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Little is known about the effectiveness of placebo interventions in patients with nonspecific low back pain (LBP). This systematic review assessed the magnitude of the effects of placebo interventions as compared to no intervention in randomized controlled trials (RCTs) including patients with LBP. Embase, MEDLINE (Ovid), and Cochrane CENTRAL databases were searched from inception to December 5, 2019. Randomized controlled trials comparing placebo intervention vs no intervention in adult patients with nonspecific LBP were included. Pain intensity, physical functioning, and health-related quality of life measured at short-term, medium-term, and long-term follow-up were the outcomes of this review. Twenty-one randomized controlled trials were included; one concerning acute LBP and one subacute LBP, whereas 19 studies reported on chronic LBP. In chronic LBP, placebo interventions were more effective than no intervention at short-term follow-up for pain intensity (standardized mean difference = -0.37, 95% confidence interval [CI] = -0.55 to -0.18, moderate-quality evidence), physical functioning (standardized mean difference -0.19, 95% CI = -0.39-0.01, moderate-quality evidence), and physical quality of life (mean difference = -2.71, 95% CI = -4.71-0.71, high-quality evidence), respectively. These effects were not significant at medium-term follow-up, and no data were available at long-term follow-up. These results show placebo interventions are more effective than no intervention at short-term follow-up in patients with chronic LBP. However, the magnitude of the effects is probably not clinically relevant (approximately 8 points on a 0-100 pain scale). Future research should identify effect modifiers and causal mechanisms explaining the short-term effects of placebo interventions in patients with chronic LBP.

BackgroundNeck pain is one of the leading causes of disability in most countries and it is likely to increase further. Numerous prognostic models for people with neck pain have been developed, few have been validated. In a recent systematic review, external validation of three promising models was advised before they can be used in clinical practice.ObjectiveThe purpose of this study was to externally validate three promising models that predict neck pain recovery in primary care.MethodsThis validation cohort consisted of 1311 patients with neck pain of any duration who were prospectively recruited and treated by 345 manual therapists in the Netherlands. Outcome measures were disability (Neck Disability Index) and recovery (Global Perceived Effect Scale) post-treatment and at 1-year follow-up. The assessed models were an Australian Whiplash-Associated Disorders (WAD) model (Amodel), a multicenter WAD model (Mmodel), and a Dutch non-specific neck pain model (Dmodel). Models' discrimination and calibration were evaluated.ResultsThe Dmodel and Amodel discriminative performance (AUC < 0.70) and calibration measures (slope largely different from 1) were poor. The Mmodel could not be evaluated since several variables nor their proxies were available.ConclusionsExternal validation of promising prognostic models for neck pain recovery was not successful and their clinical use cannot be recommended. We advise clinicians to underpin their current clinical reasoning process with evidence-based individual prognostic factors for recovery. Further research on finding new prognostic factors and developing and validating models with up-to-date methodology is needed for recovery in patients with neck pain in primary care.

Methodological shortcomings in prognostic modeling for patients with spinal disorders are highly common. This general commentary discusses methodological challenges related to the specific nature of this field. Five specific methodological challenges in prognostic modeling for patients with spinal disorders are presented with their potential solutions, as related to the choice of study participants, purpose of studies, limitations in measurements of outcomes and predictors, complexity of recovery predictions, and confusion of prognosis and treatment response. Large studies specifically designed for prognostic model research are needed, using standard baseline measurement sets, clearly describing participants’ recruitment and accounting and correcting for measurement limitations.

Purpose: To estimate the healthcare resource utilisation of an Australian cohort of people with sciatica and explore individual-level factors associated with expenditure. Methods: Healthcare utilisation (services and medication) data from a randomised, double-blind, placebo-controlled trial of pregabalin in patients with sciatica (n = 185) were analysed to estimate healthcare expenditure of participants over 12 months. Associations between key baseline socio-economic, pain and quality of life characteristics and healthcare expenditure were examined using generalised linear imputation models. Results: On average, participants accessed AUD$1,134 of healthcare over the year, predominantly made up of $114 of medication and $914 of health services, which included $418 of physiotherapy services. Participants randomised to receive pregabalin incurred higher expenditure ($1,263 compared to $1,001 for placebo), which was largely driven by pregabalin ($158) and greater health services ($107). Healthcare expenditure was significantly higher for participants prescribed pregabalin, earning greater than $1,700 per week ($88,400 per year) and reporting poorer quality of life (physical and mental). Conclusion: Our results suggest inefficiency in the use of healthcare resources due to increased healthcare resource utilisation in people with sciatica treated with pregabalin, compared to placebo. Costs of treating sciatica varied based on individual quality of life and socio-economic characteristics.

Highlights • A previous running-related injury was the strongest risk factor for an injury in long-distance runners. • Previous injuries not attributed to running, was the strongest risk factor in short-distance runners. Higher body mass index, higher age, sex (male), having no previous running experience and lower running volume were strong risk factors for short-distance runners. • Low quality evidence was found for all risk models as predictor for running-related injuries in short- and long-distance runners. • The quality of evidence for risk factors for running-related injurie is limited and running injuries seem to have a multifactorial origin both in short- and long-distance runners., Purpose The aim of this study was to review information about risk factors for lower extremity running injuries in both short-distance (mean running distance ≤20 km/week and ≤10 km/session) and long-distance runners (mean running distance >20 km/week and >10 km/session). Methods Electronic databases were searched for articles published up to February 2019. Prospective cohort studies using multivariable analysis for the assessment of individual risk factors or risk models for the occurrence of lower extremity running injuries were included. Two reviewers independently selected studies for eligibility and assessed risk of bias with the Quality in Prognostic Studies Tool. The GRADE approach was used to assess the quality of the evidence. Results A total of 29 studies were included: 17 studies focused on short-distance runners, 11 studies focused on long-distance runners, and 1 study focused on both types of runners. A previous running-related injury was the strongest risk factor for an injury for long-distance runners, with moderate-quality evidence. Previous injuries not attributed to running was the strongest risk factor for an injury for short-distance runners, with high-quality evidence. Higher body mass index, higher age, sex (male), having no previous running experience, and lower running volume were strong risk factors, with moderate quality evidence, for short-distance runners. Low-quality evidence was found for all risk models as predictors of running-related injuries among short- and long-distance runners. Conclusion Several risk factors for lower extremity injuries have been identified among short- and long-distance runners, but the quality of evidence for these risk factors for running-related injuries is limited. Running injuries seem to have a multifactorial origin both in short- and long-distance runners., Graphical Abstract Image, graphical abstract

OBJECTIVES: To evaluate the cost-effectiveness of radiofrequency denervation when added to a standardized exercise program for patients with chronic low back pain.METHODS: An economic evaluation was conducted alongside 3 pragmatic multicenter, nonblinded randomized clinical trials (RCTs) in The Netherlands with a follow up of 52 weeks. Eligible participants were included between January 1, 2013, and October 24, 2014, and had chronic low back pain; a positive diagnostic block at the facet joints (n = 251), sacroiliac (SI) joints (n = 228), or a combination of facet joints, SI joints, and intervertebral discs (n = 202); and were unresponsive to initial conservative care. Quality-adjusted life-years (QALYs) and societal costs were measured using self-reported questionnaires. Missing data were imputed using multiple imputation. Bootstrapping was used to estimate statistical uncertainty.RESULTS: After 52 weeks, no difference in costs between groups was found in the facet joint or combination RCT. The total costs were significantly higher for the intervention group in the SI joint RCT. The maximum probability of radiofrequency denervation being cost-effective when added to a standardized exercise program ranged from 0.10 in the facet joint RCT to 0.17 in the SI joint RCT irrespective of the ceiling ratio, and 0.65 at a ceiling ratio of €30 000 per QALY in the combination RCT.CONCLUSIONS: Although equivocal among patients with symptoms in a combination of the facet joints, SI joints, and intervertebral discs, evidence suggests that radiofrequency denervation combined with a standardized exercise program cannot be considered cost-effective from a societal perspective for patients with chronic low back pain originating from either facet or SI joints in a Dutch healthcare setting.

Background Low back pain (LBP) is very common and is a main cause of limited activity and work absence. Patients with LBP may also report spinal morning stiffness; this symptom could be useful for identifying subgroups with signs and symptoms related to spinal osteoarthritis. Objective This study investigated whether an association exists between reported spinal morning stiffness and radiographic evidence of lumbar disk degeneration (LDD) in people with LBP and a history of pain of the hip and/or knee. Design This cross-sectional study used 8-year follow-up data from the Cohort Hip and Cohort Knee study. Methods The association between spinal morning stiffness and radiographic LDD features was assessed with multivariable logistic regression models. Results The presence of osteophytes was significantly associated with spinal morning stiffness (odds ratio [OR] = 2.1 [95% confidence interval [CI] = 1.3–3.2]) as was the presence of grade 2 or 3 disk space narrowing (OR = 2.0 [95% CI = 1.1–3.5]). There was also a significant association between morning stiffness persisting for > 30 minutes and grade 2 osteophytes (OR = 2.6 [95% CI = 1.1–6.2]) and grade 1 disk space narrowing (OR = 2.0 [95% CI = 1.1–3.6]). Furthermore, there was a significant association between moderate spinal morning stiffness and the presence of osteophytes (OR = 2.0 [95% CI = 1.2–3.2]). Both the presence of osteophytes and disk space narrowing were significantly associated with severe spinal morning stiffness (for osteophytes: OR = 2.0 [95% CI = 1.2–3.7]; for narrowing at L1-S1: OR = 1.8 [95% CI = 1.1–3.1]). Limitations Only lumbar lateral radiographs were available for each participant, implying that the LDD features could have been underestimated. The quality of the radiographs was not consistent. Conclusions This study showed an association between self-reported spinal morning stiffness and symptomatic LDD. When morning stiffness lasted > 30 minutes, there was a significant association with the features of LDD. The association was stronger when the severity of spinal morning stiffness increased.

