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In her editorial in the winter 2009 issue of Physiotherapy Canada, Allison Francis outlined a number of online resources that are available to physiotherapists in their quest to find current evidence to inform their practice.1 One of the resources listed as “by subscription only” was The Cochrane Library (http://www.thecochranelibrary.com). This valuable resource was freely available to all Canadians with Internet access to the end of 2009, as a pilot project organized by the Canadian Cochrane Centre and the Canadian Health Libraries Association. Negotiations for ongoing funding were still in progress at the time of writing; however, abstracts and plain-language summaries continue to be free to all readers. We would like to take this opportunity to give you a brief overview of one the Review Groups that publish and maintain Cochrane Reviews that can help to inform your practice. The Cochrane Back Review Group (CBRG) is one of 52 Review Groups that produce and maintain systematic reviews on the effects of health care. The goal is to provide the most current information to inform clinical decisions at the individual, institutional, and policy levels. The scope of the CBRG is primary and secondary prevention and treatment of neck and back pain and other spinal disorders, excluding inflammatory diseases and fractures. The CBRG is hosted by the Institute for Work & Health (http://www.iwh.on.ca), an independent, not-for-profit research organization located in Toronto, Ontario, whose mission is to conduct and share research with workers, organized labour, employers, clinicians, and policy makers to promote, protect, and improve the health of working people. The CBRG also receives funding from the Canadian Institutes of Health Research and from the Canadian Agency for Drugs and Technologies in Health. Our authors, editors, and peer referees are international, multidisciplinary practitioners and researchers in the field of neck and back pain. The editorial team comprises two co-ordinating editors, a managing editor, a librarian, two editorial assistants, an editorial board, and an advisory board that provides peer review. Completed protocols and reviews are published quarterly in The Cochrane Library. Our reviews can be accessed via http://www.thecochranelibrary.com by browsing ‘by review group,’ or via the CBRG's website (http://www.cochrane.iwh.on.ca). Access to The Cochrane Library is available by subscription or without charge, depending on the jurisdiction. The CBRG published 40 reviews and 11 protocols (reviews in progress) in The Cochrane Library 2009, issue 3, released on July 8, 2009. It is the policy of The Cochrane Collaboration to update reviews every two years and to withdraw them if they are out of date. Review teams are currently updating a number of reviews that we expect to be published over the next few months. The year 2008 was a busy and exciting one. The Cochrane Collaboration released an update of the Handbook for Systematic Reviews of Interventions2 and Review Manager 5, the software used for producing reviews (March 2008), and the CBRG Editorial Board finished their “Updated Methods for Systematic Review in the Cochrane Back Review Group.”3 There are several new features in the handbook, the updated guidelines, and the software that have been developed to make our reviews more transparent and user friendly. It is recognized that differences in the design and conduct of individual studies can affect the validity (risk of over- or underestimation of the true intervention effect) and rigour of the findings and final conclusion of a systematic review. Assessing the risk of bias (internal validity—the confidence with which we can “believe” the results) of included studies is an integral step in systematic reviews. For over a decade, the CBRG has recommended the use of 11 criteria to assess the risk of bias in primary studies. The new Cochrane Handbook2 recommends one that has not previously been considered, bringing the currently recommended number to 12. The 12 criteria assess sequence generation, allocation concealment, blinding of study participants, completeness and similarity of outcome reporting, similarity of important characteristics at baseline, compliance and co-interventions. Other risks of bias can be added as indicated by the