "shoulder surgery" and searching "orthopedic surgeon" linked to each Australian capital city and (2) websites of relevant professional associations (eg, Australian Orthopaedic Association). Two reviewers independently identified webpages and extracted data. PARTICIPANTS: Not applicable. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Whether the webpage made an accurate portrayal of the evidence for subacromial decompression or rotator cuff repair surgery (primary outcome), mentioned benefits and harms of surgery, outlined alternatives to surgery, and made various surgical recommendations (eg, delay surgery). Outcome data were summarized using counts and percentages. RESULTS: A total of 155 webpages were analyzed (n=89 on subacromial decompression, n=90 on rotator cuff repair, n=24 on both). Only 18% (n=16) and 4% (n=4) of webpages made an accurate portrayal of the evidence for subacromial decompression and rotator cuff repair surgery, respectively. For subacromial decompression and rotator cuff repair, respectively, 85% (n=76) and 80% (n=72) of webpages mentioned benefits, 38% (n=34) and 47% (n=42) mentioned harms, 94% (n=84) and 92% (n=83) provided alternatives to surgery, and 63% (n=56) and 62% (n=56) recommended delayed surgery (the most common recommendation). CONCLUSIONS: Most online information about subacromial decompression and rotator cuff repair surgery does not accurately portray the best available evidence for surgery and may be inadequate to inform patient decision making.

Immediate Effects of Dry Needling and Myofascial Release on Local and Widespread Pressure Pain Threshold in Individuals With Active Upper Trapezius Trigger Points: A Randomized Clinical Trial.

OBJECTIVE: This study sought to compare the immediate effects of a single session of dry needling (DN), myofascial release (MR), and sham DN on pressure pain threshold (PPT) and neck pain intensity in individuals with chronic neck pain. METHODS: This was a randomized trial with a blinded outcome assessor. Forty-four individuals with chronic neck pain and unilateral myofascial trigger points in the upper trapezius muscle (UTM) were randomized to receive DN (n = 15), MR (n = 14), or sham DN (n = 15). The PPT over the UTM (ipsilateral and contralateral sides) and the proximal head of the radius (ipsilateral and contralateral to the treated side) and neck pain were assessed immediately and 10 minutes after the intervention. RESULTS: There was no significant Group × Time interaction for PPT in the UTM on the treated side (F = 0.63, P = .641) or the contralateral side (F = 1.77, P = .144). However, there was a main effect of time on both the treated side (F = 4.917, P = .001) and the contralateral side (F = 4.70, P = .015), with DN and MR increasing PPT at the UTM. No significant Group × Time × Side interaction was found for PPT at the proximal head of the radius (F = 1.23, P = .276). Within-group analysis revealed a significant increase in PPT on the ipsilateral and contralateral sides in both DN and MR. Neck pain decreased after DN (P < .001), MR (P < .001), and sham DN (P = .008). CONCLUSION: A single application of DN or MR generated local and distant hypalgesic responses superior to placebo. Future trials are needed to examine whether these findings occur in long-term follow-ups.

Credibility, Accuracy, and Comprehensiveness of Internet-Based Information About Low Back Pain: A Systematic Review.

BACKGROUND: Low back pain (LBP) affects millions of people worldwide, and misconceptions about effective treatment options for this condition are very common. Websites sponsored by organizations recognized as trustworthy by the public, such as government agencies, hospitals, universities, professional associations, health care organizations and consumer organizations are an important source of health information for many people. However, the content of these websites regarding treatment recommendations for LBP has not been fully evaluated. OBJECTIVE: This study aimed to determine the credibility, accuracy, and comprehensiveness of treatment recommendations for LBP in noncommercial, freely accessible websites. METHODS: We conducted a systematic review of websites from government agencies, hospitals, universities, professional associations, health care organizations and consumer organizations. We conducted searches on Google. Treatment recommendations were coded based on the 2016 National Institute for Health and Care Excellence (NICE) guidelines and the 2017 American College of Physicians guideline on LBP. Primary outcomes were credibility of the website (4-item Journal of the American Medical Association benchmark), accuracy (proportion of website treatment recommendations that were appropriate), and comprehensiveness of website treatment recommendations (proportion of guideline treatment recommendations that were appropriately covered by a website). RESULTS: We included 79 websites from 6 English-speaking countries. In terms of credibility, 31% (25/79) of the websites clearly disclosed that they had been updated after the publication of the NICE guidelines. Only 43.28% (487/1125) website treatment recommendations were judged as accurate. Comprehensiveness of treatment recommendations correctly covered by websites was very low across all types of LBP. For acute LBP, an average of 28% (4/14) guideline recommendations were correctly covered by websites. Websites for radicular LBP were the least comprehensive, correctly covering an average of 16% (2.3/14) recommendations. CONCLUSIONS: Noncommercial freely accessible websites demonstrated low credibility standards, provided mostly inaccurate information, and lacked comprehensiveness across all types of LBP.

Autonomic Effects of Spinal Manipulative Therapy: Systematic Review of Randomized Controlled Trials.

OBJECTIVE: The purpose of this study was to systematically review the effects of spinal manipulative therapy (SMT) on autonomic nervous system (ANS)-mediated outcomes, in both symptomatic and healthy populations, and to assess the quality of evidence for the most prevalent outcomes with the Grading of Recommendations, Assessment, Development and Evaluation approach. METHODS: PubMed, Cochrane Library, PEDro, Web of Science, and EMBASE were searched from their inception to March 2014. Randomized controlled trials involving SMT, such as mobilization and manipulation, that reported at least 1 outcome related to the ANS, with placebo, control groups, or other SMT techniques as comparators, with either healthy or symptomatic samples were included. The Physiotherapy Evidence Database scale and the Grading of Recommendations, Assessment, Development and Evaluation approach were used to assess risk of bias and the quality of evidence, respectively. RESULTS: Eighteen trials were included in this systematic review. Passive accessory intervertebral mobilization produced sympathoexcitation independently of the treated region (cervical, thoracic, or lumbar spine); although sustained natural apophyseal glides did not influence the ANS, conflicting results were observed regarding manipulation techniques. The overall quality of evidence for all analyzed outcomes ranged from low to very low quality. CONCLUSION: There is evidence pointing toward the existence of sympathoexcitatory short-term effects following passive accessory intervertebral mobilization mobilizations, but not for sustained natural apophyseal glide mobilizations. There is conflicting evidence regarding the ability of manipulation to elicit sympathoexcitation. However, the low quality of the evidence precludes a definitive conclusion of such effects. Based on the current evidence, there is uncertainty regarding the true effect estimates of SMT on ANS-mediated outcomes.