Adverse Events and Manipulation

1. J Man Manip Ther. 2015 Jul;23(3):154-61. Safety of thrust joint manipulation in the thoracic spine: a systematic review. Puentedura EJ(1), O'Grady WH(1). Author information: (1)University of Nevada Las Vegas, School of Allied Health Sciences, Department of Physical Therapy, Las Vegas, NV, USA. BACKGROUND: There appears to be very little in the research literature on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine. PURPOSE: To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine. DATA SOURCES: Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015. STUDY SELECTION: Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015; (3) provided case reports or case series; and (4) had TJM as an intervention. Articles were excluded if: (1) the AE occurred without TJM (e.g. spontaneous); (2) the article was a systematic or literature review; or (3) it was written in a language other than English or Spanish. DATA EXTRACTION: Data extracted from each case report included: gender; age; who performed the TJM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the TJM; as well as type of severe AE that resulted. RESULTS: Ten cases, reported in 7 case reports, were reviewed. Cases involved females (8) more than males (2), with mean age being 43.5 years (SD=18.73, Range = 17 -71). The most frequent AE reported was injury (mechanical or vascular) to the spinal cord (7/10), with pneumothorax and hematothorax (2/10) and CSF leak secondary to dural sleeve injury (1/10). LIMITATIONS: There were only a small number of case reports published in the literature and there may have been discrepancies between what was reported and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the TJM, published the cases. CONCLUSIONS: Serious AE do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax. This suggests that excessive peak forces may have been applied to thoracic spine, and it should serve as a cautionary note for clinicians to decrease these peak forces. PMCID: PMC4534851 [Available on 2016-07-01] PMID: 26309386 [PubMed]

2. Clin Rehabil. 2016 Feb;30(2):145-55. doi: 10.1177/0269215515570382. Epub 2015 Feb 13. Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta-analysis. Zhu L(1), Wei X(2), Wang S(3). Author information: (1)Department of Spine, Wangjing Hospital, Beijing, People's Republic of China. (2)Department of Scientific Research, Wangjing Hospital, Beijing, People's Republic of China weixu.007@163.com. (3)Department of General Orthopedics, Wangjing Hospital, Beijing, People's Republic of China. OBJECTIVE: To access the effectiveness and safety of cervical spine manipulation for cervical radiculopathy. DATA SOURCES: PubMed, the Cochrane Central Registry of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Wanfang data, the website of Chinese clinical trial registry and international clinical trial registry by US National Institutes of Health. REVIEW METHODS: Randomized controlled trials that investigated the effects of cervical manipulation compared with no treatment, placebo or conventional therapies on pain measurement in patients with degenerative cervical radiculopathy were searched. Two authors independently evaluated the quality of the trials according to the risk of bias assessment provided by the PEDro (physiotherapy evidence database) scale. RevMan V.5.2.0 software was employed for data analysis. The GRADE approach was used to evaluate the overall quality of the evidence. RESULTS: Three trials with 502 participants were included. Meta-analysis suggested that cervical spine manipulation (mean difference 1.28, 95% confidence interval 0.80 to 1.75; P < 0.00001; heterogeneity: Chi(2) = 8.57, P = 0.01, I(2) = 77%) improving visual analogue scale for pain showed superior immediate effects compared with cervical computer traction. The overall strength of evidence was judged to be moderate quality. One out of three trials reported the adverse events and none with a small sample size. CONCLUSION: There was moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy. The safety of cervical manipulation cannot be taken as an exact conclusion so far. © The Author(s) 2015. PMID: 25681406 [PubMed - in process] 3. Evid Based Complement Alternat Med. 2014;2014:480956. doi: 10.1155/2014/480956. Epub 2014 Aug 12.

