Self reported aggravating activities do not demonstrate a consistent directional pattern in chronic non specific low back pain patients: An observational study

Question: Do the self-reported aggravating activities of chronic non-specific low back pain patients demonstrate a consistent directional pattern? Design: Cross-sectional observational study. Participants: 240 chronic non specific low back pain patients. Outcome measure: We invited experienced clinicians to classify each of the three self-nominated aggravating activities from the Patient Specific Functional Scale by the direction of lumbar spine movement. Patients were described as demonstrating a directional pattern if all nominated activities moved the spine into the same direction. Analyses were undertaken to determine if the proportion of patients demonstrating a directional pattern was greater than would be expected by chance. Results: In some patients, all tasks did move the spine into the same direction, but this proportion did not differ from chance (p = 0.328). There were no clinical or demographic differences between those who displayed a directional pattern and those who did not (all p > 0.05). Conclusion: Using patient self-reported aggravating activities we were unable to demonstrate the existence of a consistent pattern of adverse movement in patients with chronic non-specific low back pain

Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II (Review)

Background: Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery. When it occurs, it is associated with significant pain and disability. It is thought to arise and persist as a consequence of a maladaptive pro-inflammatory response and disturbances in sympathetically-mediated vasomotor control, together with maladaptive peripheral and central neuronal plasticity. CRPS can be classified into two types: type I (CRPS I) in which a specific nerve lesion has not been identified, and type II (CRPS II) where there is an identifiable nerve lesion. Guidelines recommend the inclusion of a variety of physiotherapy interventions as part of the multimodal treatment of people with CRPS, although their effectiveness is not known. Objectives: To determine the effectiveness of physiotherapy interventions for treating the pain and disability associated with CRPS types I and II. Search methods: We searched the following databases from inception up to 12 February 2015: CENTRAL (the Cochrane Library), MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS, PEDro, Web of Science, DARE and Health Technology Assessments, without language restrictions, for randomised controlled trials (RCTs) of physiotherapy interventions for treating pain and disability in people CRPS. We also searched additional online sources for unpublished trials and trials in progress. Selection criteria: We included RCTs of physiotherapy interventions (including manual therapy, therapeutic exercise, electrotherapy, physiotherapist administered education and cortically directed sensory-motor rehabilitation strategies) employed in either a stand-alone fashion or in combination, compared with placebo, no treatment, another intervention or usual care, or of varying physiotherapy interventions compared with each other in adults with CRPS I and II. Our primary outcomes of interest were patient-centred outcomes of pain intensity and functional disability. Data collection and analysis: Two review authors independently evaluated those studies identified through the electronic searches for eligibility and subsequently extracted all relevant data from the included RCTs. Two review authors independently performed ’Risk of bias’ assessments and rated the quality of the body of evidence for the main outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Main results: We included 18 RCTs (739 participants) that tested the effectiveness of a broad range of physiotherapy-based interventions. Overall, there was a paucity of high quality evidence concerning physiotherapy treatment for pain and disability in people with CRPS I. Most included trials were at ’high’ risk of bias (15 trials) and the remainder were at ’unclear’ risk of bias (three trials). The quality of the evidence was very low or low for all comparisons, according to the GRADE approach. We found very low quality evidence that graded motor imagery (GMI; two trials, 49 participants) may be useful for improving pain (0 to 100 VAS) (mean difference (MD) −21.00, 95% CI −31.17 to −10.83) and functional disability (11-point numerical rating scale) (MD 2.30, 95% CI 1.12 to 3.48), at long-term (six months) follow-up, in people with CRPS I compared to usual care plus physiotherapy; very low quality evidence that multimodal physiotherapy (one trial, 135 participants) may be useful for improving ’impairment’ at long-term (12 month) follow-up compared to a minimal ’social work’ intervention; and very low quality evidence that mirror therapy (two trials, 72 participants) provides clinically meaningful improvements in pain (0 to 10 VAS) (MD 3.4, 95% CI −4.71 to −2.09) and function (0 to 5 functional ability subscale of the Wolf Motor Function Test) (MD −2.3, 95% CI −2.88 to −1.72) at long-term (six month) follow-up in people with CRPS I post stroke compared to placebo (covered mirror). There was low to very low quality evidence that tactile discrimination training, stellate ganglion block via ultrasound and pulsed electromagnetic field therapy compared to placebo, and manual lymphatic drainage combined with and compared to either anti-inflammatories and physical therapy or exercise are not effective for treating pain in the short-termin people with CRPS I. Laser therapy may provide small clinically insignificant, short-term, improvements in pain compared to interferential current therapy in people with CRPS I. Adverse events were only rarely reported in the included trials. No trials including participants with CRPS II met the inclusion criteria of this review. Authors’ conclusions: The best available data show that GMI and mirror therapy may provide clinically meaningful improvements in pain and function in people with CRPS I although the quality of the supporting evidence is very low. Evidence of the effectiveness of multimodal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS types I and II is generally absent or unclear. Large scale, high quality RCTs are required to test the effectiveness of physiotherapy-based interventions for treating pain and disability of people with CRPS I and II. Implications for clinical practice and future research are considered