intervention and the outcome. Because of the high risk of bias and the heterogeneity of important components in many trials in this field, the CBRG used Levels of Evidence to help synthesis the results, first used in the 1994 Guidelines for the Management of Acute Low-Back Pain in Adults.2 Following a new approach introduced in the updated Cochrane Handbook,3 the Updated Method Guidelines now recommend that the overall quality of the evidence for each outcome be assessed using an adapted GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.4 More than 20 other organizations, including the World Health Organization (WHO), the American College of Physicians, and the Canadian Agency for Drugs and Technology in Health (CADTH), have adopted the GRADE approach.5 Five domains are considered in assessing the quality of the evidence: (1) limitations of the study design; (2) inconsistency, (3) indirectness (inability to generalize), and (4) imprecision (insufficient or imprecise data) of results; and (5) publication bias across all studies that measure that particular outcome. The quality starts at “high” when at least 75% of RCTs with a low risk of bias provide consistent, direct, generalizable results for the outcome, and is reduced by one level for each of the domains not met. The CBRG has found that if more than six criteria are met and there are no serious threats to the internal validity of the study (e.g., >50% of participants lost to follow-up), a study can be assessed as having a low risk of bias.6 Cochrane reviews are intended to help people make well-informed decisions about health care research. Drawing conclusions about the practical usefulness of an intervention entails making trade-offs, either implicitly or explicitly, between the estimated benefits, harms, and costs. However, making specific recommendations for an action goes beyond a systematic review and requires additional information and informed judgements, which are typically the domain of clinical practice guideline developers. The CBRG welcomes both consumers and experienced authors and referees to the group. We invite you to join online (http://www.cochrane.iwh.on.ca) to receive periodic newsletters that will keep you abreast of initiatives in The Cochrane Collaboration in general and the Cochrane Back Review Group in particular.

More than two-thirds of pregnant women experience low-back pain (LBP) and almost one-fifth experience pelvic pain. Pain increases with advancing pregnancy and interferes with work, daily activities and sleep.To assess the effects of interventions for preventing and treating pelvic and back pain in pregnancy.We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 July 2012), identified related studies and reviews from the Cochrane Back Review Group search strategy to July 2012, and checked reference lists from identified reviews and studies.Randomised controlled trials (RCTs) of any treatment to prevent or reduce the incidence or severity of pelvic or back pain in pregnancy.Two review authors independently assessed risk of bias and extracted data. Quality of the evidence for outcomes was assessed using the five criteria outlined by the GRADE Working Group.We included 26 randomised trials examining 4093 pregnant women in this updated review. Eleven trials examined LBP (N = 1312), four examined pelvic pain (N = 661), and 11 trials examined lumbo-pelvic (LBP and pelvic) pain (N = 2120). Diagnoses ranged from self-reported symptoms to the results of specific tests. All interventions were added to usual prenatal care and unless noted, were compared to usual prenatal care. For LBP, there was low-quality evidence that in general, the addition of exercise significantly reduced pain (standardised mean difference (SMD) -0.80; 95% confidence interval (CI) -1.07 to -0.53; six RCTs, N = 543), and disability (SMD -0.56; 95% CI -0.89 to -0.23; two RCTs, N = 146); and water-based exercise significantly reduced LBP-related sick leave (risk ratio (RR) 0.40; 95% CI 0.17 to 0.92; one RCT, N = 241). Low-quality evidence from single trials suggested no significant difference in pain or function between two types of pelvic support belt, between osteopathic manipulation (OMT) and usual care or sham ultrasound (sham US). Very low-quality evidence suggested that a specially-designed pillow may relieve night pain better than a regular