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QUESTION: Can existing post-treatment prognostic models for predicting neck pain recovery (primarily in terms of disability and secondarily in terms of pain intensity and perceived improvement) be externally validated and updated at the end of the treatment period and at 6 and 12 weeks of follow-up in a new Dutch cohort of people with neck pain treated with guideline-based usual care physiotherapy?DESIGN: External validation and model updating in a new prospective cohort of three previously developed prognostic models.PARTICIPANTS: People with (sub)acute neck pain and registered for primary care physiotherapy treatment.OUTCOME MEASURES: Recovery of disability, pain intensity, and perceived recovery at 6 and 12 weeks and at the end of the treatment period.RESULTS: Discriminative performance (c-statistic) of the disability model at 6 weeks was 0.73 (95% CI 0.69 to 0.77) and reasonably well calibrated after intercept recalibration. The disability model at 12 weeks and at the end of the treatment period showed discriminative c-statistic performance values of 0.69 (95% CI 0.64 to 0.73) and 0.68 (95% CI 0.63 to 0.72), respectively, and was well calibrated. Pain models and perceived recovery models did not reach acceptable performance. Cervical mobility added value to the disability models and pain catastrophising to the disability and pain models at 6 weeks.DISCUSSION: Broad external validation of the disability model was successful in people with (sub)acute neck pain and clinicians may use this model in clinical practice with reasonable accuracy. Further research is required to assess the disability model's clinical impact and generalisability, and to identify additional valuable model predictors.REGISTRATION: https://osf.io/a6r3k/.

Background Children with overweight and obesity in socially deprived areas (SDAs) are less likely to complete and be compliant to a weight-loss programme. Objectives To identify factors associated with dropout and compliance of a multidisciplinary weight-loss programme in SDA. Methods This prospective longitudinal cohort study included children (6–12 years) with overweight and obesity in a 12-week multidisciplinary intervention living in SDA in Rotterdam, the Netherlands. Potential predictive variables for dropout and compliance included were age, sex, the weight of the child and parents, quality of life, and referral status (self-registration or referral). A Cox proportional hazards model was performed to study the association between dropout and its potential predictive variables, whereas logistic regression analyses were used for the potential predictors for compliance. Results A total of 121 children started the intervention programme. Forty-one (33.9%) children dropped out and 68 (56.2%) were compliant with the intervention. The risk of dropping out of the intervention was significantly lower for a child with overweight parents than for those with parents with normal weight (adjusted hazard ratio [HR] 0.22 [95% confidence interval, CI 0.063–0.75]), and for those with parents with obesity (adjusted HR 0.18 [95% CI 0.060–0.52]). No other potential predictive variables were associated with dropout or compliance. Conclusion Children from SDA participating in a weight-loss programme have a relatively high dropout and a low compliance rate. Parental weight seems to be an important predictor for dropout of children from SDA, where children with normal weight or obese parents have the highest risk of dropout compared with children of overweight parents.

Dancers need adequate cardiorespiratory fitness (CRF) levels in order to cope with the demands of dance classes and choreographies. Screening and monitoring of CRF is advised. The aim of this systematic review was to provide an overview of tests used to assess CRF in dancers and to examine the measurement properties of these tests. A literature search was performed in three online databases (PubMed, EMBASE, and SPORTDiscus) up until August 16, 2021. Study inclusion criteria were: 1. a CRF test was used; 2. participants were ballet, contemporary or modern, or jazz dancers; and 3. English full-text peer-reviewed article. General study information, participant information, CRF test used, and study outcome were extracted. If available, measurement property data were extracted (i.e., test reliability, validity, responsiveness, and interpretability). Of the 48 articles included in the review, most used a maximal treadmill test (n = 22) or the multistage Dance Specific Aerobic Fitness test (DAFT; n = 11). Out of the 48 included studies, only six examined the measurement properties of CRF tests: Aerobic Power Index (API), Ballet-specific Aerobic Fitness Test (B-DAFT), DAFT, High-Intensity Dance Performance Fitness Test (HIDT), Seifert Assessment of Functional Capactiy for Dancers (SAFD), and the 3-minute step test. Good test-retest reliability was found for the B-DAFT, DAFT, HIDT, and SAFD. Criterion validity was determined for the VO2peak of the API, the 3-MST, HIDT, and SAFD. For HRpeak, criterion validity was studied for the 3-MST, HIDT, and SAFD. While different CRF tests are being used in descriptive and experimental research within dance populations, the body of research supporting the measurement properties of such tests is very small. As many studies have methodological flaws (e.g., small participant numbers or no statistical analysis for validity or reliability), additional good quality research is required to re-examine and complement current measurement property results of the API, B-DAFT, DAFT, HIDT, SAFD, and 3-MST.

