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ED FROM Hernandez-Molina G, Reichenbach S, Zhang B, et al. Effect of therapeutic exercise for hip osteoarthritis pain: results of a meta-analysis. Arthritis Rheum 2008;59:1221–8. Correspondence to: Dr G Hernandez-Molina, Clinical Epidemiology Research and Training Unit, Boston, MA, USA; gabyhm@yahoo.com Source of funding: National Institutes of Health. c Clinical impact ratings: Physical medicine & rehabilitation 5/7; Rheumatology 5/7 Exercise interventions v no exercise for hip osteoarthritis (OA) Outcome Type of OA Number of trials (n) Standardised effect size at median 8 weeks (95% CI)* Hip pain Hip i knee 9 (1234) 20.38 (20.68 to 20.08) 8 (493){ 20.47 (20.65 to 20.28) Hip only 8 (1063) 20.43 (20.80 to 20.06) 7 (322){ 20.58 (20.81 to 20.35) *CI defined in glossary. A negative effect size favours exercise. {Omitting 1 cluster-randomised trial (n = 741) with no personal exercise instruction and poor adherence. C O M M EN TA R Y T he review by Hernandez-Molina et al claims to be the first to specifically examine the role of strengthening and/or aerobic exercises for hip OA. A moderate effect size was achieved in patients with the hip as the index joint compared with a small effect in those with OA in the hip and knee. The key features of effective exercise programmes included duration >4 weeks, completion by >60% of participants, and personal supervision with tailoring of the programme to individuals. The key features of the largest and only negative trial were that instruction was done via videotape, adherence to exercise was low, and both the intervention and control groups were on rofecoxib. However, that trial did have longer follow-up (24 wks) compared with only 6–12 weeks for all but 1 of the other 8 trials. Therefore, the long-term benefits of exercise remain uncertain. Hernandez-Molina et al compared the benefits of exercise with those of medication, noting that exercise is more effective in reducing pain than paracetamol and less effective than non-steroidal anti-inflammatory drugs. The results of the review are very similar to those reported in a Cochrane review of exercises for knee OA, with the same effect size and greater benefits with increasing levels of supervision. Hernandez-Molina et al could only conclude that exercise may be safe because adverse event reporting was not comprehensive. Nonetheless, the key message for clinicians is that supervised strengthening and/or aerobic exercise programmes with good adherence are likely to offer small-tomoderate benefits for the pain of hip OA. Michael Yelland, MBBS, PhD Griffith University Logan, Queensland, Australia 1. Ravaud P, Giraudeau B, Logeart I, et al. Management of osteoarthritis (OA) with an unsupervised home based exercise programme and/or patient administered assessment tools. A cluster randomised controlled trial with a 2x2 factorial design. Ann Rheum Dis 2004;63: 703–8. 2. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev 2008;(4): CD004376.

ED FROM Peul WC, van den Hout WB, Brand R, et al. Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ 2008;336:135528. Correspondence to: Dr W C Peul, Leiden University Medical Centre, Leiden, The Netherlands; w.c.peul@lumc.nl Sources of funding: Netherlands Organisation for Health Research and Development and Hoelen Foundation, The Hague. c Clinical impact ratings: GP/FP/Primary care 6/7; Surgery/Orthopaedics 6/7; Surgery/Neurosurgery 5/7 C O M M EN TA R Y T he trial by Peul et al helps resolve some of the uncertainty about the role of discectomy in the treatment of sciatica. It has many messages for clinicians dealing with patients with sciatica due to disc herniation. Although long-term outcomes were similar for both groups, by 12 weeks those treated with early surgery had recovered faster than those treated conservatively (data not reported). This applied not only to leg pain and disability, but also to back pain. Over the ensuing 3–6 months, the early surgery group lost their initial advantage, but delayed surgery was performed in 44% of the conservative care group by the end of the trial. Unfortunately, 20% of patients reported unsatisfactory outcomes at 2 years, and 6% of those who had surgery required repeat surgery within 2 years. Conservative care was given by family practitioners, who provided analgesia, encouraged mobilisation, and referred patients to physiotherapy or back to hospital as needed. There was no mention of epidural injections, an option that may offer relief for about half of patients during the early stages of sciatica. This treatment may be less expensive and more acceptable to those who do not want surgery or cannot have surgery for other reasons. The authors rightly advocate more patient involvement in decision making about surgery because the results suggest that both treatment options are legitimate. Patients with a preference for conservative care can be assured that their long-term outcomes will not be inferior but that surgery may be indicated if their condition worsens. The same applies for those who do not have ready access to early surgery. Michael Yelland, MD Griffith University Logan City, Queensland, Australia 1. Gibson JN, Waddell G. Cochrane Database Syst Rev 2007;(2):CD001350. 2. Buttermann GR. J Bone Joint Surg Am 2004;86-A: 670–9. Repeated measurement analysis curves of mean scores for visualanalogue scale for leg pain. Reproduced with permission from Peul WC, van den Hout WB, Brand R, et al. BMJ 2008;336:1355–8. Therapeutics EBM December 2008 Vol 13 No 6 185 on 4 December 2008 ebm.bmj.com Downloaded from

Source Citation Ylinen J, Takala EP, Nykanen M, et al. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. JAMA. 2003;289:2509-16. 12759322

(2002) Spine 27, 1835. Jull G, Trott P, Potter H, et al. . A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. . ; . : . –43 . [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] QUESTION: In patients with cervicogenic headache, does manipulative therapy and/or specific low load exercise reduce headaches? Randomised (allocation concealed*), blinded (outcome assessors),* controlled trial with follow up immediately after treatment and at 12 months. 5 centres in Australia. 200 patients (mean age 37 y, 70% women) with cervicogenic headache, defined as unilateral (or unilateral dominant-side consistent) headache associated with neck pain and aggravated by neck postures or movement, joint tenderness in ≥1 of the upper 3 cervical joints, and headache frequency of ≥1 per week over a period of 2 months to 10 years. Exclusion criteria were bilateral headaches, features suggestive of migraine, contraindications to manipulative therapy, involvement in litigation or workers’ compensation, and physiotherapy or chiropractic treatment for headache in the previous 12 months. Follow up at 12 months was 97%. 51 patients were allocated to manipulative therapy (MT), which included low velocity cervical joint mobilisation and high velocity manipulation. 52 patients were allocated to therapeutic exercise (ExT), which used … [1]: {openurl}?query=rft.jtitle%253DSpine%26rft.stitle%253DSpine%26rft.aulast%253DJull%26rft.auinit1%253DG.%26rft.volume%253D27%26rft.issue%253D17%26rft.spage%253D1835%26rft.epage%253D1843%26rft.atitle%253DA%2Brandomized%2Bcontrolled%2Btrial%2Bof%2Bexercise%2Band%2Bmanipulative%2Btherapy%2Bfor%2Bcervicogenic%2Bheadache.%26rft_id%253Dinfo%253Adoi%252F10.1097%252F00007632-200209010-00004%26rft_id%253Dinfo%253Apmid%252F12221344%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1097/00007632-200209010-00004&link_type=DOI [3]: /lookup/external-ref?access_num=12221344&link_type=MED&atom=%2Febmed%2F8%2F4%2F109.atom [4]: /lookup/external-ref?access_num=000177959500003&link_type=ISI