Adverse events of massage therapy in pain-related conditions: a systematic review. Yin P(1), Gao N(2), Wu J(1), Litscher G(3), Xu S(1). Author information: (1)Acupuncture Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai 200071, China. (2)Traumatology Department, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China. (3)Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and TCM Research Center Graz, Medical University of Graz, 8036 Graz, Austria. Pain-related massage, important in traditional Eastern medicine, is increasingly used in the Western world. So the widening acceptance demands continual safety assessment. This review is an evaluation of the frequency and severity of adverse events (AEs) reported mainly for pain-related massage between 2003 and 2013. Relevant all-languages reports in 6 databases were identified and assessed by two coauthors. During the 11-year period, 40 reports of 138 AEs were associated with massage. Author, year of publication, country of occurrence, participant related (age, sex) or number of patients affected, the details of manual therapy, and clinician type were extracted. Disc herniation, soft tissue trauma, neurologic compromise, spinal cord injury, dissection of the vertebral arteries, and others were the main complications of massage. Spinal manipulation in massage has repeatedly been associated with serious AEs especially. Clearly, massage therapies are not totally devoid of risks. But the incidence of such events is low. PMCID: PMC4145795 PMID: 25197310 [PubMed] 4. J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):677-91. doi: 10.1016/j.jmpt.2013.05.009. Epub 2013 Jun 17. Serious Adverse Events and Spinal Manipulative Therapy of the Low Back Region: A Systematic Review of Cases. Hebert JJ(1), Stomski NJ(2), French SD(3), Rubinstein SM(4). Author information: (1)Senior Lecturer, School of Psychology and Exercise Science, Murdoch University, Perth, Western Australia, Australia. Electronic address: j.hebert@murdoch.edu.au. (2)Postdoctoral Researcher, School of Health Professions, Murdoch University, Perth, Western Australia, Australia. (3)Adjunct Senior Lecturer, School of Health Professions, Murdoch University, Perth, Western Australia, Australia; Senior Research Fellow, Melbourne School of Health Sciences, The University of Melbourne, Carlton, Victoria, Australia. (4)Senior Researcher, Department of Epidemiology and Biostatistics, EMGO+ Institute for

Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands. OBJECTIVE: The purpose of this study was to systematically search the literature for studies reporting serious adverse events following lumbopelvic spinal manipulative therapy (SMT) and to describe the case details. METHODS: A systematic search was conducted in PubMed including MEDLINE, EMBASE, CINAHL, and The Cochrane Library up to January 12, 2012, by an experienced reference librarian. Study selection was performed by 2 independent reviewers using predefined criteria. We included cases involving individuals 18 years or older who experienced a serious adverse event following SMT applied to the lumbar spine or pelvis by any type of provider (eg, chiropractic, medical, physical therapy, osteopathic, layperson). A serious adverse event was defined as an untoward occurrence that results in death or is life threatening, requires hospital admission, or results in significant or permanent disability. We included studies published in English, German, Dutch, and Swedish. RESULTS: A total of 2046 studies were screened, and 41 studies reporting on 77 cases were included. Important case details were frequently unreported, such as descriptions of SMT technique, the pre-SMT presentation of the patient, the specific details of the adverse event, time from SMT to the adverse event, factors contributing to the adverse event, and clinical outcome. Adverse events consisted of cauda equina syndrome (29 cases, 38% of total); lumbar disk herniation (23 cases, 30%); fracture (7 cases, 9%); hematoma or hemorrhagic cyst (6 cases, 8%); or other serious adverse events (12 cases, 16%) such as neurologic or vascular compromise, soft tissue trauma, muscle abscess formation, disrupted fracture healing, and esophageal rupture. CONCLUSIONS: This systematic review describes case details from published articles that describe serious adverse events that have been reported to occur following SMT of the lumbopelvic region. The anecdotal nature of these cases does not allow for causal inferences between SMT and the events identified in this review. Recommendations regarding future case reporting and research aimed at furthering the understanding of the safety profile of SMT are discussed. Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 23787298 [PubMed - in process] 5. PLoS One. 2013;8(3):e59170. doi: 10.1371/journal.pone.0059170. Epub 2013 Mar 20. The quality of reports on cervical arterial dissection following cervical spinal manipulation. Wynd S(1), Westaway M, Vohra S, Kawchuk G. Author information: (1)Texas Chiropractic College, Pasadena, Texas, United States of America. swynd@txchiro.edu Erratum in