pillow. For pelvic pain, there was moderate-quality evidence that acupuncture significantly reduced evening pain better than exercise; both were better than usual care. Low-quality evidence from single trials suggested that adding a rigid belt to exercise improved average pain but not function; acupuncture was significantly better than sham acupuncture for improving evening pain and function, but not average pain; and evening pain relief was the same following either deep or superficial acupuncture. For lumbo-pelvic pain, there was moderate-quality evidence that an eight- to 20-week exercise program reduced the risk of women reporting lumbo-pelvic pain (RR 0.85; 95% CI 0.73 to 1.00; four RCTs, N = 1344); but a 16- to 20-week training program was no more successful than usual care at preventing pelvic pain (one RCT, N = 257). Low-quality evidence suggested that exercise significantly reduced lumbo-pelvic-related sick leave (RR 0.76; 95% CI 0.62 to 0.94, two RCTs, N = 1062), and improved function. Low-quality evidence from single trials suggested that OMT significantly reduced pain and improved function; either a multi-modal intervention that included manual therapy, exercise and education (MOM) or usual care significantly reduced disability, but only MOM improved pain and physical function; acupuncture improved pain and function more than usual care or physiotherapy; pain and function improved more when acupuncture was started at 26- rather than 20- weeks' gestation; and auricular (ear) acupuncture significantly improved these outcomes more than sham acupuncture.When reported, adverse events were minor and transient.Moderate-quality evidence suggested that acupuncture or exercise, tailored to the stage of pregnancy, significantly reduced evening pelvic pain or lumbo-pelvic pain more than usual care alone, acupuncture was significantly more effective than exercise for reducing evening pelvic pain, and a 16- to 20-week training program was no more successful than usual prenatal care at preventing pelvic or LBP. Low-quality evidence suggested that exercise significantly reduced pain and disability from LBP.There was low-quality evidence from single trials for other outcomes because of high risk of bias and sparse data; clinical heterogeneity precluded pooling. Publication bias and selective reporting cannot be ruled out.Physiotherapy, OMT, acupuncture, a multi-modal intervention, or the addition of a rigid pelvic belt to exercise seemed to relieve pelvic or back pain more than usual care alone. Acupuncture was more effective than physiotherapy at relieving evening lumbo-pelvic pain and disability and improving pain and function when it was started at 26- rather than 20-weeks' gestation, although the effects were small.There was no significant difference in LBP and function for different support belts, exercise, neuro emotional technique or spinal manipulation (SMT), or in evening pelvic pain between deep and superficial acupuncture.Very low-quality evidence suggested a specially-designed pillow may reduce night-time LBP.Further research is very likely to have an important impact on our confidence in the estimates of effect and is likely to change the estimates. Future research would benefit from the introduction of an agreed classification system that can be used to categorise women according to presenting symptoms.

To evaluate the ability of a systematic educational intervention strategy to change the plain radiography ordering behavior of chiropractors toward evidence-based practice for patients with acute low back pain (LBP).A quasi-experimental method was used comparing outcomes before and after the intervention with those of a control community.Two communities in southern Ontario.Mailed survey data on the management of acute LBP. Outcome Measures Plain radiography use rates for acute LBP based on responses to mailed surveys.Following the intervention, there was a 42% reduction in the self-report need for plain radiography for uncomplicated acute LBP (P.025) and a 50% reduction for patients with acute LBP1 month (P.025) in the intervention community. There was no significant change in the self-report need for plain radiography in the control community (P.05).The educational intervention strategy used in this study appeared to have an effect in reducing the perceived need for plain radiography in acute LBP.