Objective Patients with osteoarthritis are mainly managed in primary care settings and many patients use pain medication as symptomatic treatment. We investigated in OA-patients receiving an education and exercise program, the use and type of pain medication and its impact on outcomes at 3 months follow-up. Design, Setting and Subjects The design was a retrospective cohort study using prospectively collected data from the GLA: D® registry. The study included 15,918 primary care patients. Results Among the included patients, 62% were pain medication users and 38% were non-users. Among the pain medications users, 35% were classified as paracetamol users, 54% as NSAID users, and 11% as opioid users. Medication users and non-users differed regarding a higher pain intensity, poorer physical and mental health. Pain medication use before and during the education and exercise program was associated with the pain intensity at 3 months follow-up. However, patients either using or not using pain medications improved over time, and the magnitude of the difference between patient groups was small (less than 10 mm on a 0–100 scale). Conclusions Pain medication use is weakly associated with outcome at 3 months follow up in OA-patients receiving an education and exercise program. Between-group differences, however, are small and probably not clinically important.

Background Over the past decades, opioid prescriptions have increased in the Netherlands. The Dutch general practitioners’ guideline on pain was recently updated and now aims to reduce opioid prescriptions and high-risk opioid use for non-cancer pain. The guideline, however, lacks practical measures for implementation. Objective This study aims to determine practical components for a tool that should assist Dutch primary care prescribers and implements the recently updated guideline to reduce opioid prescriptions and high-risk use. Methods A modified Delphi approach was used. The practical components for the tool were identified based on systematic reviews, qualitative studies, and Dutch primary care guidelines. Suggested components were divided into Part A, containing components designed to reduce opioid initiation and stimulate short-term use, and Part B, containing components designed to reduce opioid use among patients on long-term opioid treatment. During three rounds, a multidisciplinary panel of 21 experts assessed the content, usability, and feasibility of these components by adding, deleting, and adapting components until consensus was reached on the outlines of an opioid reduction tool. Results The resulting Part A consisted of six components, namely education, opioid decision tree, risk assessment, agreements on dosage and duration of use, guidance and follow-up, and interdisciplinary collaboration. The resulting Part B consisted of five components, namely education, patient identification, risk assessment, motivation, and tapering. Conclusions In this pragmatic Delphi study, components for an opioid reduction tool for Dutch primary care-givers are identified. These components need further development, and the final tool should be tested in an implementation study.

