Spine
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"Chronic" low back pain (LBP), defined as present for 3 or more months, has become a major socioeconomic problem insufficiently addressed by five major entities largely working in isolation from one another - procedural based specialties, strength based rehabilitation, cognitive behavioral therapy, pain management and manipulative care. As direct and indirect costs continue to rise, many authors have systematically evaluated the body of evidence in an effort to demonstrate the effectiveness (or lack thereof) for various diagnostic and therapeutic interventions. The objective of this Spine Focus issue is not to replicate previous work in this area. ⋯ The efficacy of some treatments may be appreciated only through a better understanding of heterogeneity of treatment effects (i.e., identification of clinically relevant subgroups with differing responses to the same treatment). Current clinical guidelines and payer policies for LBP are systematically compared for consistency and quality. Novel approaches for data gathering, such as national spine registries, may offer a preferable approach to gain meaningful data and direct us towards a "results-based medicine." This approach would require more high-quality studies, more consistent recording for various phenotypes and exploration of studies on genetic epidemiologic undertones to guide us in the emerging era of "results based medicine."
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Prospective case series. ⋯ The underlying mechanisms explaining the benefits of SMT appear to be multifactorial. Both spinal stiffness characteristics and LM recruitment changes appear to play a role.
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Review
Comparative effectiveness of exercise, acupuncture, and spinal manipulation for low back pain.
Systematic review. ⋯ Structured exercise and SMT appear to offer equivalent benefits in the management of pain and function for patients with nonspecific chronic LBP. If no clinical benefit is appreciated after using one of these approaches for 8 weeks, then the treatment plan should be reevaluated and consideration should be given to modifying the treatment approach or using alternate forms of care. Strength of recommendation: Weak.There is insufficient evidence regarding the relative benefits of the acupuncture compared with either structured exercise or SMT in the treatment of chronic LBP.There is insufficient evidence to address differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP.
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Review
Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes?
Systematic review. ⋯ Recommendation 1: Chronic LBP patients with depression, neuroticism, and certain personality disorders should preferentially be treated nonoperatively. Strength of recommendation: Weak. Recommendation 2: Consider the use of a validated psychological screening questionnaire such as the BDI, FABQ, DRAM, ZDI or STAI, when treating patients with CLBP. Strength of recommendation: Weak.
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Randomized Controlled Trial Multicenter Study Comparative Study
ISSLS prize winner: Function After Spinal Treatment, Exercise, and Rehabilitation (FASTER): a factorial randomized trial to determine whether the functional outcome of spinal surgery can be improved.
This was a multicenter, factorial, randomized, controlled trial on the postoperative management of spinal surgery patients, with randomization stratified by surgeon and operative procedure. ⋯ This study found that neither intervention had a significant impact on long-term outcome.