Abstract Background context Cervical spine disc herniation is a disabling source of cervical radiculopathy. However, little is known about its course and prognosis. Understanding the course and ...prognosis of symptomatic cervical disc herniation is necessary to guide patients' expectations and assist clinicians in managing patients. Purpose To describe the natural history, clinical course, and prognostic factors of symptomatic cervical disc herniations with radiculopathy. Study design Systematic review of the literature and best evidence synthesis. Methods A systematic search of MEDLINE, EMBASE, CINAHL, SportsDiscus, and the Cochrane Central Register of Controlled Trials from inception to 2013 was conducted to retrieve eligible articles. Eligible articles were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results from articles with low risk of bias were analyzed using best evidence synthesis principles. Results We identified 1,221 articles. Of those, eight articles were eligible and three were accepted as having a low risk of bias. Two studies pertained to course and one study pertained to prognosis. Most patients with symptomatic cervical disc herniations with radiculopathy initially present with intense pain and moderate levels of disability. However, substantial improvements tend to occur within the first 4 to 6 months post-onset. Time to complete recovery ranged from 24 to 36 months in, approximately, 83% of patients. Patients with a workers' compensation claim appeared to have a poorer prognosis. Conclusions Our best evidence synthesis describes the best available evidence on the course and prognosis of cervical disc herniations with radiculopathy. Most patients with symptomatic cervical spine disc herniation with radiculopathy recover. Possible recurrences and time to complete recovery need to be further studied. More studies are also needed to understand the prognostic factors for this condition.
Abstract Background Context In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of ...manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). Purpose To update findings of the Neck Pain Task Force examining the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. Study Design/Setting Systematic review and best evidence synthesis. Sample Randomized controlled trials (RCTs), cohort studies, case-control studies comparing manual therapies, passive physical modalities, or acupuncture to other interventions, placebo/sham, or no intervention. Outcome measures Self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events. Methods We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory versus evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance. Results We screened 8551 citations, 38 studies were relevant, and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that: 1) for recent but not persistent NAD I-II: thoracic manipulation offers short-term benefits; 2) for persistent NAD I-II: technical parameters of cervical mobilization (e.g., direction or site of manual contact) do not impact outcomes, while one session of cervical manipulation is similar to Kinesiotaping; and 3) for NAD I-II: strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that: 1) for recent NAD I-II: cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises; Swedish/clinical massage adds benefit to self-care advice; 2) for persistent NAD I-II: home-based cupping massage has similar outcomes to home-based muscle relaxation; low-level laser therapy (LLLT) does not offer benefits; Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture; needle acupuncture provides similar outcomes to sham-penetrating acupuncture; 3) for WAD I-II: needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and 4) for recent NAD III: a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes; LLLT does not offer benefits. Conclusions Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, ultrasound) are not effective and should not be used to manage neck pain.
Abstract Background context In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available ...on the effectiveness of exercise for Grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises. Purpose To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III. Study design/setting Systematic review and best evidence synthesis. Sample Studies comparing the effectiveness of exercise to other conservative interventions or no intervention. Outcome measures Outcomes of interest included self-rated recovery, functional recovery, pain intensity, health-related quality of life, psychological outcomes, and/or adverse events. Methods We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results of scientifically admissible studies were synthesized following best-evidence synthesis principles. Results We retrieved 4,761 articles, and 21 randomized controlled trials (RCTs) were critically appraised. Ten RCTs were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain Grade I/II, unsupervised range-of-motion exercises, nonsteroidal anti-inflammatory drugs and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain Grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD Grade I/II, supervised qigong and combined strengthening, range-of-motion, and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally, supervised high-dose strengthening is not superior to home exercises or advice. Conclusions We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone.
Abstract Background Context Whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) are prevalent conditions that impact society and impose a significant economic burden on ...health-care systems. Health economic evidence on WAD and NAD interventions has been sparse: only three economic evaluations of interventions for NAD were identified by the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (NPTF). An updated overview is needed to inform health-care policy and guidelines. Purpose This study aimed to determine the cost-effectiveness of interventions for grades I–III WAD and NAD in children and adults. Study Design Systematic review of health economic literature, best-evidence synthesis. Methods We systematically searched CINAHL, the Cochrane economic databases (Health Technology Assessment, NHS Economic Evaluation Database), EconLit, EMBASE, MEDLINE, PsycINFO, and Tufts CEA Registry from 2000 to 2015 for economic evaluations of WAD and NAD interventions. We appraised relevant evaluations using the Scottish Intercollegiate Guidelines Network Methodology Criteria for Economic Evaluations. We extracted data, including mean costs (standardized to 2013 Canadian dollars CAD) and quality-adjusted life years (QALYs), from studies with adequate methodological quality. We recalculated cost-effectiveness statistics based on the standardized currency using a willingness-to-pay of CAD $50,000 per additional QALY. Funding was provided by the Ministry of Finance. Results Our search identified 1,616 citations. Six studies fulfilled our selection criteria, including three studies previously reviewed by the NPTF. Structured education appears cost-effective for adults with WAD. For adults with NAD, acupuncture added to routine medical care; manual therapy; multimodal care that includes manual therapy; advice and exercise; and psychological care using cognitive-behavioral therapy appear cost-effective. In contrast, adding manual therapy or diathermy to advice and exercise; multimodal care by a physiotherapist or physician; and behavioral-graded activity do not appear cost-effective for adults with NAD. Conclusions Our review adds to the findings of the NPTF. Recent evidence suggests that structured education is cost-effective for WAD, whereas advice and exercise and multimodal care that include manual therapy are cost-effective for NAD. Obtaining more robust health economic evidence for non-invasive interventions for WAD and NAD in children and adults remains an essential research priority.
