The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review.

Wertli MM et al 

Spine J. May 2014

Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP).

The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP.

The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP), researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive.

Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.

Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature.

Seffinger MA et al Spine Oct 2004

To determine the quality of the research and assess the interexaminer and intraexaminer reliability of spinal palpatory diagnostic procedures.

Conflicting data have been reported over the past 35 years regarding the reliability of spinal palpatory tests.

The authors used 13 electronic databases and manually searched the literature from January 1, 1966 to October 1, 2001. Forty-nine (6%) of 797 primary research articles met the inclusion criteria. Two blinded, independent reviewers scored each article. Consensus or a content expert reconciled discrepancies.

A higher percentage of the pain provocation studies (64%) demonstrated acceptable reliability, followed by motion studies (58%), landmark (33%), and soft tissue studies (0%). Regional range of motion is more reliable than segmental range of motion, and intraexaminer reliability is better than interexaminer reliability. Overall, examiners’ discipline, experience level, consensus on procedure used, training just before the study, or use of symptomatic subjects do not improve reliability.

The quality of the research on intra reliability and intra reliability of spinal palpatory diagnostic procedures needs to be improved. Pain provocation tests are most reliable. Soft tissue paraspinal palpatory diagnostic tests are not reliable.

Braces and orthoses for treating osteoarthritis of the knee.

Cochrane Database Syst Rev. 2015 Mar 16;(3)

Duivenvoorden T, Brouwer RW, et al

Individuals with osteoarthritis (OA) of the knee can be treated with a knee brace or a foot/ankle orthosis. The main purpose of these aids is to reduce pain, improve physical function and, possibly, slow disease progression. This is the second update of the original review published in Issue 1, 2005, and first updated in 2007.

To assess the benefits and harms of braces and foot/ankle orthoses in the treatment of patients with OA of the knee.

Evidence was inconclusive for the benefits of bracing for pain, stiffness, function and quality of life in the treatment of patients with knee OA. On the basis of one laterally wedged insole versus no treatment study, we conclude that evidence of an effect on pain in patients with varus knee OA is lacking. Moderate-quality evidence shows lack of an effect on improvement in pain, stiffness and function between patients treated with a laterally wedged insole and those treated with a neutral insole. Low-quality evidence shows lack of an effect on improvement in pain, stiffness and function between patients treated with a valgus knee brace and those treated with a laterally wedged insole. The optimal choice for an orthosis remains unclear, and long-term implications are lacking.

Note: It’s interesting how committed we can be to certain ‘ideas, concepts and procedures’ when in fact there is (and perhaps never was) any real scientific backing for them(?)….

Quality of life in preoperative patients with sacroiliac joint dysfunction is at least as depressed as in other lumbar spinal conditions.

Cher DJ Reckling WC Med devices (Auckland) Dec 2015

Pain from the sacroiliac joint (SIJ) is an under-recognized cause of low back pain. The degree to which SIJ pain decreases quality of life has not been directly compared to other more familiar conditions of the lumbar spine.

Multivariate regression analysis of individual patient data from two prospective multicenter clinical trials of SIJ fusion and three prospective multicenter clinical trials of surgical treatments for degenerative lumbar spine conditions.

Controlling for baseline demographic parameters as well as a validated disability score, quality of life scores (EuroQOL 5-D and SF-36) were, in most cases, lower in the SIJ cohorts compared to the three other spine surgery cohorts.

Patients with SIJ dysfunction considering surgery have decrements in quality of life as or more severe compared to patients with degenerative spondylolisthesis, spinal stenosis, and intervertebral disc herniation.

What Are Long-term Predictors of Outcomes for Lumbar Disc Herniation? A Randomized and Observational Study.

Kerr D1, Zhao W, Lurie JD. Clin ortho res 2014

Although previous studies have illustrated improvements in surgical cohorts for patients with disc herniation, there are limited data on long-term outcomes comparing surgical and nonsurgical outcomes.

Patients with symptomatic lumbar radiculopathy for at least 6 weeks associated with nerve root irritation or neurologic deficit on examination and a confirmed disc herniation.Those who declined randomization entered the observational cohort group based on treatment preference but were otherwise treated and followed identically to the randomized cohort. Of those in the randomized cohort, 309 of 501 (62%) provided 8-year data and in the observational group 469 of 743 (63%). Patients were treated with either surgical discectomy or usual nonoperative care. By 8 years, only 148 of 245 (60%) of those randomized to surgery had undergone surgery, whereas 122 of 256 (48%) of those randomized to nonoperative treatment had undergone surgery.