Resistance training for rehabilitation after burn injury: A systematic literature review and meta-analysis

Background/aim: Resistance training is beneficial for rehabilitation in many clinical conditions, though this has not been systematically reviewed in burns. The objective was to determine the effectiveness of resistance training on muscle strength, lean mass, function, quality of life and pain, in children and adults after burn injury. Methods: Medline & EMBASE, PubMed, CINAHL and CENTRAL were searched from inception to October 2016. Studies were identified that implemented resistance training in rehabilitation. Data were combined and included in meta-analyses for muscle strength and lean mass. Otherwise, narrative analysis was completed. The quality of evidence for each outcome was summarised and rated using the GRADE framework. Results: Eleven studies matched our inclusion criteria. Primary analysis did not demonstrate significant improvements for increasing muscle strength (SMD 0.74, 95% CI _0.02 to 1.50, p=0.06). Sensitivity analysis to correct an apparent anomaly in published data suggested a positive effect (SMD 0.37, 95% CI 0.08–0.65, p=0.01). Psychological quality of life demonstrated benefit from training (MD=25.3, 95% CI 3.94–49.7). All studies were rated as having high risk of bias. The quality of the evidence was rated as low or very low. Conclusion: Further research with robust methodology is recommended to assess the potential benefit suggested in this review

Non-invasive brain stimulation techniques for chronic pain (Review)

Background: This is an updated version of the original Cochrane Review published in 2010, Issue 9, and last updated in 2014, Issue 4. Non-invasive brain stimulation techniques aim to induce an electrical stimulation of the brain in an attempt to reduce chronic pain by directly altering brain activity. They include repetitive transcranial magnetic stimulation (rTMS), cranial electrotherapy stimulation (CES), transcranial direct current stimulation (tDCS), transcranial random noise stimulation (tRNS) and reduced impedance non-invasive cortical electrostimulation (RINCE). Objectives: To evaluate the efficacy of non-invasive cortical stimulation techniques in the treatment of chronic pain. Search methods: For this update we searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, LILACS and clinical trials registers from July 2013 to October 2017. Selection criteria: Randomised and quasi-randomised studies of rTMS, CES, tDCS, RINCE and tRNS if they employed a sham stimulation control group, recruited patients over the age of 18 years with pain of three months’ duration or more, and measured pain as an outcome. Outcomes of interest were pain intensity measured using visual analogue scales or numerical rating scales, disability, quality of life and adverse events. Data collection and analysis: Two review authors independently extracted and verified data. Where possible we entered data into meta-analyses, excluding studies judged as high risk of bias. We used the GRADE system to assess the quality of evidence for core comparisons, and created three ’Summary of findings’ tables. Main results: We included an additional 38 trials (involving 1225 randomised participants) in this update, making a total of 94 trials in the review (involving 2983 randomised participants). This update included a total of 42 rTMS studies, 11 CES, 36 tDCS, two RINCE and two tRNS. One study evaluated both rTMS and tDCS. We judged only four studies as low risk of bias across all key criteria. Using the GRADE criteria we judged the quality of evidence for each outcome, and for all comparisons as low or very low; in large part this was due to issues of blinding and of precision. rTMS: Meta-analysis of rTMS studies versus sham for pain intensity at short-term follow-up (0 to \u3c 1 week postintervention), (27 studies, involving 655 participants), demonstrated a small effect with heterogeneity (standardised mean difference (SMD) -0.22, 95% confidence interval (CI) -0.29 to -0.16, low-quality evidence). This equates to a 7% (95% CI 5% to 9%) reduction in pain, or a 0.40 (95% CI 0.53 to 0.32) point reduction on a 0 to 10 pain intensity scale, which does not meet the minimum clinically important difference threshold of 15% or greater. Pre-specified subgroup analyses did not find a difference between low-frequency stimulation (low-quality evidence) and rTMS applied to the prefrontal cortex compared to sham for reducing pain intensity at short-term follow-up (very low-quality evidence). High-frequency stimulation of the motor cortex in single-dose studies was associated with a small short-term reduction in pain intensity at short-term follow-up (low-quality evidence, pooled n = 249, SMD -0.38 95% CI -0.49 to -0.27). This equates to a 12% (95% CI 9% to 16%) reduction in pain, or a 0.77 (95% CI 0.55 to 0.99) point change on a 0 to 10 pain intensity scale, which does not achieve the minimum clinically important difference threshold of 15% or greater. The results from multiple-dose studies were heterogeneous and there was no evidence of an effect in this subgroup (very low-quality evidence). We did not find evidence that rTMS improved disability. Meta-analysis of studies of rTMS versus sham for quality of life (measured using the Fibromyalgia Impact Questionnaire (FIQ) at short-term follow-up demonstrated a positive effect (MD -10.80 95% CI -15.04 to -6.55, low-quality evidence). CES: For CES (five studies, 270 participants) we found no evidence of a difference between active stimulation and sham (SMD -0.24, 95% CI -0.48 to 0.01, low-quality evidence) for pain intensity. We found no evidence relating to the effectiveness of CES on disability. One study (36 participants) of CES versus sham for quality of life (measured using the FIQ) at short-term follow-up demonstrated a positive effect (MD -25.05 95% CI -37.82 to -12.28, very low-quality evidence). tDCS: Analysis of tDCS studies (27 studies, 747 participants) showed heterogeneity and a difference between active and sham stimulation (SMD -0.43 95% CI -0.63 to -0.22, very low-quality evidence) for pain intensity. This equates to a reduction of 0.82 (95% CI 0.42 to 1.2) points, or a percentage change of 17% (95% CI 9% to 25%) of the control group outcome. This point estimate meets our threshold for a minimum clinically important difference, though the lower confidence interval is substantially below that threshold. We found evidence of small study bias in the tDCS analyses. We did not find evidence that tDCS improved disability. Meta-analysis of studies of tDCS versus sham for quality of life (measured using different scales across studies) at short-term follow-up demonstrated a positive effect (SMD 0.66 95% CI 0.21 to 1.11, low-quality evidence). Adverse events: All forms of non-invasive brain stimulation and sham stimulation appear to be frequently associated with minor or transient side effects and there were two reported incidences of seizure, both related to the active rTMS intervention in the included studies. However many studies did not adequately report adverse events. Authors’ conclusions: There is very low-quality evidence that single doses of high-frequency rTMS of the motor cortex and tDCS may have short-term effects on chronic pain and quality of life but multiple sources of bias exist that may have influenced the observed effects. We did not find evidence that low-frequency rTMS, rTMS applied to the dorsolateral prefrontal cortex and CES are effective for reducing pain intensity in chronic pain. The broad conclusions of this review have not changed substantially for this update. There remains a need for substantially larger, rigorously designed studies, particularly of longer courses of stimulation. Future evidence may substantially impact upon the presented results