Background Lumbar spinal stenosis with neurogenic claudication is one of the most commonly diagnosed and treated pathological spinal conditions. It frequently afflicts the elderly population. Objectives To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication. Search methods CENTRAL, MEDLINE, CINAHL, and Index to Chiropractic Literature (ICL) databases were searched up to June 2012. Selection criteria Randomized controlled trials published in English, in which at least one arm provided data on nonoperative treatments Data collection and analysis We used the standard methodological procedures expected by The Cochrane Collaboration. Risk of bias in each study was independently assessed by two review authors using the 12 criteria recommended by the Cochrane Back Review Group (Furlan 2009). Dichotomous outcomes were expressed as relative risk, continuous outcomes as mean difference or standardized mean difference; uncertainty was expressed with 95% confidence intervals. If possible a meta-analysis was performed, otherwise results were described qualitatively. GRADE was used to assess the quality of the evidence. Main results From the 8635 citations screened, 56 full-text articles were assessed and 21 trials (1851 participants) were included. There was very low-quality evidence from six trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome assessed. From single small trials, there was low-quality evidence for prostaglandins, and very low-quality evidence for gabapentin or methylcobalamin that they improved walking distance. There was very low-quality evidence from a single trial that epidural steroid injections improved pain, function, and quality of life, up to two weeks, compared with home exercise or inpatient physical therapy. There was low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There was low and very low-quality evidence from six trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion. A meta-analysis of two trials comparing direct decompression with or without fusion to multimodal nonoperative care found no significant difference in function at six months (mean difference (MD) -3.66, 95% CI -10.12 to 2.80) and one year (MD -6.18, 95% CI -15.03 to 2.66), but at 24 months a significant difference was found favouring decompression (MD -4.43, 95% CI -7.91 to -0.96). Authors' conclusions Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

Background More than two-thirds of pregnant women experience low-back pain (LBP) and almost one-fifth experience pelvic pain. Pain increases with advancing pregnancy and interferes with work, daily activities and sleep. Objectives To assess the effects of interventions for preventing and treating pelvic and back pain in pregnancy. Search methods We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 July 2012), identified related studies and reviews from the Cochrane Back Review Group search strategy to July 2012, and checked reference lists from identified reviews and studies. Selection criteria Randomised controlled trials (RCTs) of any treatment to prevent or reduce the incidence or severity of pelvic or back pain in pregnancy. Data collection and analysis Two review authors independently assessed risk of bias and extracted data. Quality of the evidence for outcomes was assessed using the five criteria outlined by the GRADE Working Group. Main results We included 26 randomised trials examining 4093 pregnant women in this updated review. Eleven trials examined LBP (N = 1312), four examined pelvic pain (N = 661), and 11 trials examined lumbo-pelvic (LBP and pelvic) pain (N = 2120). Diagnoses ranged from self-reported symptoms to the results of specific tests. All interventions were added to usual prenatal care and unless noted, were compared to usual prenatal care. For LBP, there was low-quality evidence that in general, the addition of exercise significantly reduced pain (standardised mean difference (SMD) -0.80; 95% confidence interval (CI) -1.07 to -0.53; six RCTs, N = 543), and disability (SMD -0.56; 95% CI -0.89 to -0.23; two RCTs, N = 146); and water-based exercise significantly reduced LBP-related sick leave (risk ratio (RR) 0.40; 95% CI 0.17 to 0.92; one RCT, N = 241). Low-quality evidence from single trials suggested no significant difference in pain or function between two types of pelvic support belt, between osteopathic manipulation (OMT) and usual care or sham ultrasound (sham US). Very low-quality evidence suggested that a specially-designed pillow may relieve night pain better than a regular pillow. For pelvic pain, there was moderate-quality evidence that acupuncture significantly reduced evening pain better than exercise; both were better than usual care. Low-quality evidence from single trials suggested that adding a rigid belt to exercise