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Objective: To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain., Design: Systematic review and random effects meta-analysis of randomised controlled trials., Data Sources: Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials., Study Selection Criteria: Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention., Results: Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, -0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery., Conclusions: Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care., (© Kamper et al 2015.)

Background: Although back pain is common among older people, limited information is available about the characteristics of these patients in primary care. Earlier research suggests that the severity of back symptoms increases with older age., Methods: Patients aged >55 years visiting a general practitioner with a new episode of back pain were included in the BACE study. Information on patients' characteristics, characteristics of the complaint and physical examination were derived from the baseline measurement. Cross-sectional differences between patients aged >55-74 and ≥75 years were analysed using an unpaired t-test, Mann-Whitney U-test or a chi-square test., Results: A total of 675 back pain patients were included in the BACE study, with a median age of 65 (interquartile range 60-71) years. Patients aged >55-74 years had a mean disability score (measured with the Roland Disability Questionnaire) of 9.4 [standard deviation (SD) 5.8] compared with 12.1 (SD 5.5) in patients aged ≥75 years (p ≤ 0.01). The older group reported more additional musculoskeletal disorders and more often had low bone quality (based on ultrasound measurement of the heel) than patients aged >55-74 years. Average back pain severity over the previous week showed no difference (p = 0.11) between the age groups, but severity of back pain at the moment of filling in the questionnaire was higher (p = 0.03) in the older age group., Conclusions: In this study, older back pain patients reported more disabilities and co-morbidity. However, the clinical relevance of these differences for the course of the back pain episode in older patients remains a subject for further research., (© 2013 European Pain Federation - EFIC®)

Background: Spinal manipulative therapy (SMT) is frequently used by health professionals to manage spinal pain. With many treatments having comparable outcomes to SMT, determining the cost-effectiveness of these treatments has been identified as a high research priority., Objective: To investigate the cost-effectiveness of SMT compared to other treatment options for people with spinal pain of any duration., Methods: We searched eight clinical and economic databases and the reference lists of relevant systematic reviews. Full economic evaluations conducted alongside randomised controlled trials with at least one SMT arm were eligible for inclusion. Two authors independently screened search results, extracted data and assessed risk of bias using the CHEC-list., Results: Six cost-effectiveness and cost-utility analysis were included. All included studies had a low risk of bias scoring ≥16/19 on the CHEC-List. SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to GP care, exercise and physiotherapy., Conclusions: This review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. However, as this conclusion is primarily based on single studies more high quality research is needed to identify whether these findings are applicable in other settings., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Back and neck pain are important health problems with serious societal and economic implications. Conventional treatments have been shown to have limited benefit in improving patient outcomes. Complementary and Alternative Medicine (CAM) therapies offer additional options in the management of low back and neck pain. Many trials evaluating CAM therapies have poor quality and inconsistent results., Objectives: To systematically review the efficacy, effectiveness, cost-effectiveness, and harms of acupuncture, spinal manipulation, mobilization, and massage techniques in management of back, neck, and/or thoracic pain., Data Sources: MEDLINE, Cochrane Central, Cochrane Database of Systematic Reviews, CINAHL, and EMBASE were searched up to 2010; unpublished literature and reference lists of relevant articles were also searched. study selection: All records were screened by two independent reviewers. Primary reports of comparative efficacy, effectiveness, harms, and/or economic evaluations from randomized controlled trials (RCTs) of the CAM therapies in adults (age ≥ 18 years) with back, neck, or thoracic pain were eligible. Non-randomized controlled trials and observational studies (case-control, cohort, cross-sectional) comparing harms were also included. Reviews, case reports, editorials, commentaries or letters were excluded., Data Extraction: Two independent reviewers using a predefined form extracted data on study, participants, treatments, and outcome characteristics., Results: 265 RCTs and 5 non-RCTs were included. Acupuncture for chronic nonspecific low back pain was associated with significantly lower pain intensity than placebo but only immediately post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture was not different from placebo in post-treatment disability, pain medication intake, or global improvement in chronic nonspecific low back pain. Acupuncture did not differ from sham-acupuncture in reducing chronic non-specific neck pain immediately after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture was superior to no treatment in improving pain intensity (VAS: -1.19, 95 percent CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ), well-being (SF-36), and range of mobility (extension, flexion), immediately after the treatment. In general, trials that applied sham-acupuncture tended to produce negative results (i.e., statistically non-significant) compared to trials that applied other types of placebo (e.g., TENS, medication, laser). Results regarding comparisons with other active treatments (pain medication, mobilization, laser therapy) were less consistent Acupuncture was more cost-effective compared to usual care or no treatment for patients with chronic back pain. For both low back and neck pain, manipulation was significantly better than placebo or no treatment in reducing pain immediately or short-term after the end of treatment. Manipulation was also better than acupuncture in improving pain and function in chronic nonspecific low back pain. Results from studies comparing manipulation to massage, medication, or physiotherapy were inconsistent, either in favor of manipulation or indicating no significant difference between the two treatments. Findings of studies regarding costs of manipulation relative to other therapies were inconsistent. Mobilization was superior to no treatment but not different from placebo in reducing low back pain or spinal flexibility after the treatment. Mobilization was better than physiotherapy in reducing low back pain (VAS: -0.50, 95 percent CI: -0.70, -0.30) and disability (Oswestry: -4.93, 95 percent CI: -5.91, -3.96). In subjects with acute or subacute neck pain, mobilization compared to placebo significantly reduced neck pain. Mobilization and placebo did not differ in subjects with chronic neck pain. Massage was superior to placebo or no treatment in reducing pain and disability only amongst subjects with acute/sub-acute low back pain. Massage was also significantly better than physical therapy in improving back pain (VAS: -2.11, 95 percent CI: -3.15, -1.07) or disability. For subjects with neck pain, massage was better than no treatment, placebo, or exercise in improving pain or disability, but not neck flexibility. Some evidence indicated higher costs for massage use compared to general practitioner care for low back pain. Reporting of harms in RCTs was poor and inconsistent. Subjects receiving CAM therapies reported soreness or bleeding on the site of application after acupuncture and worsening of pain after manipulation or massage. In two case-control studies cervical manipulation was shown to be significantly associated with vertebral artery dissection or vertebrobasilar vascular accident., Conclusions: Evidence was of poor to moderate grade and most of it pertained to chronic nonspecific pain, making it difficult to draw more definitive conclusions regarding benefits and harms of CAM therapies in subjects with acute/subacute, mixed, or unknown duration of pain. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. Very few studies reported long-term outcomes. There was insufficient data to explore subgroup effects. The trial results were inconsistent due probably to methodological and clinical diversity, thereby limiting the extent of quantitative synthesis and complicating interpretation of trial results. Strong efforts are warranted to improve the conduct methodology and reporting quality of primary studies of CAM therapies. Future well powered head to head comparisons of CAM treatments and trials comparing CAM to widely used active treatments that report on all clinically relevant outcomes are needed to draw better conclusions.