Transcutaneous Electrical Nerve Stimulation (TENS) for chronic pain - an overview of Cochrane reviews (Protocol)

This is the protocol for a review and there is no abstract. The objectives are as follows: To provide an overview of evidence from Cochrane systematic reviews of the effectiveness of TENS to reduce pain in adults with chronic pain (excluding headache or migraine). To provide an overview of evidence from Cochrane systematic reviews of the safety of TENS to reduce pain in adults with chronic pain (excluding headache or migraine). To identify possible sources of inconsistency in the approaches taken to evaluating the evidence related to TENS for chronic pain (excluding headache or migraine) in the Cochrane Library with a view to recommending strategies to improve consistency. To highlight areas of remaining uncertainty regarding the effectiveness of TENS for chronic pain (excluding headache or migraine) with a view to recommending strategies to reduce any uncertainty

Local anaesthetic sympathetic blockade for complex regional pain syndrome

Local anaesthetic sympathetic blockade (LASB) is a common treatment for complex regional pain syndrome (CRPS). It involves blocking the activity of sympathetic nerves in the spine through the injection of a local anaesthetic drug. This updated review sought to identify the available evidence regarding whether LASB is effective at reducing pain in CRPS, how long any pain relief might last, and whether LASB is safe. We found a small number of small trials, all of which may be at risk of bias. We did not find evidence that LASB was better than placebo in reducing pain, or that it provided additional pain relief when added to rehabilitation. While a number of small studies compared LASB to other treatments, most did not find that LASB was better than any other intervention. Only five studies reported on adverse events. These studies reported only minor side effects but since most studies did not report this information we can draw no firm conclusions about the safety of LASB. Overall, while the evidence is very limited and precludes the drawing of strong conclusions, the existing evidence does not provide support for the efficacy of LASB in managing people with CRPS

Adverse pregnancy and neonatal outcomes associated with <i>Neisseria gonorrhoeae:</i> systematic review and meta-analysis.