The intent-to-treat analysis of the randomized cohort at 8 years showed no difference between surgical and nonoperative treatment for the primary outcome measures. Secondary outcome measures of sciatica bothersomeness, leg pain, satisfaction with symptoms, and self-rated improvement showed greater improvement in the group randomized to surgery despite high levels of crossover. The as-treated analysis of the combined randomized and observational cohorts, adjusted for potential confounders, showed advantages for surgery for all primary outcome measures; however, this has the potential for confounding from other unrecognized variables. Smokers and patients with depression or comorbid joint problems had worse functional outcomes overall (with surgery and nonoperative care) but similar surgical treatment effects. Patients with sequestered fragments, symptom duration greater than 6 months, those with higher levels of low back pain, or who were neither working nor disabled at baseline showed greater surgical treatment effects.

The intent-to-treat analysis showed no difference over 8 years for primary outcomes of overall pain & physical function….sequestered fragments, higher levels of baseline back pain with radiculopathy, a longer duration of symptoms, and those who were neither working nor disabled at baseline with a greater relative advantage from surgery at 8 years.

Surgical vs Conservative treatment for lumbar disc herniation: a prospective cohort study.

BMJ Dec 2016
Gugliotta M. et al

Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation.

Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy were more likely to report ≥50% decrease in back pain and reported less physical function disability at 52 weeks.The other assessments showed minimal between-groups.

Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term outcomes.

Complementary Medicine

Selling falsehoods? A cross-sectional study of Canadian naturopathy, homeopathy, chiropractic and acupuncture clinic website claims relating to allergy and asthma  

Blake Murdoch, Stuart Carr


Objective To identify the frequency and qualitative characteristics of marketing claims made by Canadian chiropractors, naturopaths, homeopaths and acupuncturists relating to the diagnosis and treatment of allergy and asthma.

Setting Canada.

Data set 392 chiropractic, naturopathic, homeopathic and acupuncture clinic websites located in 10 of the largest metropolitan areas in Canada, as identified using 400 Google search results. Duplicates were not excluded from data analysis.

Results Naturopath clinic websites have the highest rates of advertising at least one of diagnosis, treatment or efficacy for allergy or sensitivity (85%) and asthma (64%), followed by acupuncturists (68% and 53%, respectively), homeopaths (60% and 54%) and chiropractors (33% and 38%). Search results from Vancouver, British Columbia were most likely to advertise at least one of diagnosis, treatment or efficacy for allergy or sensitivity (72.5%) and asthma (62.5%), and results from London, Ontario were least likely (50% and 40%, respectively). Of the interventions advertised, few are scientifically supported; the majority lack evidence of efficacy, and some are potentially harmful.


The majority of alternative healthcare clinics studied advertised interventions for allergy and asthma. Many offerings are unproven. A policy response may be warranted in order to safeguard the public interest.

Cranberries to prevent UTI: The evidence doesn’t support it.

Cranberries (usually as cranberry juice) have been ‘tried’ for years to prevent urinary tract infections (UTIs). Cranberries contain a substance that can prevent bacteria from sticking on the walls of the bladder. This may help prevent bladder and other UTIs. A systematic review identified 24 studies (4473 participants) comparing cranberry products with control or alternative treatments. There was a small trend towards fewer UTIs in people taking cranberry product compared to placebo or no treatment but this was not a significant finding. Many people in the studies stopped drinking the juice, suggesting it may not be an acceptable intervention. Cranberry juice does not appear to have a significant benefit in preventing UTIs and may be unacceptable to consume in the long term. Cranberry products (such as tablets or capsules) were also ineffective (although had the same effect as taking antibiotics), possibly due to lack of potency of the ‘active ingredient’.

Chiropractic or osteopathic manipulation for children in the United States: an analysis of data from the 2007 National Health Interview Survey.

Ndetan H Evans MW Jr, Hawk C, Walker C.
J Comp Med Dec. 2012

The aim of this study was to describe use of chiropractic and/or osteopathic manipulation by children in the United States along with the specific health conditions for which they sought care.

National estimates indicated that 2.3 million children (2.3%) in the United States had used Complementary procedures in 2007. SMT was the most common complementary and alternative medicine procedure. Children aged 12-18 years were more likely to have seen these providers than were younger age groups.
The most common complaints were back and neck pain. Other conditions for which children were seen included other musculoskeletal conditions, sinusitis, allergies, and non-migraine headaches.

Chiropractic or osteopathic manipulation is primarily used for back and neck pain, which is increasing in prevalence in children. Teens are more likely to use it than are younger children.

Association of sugary beverages with survival among patients with cancers of the upper aerodigestive tract.

Cancer causes cont Nov. 2016

Miles FL et al

The role of consumption of added sugars in cancers of the upper aerodigestive tract (UADT) is unclear. We examined associations between sugary beverages and susceptibility to UADT cancer as well as overall survival among UADT cancer patients.

A positive association was observed with consumption of grams of sugar from beverages, including soft drinks and fruit juices, and poorer survival among UADT cancer cases. Particularly, high consumption of sugary beverages was associated with poorer survival among esophageal cancer cases.

These findings suggest that consumption of sugary beverages may decrease survival associated with UADT cancers. Additional studies should be conducted to examine survival among cancer patients consuming high amounts of added or refined sugars. Such studies may highlight prognostic factors for UADT cancers.