Abstract Background context In 2008, the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders recommended patient education for the management of neck pain. ...However, the effectiveness of education interventions has recently been challenged. Purpose To update the findings of the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of structured patient education for the management of patients with whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). Study design/setting Systematic review of the literature and best-evidence synthesis. Patient sample Randomized controlled trials that compared structured patient education with other conservative interventions. Outcome measures Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes such as depression or fear, or adverse effects. Methods We systematically searched eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, DARE, PubMed, and ICL) from 2000 to 2012. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized in evidence tables and synthesized following best-evidence synthesis principles. Results We retrieved 4,477 articles. Of those, nine were eligible for critical appraisal and six were scientifically admissible. Four admissible articles investigated patients with WAD and two targeted patients with NAD. All structured patient education interventions included advice on activation or exercises delivered orally combined with written information or as written information alone. Overall, as a therapeutic intervention, structured patient education was equal or less effective than other conservative treatments including massage, supervised exercise, and physiotherapy. However, structured patient education may provide small benefits when combined with physiotherapy. Either mode of delivery (ie, oral or written education) provides similar results in patients with recent WAD. Conclusions This review adds to the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders by defining more specifically the role of structured patient education in the management of WAD and NAD. Results suggest that structured patient education alone cannot be expected to yield large benefits in clinical effectiveness compared with other conservative interventions for patients with WAD or NAD. Moreover, structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care. These benefits are small and short lived.
Abstract Background context Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD). Purpose ...To update findings of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD. Study design/setting Systematic review and best-evidence synthesis. Patient sample We included randomized controlled trials (RCTs), cohort studies, and case-control studies. Outcome measures Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events. Methods We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles. Results We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD. Conclusions Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD.
Abstract Background Context In 2008, the lack of published evidence prevented the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force NPTF) from ...commenting on the effectiveness of psychological interventions for the management of neck pain. Purpose This study aimed to update findings of the NPTF and evaluate the effectiveness of psychological interventions for the management of neck pain and associated disorders (NAD) or whiplash-associated disorders (WAD). Study Design/setting This study used systematic review and best-evidence synthesis. Sample Randomized controlled trials, cohort studies, and case-control studies comparing psychological interventions to other non-invasive interventions or no intervention were the samples used in this study. Outcome measures The outcome measures are (1) self-rated recovery; (2) functional recovery; (3) clinical outcomes; (4) administrative outcomes; and (5) adverse effects. Methods We searched six databases from 1990 to 2015. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers used the Scottish Intercollegiate Guidelines Network criteria to critically appraise eligible studies. Studies with a low risk of bias were synthesized following best evidence synthesis principles. This study was funded by the Ontario Ministry of Finance. Results We screened 1,919 articles, 19 were eligible for critical appraisal and 10 were judged to have low risk of bias. We found no clear evidence supporting relaxation training or cognitive behavioral therapy (CBT) for persistent grades I–III NAD for reducing pain intensity or disability. Similarly, we did not find evidence to support the effectiveness of biofeedback or relaxation training for persistent grade II WAD, and there is conflicting evidence for the use of CBT in this population. However, adding a progressive goal attainment program to functional restoration physiotherapy may benefit patients with persistent grades I–III WAD. Furthermore, Jyoti meditation may help reduce neck pain intensity and bothersomeness in patients with persistent NAD. Conclusions We did not find evidence for or against the use of psychological interventions in patients with recent onset NAD or WAD. We found evidence that a progressive goal attainment program may be helpful for the management of persistent WAD and that Jyoti meditation may benefit patients with persistent NAD. The limited evidence of effectiveness for psychological interventions may be due to several factors, such as interventions that are ineffective, poorly conceptualized, or poorly implemented. Further methodologically rigorous research is needed.
Abstract Objective The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee. Methods We conducted a ...systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. Results We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a “wait and see” approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. Conclusion We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed.
Abstract Objective The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the lower extremity. Methods We ...systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Random pairs of independent reviewers screened studies for relevance and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. Results We screened 6794 articles. Six studies had a low risk of bias and addressed the following: plantar heel pain (n = 2), adductor-related groin pain (n = 1), and patellofemoral pain (n = 3). The evidence suggests that multimodal care for the management of persistent plantar heel pain may include mobilization and stretching exercise. An intensive, clinic-based, group exercise program (strengthening, stretching, balance, agility) is more effective than multimodal care for the management of adductor-related groin pain in male athletes. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Our search did not identify any low risk of bias studies examining multimodal care for the management of other soft tissue injuries of the lower extremity. Conclusion A multimodal program of care for the management of persistent plantar heel pain may include mobilization and stretching exercise. Multimodal care for adductor-related groin pain is not recommended based on the current evidence. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain.