improved average pain but not function; acupuncture was significantly better than sham acupuncture for improving evening pain and function, but not average pain; and evening pain relief was the same following either deep or superficial acupuncture. For lumbo-pelvic pain, there was moderate-quality evidence that an eight- to 20-week exercise program reduced the risk of women reporting lumbo-pelvic pain (RR 0.85; 95% CI 0.73 to 1.00; four RCTs, N = 1344); but a 16- to 20-week training program was no more successful than usual care at preventing pelvic pain (one RCT, N = 257). Low-quality evidence suggested that exercise significantly reduced lumbo-pelvic-related sick leave (RR 0.76; 95% CI 0.62 to 0.94, two RCTs, N = 1062), and improved function. Low-quality evidence from single trials suggested that OMT significantly reduced pain and improved function; either a multi-modal intervention that included manual therapy, exercise and education (MOM) or usual care significantly reduced disability, but only MOM improved pain and physical function; acupuncture improved pain and function more than usual care or physiotherapy; pain and function improved more when acupuncture was started at 26- rather than 20- weeks' gestation; and auricular (ear) acupuncture significantly improved these outcomes more than sham acupuncture. When reported, adverse events were minor and transient. Authors' conclusions Moderate-quality evidence suggested that acupuncture or exercise, tailored to the stage of pregnancy, significantly reduced evening pelvic pain or lumbo-pelvic pain more than usual care alone, acupuncture was significantly more effective than exercise for reducing evening pelvic pain, and a 16- to 20-week training program was no more successful than usual prenatal care at preventing pelvic or LBP. Low-quality evidence suggested that exercise significantly reduced pain and disability from LBP. There was low-quality evidence from single trials for other outcomes because of high risk of bias and sparse data; clinical heterogeneity precluded pooling. Publication bias and selective reporting cannot be ruled out. Physiotherapy, OMT, acupuncture, a multi-modal intervention, or the addition of a rigid pelvic belt to exercise seemed to relieve pelvic or back pain more than usual care alone. Acupuncture was more effective than physiotherapy at relieving evening lumbo-pelvic pain and disability and improving pain and function when it was started at 26- rather than 20-weeks' gestation, although the effects were small. There was no significant difference in LBP and function for different support belts, exercise, neuro emotional technique or spinal manipulation (SMT), or in evening pelvic pain between deep and superficial acupuncture. Very low-quality evidence suggested a specially-designed pillow may reduce night-time LBP. Further research is very likely to have an important impact on our confidence in the estimates of effect and is likely to change the estimates. Future research would benefit from the introduction of an agreed classification system that can be used to categorise women according to presenting symptoms.

Objective This study describes instruction provided at chiropractic schools worldwide on the use of spine radiography and compares instruction with evidence-based guidelines for low back pain. Methods Individuals responsible for radiology instruction at accredited chiropractic schools throughout the world were contacted and invited to participate in a Web-based survey. The survey included questions on the role of conventional radiography in chiropractic practice and instruction given to students for its use in patients with acute low back pain. Results Of the 33 chiropractic schools identified worldwide, 32 (97%) participated in the survey. Consistent with the guidelines, 25 (78%) respondents disagreed that “routine radiography should be used prior to spinal manipulative therapy,” 29 (91%) disagreed that there “was a role for full spine radiography for assessing patients with low back pain,” and 29 (91%) disagreed that “oblique views should be part of a standard radiographic series for low back pain.” However, only 14 (44%) respondents concurred with the guidelines and disagreed with the statement that there “is a role for radiography in acute low back pain in the absence of ‘red flags’ for serious disease.” Conclusions This survey suggests that many aspects of radiology instruction provided by accredited chiropractic schools appear to be evidence based. However, there appears to be a disparity between some schools and existing evidence with respect to the role of radiography for patients with acute low back pain without “red flags” for serious disease. This may contribute to chiropractic overutilization of radiography for low back pain.