Purpose: To estimate the prevalence of degenerative lumbar spinal stenosis (LSS) in adults, identified by clinical symptoms and/or radiological criteria. Methods: Systematic review of the literature. Pooled prevalence estimates by care setting and clinical or radiological diagnostic criteria were calculated and plotted [PROSPERO ID: CRD42018109640]. Results: In total, 41 papers reporting on 55 study samples were included. The overall risk of bias was considered high in two-thirds of the papers. The mean prevalence, based on a clinical diagnosis of LSS in the general population, was 11% (95% CI 4–18%), 25% (95% CI 19–32%) in patients from primary care, 29% (95% CI 22–36%) in patients from secondary care and 39% (95% CI 39–39%) in patients from mixed primary and secondary care. Evaluating the presence of LSS based on radiological diagnosis, the pooled prevalence was 11% (95% CI 5–18%) in the asymptomatic population, 38% (95% CI − 10 to 85%) in the general population, 15% (95% CI 13–18%) in patients from primary care, 32% (95% CI 22–41%) in patients from secondary care and 21% (95% CI 16–26%) in a mixed population from primary and secondary care. Conclusions: The mean prevalence estimates based on clinical diagnoses vary between 11 and 39%, and the estimates based on radiological diagnoses similarly vary between 11 and 38%. The results are based on studies with high risk of bias, and the pooled prevalence estimates should therefore be interpreted with caution. With an growing elderly population, there is a need for future low risk-of-bias research clarifying clinical and radiological diagnostic criteria of lumbar spinal stenosis. Graphic abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.]

Objectives: The aim of this study was to reanalyze and reinterpret data obtained in Paracetamol in Acute Low Back Pain (PACE), the first large randomized controlled trial evaluating the efficacy of paracetamol in acute low back pain, to assess the inferential reproducibility of the original conclusions. Study Design and Setting: Mixed effects models were used to reanalyze pain intensity (primary outcome; 11-point Numeric Rating Scale) and physical functioning, health-related quality of life, sleep quality, and time until recovery (as secondary outcomes), according to the intention-to-treat principle. The original authors of the PACE study were not involved in the development of the methods for this reanalysis. Results: The reproduction analyses indicated no effect of treatment on pain intensity and confidence intervals excluded clinically worthwhile effects (adjusted main effect for regular paracetamol vs. placebo 0.00 [−0.02, 0.01; P = 0.85]; adjusted main effect for paracetamol as-needed vs. placebo 0.00 [−0.02, 0.01; P = 0.92]). Similar results were obtained for all secondary outcomes. Conclusion: This study indicates that the conclusions of the PACE trial are inferentially reproducible, even when using a different analytical approach. This reinforces the notion that the management of acute low back pain should focus on providing patients advice and reassurance without the addition of paracetamol.

Background Dealing with the opioid crisis, medical doctors are keen to learn how to best treat opioid dependency in patients with chronic non-cancer pain. Opioid replacement therapy is commonly used, but success rates vary widely. Since many patients still experience severe withdrawal symptoms, additional interventions are necessary. Objective To review the effectiveness of interventions in the treatment of withdrawal symptoms during opioid tapering or acute withdrawal in patients with long-term non-cancer pain. Methods A systematic review was conducted in Embase.com, MEDLINE, Web of Science, PsycINFO, and Cochrane CENTRAL register of trials. Studies eligible for inclusion were (non-)randomized controlled trials in adults with long-term opioid prescriptions for non-cancer pain. Included trials had to compare a non-opioid intervention to placebo, usual care, no treatment, or non-opioid drug and had to report on withdrawal symptoms as an outcome. Study quality was assessed with the 2.0 Cochrane risk of bias (RoB) tool. Evidence quality was rated following the GRADE approach. Results One trial (n = 21, some concerns regarding RoB) compared Varenicline to placebo. There was no statistically significant between-group reduction of withdrawal symptoms (moderate-quality evidence). Conclusions Evidence from clinical trials on interventions reducing withdrawal symptoms is scarce. Based on one trial with a small sample size, no firm conclusion can be drawn. Meanwhile, doctors are in dire need for therapeutic options to tackle withdrawal symptoms while tapering patients with prescription opioid dependence. We hope this review draws attention to this unfortunate research gap so that future research can provide doctors with answers.

BackgroundChildren and adolescents with overweight are known to have lower Quality of Life (QoL) compared to peers with a normal weight. QoL is a broad concept and is associated with many factors. A better understanding of the factors associated with QoL in children and adolescents and their impact on the association between overweight/obesity and QoL, may help to develop and improve interventions that lead to an improvement in QoL in children/adolescents with a high body mass index (BMI > 25). This study investigated the possible mediating effects of somatic complaints and general practitioner consultations in the association between overweight/obesity and QoL in children and adolescents.MethodsFor the current study, cross-sectional data were used from a longitudinal study, the DOERAK cohort, collected from general practitioners’ medical files and through questionnaires.This cohort included 2-18 year olds with normal weight and overweight. Uni- and multivariate regression analyses were performed to gain more insight into variables associated with QoL. Mediation analyses were performed to investigate the possible mediating effects of somatic complaints and GP consultations in the association between overweight/obesity and QoL in children.ResultsIn the total sample of 733 participants aged 2-18 years, participants with normal weight had a significantly higher QoL (83.64, SD10.65) compared to participants with overweight (78.61, SD14.34) and obesity (76.90, SD13.63) at baseline. The multivariate analyses showed that a lower socio-economic status (SES), higher BMIz, and the presence of somatic complaints are associated with a lower QoL. The mediation analysis showed a significant effect of the indirect pathway of BMIz on QoL through somatic complaints (β = − 0.46, 95% CI[− 0.90, − 0.06]).ConclusionBMIz has a direct impact on QoL in children and adolescents. Somatic complaints seem to mediate the effect of BMIz on QoL.

The practise of evidence-based medicine is a process of lifelong learning that requires up-to-date and insightful syntheses of existing evidence. Systematic reviews and meta-analyses are an effective method for consolidating high-volume, rapidly accruing and often conflicting scientific studies on a specific topic. Systematic reviews are crucial for the avoidance of research waste, by ensuring that new primary research is performed with full knowledge of what has already been conducted, and that new research evidence is interpreted in light of what is already known.1 Systematic reviews have become an invaluable resource in the sports medicine and rehabilitation literature that generates high-quality evidence and enhance clinical decision-making. A successful systematic review project depends on how well the authors formulate the research question based on their preliminary search and/or their clinical interest. Each systematic review type needs a specific review question format to help authors focus specifically on elements related to their study. The current proliferation of review types is creating challenges to the terminology for describing such reviews.2 Hence, this paper aims to summarise and propose several formats to generate appropriate review questions in the field of sports medicine and rehabilitation research. Systematic review methodology was pioneered in health sciences in the 1980s, and the number of systematic reviews published each year has exponentially increased since 1990. A preliminary search in the PubMed database showed that annual publications of systematic reviews in …

INTRODUCTION: Back pain is a prevalent health problem. Research often focuses on adults. Evidence on the long-term course of back pain in older patients is limited. A prospective cohort study (BACE) was conducted in a primary care setting in the Netherlands. We aim to investigate the 5-year course and medical consumption of older adults (>55 years) presenting with back pain in general practice.METHODS: Patients aged >55 years, consulting their general practitioner with a new back pain episode, were included between 2009 to 2011. Follow-up questionnaires included, for example, pain severity, disability, quality of life, recovery, and medical consumption.RESULTS: A total of 675 patients (mean age ± SD, 66.4 ± 7.6 years) participated, showing a mean (± SD) back pain reduction from 5.2 (± 2.7) to 3.6 (± 2.8) (numeric rating scale, 0 to 10) at 3 months follow-up; disability decreased from 9.8 (± 5.8) to 7.8 (± 6.2) (Roland-Morris Disability Questionnaire, 0 to 24). After 6 months, this remained practically constant over time. Medical consumption was highest in the first months; medication was used by 72% at baseline and approximately one-third (25% to 39%) during follow-up. At 5-year follow-up (response rate 58%; n = 392), 43% had recovered; a majority reported persistent or recurrent back pain.CONCLUSION: Clinically relevant improvements in back pain intensity and disability were seen in the first 3 to 6 months of follow-up. A majority of patients does not become pain free within 3 months; this does not improve over 5 years. However, most patients stop consulting health care professionals during follow-up. Current medical strategies may not be sufficient in older back pain patients, where back pain becomes a recurrent or chronic condition in the majority of patients.