PLoS One. 2015;10(6):e0130221. BACKGROUND: Cervical artery dissection (CAD) and stroke are serious harms that are sometimes associated with cervical spinal manipulation therapy (cSMT). Because of the relative rarity of these adverse events, studying them prospectively is challenging. As a result, systematic review of reports describing these events offers an important opportunity to better understand the relation between adverse events and cSMT. Of note, the quality of the case report literature in this area has not yet been assessed. PURPOSE: 1) To systematically collect and synthesize available reports of CAD that have been associated with cSMT in the literature and 2) assess the quality of these reports. METHODS: A systematic review of the literature was conducted using several databases. All clinical study designs involving CADs associated with cSMT were eligible for inclusion. Included studies were screened by two independent reviewers for the presence/absence of 11 factors considered to be important in understanding the relation between CAD and cSMT. RESULTS: Overall, 43 articles reported 901 cases of CAD and 707 incidents of stroke reported to be associated with cSMT. The most common type of stroke reported was ischemic stroke (92%). Time-to-onset of symptoms was reported most frequently (95%). No single case included all 11 factors. CONCLUSIONS: This study has demonstrated that the literature infrequently reports useful data toward understanding the association between cSMT, CADs and stroke. Improving the quality, completeness, and consistency of reporting adverse events may improve our understanding of this important relation. PMCID: PMC3604043 PMID: 23527121 [PubMed - indexed for MEDLINE] 6. Man Ther. 2010 Oct;15(5):434-44. doi: 10.1016/j.math.2010.02.006. Epub 2010 Mar 12. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Carlesso LC(1), Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Author information: (1)Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. carlesl@mcmaster.ca Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a

modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p < 0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p > .05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 20227325 [PubMed - indexed for MEDLINE] 7. Spine (Phila Pa 1976). 2009 May 15;34(11):E405-13. doi: 10.1097/BRS.0b013e3181a16d63. Safety of chiropractic interventions: a systematic review. Gouveia LO(1), Castanho P, Ferreira JJ. Author information: (1)Department of Neurology, Hospital de Santa Maria, Lisbon, Portugal. lilianafog@gmail.com Comment in Spine (Phila Pa 1976). 2010 Apr 1;35(7):840. Spine (Phila Pa 1976). 2009 Oct 15;34(22):2476; author reply 2476-7. Spine (Phila Pa 1976). 2009 Oct 15;34(22):2475-6; author reply 2476-7. Spine (Phila Pa 1976). 2010 Feb 15;35(4):467-8. STUDY DESIGN: Systematic review of reported adverse events. OBJECTIVE: To evaluate the tolerability and safety of chiropractic procedures. SUMMARY OF BACKGROUND DATA: Despite the increasing popularity of chiropractic, there are few properly designed prospective controlled trials, and there is a disproportionate lack of evaluation of its safety profile. The literature reports multiple neurologic complications of spinal manipulation, some of which are clinically relevant and even life threatening. METHODS: We performed an electronic search in 2 databases: Pubmed and the Cochrane Library for the years 1966 to 2007. All articles that reported adverse reactions associated with chiropractic were included irrespective of type of design. The outcome measures were the type of adverse events associated or attributed to chiropractic interventions and their frequency. RESULTS: A total of 376 potential relevant articles were identified, 330 of which were discarded after abstract or complete article analysis. The search identified 46 articles that included data concerning adverse events: 1 randomized controlled trial, 2 case-control studies, 7 prospective studies, 12 surveys, 3 retrospective studies, and 115 case reports. Most of the adverse events reported were benign and transitory, however, there are reports of complications that were life threatening, such as arterial dissection, myelopathy, vertebral disc extrusion,