Background Low-back pain (LBP) and related disabilities are major public health problems and a major cause of medical expenses, absenteeism and disablement. Low level laser therapy (LLLT) can be used as a therapeutic intervention for musculoskeletal disorders such as back pain. Objectives To assess the effects of LLLT in patients with non-specific low-back pain and to explore the most effective method of administering LLLT for this disorder. Search strategy We searched CENTRAL (The Cochrane Library 2005, Issue 2), MEDLINE and CINAHL from their start to January 2007 and EMBASE, AMED and PEDro from their start to 2005 with no language restrictions. We screened references in the included studies and in reviews of the literature and conducted citation tracking of identified RCTs and reviews using Science Citation Index. We also contacted content experts. Selection criteria Only randomised controlled clinical trials (RCTs) investigating low level laser therapy as a light source treatment for non-specific low-back pain were included. Data collection and analysis Two authors independently assessed methodological quality using the criteria recommended by the Cochrane Back Review Group and extracted data. Consensus was used to resolve disagreements. Clinically and statistically homogeneous studies were pooled using the fixed-effect model; clinically homogeneous and statistically heterogeneous studies were pooled using the random-effects model. Main results Six RCTs with reasonable quality were included in the review. All of them were published in English. Because of clinical heterogeneity in study populations, interventions used and reported outcomes, meta-analysis was not possible to determine an overall effect for pain, disability and range of motion. Three studies (n=168) separately showed a significant pain relief effect of LLLT compared to sham therapy for sub-acute and chronic low-back pain. These effects were only observed at short-term and intermediate-term follow-ups. Long-term follow-ups were not reported. There was insufficient evidence to investigate the difference between LLLT and comparison groups for pain-related disability. There is insufficient evidence to determine the effectiveness of LLLT on anterior-posterior lumbar range of motion compared to control group in short-term follow-up. The relapse rate in the LLLT group was significantly lower than in the control group at six months follow-up period according to the findings of two trials. One study (n=50) reported a significant improvement in pain in LLLT group versus exercise therapy. Authors' conclusions No side effects were reported. However, we conclude that there are insufficient data to draw firm conclusions. There is a need for further methodologically rigorous RCTs to evaluate the effects of LLLT compared to other treatments, different lengths of treatment, different wavelengths and different dosages. Comparison of different LLLT treatments will be more reasonable if dose calculation methods are harmonized.

Background and Objective To describe challenges when extracting and presenting relevant, consistent, and accessible information from systematic reviews. Materials and Methods We systematically selected comparisons and outcomes from 18 Cochrane reviews, evaluated the quality of evidence for each outcome using the GRADE system, and developed standardized patient information. We evaluated the information using patient, review author, researcher, and clinician feedback. Results Challenges included large numbers of comparisons and outcomes; missing information about treatments and adverse effects; and variations in how effect was measured and presented. By selecting comparisons and outcomes based on patient-relevance, quality, and nonredundancy, we halved the number of outcomes. We prepared information about treatments and adverse effects using other sources. We framed outcomes consistently and standardized the presentation of magnitude of effect. Conclusions The incorporation of summary of findings tables in reviews could address these challenges. Problems could also be reduced if review groups agreed upon standard outcomes; excluded less relevant outcomes; incorporated more information about interventions and adverse effects; and implemented clearer guidelines for the presentation of results.

STUDY DESIGN: Systematic review of clinical guidelines. OBJECTIVES: To assess the methodologic quality of existing guidelines for the management of acute low back pain. SUMMARY OF BACKGROUND DATA: Guidelines are playing an increasingly important role in evidence-based practice. After publication of the Quebec Task Force in Canada in 1987 and the Agency for Health Care Policy and Research guidelines in the United States in 1994, guidelines for acute low back pain were developed in many other countries. However, little is known about the methodologic quality of these guidelines. METHODS: Guidelines were selected by electronically searching MEDLINE and the Internet and through personal communication with experts in the field of low back pain research in primary care. The methodologic quality of the guidelines was assessed by two authors independently using the AGREE instrument. RESULTS: A total of 17 guidelines were included. Overall, the quality of reporting of guidelines was disappointing. Most guidelines clearly described the aim of the guideline and its target population, and most guideline development committees were multiprofessional. However, many other methodologic flaws were identified. More than half of the guidelines did not take patients' preferences into account, did not perform a pilot test among target users, did not clearly describe the methods of study identification and selection, did not include an external review, did not provide a procedure for updating, were not supported with tools for application, did not consider potential organizational barriers and cost implications, did not provide criteria for monitoring and audit, did not include recommendations for implementation strategies, and did not adequately record editorial independence and conflict of interest of the members. The diagnostic and therapeutic recommendations of the guidelines were largely similar. CONCLUSIONS: The quality and transparency of the development process and the consistency in the reporting of primary care guidelines for low back pain need to be improved.