Objectives The purpose of this study was to describe the design and baseline measurements of a prospective multicenter cohort study in patients with neck pain treated by Dutch manual therapists. Objectives of the study were to determine which patients seek help from a manual therapist, to describe usual care manual therapy in patients with neck pain, to examine the occurrence of nonserious adverse events after treatment, to describe predictors of adverse events, and to determine whether the occurrence of nonserious adverse events affect outcome after manual therapy care. Methods During a 3-month inclusion period, consecutive patients aged between 18 and 80 years presenting with neck pain in manual therapy practices in The Netherlands were included in the study. Baseline questionnaires included the Numeric Rating Scale, Neck Disability Index (NDI), Neck Bournemouth Questionnaire, Fear Avoidance Beliefs Questionnaire (FABQ), and Patient Expectancy List. Within the treatment episode, manual therapist clinical reasoning and applied interventions were registered and patients reported on adverse events. At the end of the treatment episode and at 12-month follow-up, pain intensity (Numeric Rating Scale), functional outcomes (NDI, Neck Bournemouth Questionnaire), personal factors (FABQ), and global perceived effect were measured. Results During the 3-month inclusion period, 263 participating manual therapists collected data on 1193 patients with neck pain. Most patients (69.4%) were female. The mean age was 44.7 (±13.7) years. The NDI showed overall mild disability (mean score 26%). Mean scores in pain intensity were moderate (4.8), and there was low risk of prolonged disability owing to personal factors (FABQ). Conclusion This study provides information on baseline characteristics of patients visiting manual therapists for neck pain. In The Netherlands, patients seeking care of manual therapists are comparable to patients in other countries regarding demographics and neck pain characteristics.

STUDY DESIGN: A systematic overview of the literature and an agreement study.OBJECTIVES: The aim of this study is to explore the inter-professional agreement of diagnostic musculoskeletal ultrasound (DMUS) between physical therapists (PT) and radiologists, using a new classification strategy based upon the therapeutic consequences in patients with shoulder pain.BACKGROUND: DMUS is frequently used by PTs, although the agreement regarding traditional diagnostic labels between PTs and radiologists is only fair. Nevertheless, DMUS could be useful when used as a stratifying-tool.METHODS: First, a systematic overview of current evidence was performed to assess which traditional diagnostic labels could be recoded into new treatment related categories (referral to secondary care, corticosteroid injections, physical therapy, watchful waiting). Next, kappa values were calculated for these categories between PTs and radiologists.RESULTS: Only three categories were extracted, as none of the traditional diagnostic labels were classified into the 'corticosteroid injection' category. Overall, we found moderate agreement to stratify patients into treatment related categories and substantial agreement for the category 'referral to secondary care'. Both categories 'watchful waiting' and 'indication for physical therapy' showed moderate agreement between the two professions.CONCLUSION: Our results indicate that the agreement between radiologists and PTs is moderate to substantial when labelling is based on treatment consequences. DMUS might be able to help the PT to guide treatment, especially for the category 'referral to secondary care' as this showed the highest agreement. However, as this is just an explorative study, more research is needed, to validate and assess the consequences of this stratification classification for clinical care.

Combining medicines may give greater pain relief and/or improved tolerability. We conducted a systematic review to investigate the effects of combination drug therapy in patients with low back pain and/or sciatica on pain, disability, and adverse events. Databases and trial registers were searched from inception to July 27, 2017, for randomized trials of (sub)acute or chronic back pain or sciatica participants that were administered combination drug therapy compared with monotherapy or placebo. Of the 27 studies included, most combinations (21 of 23) consisted of single trials. Most combinations had no or small effect on pain and disability. A clinically important difference was found in one combination, buprenorphine plus pregabalin versus buprenorphine for chronic back pain at immediate (mean difference = –23.30; 95% confidence interval = –27.68 to –18.92) and short (mean difference = –27.60; 95% confidence interval = –31.70 to –23.50) terms; however, the quality of evidence was low. There was no statistically significant increased risk of serious adverse events. When the risk of adverse events was statistically significant, it favored monotherapy or placebo. There is no clear evidence to support any combination drug therapy for the management of low back pain and sciatica due to the limited number of studies and overall low quality of evidence. Perspective: Combining medicines may give greater pain relief and/or improved tolerability compared with single-ingredient medicines. However, the lack of studies and overall low quality of evidence limit the recommendation of combination drug therapy for the management of low back pain and sciatica.

Objectives: To determine the proportion of participants of a running program for novice runners that discontinued running and investigate the main reasons to discontinue and characteristics associated with discontinuation.Design: Prospective cohort study.Methods: The study included 774 participants of Start to Run, a 6-week running program for novice runners. Before the start of the program, participants filled-in a baseline questionnaire to collect information on demographics, physical activity and perceived health. The 26-weeks follow-up questionnaire was used to obtain information on the continuation of running (yes/no) and main reasons for discontinuation. To determine predictors for discontinuation of running, multivariable logistic regression was performed.Results: Within 26 weeks after the start of the 6-week running program, 29.5% of the novice runners (n = 225) had stopped running. The main reason for discontinuation was a running-related injury (n = 108, 48%). Being female (OR 1.74; 95% CI 1.13-2.68), being unsure about the continuation of running after the program (OR 2.06; 95% CI 1.31-3.24) and (almost) no alcohol use (OR 1.62; 95%CI 1.11-2.37) were associated with a higher chance of discontinuation of running. Previous running experience less than one year previously (OR 0.46; 95% CI 0.26-0.83) and a higher score on the RAND-36 subscale physical functioning (OR 0.98; 95% CI 0.96-0.99) were associated with a lower chance of discontinuation.Conclusions: In this group of novice runners, almost one-third stopped running within six months. A running-related injury was the main reason to stop running. Women with a low perceived physical functioning and without running experience were prone to discontinue running. (C) 2018 Published by Elsevier Ltd on behalf of Sports Medicine Australia.

Introduction: Analgesic drugs are often prescribed to patients with non-specific low back pain (NSLBP). Recommendations for non-invasive pharmacological management of NSLBP from recent clinical practice guidelines were compared with each other and with the best available evidence on drug efficacy. Areas covered: Recommendations concerning opioids, non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol, antidepressants, anticonvulsants and muscle relaxants from national primary care guidelines published within the last 3 years were included in this review. For each pharmacological treatment, the most recent systematic review was included as the best available evidence on drug efficacy and common adverse effects were summarized. Expert opinion: Although differences exist between guidelines, publications are universally moving away from pharmacotherapy due to the limited efficacy and the risk of adverse effects. NSAIDs have replaced paracetamol as the first choice analgesics for NSLBP in many guidelines. Opioids are generally considered to be a last resort, but opioid prescriptions have been increasing over recent years. Upcoming guideline updates should explicitly shift their focus from pain to function and from pharmacotherapy to non-pharmacological treatments; patient education is important to make sure NSLBP patients accept these changes. To improve the quality of NSLBP care, the evidence-practice gap should be closed through guideline implementation strategies.

Background. Multidisciplinary intervention programs for overweight and obese children mainly focus on reducing bodyweight and body mass index (BMI), but they may also positively impact blood pressure (BP), and cardiorespiratory fitness (CRF), which is a stronger predictor for all-cause mortality than BMI. Objective. To evaluate whether Kids4Fit, a multidisciplinary weight reduction program, has a positive effect on CRF and BP in overweight and obese children in socially deprived areas. Methods. A quasi-experimental study design with a waiting list control period including children who participated in a multidisciplinary intervention program of 12 weeks was set-up. Blood pressure measurements and shuttle-run test (SRT) were performed at baseline, at the start of the intervention, at the end of intervention and after 52 weeks. The effect of Kids4Fit on BP and on SRT scores were analyzed using mixed models. Results. A total of 154 children were included [mean age 8.5 years (SD 1.8)]. No significant change was seen in systolic BP percentiles at 52 weeks after start of the Kids4Fit intervention (β 0.08, (95%CI −0.06, 0.22)). Diastolic BP percentiles increased significantly over time (β 0.20 (0.08, 0.31)). Effect plots showed an initial significant increase of the SRT scores but this effect diluted after the intervention. Conclusion. A local multidisciplinary intervention program in deprived areas had a significant positive effect on CRF, but this effect diluted after the intervention. Diastolic BP percentiles significantly increased over time. However, systolic BP did not change over time.

