Best practice & research. Clinical rheumatology
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Best Pract Res Clin Rheumatol · Apr 2010
ReviewExercise therapy for chronic nonspecific low-back pain.
Exercise therapy is the most widely used type of conservative treatment for low back pain. Systematic reviews have shown that exercise therapy is effective for chronic but not for acute low back pain. During the past 5 years, many additional trials have been published on chronic low back pain. ⋯ The authors conclude that evidence from randomised controlled trials demonstrated that exercise therapy is effective at reducing pain and function in the treatment of chronic low back pain. There is no evidence that one particular type of exercise therapy is clearly more effective than others. However, effects are small and it remains unclear which subgroups of patients benefit most from a specific type of treatment.
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Sciatica is a symptom rather than a specific diagnosis. Available evidence from basic science and clinical research indicates that both inflammation and compression are important in order for the nerve root to be symptomatic. Tumour necrosis factor-alpha (TNF-alpha) is a key mediator in animal models, but its exact contribution in human radiculopathy is still a matter of debate. ⋯ A recent review showed that the prevalence of sciatic symptoms is rather variable, with values ranging from 1.6% to 43%. If stricter definitions of sciatica were used, for example, in terms of pain distribution and/or pain duration, lower prevalence rates were reported. Studies in working populations with physically demanding jobs consistently report higher rates of sciatica compared with studies in the general population.
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Best Pract Res Clin Rheumatol · Apr 2010
ReviewHow important are back pain beliefs and expectations for satisfactory recovery from back pain?
In this article, we provide an evidence-based review of pain beliefs and their influence on pain perception and response to treatment. We examine the nature of pain perception and the role of cognitive and emotional processes in the interpretation of pain signals, giving meaning to pain and shaping our response to it. ⋯ We then adopt a broader societal perspective, considering secondary prevention and campaigns, which have attempted to change beliefs at a population level. The article concludes with a summary of the key messages for clinical management of patients presenting with painful conditions and suggestions for further research.
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Best Pract Res Clin Rheumatol · Apr 2010
Challenges in using evidence to inform your clinical practice in low back pain.
The aim of evidence-based medicine (EBM) from its early days was to provide the appropriate means for making effective clinical decisions, not only for avoiding habitual practice but also for enhancing clinical performance. It is, however, unrealistic to simply assume that the results of research will soon evolve into practice. In this article, when aiming to translate results from research into practice, we focus on certain challenges, which can be broadly categorised into two: how the evidence is generated, and how the evidence is implemented. ⋯ Although the importance of implementing clinical guidelines is widely recognised, little is known about the optimal implementation strategy. We present two examples of implementing low back pain guidelines, illustrating that it remains difficult to develop effective implementation strategies. Finally, we discuss some future directions that have been proposed for EBM, which aim to overcome the essential tension between internal validity and external validity (generalisability), specifically in fields where complex syndromes and complex interventions are the focus of attention.
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Understanding prognosis is important in managing low back pain. In this article, we discuss the available evidence on low back pain prognosis and describe how prognostic evidence can be used to inform clinical decision making. We describe three main types of related prognosis questions: 'What is the most likely course?' (Course studies); 'What factors are associated with, or determine, outcome?' (Prognostic factor or explanatory studies); and 'Can we identify risk groups who are likely to have different outcomes?' (Risk group or outcome prediction studies). ⋯ Important low back pain prognostic factors are related to the back pain episode, the individual and psychological characteristics, as well as the work and social environment. Although numerous studies have developed prediction models in the field, most models/tools explain less than 50% of outcome variability and few have been tested in independent samples. We discuss limitations and future directions for research in the area of low back pain prognosis.