ObjectiveTo examine associations between Neisseria gonorrhoeae (NG) infection during pregnancy and the risk of preterm birth, spontaneous abortion, premature rupture of membranes, perinatal mortality, low birth weight and ophthalmia neonatorum.Data sourcesWe searched Medline, EMBASE, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature for studies published between 1948 and 14 January 2020.MethodsStudies were included if they reported testing for NG during pregnancy and compared pregnancy, perinatal and/or neonatal outcomes between women with and without NG. Two reviewers independently assessed papers for inclusion and extracted data. Risk of bias was assessed using established checklists for each study design. Summary ORs with 95% CIs were generated using random effects models for both crude and, where available, adjusted associations.ResultsWe identified 2593 records and included 30 in meta-analyses. Women with NG were more likely to experience preterm birth (OR 1.55, 95% CI 1.21 to 1.99, n=18 studies); premature rupture of membranes (OR 1.41, 95% CI 1.02 to 1.92, n=9); perinatal mortality (OR 2.16, 95% CI 1.35 to 3.46, n=9); low birth weight (OR 1.66, 95% CI 1.12 to 2.48, n=8) and ophthalmia neonatorum (OR 4.21, 95% CI 1.36 to 13.04, n=6). Summary adjusted ORs were, for preterm birth 1.90 (95% CI 1.14 to 3.19, n=5) and for low birth weight 1.48 (95% CI 0.79 to 2.77, n=4). In studies with a multivariable analysis, age was the variable most commonly adjusted for. NG was more strongly associated with preterm birth in low-income and middle-income countries (OR 2.21, 95% CI 1.40 to 3.48, n=7) than in high-income countries (OR 1.38, 95% CI 1.04 to 1.83, n=11).ConclusionsNG is associated with a number of adverse pregnancy and newborn outcomes. Further research should be done to determine the role of NG in different perinatal mortality outcomes because interventions that reduce mortality will have the greatest impact on reducing the burden of disease in low-income and middle-income countries.Prospero registration numberCRD42016050962

Einstein energy associated with the Friedmann -Robertson -Walker metric

Following Einstein's definition of Lagrangian density and gravitational field energy density (Einstein, A., Ann. Phys. Lpz., 49, 806 (1916); Einstein, A., Phys. Z., 19, 115 (1918); Pauli, W., {\it Theory of Relativity}, B.I. Publications, Mumbai, 1963, Trans. by G. Field), Tolman derived a general formula for the total matter plus gravitational field energy ($P_0$) of an arbitrary system (Tolman, R.C., Phys. Rev., 35(8), 875 (1930); Tolman, R.C., {\it Relativity, Thermodynamics & Cosmology}, Clarendon Press, Oxford, 1962)); Xulu, S.S., arXiv:hep-th/0308070 (2003)). For a static isolated system, in quasi-Cartesian coordinates, this formula leads to the well known result $P_0 = \int \sqrt{-g} (T_0^0 - T_1^1 -T_2^2 -T_3^3) ~d^3 x$, where $g$ is the determinant of the metric tensor and $T^a_b$ is the energy momentum tensor of the {\em matter}. Though in the literature, this is known as "Tolman Mass", it must be realized that this is essentially "Einstein Mass" because the underlying pseudo-tensor here is due to Einstein. In fact, Landau -Lifshitz obtained the same expression for the "inertial mass" of a static isolated system without using any pseudo-tensor at all and which points to physical significance and correctness of Einstein Mass (Landau, L.D., and Lifshitz, E.M., {\it The Classical Theory of Fields}, Pergamon Press, Oxford, 2th ed., 1962)! For the first time we apply this general formula to find an expression for $P_0$ for the Friedmann- Robertson -Walker (FRW) metric by using the same quasi-Cartesian basis. As we analyze this new result, physically, a spatially flat model having no cosmological constant is suggested. Eventually, it is seen that conservation of $P_0$ is honoured only in the a static limit.Comment: By mistake a marginally different earlier version was loaded, now the journal version is uploade

A reification calculus for model-oriented software specification

This paper presents a transformational approach to the derivation of implementations from model-oriented specifications of abstract data types. The purpose of this research is to reduce the number of formal proofs required in model refinement, which hinder software development. It is shown to be appli- cable to the transformation of models written in Meta-iv (the specification lan- guage of Vdm) towards their refinement into, for example, Pascal or relational DBMSs. The approach includes the automatic synthesis of retrieve functions between models, and data-type invariants. The underlying algebraic semantics is the so-called final semantics “`a la Wand”: a specification “is” a model (heterogeneous algebra) which is the final ob ject (up to isomorphism) in the category of all its implementations. The transformational calculus approached in this paper follows from exploring the properties of finite, recursively defined sets. This work extends the well-known strategy of program transformation to model transformation, adding to previous work on a transformational style for operation- decomposition in META-IV. The model-calculus is also useful for improving model-oriented specifications.(undefined