In 2014, the Paracetamol for Acute Low Back Pain (PACE) trial demonstrated that paracetamol had no effect compared with placebo in acute low back pain (LBP). However, noncompliance was a potential limitation of this trial. The aim of this study was to investigate the efficacy of paracetamol in acute LBP among compliers. Using individual participant data from the PACE trial (ACTN12609000966291), complier average causal effect (CACE), intention-to-treat, and per protocol estimates were calculated for pain intensity (primary), disability, global rating of symptom change, and function (all secondary) after 2 weeks of follow-up. Compliance was defined as intake of an average of at least 4 of the prescribed 6 tablets of regular paracetamol per day (2660 mg in total) during the first 2 weeks after enrolment. Exploratory analyses using alternative time points and definitions of compliance were conducted. Mean between-group differences in pain intensity on a 0 to 10 scale using the primary time point and definition of compliance were not clinically relevant (propensity-weighted CACE 0.07 [-0.37 to 0.50] P = 0.76; joint modelling CACE 0.23 [-0.16 to 0.62] P = 0.24; intention-to-treat 0.11 [-0.20 to 0.42] P = 0.49; per protocol 0.29 [-0.07 to 0.65] P = 0.12); results for secondary outcomes and for exploratory analyses were similar. Paracetamol is ineffective for acute LBP even for patients who comply with treatment. This reinforces the notion that management of acute LBP should focus on providing patients advice and reassurance without the addition of paracetamol.

What you need to know Lumbar spinal stenosis (LSS) affects about 11% of the population,1 and primarily affects older adults.1 Pain in legs and difficulty walking can limit function and participation in daily activities, which can have negative psychological effects.2 Diagnosis can be challenging because of the overlap of symptoms with other conditions that cause leg or low back pain in older adults. Lumbar spinal stenosis can usually be diagnosed clinically and managed conservatively in primary care. Patients with severe symptoms may require referral for imaging and intervention. The evidence for most treatment options is limited.345 Shared decision making with patients must consider the severity of symptoms and their impact on the person’s life, risks and benefits of treatments, and individual preferences. Degenerative changes in the spine can cause narrowing of the central spinal canal, lateral recesses, or intervertebral foramen. Changes include disc degeneration and bony or soft tissue changes, such as facet joint arthrosis and hypertrophy of the ligamentum flavum, …

Three clinical prediction models were developed for nonrecovery in older adults seeking care for back pain; the model predicting persistent disability performed best (optimism-adjusted R2 46%, area under the curve 0.85)., Back pain is a leading cause of disability worldwide and is common in older adults. No clinical prediction models for poor long-term outcomes have been developed in older patients with back pain. This study aimed to develop and internally validate 3 clinical prediction models for nonrecovery in this population. A prospective cohort study in general practice was conducted (Back Complaints in the Elders, Netherlands), including 675 patients >55 years with a new episode of care for back pain. Three definitions of nonrecovery were used combining 6-month and 12-month follow-up data: (1) persistent back pain, (2) persistent disability, and (3) perceived nonrecovery. Sample size calculation resulted in a maximum of 14 candidate predictors that were selected from back pain prognostic literature and clinical experience. Multivariable logistic regression was used to develop the models (backward selection procedure). Models' performance was evaluated with explained variance (Nagelkerke's R2), calibration (Hosmer–Lemeshow test), and discrimination (area under the curve [AUC]) measures. The models were internally validated in 250 bootstrapped samples to correct for overoptimism. All 3 models displayed good overall performance during development and internal validation (ie, R2 > 30%; AUC > 0.77). The model predicting persistent disability performed best, showing good calibration, discrimination (AUC 0.86, 95% confidence interval 0.83-0.89; optimism-adjusted AUC 0.85), and explained variance (R2 49%, optimism-adjusted R2 46%). Common predictors in all models were: age, chronic duration, disability, a recent back pain episode, and patients' recovery expectations. Spinal morning stiffness and pain during spinal rotation were included in 2 of 3 models. These models should be externally validated before being used in a clinical primary care setting.

Eleanor Boyle,1 Lars Folkestad,2– 5 Erik Frafjord,6 Bart W Koes,1,7 Soren Thorgaard Skou,1,8 Jan Hartvigsen1,6 1Center for Muscle and Joint Health, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark; 2Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark; 3Department of Internal Medicine, Hospital of South West Denmark, Esbjerg, Denmark; 4Department of Clinical Research, University of Southern Denmark, Odense, Denmark; 5Open Patient Exploratory Network, University of Southern Denmark, Odense, Denmark; 6Chiropractic Knowledge Hub, Odense, Denmark; 7Department of General Practice, Erasmus MC, Rotterdam, the Netherlands; 8The Research Unit PROgrez, Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, DenmarkCorrespondence: Jan HartvigsenDepartment of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, Odense M, Odense, 5230, DenmarkTel +45 65504522Email jhartvigsen@health.sdu.dkPurpose: To conduct a non-responder analysis on a musculoskeletal (MSK) electronic questionnaire.Methods: Individuals aged 18 years and older, diagnosed with diabetes mellitus (DM), and attended an ambulatory DM clinic formed the sample frame. They were invited to complete an electronic musculoskeletal (MSK) conditions and symptoms questionnaire booklet using a secured electronic email system. Individuals whose secured email box was not active at the time were discarded. Using the Central Person Registry number, a unique number assigned to all Danish residents, we linked the sample frame to different registries to learn more about non-responders. Non-responders were either individuals who did not respond to a single question and those who responded “No” to the first question about willing to participate. We calculated descriptive statistics for each characteristic. Univariate logistic regression models were conducted to determine the relationship between each characteristic and non-responder status.Results: The response rate was 36% (n = 3812). Individuals with type 2 DM (OR 2.0 (95% CI 1.8– 2.2)), secondary DM (1.9 (1.3– 2.8)) or unspecified DM (2.1 (1.8– 2.4)) were more likely to be non-responders than individuals with Type 1 DM. Also, individuals aged 70– 79 (1.3 (1.1– 1.6)) and 80 years and older (5.9 (4.5– 7.7)) were more likely to be non-responders than 18– 29 years old individuals. However, individuals aged 40– 49 (1.5 (1.2– 1.8)), 50– 59 (1.5 (1.3– 1.8)) or 60– 69 (1.4 (1.1– 1.6)) were more likely to be responders than 18– 29 years old individuals. Individuals with Charlson Comorbidity Index (CCI) of 1 (2.0 (1.3.2.9) or CCI of 2 (1.7 (1.1– 2.5) were more likely to be responders than individuals with a CCI of 0. Lastly, individuals who were currently outside of the workforce (1.6 (2.4– 2.9) or had unknown/missing socioeconomic status (3.9 (2.8– 5.3) were more likely to be non-responders than individuals who were working.Conclusion: Although we did find a non-response bias, this cohort will be an important source to determine the prevalence and consequences of MSK conditions in a secondary care DM population.Keywords: diabetes, survey, non-participation analysis, musculoskeletal conditions

Objective Dry needling is a treatment technique used by clinicians to relieve symptoms in patients with tension-type headache (TTH), cervicogenic headache (CGH), or migraine. This systematic review’s main objective was to assess the effectiveness of dry needling on headache pain intensity and related disability in patients with TTH, CGH, or migraine. Methods Medline/PubMed, Scopus, Embase, PEDro, Web of Science, Ovid, Allied and Complementary Medicine Database/EBSCO, Cochrane Central Register of Controlled Clinical Trials, Google Scholar, and trial registries were searched until April 1, 2020, along with reference lists of eligible studies and related reviews. Randomized clinical trials or observational studies that compared the effectiveness of dry needling with any other interventions were eligible for inclusion. Three reviewers independently selected studies, extracted data, and assessed risk of bias. Random-effects meta-analyses were performed to produce pooled-effect estimates (Morris dppc2) and their respective CIs. Results Of 2715 identified studies, 11 randomized clinical trials were eligible for qualitative synthesis and 9 for meta-analysis. Only 4 trials were of high quality. Very low-quality evidence suggested that dry needling is not statistically better than other interventions for improving headache pain intensity in the short term in patients with TTH (SMD −1.27, 95% CI = −3.56 to 1.03, n = 230), CGH (SMD −0.41, 95% CI = −4.69 to 3.87, n = 104), or mixed headache (TTH and migraine; SMD 0.03; 95% CI = −0.42 to 0.48, n = 90). Dry needling provided significantly greater improvement in related disability in the short term in patients with TTH (SMD −2.28, 95% CI = −2.66 to −1.91, n = 160) and CGH (SMD −0.72, 95% CI = −1.09 to −0.34, n = 144). The synthesis of results showed that dry needling could significantly improve headache frequency, health-related quality of life, trigger point tenderness, and cervical range of motion in TTH and CGH. Conclusions Dry needling produces similar effects to other interventions for short-term headache pain relief, whereas dry needling seems to be better than other therapies for improvement in related disability in the short term. Impact Although further high-methodological quality studies are warranted to provide a more robust conclusion, our systematic review suggested that for every 1 or 2 patients with TTH treated by dry needling, 1 patient will likely show decreased headache intensity (number needed to treat [NNT] = 2; large effect) and improved related disability (NNT = 1; very large effect). In CGH, for every 3 or 4 patients treated by dry needling, 1 patient will likely exhibit decreased headache intensity (NNT = 4; small effect) and improved related disability (NNT = 3; medium effect).

