Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: systematic review and meta-analysis of randomised controlled trials

OBJECTIVE To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting. REVIEW METHODS Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored. RESULTS 47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference −3.17, 95% confidence interval −7.85 to 1.51) and a small, clinically better improvement in function (SMD −0.25, 95% confidence interval −0.41 to −0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference −7.48, −11.50 to −3.47) and small to moderate clinically better improvement in function (SMD −0.41, −0.67 to −0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity coul

BAck complaints in the elders - Chiropractic (BACE-C): Protocol of an international cohort study of older adults with low back pain seeking chiropractic care

Background: Low back pain is a common condition among older adults that significantly influences physical function and participation. Compared to their younger counterparts, there is limited information available about the clinical course of low back pain in older people, in particularly those presenting for chiropractic care. Improving our understanding of this patient population and the course of their low back pain may provide input for studies researching safer and more effective care than is currently provided. Objectives: The primary objectives are to examine the clinical course over one year of pain intensity, healthcare costs and pain, functional status and recovery rates of low back pain in people 55 years and older who visit a chiropractor for a new episode of low back pain. Methods: An international prospective, multi-center cohort study with one-year follow-up. Chiropractic practices are to be recruited in the Netherlands, Sweden, United Kingdom and Australia. Treatment will be left to the discretion of the chiropractor. Inclusion/Exclusion criteria: Patients aged 55 and older who consult a chiropractor for a new episode of low back pain, meaning low back pain for the first time or those patients who have not been to a chiropractor in the previous six months. This is independent of whether they have seen another type of health care provider for the current episode. Patients who are unable to complete the web-based questionnaires because of language restrictions or those with computer literacy restrictions will be excluded as well as those with cognitive disorders. In addition, those with a suspected tumor, fracture, infection or any other potential red flag or condition considered to be a contraindication for chiropractic care will be excluded. Data will be collected using online questionnaires at baseline, and at 2 and 6 weeks and at 3, 6, 9 and 12 months. Discussion: This study, to our knowledge, is the first large-scale, prospective, multicenter, international cohort study to be conducted in a chiropractic setting to focus on older adults with low back pain consulting a chiropractor. By understanding the clinical course, satisfaction and safety of chiropractic treatment of this common debilitating condition in the aged population, this study will provide input for informing future clinical trials. Trial registration: Nederlandse Trial Registrar NL7507

Lumbale herniaoperatie: Endoscopisch of open?

_Achtergrond en het waarom van de studie_ In Nederland vinden jaarlijks veel operaties voor een lumbale discushernia plaats. Patiënten krijgen meestal een open microdiscectomie, waarbij de hernia wordt opgeheven via een klein sneetje in de rug en de zenuwwortel wordt vrijgelegd (figuur a). Een andere techniek is percutane transforaminale endoscopische discectomie (PTED) (figuur b). Hierbij wordt de hernia onder indirect zicht opgeheven door een kleinere snee van 8 mm via het wortelkanaal, dus meer vanaf de zijkant. PTED vindt plaats in dagbehandeling onder lichte sedatie, waardoor de patiënt gedurende de ingreep aanspreekbaar is. Mogelijke voordelen van deze techniek zijn minder risico op littekenvorming en een snellere revalidatie. Een mogelijk nadeel is een groter risico op recidieven omdat er minder discusmateriaal kan worden uitgeruimd. PTED behoort nog niet tot het basispakket, omdat Zorginstituut Nederland meent dat PTED niet voldoet aan de stand van de wetenschap en praktijk. Met de PTED-studie willen wij de hypothese toetsen dat PTED bij patiënten met een lumbale hernia niet minder effectief is dan open microdiscectomie. Daarnaast zullen wij ook de kosteneffectiviteit analyseren. _Vraagstelling:_ Is PTED niet minder effectief en niet minder kosteneffectief dan microdiscectomie bij patiënten met lumbosacraal radiculair syndroom door een discushernia

Surgery versus conservative care for neck pain: A systematic review

Objective: General practitioners refer patients with continued neck pain that do not respond well to conservative care frequently to secondary care for further assessment. Are surgical interventions to the cervical spine effective when compared to conservative care for patients with neck pain? Design: Systematic review. Method: The search strategy outlined by the Cochrane Back Review Group (CBRG) was followed. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to June 2011. Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of adults with neck pain, which evaluated at least one clinically relevant primary outcome measure (e.g. pain, functional status, recovery), were included. In addition, treatments had to include surgery and conservative care. Two authors independently assessed risk of bias using the criteria recommended by the CBRG and extracted the data. The quality of the evidence was rated using the GRADE method. Results: Patients included had neck pain with or without radiculopathy or myelopathy. In total, three RCTs and six CCTs were identified comparing different surgical interventions with conservative care, of which one had a low risk of bias. Overall there is very low quality of evidence available on the effectiveness of surgery compared to conservative care in neck pain patients showing overall no differences. Conclusion: Most studies on surgical techniques comparing these to conservative care showed a high risk of bias. The benefit of surgery over conservative care is not clearly demonstrated