and epidural hematoma. The frequency of adverse events varied between 33% and 60.9%, and the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations. CONCLUSION: There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue. PMID: 19444054 [PubMed - indexed for MEDLINE] 8. Pediatrics. 2007 Jan;119(1):e275-83. Epub 2006 Dec 18. Adverse events associated with pediatric spinal manipulation: a systematic review. Vohra S(1), Johnston BC, Cramer K, Humphreys K. Author information: (1)CARE Program, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada T6G 2E1. svohra@ualberta.ca Erratum in Pediatrics. 2007 Jul;120(1):251. Pediatrics. 2007 Apr;119(4):867. Comment in Pediatrics. 2007 Jun;119(6):1261-4; author reply 1266-7. Pediatrics. 2007 Jun;119(6):1265-6; author reply 1266-7. Pediatrics. 2007 Jun;119(6):1264-5; author reply 1266-7. BACKGROUND: Spinal manipulation is a noninvasive manual procedure applied to specific body tissues with therapeutic intent. Although spinal manipulation is commonly used in children, there is limited understanding of the pediatric risk estimates. OBJECTIVE: Our goal was to systematically identify and synthesize available data on adverse events associated with pediatric spinal manipulation. METHODS: A comprehensive search was performed of 8 major electronic databases (eg, Medline, AMED, MANTIS) from inception to June 2004 irrespective of language. Reports were included if they (1) were a primary investigation of spinal manipulation (eg, observation studies, controlled trials, surveys), (2) included a study population of children who were aged 18 years or younger, and (3) reported data on adverse events. Data were summarized to demonstrate the nature and severity of adverse events that may result rather than their incidence. RESULTS: Thirteen studies (2 randomized trials, 11 observational reports) were identified for inclusion. We identified 14 cases of direct adverse events involving neurologic or musculoskeletal events. Nine cases involved serious adverse events (eg, subarachnoidal hemorrhage, paraplegia), 2 involved moderately adverse events that required medical attention (eg, severe headache), and 3 involved minor adverse events (eg, midback soreness). Another 20 cases of indirect adverse events involved delayed diagnosis (eg, diabetes, neuroblastoma)

and/or inappropriate provision of spinal manipulation for serious medical conditions (ie, meningitis, rhabdomyosarcoma). CONCLUSIONS: Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric patients. PMID: 17178922 [PubMed - indexed for MEDLINE]

Adverse events and manual therapy 1. Evid Based Complement Alternat Med. 2014;2014:480956. doi: 10.1155/2014/480956. Epub 2014 Aug 12. Adverse events of massage therapy in pain-related conditions: a systematic review. Yin P(1), Gao N(2), Wu J(1), Litscher G(3), Xu S(1). Author information: (1)Acupuncture Department, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai 200071, China. (2)Traumatology Department, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China. (3)Research Unit for Complementary and Integrative Laser Medicine, Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, and TCM Research Center Graz, Medical University of Graz, 8036 Graz, Austria. Pain-related massage, important in traditional Eastern medicine, is increasingly used in the Western world. So the widening acceptance demands continual safety assessment. This review is an evaluation of the frequency and severity of adverse events (AEs) reported mainly for pain-related massage between 2003 and 2013. Relevant all-languages reports in 6 databases were identified and assessed by two coauthors. During the 11-year period, 40 reports of 138 AEs were associated with massage. Author, year of publication, country of occurrence, participant related (age, sex) or number of patients affected, the details of manual therapy, and clinician type were extracted. Disc herniation, soft tissue trauma, neurologic compromise, spinal cord injury, dissection of the vertebral arteries, and others were the main complications of massage. Spinal manipulation in massage has repeatedly been associated with serious AEs especially. Clearly, massage therapies are not totally devoid of risks. But the incidence of such events is low. PMCID: PMC4145795 PMID: 25197310 [PubMed] 2. Chiropr Osteopat. 2010 Jun 2;18:12. doi: 10.1186/1746-1340-18-12. Possible adverse events in children treated by manual therapy: a review. Humphreys BK(1). Author information: (1)Professor Chiropractic Medicine, University of Zürich and University Orthopedic Hospital Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland. kim.humphreys@balgrist.ch.