Objective: Differing clinical criteria for hip osteoarthritis (OA) are applied in primary care, but little is known regarding the utility of these criteria. The aim of this study was to evaluate and compare the proportion of patients in a primary care setting with hip OA fulfilling the American College of Rheumatology (ACR), the National Institute for Health and Care Excellence (NICE), and the Danish Health Authority (DHA) criteria. Design:A cross-sectional analysis of baseline data from the Good Life with osteoArthritis in Denmark (GLA:D®) program, a treatment program for patients with symptoms or functional limitations associated with hip OA. The prevalence of hip OA according to the ACR, NICE, and DHA criteria was calculated in all patients and in a subgroup of patients with self-reported radiographic hip OA. Results: 4699 patients were included in the analysis. Mean age (SD) was 66.8 (9.7) years and 71% of the patients were female. 64%, 80%, and 94% fulfilled the ACR, DHA, and NICE criteria, respectively. In those self-reporting radiographic hip OA, the corresponding numbers were 66%, 81%, and 94%. A limited number of patients (4%) did not fulfill any of the criteria. Conclusions: The NICE criteria identified the most patients that were treated because of their symptoms or functional limitations. The DHA and especially the ACR criteria did not identify a significant proportion of these patients. The results suggest the NICE criteria are appropriate to identify individuals treated for hip OA in primary care.

Patient recovery expectations can predict treatment outcome. Little is known about the association of patient recovery expectations on treatment outcome in patients with neck pain consulting a manual therapist. This study evaluates the predictive value of recovery expectations in neck pain patients consulting manual therapists in the Netherlands. The primary outcome measure ‘recovery’ is defined as ‘reduction in pain and perceived improvement’. A prospective cohort study a total of 1195 neck pain patients. Patients completed the Patient Expectancies List (PEL) at baseline (3 item questionnaire, score range from 3 to 12), functional status (NDI), the Global Perceived Effect (GPE) for recovery (7-points Likert scale) post treatment and pain scores (NRS) at baseline and post treatment. The relationship between recovery expectancy and recovery (dichotomized GPE scores) was assessed by logistic regression analysis. Patients generally reported high recovery expectations on all three questions of the PEL (mean sumscores ranging from 11.3 to 11.6). When adjusted for covariates the PEL sum-score did not predict recovery (explained variance was 0.10 for the total PEL). Separately, the first question of the PEL showed predictive potential (OR 3.7; 95%CI 0.19–73.74) for recovery, but failed to reach statistical significance. In this study patient recovery expectations did not predict treatment outcome. Variables predicting recovery were recurrence and duration of pain. The precise relationship between patient recovery expectations and outcome is complex and still inconclusive. Research on patient expectancy would benefit from more consistent use of theoretical expectancy and outcome models.

Study Design. Systematic with meta-analysis Objectives. The aim of this study was to investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection in reducing leg pain and disability in patients with sciatica. Summary of Background Data. Conservative treatments, including pharmacological and nonpharmacological treatments, are typically the first treatment options for sciatica but the evidence to support their use is limited. The overall quality of evidence found by previous systematic reviews varies between moderate and high, which suggests that future trials may change the conclusions. New placebo-controlled randomized trials have been published recently which highlights the importance of an updated systematic review. Methods. The searches were performed without language restrictions in the following databases from 2012 to 25 September 2019: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process & Other NonIndexed Citations, PubMed, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and trial registers. We included placebo-controlled randomized trials investigating epidural corticosteroid injections in patients with sciatica. The primary outcomes were leg pain intensity and disability. The secondary outcomes were adverse events, overall pain, and back pain intensity. We grouped similar trials according to outcome measures and their respective follow-up time points. Short-term follow-up (>2 weeks but 3 months) was considered the primary follow-up time point due to the expected mechanism of action of epidural corticosteroid injection. Weighted mean differences (MDs) and risk ratios (RRs) with their respective 95% confidence intervals (CIs) were estimated. We assessed the overall quality of evidence using the GRADE approach and conducted the analyses using random effects. Results. We included 25 clinical trials (from 29 publications) providing data for a total of 2470 participants with sciatica, an increase of six trials when compared to the previous review. Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain (MD 4.93, 95% CI 8.77 to 1.09 on a 0–100 scale), short-term disability (MD 4.18, 95% CI: 6.04 to 2.17 on a 0–100 scale) and may be slightly more effective in reducing short-term overall pain (MD 9.35, 95% CI 14.05 to 4.65 on a 0–100 scale). There were mostly minor adverse events (i.e., without hospitalization) after epidural corticosteroid injections and placebo injections without difference between groups (RR 1.14, 95% CI: 0.91–1.42). The quality of evidence was at best moderate mostly due to problems with trial design and inconsistency. Conclusion. A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety due to very low-quality evidence.

Background The aim of this study was to investigate the differences in objectively measured physical activity and in self-reported physical activity between overweight and normal-weight children. Methods Data from a prospective cohort study including children, presenting at the participating general practices in the south-west of the Netherlands, were used. Children (aged 4–15 years) were categorized as normal-weight or overweight using age- and sex specific cut-off points. They wore an ActiGraph accelerometer for one week to register physical activity, and filled out a diary for one week about physical activity. Results A total of 57 children were included in this study. Overweight children spent significantly less percentage time per day in sedentary behavior (β − 1.68 (95%CI -3.129, − 0.07)). There were no significant differences in percentage time per day spent in moderate to vigorous physical activity (β 0.33 (− 0.11, 0.78)). No significant differences were found between children of normal-weight and overweight in self-reported measures of physical activity. Conclusions Overweight children are not less physically active than normal-weight children, which may be associated with the risen awareness towards overweight/obesity and with implemented interventions for children with overweight/obesity.

Introduction: Paracetamol is one of the most frequently used analgesics for people with low back pain, but despite its frequent use there is still debate regarding its efficacy and safety for this indication. Areas covered: We describe the origin of paracetamol and its proposed mechanisms of action. We focus in on low back pain and describe the evidence it has on the efficacy of paracetamol (taken by patients orally) and current insights on its side-effects. When searching for relevant publications we focused mainly on recent Cochrane reviews and published RCTs. We found that there is increasing evidence that shows paracetamol is not more effective than placebo in patients with acute low back pain. Concerning patients with subacute and chronic back pain, the evidence for or against the efficacy of paracetamol vs placebo is lacking and would need more research. Expert opinion: We argue that we still need better evidence on the efficacy of paracetamol for acute and chronic back pain. Until that evidence becomes available paracetamol should still be considered as an option for patients with back pain. However, we suggest that a strategy focusing on nonpharmacological management as the first treatment option in low back pain may be equally effective with less side effects.

ObjectiveIn various countries, patients can visit a physiotherapist via self-referral. The aims of this study were to evaluate whether there are differences between individuals with nonspecific neck pain who consult a manual therapist via self-referral and those who do so via referral by a physician concerning patient characteristics, number of treatments, and recovery; and whether (self-)referral is associated with recovery.MethodsThis study is part of a prospective cohort study with posttreatment and 12-month follow-up in a Dutch manual-therapy setting. Adult patients with nonspecific neck pain were eligible for participation. Baseline measurements included demographic data and data concerning neck pain. At follow-up, number of treatments, recovery, and satisfaction were assessed. To evaluate differences between the groups, we used the χ2 test and the independent t test. A logistic regression analysis was used to evaluate the association between referral status and recovery.ResultsIn total, 272 manual therapists participated and 1311 patients were included. Of 831 patients whose referral data are available, about half patients consulted a manual therapist by self-referral. The mean number of treatments was 5.4, which did not differ between the 2 groups. We found no differences between the groups concerning age, sex, pain intensity at baseline, or recovery rate. Patients in the self-referral group experienced acute neck pain more frequently, had recurrent complaints more often, and reported less disability compared to the referred group. Referral status was not associated with recovery.ConclusionWe found several small differences between self-referred and referred patients.

Objectives Development and internal validation of prognostic models for post-treatment and 1-year recovery in patients with neck pain in primary care. Design Prospective cohort study. Setting Primary care manual therapy practices. Participants Patients with non-specific neck pain of any duration (n = 1193). Intervention Usual care manual therapy. Outcome measures Recovery defined in terms of pain intensity, disability, and global perceived improvement directly post-treatment and at 1-year follow-up. Results All post-treatment models exhibited acceptable discriminative performance after derivation (AUC ≥ 0.7). The developed post-treatment disability model exhibited the best overall performance (R2 = 0.24; IQR, 0.22–0.26), discrimination (AUC = 0.75; 95% CI, 0.63–0.84), and calibration (slope 0.92; IQR, 0.91–0.93). After internal validation and penalization, this model retained acceptable discriminative performance (AUC = 0.74). The five other models, including those predicting 1-year recovery, did not reach acceptable discriminative performance after internal validation. Baseline pain duration, disability, and pain intensity were consistent predictors across models. Conclusion A post-treatment prognostic model for disability was successfully developed and internally validated. This model has potential to inform primary care clinicians about a patient’s individual prognosis after treatment, but external validation is required before clinical use can be recommended.