OBJECTIVE: Spinal osteoarthritis is difficult to study and diagnose, partly due to the lack of agreed diagnostic criteria. This systematic review aims to give an overview of the associations between clinical and imaging findings suggestive of spinal osteoarthritis in patients with low back pain to make a step towards agreed diagnostic criteria. DESIGN: We searched MEDLINE, Embase, Web of Science, and CINAHL from inception to April 29, 2021 to identify observational studies in adults that assessed the association between selected clinical and imaging findings suggestive of spinal osteoarthritis. Risk of bias was assessed using the Newcastle Ottawa Scale and the quality of evidence was graded using an adaptation of the GRADE approach. RESULTS: After screening 7902 studies, 30 met the inclusion criteria. High-quality evidence was found for the longitudinal association between low back pain (LBP) intensity, and both disc space narrowing and osteophytes, as well as for the association between LBP-related physical functioning and lumbar disc degeneration, the presence of spinal morning stiffness and disc space narrowing and for the lack of association between physical functioning and Schmorl's nodes. CONCLUSIONS: There is high- and moderate-quality evidence of associations between clinical and imaging findings suggestive of spinal osteoarthritis. However, the majority of the studied outcomes had low or very low-quality of evidence. Furthermore, clinical and methodological heterogeneity was a serious limitation, adding to the need and importance of agreed criteria for spinal osteoarthritis, which should be the scope of future research.

This systematic review updates a previous systematic review on work-related physical and psychosocial risk factors for elbow disorders. Medline, Embase, Web of Science, Cochrane Central and PsycINFO were searched for studies on associations between work-related physical or psychosocial risk factors and the occurrence of elbow disorders. Two independent reviewers selected eligible studies and assessed risk of bias (RoB). Results of studies were synthesized narratively. We identified 17 new studies and lateral epicondylitis was the most studied disorder (13 studies). Five studies had a prospective cohort design, eight were cross-sectional and four were case-control. Only one study had no items rated as high RoB. Combined physical exposure indicators (e.g. physical exertion combined with elbow movement) were associated with the occurrence of lateral epicondylitis. No other consistent associations were observed for other physical and psychosocial exposures. These results prevent strong conclusions regarding associations between work-related exposures, and the occurrence of elbow disorders.

ObjectivesThe aim of this study was to examine the effectiveness of an enhanced online injury prevention programme on the number of running-related injuries (RRIs) in recreational runners.MethodsWe conducted a randomised-controlled trial in runners who registered for running events (distances: 10–42.195 km) in the Netherlands. Adult runners who provided informed consent were randomised into the intervention or control group. Participants in the intervention group received access to the online prevention programme, which included items to prevent RRIs. Participants in the control group followed their regular preparation for the running event. The primary outcome measure was the number of new RRIs from baseline to 1 month after the running event. To determine differences between injury proportions, univariate and multivariate logistic regression analyses were performed.ResultsThis study included 4050 recreational runners (63.5% males; mean (SD) age: 42.3 (12.1) years) for analyses. During follow-up, 35.5% (95% CI: 33.5 to 37.6) of the participants in the intervention group sustained a new RRI compared with 35.4% (95% CI: 33.3 to 37.5) of the participants in the control group, with no between-group difference (OR: 1.03; 95% CI: 0.90 to 1.17). There was a positive association between the number of items followed in the injury prevention programme and the number of RRIs (OR: 1.05; 95% CI: 1.00 to 1.11).ConclusionThe enhanced online injury prevention programme had no effect on the number of RRIs in recreational runners, and being compliant with the programme paradoxically was associated with a slightly higher injury rate. Future studies should focus on individual targeted prevention with emphasis on the timing and application of preventive measures.Trial registration numberNL7694.

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.

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To determine the effect of ergonomic interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work-related outcomes.

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

Lumbar bone marrow edema, also known as Modic type-1 endplate change, has a prevalence of 43% in low back pain populations and 6% in general populations. Besides mechanical factors and genetic predisposition it has been hypothesized that lumbar bone marrow edema is caused by a latent infection of low-virulence anaerobic bacteria in degenerated lumbar intervertebral discs. The hypothesis is supported by the observation that the presence of Cutibacterium acnes is more frequently found in samples of disci with Modic-1 than in discs without and by the positive effects of antibiotics in patients with back pain and Modic-1 as shown in placebo-controlled RCT's. Opponents of the hypothesis argue that the findings of bacteria are most likely a result of contamination during harvesting the samples. We conclude that time has come to make a start in the Netherlands with treatment with antibiotics of a small group of well-selected patients in well-selected clinics.

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