BACKGROUND: Pediatric manual therapy is controversial within the medical community particularly with respect to adverse events. Pediatric manual therapy (Ped MT) is commonly used by a number of professions such as chiropractors, osteopaths and naturopaths for a variety of treatments in children. Ped MT interventions range from advice, light touch, massage, through to mobilisation and high velocity spinal manipulation. However, current evidence related to adverse events associated with Ped MT is not well understood. OBJECTIVE: To update the clinical research literature from the 2007 report by Vohra, Johnston, Cramer and Humphreys on possible adverse events in children treated by spinal manipulation. METHODS: A review of the clinical research literature from June 2004 until January 2010 as reported in MEDLINE, PubMed and PubMed Central for adverse events specifically related to the treatment of pediatric cases by manual therapy. RESULTS: Only three new clinical studies, one systematic review with meta-analysis and one evidence report were identified. Two clinical studies reported on chiropractic care and one on osteopathic spinal manipulation in children. The systematic review investigated all studies of adverse events and manual therapy and was not specific for pediatric patients. The evidence review focused on effectiveness of spinal manipulation in a variety of musculoskeletal conditions. No serious or catastrophic adverse events were reported in the clinical studies or systematic review. However for adults, it has been estimated that between 0.003% and 0.13% of manual therapy treatments may result in a serious adverse event. Although mild to moderate adverse events are common in adults, an accurate estimate from high quality pediatric studies is currently not available. CONCLUSIONS: There is currently insufficient research evidence related to adverse events and manual therapy. However, clinical studies and systematic reviews from adult patients undergoing manual therapy, particularly spinal manipulation report that mild to moderate adverse events are common and self limiting. However serious adverse events are rare and much less than for medication commonly prescribed for these problems. More high quality research specifically addressing adverse events and pediatric manual therapy is needed. PMCID: PMC2890687 PMID: 20525194 [PubMed] 3. Man Ther. 2010 Oct;15(5):434-44. doi: 10.1016/j.math.2010.02.006. Epub 2010 Mar 12. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Carlesso LC(1), Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Author information: (1)Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. carlesl@mcmaster.ca Adverse events (AE) are a concern for practitioners utilizing cervical

manipulation or mobilization. While efficacious, these techniques are associated with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p < 0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p > .05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 20227325 [PubMed - indexed for MEDLINE] 4. Man Ther. 2010 Aug;15(4):355-63. doi: 10.1016/j.math.2009.12.006. Epub 2010 Jan 22. Adverse events and manual therapy: a systematic review. Carnes D(1), Mars TS, Mullinger B, Froud R, Underwood M. Author information: (1)Barts and The London School of Medicine and Dentistry, Centre for Health Sciences, 2 Newark St, London E1 2AT, UK. d.carnes@qmul.ac.uk OBJECTIVE: To explore the incidence and risk of adverse events with manual therapies. METHOD: The main health electronic databases, plus those specific to allied medicine and manual therapy, were searched. Our inclusion criteria were: manual therapies only; administered by regulated therapists; a clearly described intervention; adverse events reported. We performed a meta-analysis using incident estimates of proportions and random effects models. RESULTS: Eight prospective cohort studies and 31 manual therapy RCTs were accepted. The incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was approximately 41% (CI 95% 17-68%) in the cohort studies and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse events approximately 0.13%. The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham/passive/control interventions compared to manual therapy was similar, but for drug therapies greater (RR 0.05, CI 95% 0.01-0.20) and less with usual care (RR 1.91, CI 95% 1.39-2.64). CONCLUSIONS: The risk of major adverse events with manual therapy is low, but around half manual therapy patients may experience minor to moderate adverse

events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual care. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 20097115 [PubMed - indexed for MEDLINE]