IntroductionRunning-related injuries (RRIs) are frequent, but no effective injury prevention measures have been identified yet. Therefore, we have set up the INSPIRE trial in 2017, in which the effectiveness of an online injury prevention programme was tested. Although this programme was not effective in reducing the number of RRIs, we gained new insights from this study, which we used to design an enhanced, online multidisciplinary injury prevention programme. The aim of this study is to test the effectiveness of this enhanced injury prevention programme in a group of recreational runners.Methods and analysisFor this randomised controlled trial, we aim to include 3394 recreational runners aged 18 years or older who register for a running event (distances 10 to 42.2 km). During the preparation for the running event, runners in the intervention group get access to the enhanced online injury prevention programme. This online programme consists of 10 steps, all covering separate items of RRI prevention. Runners in the control group will follow their regular preparation. With three follow-up questionnaires (1 month before, 1 week before and 1 month after the running event), the proportions of self-reported RRIs in the intervention group and the control group are compared.Ethics and disseminationAn exemption for a comprehensive application has been obtained by the Medical Ethical Committee of the Erasmus MC University Medical Center, Rotterdam, the Netherlands. The results of the study will be disseminated among the running population, published in peer-reviewed international journals and presented on international conferences.Trial registration numberNL7694

BACKGROUND: Acute low back pain (LBP) is a common health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used in the treatment of LBP, particularly in people with acute LBP. In 2008, a Cochrane Review was published about the efficacy of NSAIDs for LBP (acute, chronic, and sciatica), identifying a small but significant effect in favour of NSAIDs compared to placebo for short-term pain reduction and global improvement in participants with acute LBP. This is an update of the previous review, focusing on acute LBP.OBJECTIVES: To assess the effects of NSAIDs compared to placebo and other comparison treatments for acute LBP.SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PubMed, and two trials registers for randomised controlled trials (RCT) to 7 January 2020. We also screened the reference lists from relevant reviews and included studies.SELECTION CRITERIA: We included RCTs that assessed the use of one or more types of NSAIDs compared to placebo (the main comparison) or alternative treatments for acute LBP in adults (≥ 18 years); conducted in both primary and secondary care settings. We assessed the effects of treatment on pain reduction, disability, global improvement, adverse events, and return to work.DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials to be included in this review, evaluated the risk of bias, and extracted the data. If appropriate, we performed a meta-analysis, using a random-effects model throughout, due to expected variability between studies. We assessed the quality of the evidence using the GRADE approach. We used standard methodological procedures recommended by Cochrane.MAIN RESULTS: We included 32 trials, with a total of 5356 participants (age range 16 to 78 years). Follow-up ranged from one day to six months. Studies were conducted across the globe, the majority taking place in Europe and North-America. Africa and the Eastern Mediterranean region were not represented. We considered seven studies at low risk of bias. Performance and attrition were the most common biases. There was often a lack of information on randomisation procedures and allocation concealment (selection bias); studies were prone to selective reporting bias, since most studies did not register their trials. Almost half of the studies were industry-funded. There is moderate quality evidence that NSAIDs are slightly more effective in short-term (≤ 3 weeks) reduction of pain intensity (visual analogue scale (VAS), 0 to 100) than placebo (mean difference (MD) -7.29 (95% confidence interval (CI) -10.98 to -3.61; 4 RCTs, N = 815). There is high quality evidence that NSAIDs are slightly more effective for short-term improvement in disability (Roland Morris Disability Questionnaire (RMDQ), 0 to 24) than placebo (MD -2.02, 95% CI -2.89 to -1.15; 2 RCTs, N = 471). The magnitude of these effects is small and probably not clinically relevant. There is low quality evidence that NSAIDs are slightly more effective for short-term global improvement than placebo (risk ratio (RR) 1.40, 95% CI 1.12 to 1.75; 5 RCTs, N = 1201), but there was substantial heterogeneity (I² 52%) between studies. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events when using NSAIDs compared to placebo (RR 0.86, 95% CI 0.63 to 1.18; 6 RCTs, N = 1394). There is very low quality evidence of no clear difference between the proportion of participants who could return to work after seven days between those who used NSAIDs and those who used placebo (RR 1.48, 95% CI 0.98 to 2.23; 1 RCT, N = 266). There is low quality evidence of no clear difference in short-term reduction of pain intensity between those who took selective COX-2 inhibitor NSAIDs compared to non-selective NSAIDs (mean change from baseline -2.60, 95% CI -9.23 to 4.03; 2 RCTs, N = 437). There is moderate quality evidence of conflicting results for short-term disability improvement between groups (2 RCTs, N = 437). Low quality evidence from one trial (N = 333) reported no clear difference between groups in the proportion of participants experiencing global improvement. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events between those who took COX-2 inhibitors and non-selective NSAIDs (RR 0.97, 95% CI 0.63 to 1.50; 2 RCTs, N = 444). No data were reported for return to work.AUTHORS' CONCLUSIONS: This updated Cochrane Review included 32 trials to evaluate the efficacy of NSAIDs in people with acute LBP. The quality of the evidence ranged from high to very low, thus further research is (very) likely to have an important impact on our confidence in the estimates of effect, and may change the estimates. NSAIDs seemed slightly more effective than placebo for short-term pain reduction (moderate certainty), disability (high certainty), and global improvement (low certainty), but the magnitude of the effects is small and probably not clinically relevant. There was no clear difference in short-term pain reduction (low certainty) when comparing selective COX-2 inhibitors to non-selective NSAIDs. We found very low evidence of no clear difference in the proportion of participants experiencing adverse events in both the comparison of NSAIDs versus placebo and selective COX-2 inhibitors versus non-selective NSAIDs. We were unable to draw conclusions about adverse events and the safety of NSAIDs for longer-term use, since we only included RCTs with a primary focus on short-term use of NSAIDs and a short follow-up. These are not optimal for answering questions about longer-term or rare adverse events.

Background: Lumbosacral radicular pain (commonly called sciatica) is a syndrome involving patients who report radiating leg pain. Epidural corticosteroid injections deliver a corticosteroid dose into the epidural space, with the aim of reducing the local inflammatory process and, consequently, relieving the symptoms of lumbosacral radicular pain. This Cochrane Review is an update of a review published in Annals of Internal Medicine in 2012. Some placebo-controlled trials have been published recently, which highlights the importance of updating the previous review. Objectives: To investigate the efficacy and safety of epidural corticosteroid injections compared with placebo injection on pain and disability in patients with lumbosacral radicular pain. Search methods: We searched the following databases without language limitations up to 25 September 2019: Cochrane Back and Neck group trial register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, International Pharmaceutical Abstracts, and two trial registers. We also performed citation tracking of included studies and relevant systematic reviews in the field. Selection criteria: We included studies that compared epidural corticosteroid injections of any corticosteroid drug to placebo injections in patients with lumbosacral radicular pain. We accepted all three anatomical approaches (caudal, interlaminar, and transforaminal) to delivering corticosteroids into the epidural space. We considered trials that included a placebo treatment as delivery of an inert substance (i.e. one with no pharmacologic activity), an innocuous substance (e.g. normal saline solution), or a pharmacologically active substance but not one considered to provide sustained benefit (e.g. local anaesthetic), either into the epidural space (i.e. to mimic epidural corticosteroid injection) or adjacent spinal tissue (i.e. subcutaneous, intramuscular, or interspinous tissue). We also included trials in which a local anaesthetic with a short duration of action was used as a placebo and injected together with corticosteroid in the intervention group. Data collection and analysis: Two authors independently performed the screening, data extraction, and 'Risk of bias' assessments. In case of insufficient information, we contacted the authors of the original studies or estimated the data. We grouped the outcome data into four time points of assessment: immediate (≤ 2 weeks), short term (> 2 weeks but ≤ 3 months), intermediate term (> 3 months but < 12 months), and long term (≥ 12 months). We assessed the overall quality of evidence for each outcome and time point using the GRADE approach. Main results: We included 25 clinical trials (from 29 publications) investigating the effects of epidural corticosteroid injections compared to placebo in patients with lumbosacral radicular pain. The included studies provided data for a total of 2470 participants with a mean age ranging from 37.3 to 52.8 years. Seventeen studies included participants with lumbosacral radicular pain with a diagnosis based on clinical assessment and 15 studies included participants with mixed duration of symptoms. The included studies were conducted mainly in North America and Europe. Fifteen studies did not report funding sources, five studies reported not receiving funding, and five reported receiving funding from a non-profit or government source. Eight trials reported data on pain intensity, 12 reported data on disability, and eight studies reported data on adverse events. The duration of the follow-up assessments ranged from 12 hours to 1 year. We considered eight trials to be of high quality because we judged them as having low risk of bias in four out of the five bias domains. We identified one ongoing trial in a trial registry. Epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing leg pain at short-term follow-up (mean difference (MD) −4.93, 95% confidence interval (CI) −8.77 to –1.09 on a 0 to 100 scale; 8 trials, n = 949; moderate-quality evidence (downgraded for risk of bias)). For disability, epidural corticosteroid injections were probably slightly more effective compared to placebo in reducing disability at short-term follow-up (MD −4.18, 95% CI −6.04 to −2.17, on a 0 to 100 scale; 12 trials, n = 1367; moderate-quality evidence (downgraded for risk of bias)). The treatment effects are small, however, and may not be considered clinically important by patients and clinicians (i.e. MD lower than 10%). Most trials provided insufficient information on how or when adverse events were assessed (immediate or short-term follow-up) and only reported adverse drug reactions — that is, adverse events that the trialists attributed to the study treatment. We are very uncertain that epidural corticosteroid injections make no difference compared to placebo injection in the frequency of minor adverse events (risk ratio (RR) 1.14, 95% CI 0.91 to 1.42; 8 trials, n = 877; very low quality evidence (downgraded for risk of bias, inconsistency and imprecision)). Minor adverse events included increased pain during or after the injection, non-specific headache, post-dural puncture headache, irregular periods, accidental dural puncture, thoracic pain, non-local rash, sinusitis, vasovagal response, hypotension, nausea, and tinnitus. One study reported a major drug reaction for one patient on anticoagulant therapy who had a retroperitoneal haematoma as a complication of the corticosteroid injection. Authors' conclusions: This study found that epidural corticosteroid injections probably slightly reduced leg pain and disability at short-term follow-up in people with lumbosacral radicular pain. In addition, no minor or major adverse events were reported at short-term follow-up after epidural corticosteroid injections or placebo injection. Although the current review identified additional clinical trials, the available evidence still provides only limited support for the use of epidural corticosteroid injections in people with lumbosacral radicular pain as the treatment effects are small, mainly evident at short-term follow-up and may not be considered clinically important by patients and clinicians (i.e. mean difference lower than 10%). According to GRADE, the quality of the evidence ranged from very low to moderate, suggesting that further studies are likely to play an important role in clarifying the efficacy and tolerability of this treatment. We recommend that further trials should attend to methodological features such as appropriate allocation concealment and blinding of care providers to minimise the potential for biased estimates of treatment and harmful effects.