Study Design: Descriptive method guidelines., Objectives: To help reviewers design, conduct, and report reviews of trials in the field of back and neck pain., Summary of Background Data: In 1997, the Cochrane Collaboration Back Review Group published method guidelines for systematic reviews. Since its publication, new methodologic evidence emerged and more experience was acquired in conducting reviews., Methods: All reviews and protocols of the Back Review Group were assessed for compliance with the 1997 method guidelines. Also, the most recent version of the Cochrane Handbook (4.1) was checked for new recommendations. In addition, some important topics that were not addressed in the 1997 method guidelines were included (e.g., methods for qualitative analysis, reporting of conclusions, and discussion of clinical relevance of the results). In May 2002, preliminary results were presented and discussed in a workshop. In two rounds, a list of all possible recommendations and the final draft were circulated for comments among the editors of the Back Review Group., Results: The recommendations are divided in five categories: literature search, inclusion criteria, methodologic quality assessment, data extraction, and data analysis. Each recommendation is classified in minimum criteria and further guidance. Additional recommendations are included regarding assessment of clinical relevance, and reporting of results and conclusions., Conclusions: Systematic reviews need to be conducted as carefully as the trials they report and, to achieve full impact, systematic reviews need to meet high methodologic standards.

Study Design: A review of controlled trials., Objectives: To determine which interventions are used to prevent back and neck pain problems as well as what the evidence is for their utility., Summary of Background Data: Given the difficulty in successfully treating long-term back and neck pain problems, there has been a call for preventive interventions. Little is known, however, about the value of preventive efforts for nonpatients, e.g., in the general population or workplace., Methods: The literature was systematically searched to locate all investigations that were: 1) specifically designed as a preventive intervention; 2) randomized or nonrandomized controlled trials; and, 3) using subjects not seeking treatment. Outcome was evaluated on the key variables of reported pain, report of injury, dysfunction, time off work, health-care utilization, and cost. Conclusions were drawn using a grading system., Results: Twenty-seven investigations meeting the criteria were found for educational efforts, lumbar supports, exercises, ergonomics, and risk factor modification. For back schools, only one of the nine randomized trials reported a significant effect, and there was strong evidence that back schools are not effective in prevention. Because the randomized trials concerning lumbar supports were consistently negative, there is strong evidence that they are not effective in prevention. Exercises, conversely, showed stable positive results in randomized controlled trials, giving consistent evidence of relatively moderate utility in prevention. Because no properly controlled trials were found for ergonomic interventions or risk factor modification, there was not good quality evidence available to draw a conclusion., Conclusions: The results concerning prevention for subjects not seeking medical care are sobering. Only exercises provided sufficient evidence to conclude that they are an effective preventive intervention. There is a dire lack of controlled trials examining broad-based multidimensional programs. The need for high quality outcome studies is underscored.

In this study we estimated the indirect costs of back pain in 1991 in The Netherlands on the basis of two approaches: the traditionally used human capital method and the more recently developed friction cost method. The indirect costs of illness were defined as the value of production losses of paid labour and related costs to society due to back pain. The results of this study in 1991 in The Netherlands show that the short-term indirect costs estimated by the human capital method were more than three times as high as the indirect costs estimated by the friction cost method (US$ 4.6 billion vs. USS 1.5 billion, respectively). The lower estimate of indirect costs when using the friction cost method is mainly due to the fact that in this method actual production losses are estimated during a relatively short friction period, which is defined as the period needed to restore the initial production level. In contrast with the human capital method, long-term absenteeism and disability do not induce additional costs when applying the friction cost method. Since the friction cost method takes into account that employees can be replaced, we believe that this method produces a more accurate estimate of indirect costs than the human capital method. Notwithstanding the resulting decrease in indirect costs of back pain, these costs are still impressive, representing 0.28% of the GNP in The Netherlands in 1991. As a consequence, but particularly stimulated by structural changes in the Dutch social security system, policies aimed at reducing indirect costs of back pain, increasingly concentrate on the development and evaluation of interventions early after the onset of disease. This is complemented, on the one hand, by the development of clinical guidelines for the management of back pain in primary care and, on the other hand, by governmental policies aimed at reintegration of chronically ill in the labour force.