CBT and chronic pain 1. Reumatol Clin. 2015 Oct 16. pii: S1699-258X(15)00110-2. doi: 10.1016/j.reuma.2015.06.001. [Epub ahead of print] "Clinical approach to fibromyalgia: Synthesis of Evidence-based recommendations, a systematic review". [Article in English, Spanish] Ángel García D(1), Martínez Nicolás I(2), Saturno Hernández PJ(2). Author information: (1)Instituto Nacional de Salud Pública de México, Cuernavaca, Morelos. Electronic address: daniel.angel@um.es. (2)Instituto Nacional de Salud Pública de México, Cuernavaca, Morelos. OBJECTIVES: Efforts have been made to standardise evidence-based practice, but clinical practice guidelines do not always follow strict development methods. The objective of this review is to identify the current guidelines, analyse the variability of its recommendations and make a synthesis for clinical practice. MATERIAL AND METHODS: A systematic review of clinical practice guidelines was made in electronic databases and guidelines databases; using "fibromyalgia" AND ["guideline" OR "Clinical Practice guideline"] as terms, from January for 2003 to July of 2013. Guidelines were selected according to the following criteria: a) aimed to fibromyalgia treatment in adults; b) based on scientific evidence, systematically searched; c) evidence levels and strength of recommendation included; d) written in English or Spanish. RESULTS: From 249 initial results, six guides fulfilled the inclusion criteria. Clinical practice guidelines analysed in this review show great variability both in the presence and level of evidence and in the strength of recommendation of many treatments. Physical exercise and cognitive-behavioural therapy are first-line treatments, showing high level of evidence. Amitriptyline, used for short periods of time for pain control, is the pharmacologic treatment with the most solid evidence. The multimodal approach reported better results than the isolated application of any treatment. CONCLUSIONS: Final recommendations in this review identify optimal treatments, facilitating the translation of evidence into practice and enabling more efficient and effective quality care. Copyright © 2014 Elsevier España, S.L.U. All rights reserved. PMID: 26481494 [PubMed - as supplied by publisher] 2. Cochrane Database Syst Rev. 2012 Nov 14;11:CD007407. doi: 10.1002/14651858.CD007407.pub3. Psychological therapies for the management of chronic pain (excluding headache) in adults.

Williams AC(1), Eccleston C, Morley S. Author information: (1)Research Department of Clinical, Educational & Health Psychology, University College London, London, UK. amanda.williams@ucl.ac.uk Update of Cochrane Database Syst Rev. 2009;(2):CD007407. BACKGROUND: Psychological treatments are designed to treat pain, distress and disability, and are in common practice. This review updates and extends the 2009 version of this systematic review. OBJECTIVES: To evaluate the effectiveness of psychological therapies for chronic pain (excluding headache) in adults, compared with treatment as usual, waiting list control, or placebo control, for pain, disability, mood and catastrophic thinking. SEARCH METHODS: We identified randomised controlled trials (RCTs) of psychological therapy by searching CENTRAL, MEDLINE, EMBASE and Psychlit from the beginning of each abstracting service until September 2011. We identified additional studies from the reference lists of retrieved papers and from discussion with investigators. SELECTION CRITERIA: Full publications of RCTs of psychological treatments compared with an active treatment, waiting list or treatment as usual. We excluded studies if the pain was primarily headache, or was associated with a malignant disease. We also excluded studies if the number of patients in any treatment arm was less than 20. DATA COLLECTION AND ANALYSIS: Forty-two studies met our criteria and 35 (4788 participants) provided data. Two authors rated all studies. We coded risk of bias as well as both the quality of the treatments and the methods using a scale designed for the purpose. We compared two main classes of treatment (cognitive behavioural therapy(CBT) and behaviour therapy) with two control conditions (treatment as usual; active control) at two assessment points (immediately following treatment and six months or more following treatment), giving eight comparisons. For each comparison, we assessed treatment effectiveness on four outcomes: pain, disability, mood and catastrophic thinking, giving a total of 32 possible analyses, of which there were data for 25. MAIN RESULTS: Overall there is an absence of evidence for behaviour therapy, except a small improvement in mood immediately following treatment when compared with an active control. CBT has small positive effects on disability and catastrophising, but not on pain or mood, when compared with active controls. CBT has small to moderate effects on pain, disability, mood and catastrophising immediately post-treatment when compared with treatment as usual/waiting list, but all except a small effect on mood had disappeared at follow-up. At present there are insufficient data on the quality or content of treatment to investigate their influence on outcome. The quality of the trial design has improved over time but the quality of treatments has not. AUTHORS' CONCLUSIONS: Benefits of CBT emerged almost entirely from comparisons with treatment as usual/waiting list, not with active controls. CBT but not behaviour therapy has weak effects in improving pain, but only immediately post-treatment and when compared with treatment as usual/waiting list. CBT but