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.

The aim of this study is to compare Dutch usual care musculoskeletal therapy in patients with non-specific neck pain with recommendations from international clinical practice guidelines. Physical therapy is diverse, as it may consist of exercise, massage, advice, and other modalities. Physical therapists with post graduate qualifications in manual therapy (MT) may additionally apply spinal thrust manipulation or non-thrust mobilization techniques to treat neck pain. It is important that, in the absence of a Dutch clinical guideline for the treatment of patients with neck pain, musculoskeletal therapists use the available recommendations from international clinical practice guidelines when treating patients with neck pain. One updated clinical practice guideline was identified (Blanpied, 2017), a report from the Task Force on Neck Pain (Guzman et al., 2008) and the IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention (Rushton et al., 2014). At baseline 1193 patients are included and data with regard to pain, disability, fear avoidance, expectations and applied treatment modalities are gathered. Outcome is measured using the Global Perceived Effect questionnaire. Results show that patients with acute neck pain are treated significantly more often with manipulation compared to patients with sub-acute or chronic neck pain (p < .000) and younger patients are treated with manipulation more often than older patients (p < .000). In the presence of comorbidity, the preference of spinal manipulation seems to diminish, in favour of mobilization and exercise. Almost every patient receives multimodal therapy (94.3%) and spinal manipulation and mobilization are rarely used as a stand-alone treatment (4.5% and 0.8%). Dutch musculoskeletal therapists choose treatment strategies that correspond with recommendations from international guidelines.

Background The first aim of this research was to investigate the current prevalence of musculoskeletal ultrasound in Dutch physiotherapy practices. The second aim was to explore experiences of physiotherapists with musculoskeletal ultrasound in a primary care setting with patients presenting with shoulder complaints. Methods A random sample of 1000 owners of primary care physiotherapy practices was sent a questionnaire to investigate the prevalence of musculoskeletal ultrasound. A second questionnaire was sent to physiotherapists using musculoskeletal ultrasound to explore experiences with it in patients with shoulder complaints. Results The net response rate of the first questionnaire was 57.7%. In 18% of the physiotherapy practices musculoskeletal ultrasound was offered. Sixty-nine physiotherapists returned the second questionnaire. Physiotherapists indicated they most often used musculoskeletal ultrasound in patients with shoulder complaints, mainly for suspected tissue damage (83.7%), followed by making a diagnosis (63.3%) and for determining the choice of treatment (36.7%). Physiotherapists reported the biggest advantage was that they were better able to diagnose presenting shoulder complaints. The most frequently mentioned disadvantage of the use of musculoskeletal ultrasound was that assessment is difficult and that there is a risk that findings may not be sufficiently linked to history and physical examination. Conclusion One in six physiotherapy practices in the Netherlands offer musculoskeletal ultrasound. It is mainly used for patients with shoulder complaints, with an emphasis on detecting tissue damage and as an aid for diagnosis. Physiotherapists trained to work with musculoskeletal ultrasound seem enthusiastic and are at the same time aware of its disadvantages.

Study designA cross-sectional inter-examiner agreement and reliability study among physical therapists in primary care.Backgroundmusculoskeletal ultrasound (MSU) is frequently used by physical therapists to improve specific diagnosis in patients with shoulder pain, especially for the diagnosis rotator cuff tendinopathy (RCT) including tears.ObjectivesTo estimate the inter-examiner agreement and reliability in physical therapists using MSU for patients with shoulder pain.MethodsPhysical therapists performed diagnostic MSU in 62 patients with shoulder pain. Both physical therapists were blinded to each other's results and patients were not informed about the test results. We calculated the overall inter-examiner agreement, specific positive and negative inter-examiner agreement, and inter-examiner reliability (Cohen's Kappa's).ResultsOverall agreement for detecting RC ruptures ranged from 61.7% to 85.5% and from 43.9% to 91.4% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures. Overall agreement for other pathology than ruptures related to SAPS, ranged from 72.6% to 93.6% and from 77.3% to 96% for specific positive agreement. The specific negative agreement was lower with values ranging from 44.4% to 79.1% for RC ruptures and 52.5%-83.3% for other pathology than ruptures related to SAPS. Reliability values varied from substantial for any thickness ruptures to moderate for partial thickness ruptures and fair for full thickness tears. Moreover, reliability was fair for cuff tendinopathy. The reliability for AC arthritis and no pathology found was fair and moderate. There was substantial agreement for the calcifying tendinopathy.ConclusionsPhysical therapists using MSU agree on the diagnosis of cuff tendinopathy and on the presence of RCT in primary care, but agree less on the absence of pathology.

BACKGROUND: A substantial number of patients with chronic low back pain (CLBP) have axial spondyloarthritis (axSpA), but early recognition of these patients is difficult for general practitioners (GPs). The Case Finding Axial Spondyloarthritis (CaFaSpA) referral strategy has shown to be able to identify patients with CLBP at risk for axSpA, but its impact on clinical daily practice is yet unknown.OBJECTIVE: To assess the effect of the CaFaSpA referral strategy on pain caused by disability in primary care patients with CLBP.METHODS: Within this clustered randomized controlled trial 93 general practices were randomized to either the CaFaSpA referral model (intervention) or usual primary care (control). In each group primary care patients between 18 and 45 years with CLBP were included. The primary outcome was disability caused by CLBP, measured with the Roland Morris Disability Questionnaire (RMDQ) at baseline and four months. Secondary outcome was the frequency of new axSpA diagnosis. Descriptive analyses were performed, and a linear mixed-effects model was used.RESULTS: In total 679 CLBP patients were included of which 333 patients were allocated to the intervention group and 346 to the control group. Sixty-four percent were female and mean age was 36.2 years. The mean RMDQ score at baseline was 8.39 in the intervention group and 8.61 in the control group. At four months mean RMDQ score was 7.65 in the intervention group and 8.15 in the control group. This difference was not statistically significant (p = 0.50). Six (8%) out of the 75 finally referred patients, were diagnosed with axSpA by their rheumatologist.CONCLUSIONS: The CaFaSpA referral strategy for axSpA did not have an effect on disability after four months caused by CLBP. However, the strategy is able to detect the axSpA patient within the large CLBP population sufficiently. Trial registration number: NCT01944163, Clinicaltrials.gov.

Summary Objective To determine and compare the proportion of patients treated in a primary care setting that have knee osteoarthritis (OA) according to the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), and the National Institute for Health and Care Excellence (NICE) clinical classification criteria. Design A cross-sectional analysis of baseline data from 13,459 patients with knee symptoms or functional limitations associated with OA participating in the Good Life with osteoArthritis in Denmark (GLA:D®) treatment program. The prevalence of knee OA according to the EULAR, ACR and NICE criteria were calculated in all participants and in the subgroup of patients with self-reported radiographic changes associated with knee OA (n = 10,651 or 79%). Results Mean age (SD) was 65.3 (9.8) years, median (IQR) duration of symptoms 12 (6–36) months and mean pain intensity (0–100; SD) 46.5 (22.1) mm. 39% fulfilled all three sets of criteria. 48%, 52% and 89% fulfilled the EULAR, ACR, and NICE criteria for having knee OA, respectively. In the subgroup with self-reported radiographic changes, the corresponding numbers were 49%, 54% and 90%. Conclusions While the EULAR and ACR criteria only identified around half of those, with or without self-reported radiographic knee OA, that were treated because of symptoms or functional limitations associated with knee OA, the NICE criteria identified most patients. The results indicate that the NICE criteria are relevant and appropriate to identify individuals treated for knee OA in primary care.

Objectives To explore whether a therapist effect exists in physiotherapists treating patients with shoulder pain and to identify if personality traits of the physiotherapist influences patients outcome. Design Observational cohort study. Setting Primary care physiotherapy practices. Participants Data on patients with shoulder complaints that started and finished treatment between 2009 and 2012 were derived from the NIVEL Primary Care Database. Personality traits of the physiotherapist were identified using the Big Five Inventory. Data of 2,814 patients and 56 physiotherapists were analysed using multi-level linear regression. Main outcome measure Severity of complaint was measured on a 10-point Likert scale at the start and end of treatment. Change score is used as outcome. Results A therapist effect exists in the rehabilitation of patients with shoulder complaints in a physiotherapy setting; the physiotherapist explained 12% of variance and the personality trait extraversion showed a significant association (p = 0.03) with change in treatment outcome. Conclusion Current explorative study suggests that patients who were treated by therapists that tend to be more outgoing and energetic achieved better treatment results. Additional studies are needed to unravel the interplay between personality traits and other variables of importance, like patients’ personality traits or psychological factors, in treating patients with shoulder complaints.

BACKGROUND: Patients with back pain can show one or more features of spinal osteoarthritis (OA), such as morning stiffness, limited or painful range of motion (ROM), and lumbar disc degeneration (LDD). However, it has not been investigated whether these features are prognostic of long-term back pain.OBJECTIVES: This study assessed whether spinal morning stiffness, ROM and LDD are prognostic factors for back pain after 1 year in older adults with back pain.METHODS: This prospective observational study (BACE cohort) included patients aged>55 years visiting a general practitioner for a back-pain episode. Baseline patient-reported morning stiffness, physical examined ROM and radiographic LDD features (i.e., multilevel osteophytes and disc space narrowing) were analysed as potential prognostic factors in unadjusted and adjusted regression models with the outcomes of persistent back pain (yes/no) and back pain severity after 1-year follow-up.RESULTS: This study included 543 patients with mean (SD) age 67 (8) years, 59% female, and 62% reporting back pain at 1-year follow-up. When studied in separate adjusted models, persistent back pain was associated with morning stiffness>30min (OR 3.0, 95%CI 1.3; 5.5), restricted lateroflexion (OR 1.8, 95%CI 1.0; 3.2), pain during rotation (OR=1.7, 95%CI 1.0; 2.9), multilevel osteophytes (OR 2.4, 95%CI 1.4; 4.1), and multilevel disc space narrowing (OR 1.5, 95%CI 0.9; 2.4). When investigated in the same adjusted model, persistent back pain remained associated with only morning stiffness>30min (OR 2.4, 95%CI 1.0; 3.9), pain during rotation (OR 1.6, 95%CI 0.9; 2.8), and multilevel osteophytes (OR 2.1, 95%CI 1.2; 3.7). The same spinal OA-related features were associated with back pain severity.CONCLUSIONS: Spinal morning stiffness, painful rotation, and multilevel osteophytes are prognostic factors for persistent back pain and back pain severity after 1 year. Evaluating these clinical and radiographic features of spinal OA could help clinicians identify older patients who will experience long-term back pain.

It is unclear whether bone quality associates with severity and prognosis of back pain.To investigate the association between bone quality and back pain severity at baseline, and whether low bone quality is a prognostic factor for persistent back pain in patients aged over 55 years at 1-year follow-up.In this prospective cohort study persistent back pain was defined as a decrease in the back pain severity score of less than 30% at 1-year follow-up compared with baseline score or as a back pain severity score greater than 1 (0-10: 0 = no pain) Low bone quality was categorized as a T-score, calculated using a stiffness index by quantitative ultrasound of the heel, of 2.5 or below. Data were analyzed in multiple regression analyses.Of all 513 patients, 68 (13%) showed low bone quality at baseline. Back pain severity showed no differences between patients with normal and with low bone quality. At 1-year follow-up, low bone quality was not associated with persistent back pain (defined as30%: OR 1.0; 95% CI: 0.40-2.30, p-value = 0.93; and defined as score1: OR 0.4; 95% CI: 0.17-1.15), p-value = 0.09), adjusted for all covariates.In older adults with back pain presenting in general practice, low bone quality was not associated with severity of back pain at baseline nor with persistent back pain at 1-year follow-up.

Many clinical practice guidelines recommend similar approaches for the assessment and management of low back pain. Recommendations include use of a biopsychosocial framework to guide management with initial non-pharmacological treatment, including education that supports self-management and resumption of normal activities and exercise, and psychological programmes for those with persistent symptoms. Guidelines recommend prudent use of medication, imaging, and surgery. The recommendations are based on trials almost exclusively from high-income countries, focused mainly on treatments rather than on prevention, with limited data for cost-effectiveness. However, globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence, reduce the focus on spinal abnormalities, and ensure promotion of activity and function, including work participation. We have identified effective, promising, or emerging solutions that could offer new directions, but that need greater attention and further research to determine if they are appropriate for large-scale implementation. These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.

Objective To review scientific literature studying the effectiveness of physical therapy and electrophysical modalities for carpal tunnel syndrome (CTS). Data Sources The Cochrane Library, PubMed, Embase, CINAHL, and Physiotherapy Evidence Database. Study Selection Two reviewers independently applied the inclusion criteria to select potential eligible studies. Data Extraction Two reviewers independently extracted the data and assessed the methodologic quality using the Cochrane Risk of Bias Tool. Data Synthesis A best-evidence synthesis was performed to summarize the results of the included studies (2 reviews and 22 randomized controlled trials [RCTs]). For physical therapy, moderate evidence was found for myofascial massage therapy versus ischemic compression on latent, or active, trigger points or low-level laser therapy in the short term. For several electrophysical modalities, moderate evidence was found in the short term (ultrasound vs placebo, ultrasound as single intervention vs other nonsurgical interventions, ultrasound vs corticosteroid injection plus a neutral wrist splint, local microwave hyperthermia vs placebo, iontophoresis vs phonophoresis, pulsed radiofrequency added to wrist splint, continuous vs pulsed vs placebo shortwave diathermy, and interferential current vs transcutaneous electrical nerve stimulation vs a night-only wrist splint). In the midterm, moderate evidence was found in favor of radial extracorporeal shockwave therapy (ESWT) added to a neutral wrist splint, in favor of ESWT versus ultrasound, or cryo-ultrasound, and in favor of ultrasound versus placebo. For all other interventions studied, only limited, conflicting, or no evidence was found. No RCTs investigating the long-term effects of physical therapy and electrophysical modalities were found. Because of heterogeneity in the treatment parameters used in the included RCTs, optimal treatment parameters could not be identified. Conclusions Moderate evidence was found for several physical therapy and electrophysical modalities for CTS in the short term and midterm. Future studies should concentrate on long-term effects and which treatment parameters of physical therapy and electrophysical modalities are most effective for CTS.

© 2017 Australian Physiotherapy Association Question Which multivariable prognostic model(s) for recovery in people with neck pain can be used in primary care? Design Systematic review of studies evaluating multivariable prognostic models. Participants People with non-specific neck pain presenting at primary care. Determinants Baseline characteristics of the participants. Outcome measures Recovery measured as pain reduction, reduced disability, or perceived recovery at short-term and long-term follow-up. Results Fifty-three publications were included, of which 46 were derivation studies, four were validation studies, and three concerned combined studies. The derivation studies presented 99 multivariate models, all of which were at high risk of bias. Three externally validated models generated usable models in low risk of bias studies. One predicted recovery in non-specific neck pain, while two concerned participants with whiplash-associated disorders (WAD). Discriminative ability of the non-specific neck pain model was area under the curve (AUC) 0.65 (95% CI 0.59 to 0.71). For the first WAD model, discriminative ability was AUC 0.85 (95% CI 0.79 to 0.91). For the second WAD model, specificity was 99% (95% CI 93 to 100) and sensitivity was 44% (95% CI 23 to 65) for prediction of non-recovery, and 86% (95% CI 73 to 94) and 55% (95% CI 41 to 69) for prediction of recovery, respectively. Initial Neck Disability Index scores and age were identified as consistent prognostic factors in these three models. Conclusion Three externally validated models were found to be usable and to have low risk of bias, of which two showed acceptable discriminative properties for predicting recovery in people with neck pain. These three models need further validation and evaluation of their clinical impact before their broad clinical use can be advocated. Registration PROSPERO CRD42016042204. [Wingbermühle RW, van Trijffel E, Nelissen PM, Koes B, Verhagen AP (2018) Few promising multivariable prognostic models exist for recovery of people with non-specific neck pain in musculoskeletal primary care: a systematic review. Journal of Physiotherapy 64: 16–23]