not behaviour therapy has small effects on disability associated with chronic pain, with some maintenance at six months. CBT is effective in altering mood and catastrophising outcomes, when compared with treatment as usual/waiting list, with some evidence that this is maintained at six months. Behaviour therapy has no effects on mood, but showed an effect on catastrophising immediately post-treatment. CBT is a useful approach to the management of chronic pain. There is no need for more general RCTs reporting group means: rather, different types of studies and analyses are needed to identify which components of CBT work for which type of patient on which outcome/s, and to try to understand why. PMID: 23152245 [PubMed - indexed for MEDLINE]

CBT and low back pain 1. Fam Pract. 2014 Aug;31(4):379-88. doi: 10.1093/fampra/cmu008. Epub 2014 Mar 15. Interventions focusing on psychosocial risk factors for patients with non-chronic low back pain in primary care--a systematic review. Ramond-Roquin A(1), Bouton C(2), Gobin-Tempereau AS(3), Airagnes G(4), Richard I(5), Roquelaure Y(6), Huez JF(2). Author information: (1)Department of General Practice and Laboratory of Ergonomics and Epidemiology in Occupational Health, University of Angers, PRES L'UNAM, Angers and Aline.ramond@univ-angers.fr. (2)Department of General Practice and Laboratory of Ergonomics and Epidemiology in Occupational Health, University of Angers, PRES L'UNAM, Angers and. (3)Department of General Practice and. (4)Laboratory of Ergonomics and Epidemiology in Occupational Health, University of Angers, PRES L'UNAM, Angers and. (5)Laboratory of Ergonomics and Epidemiology in Occupational Health, University of Angers, PRES L'UNAM, Angers and Regional Center for Rehabilitation of Angers and. (6)Laboratory of Ergonomics and Epidemiology in Occupational Health, University of Angers, PRES L'UNAM, Angers and Department of Occupational Health, University Hospital of Angers, Angers, France. BACKGROUND: Low back pain (LBP) is a problem that is frequently encountered in primary care, and current guidelines encourage care providers to take into account psychosocial risk factors in order to avoid transition from acute to chronic LBP. OBJECTIVE: To review the effectiveness of interventions focusing on psychosocial risk factors for patients with non-chronic LBP in primary care. METHODS: A systematic search was undertaken for controlled trials focusing on psychosocial factors in adult patients with non-chronic, non-specific LBP in primary care by exploring Medline, Embase, PsycInfo, Francis, Web of Sciences and The Cochrane Library. The methodological quality of the studies included was assessed before analysing their findings. RESULTS: Thirteen studies were selected, seven being considered as having a low risk of bias. Information strategies were assessed by eight trials, with high-quality evidence of no effectiveness for pain, function, work issues and health care use, low-quality evidence of no effectiveness for self-rated overall improvement, satisfaction and pain beliefs and lack of evidence in terms of quality of life. Cognitive behavioural therapy was assessed by three trials, with very low-quality evidence of moderate effectiveness for pain, function, quality of life, work issues and health care use. There was lack of evidence concerning the effectiveness of individual and group education intervention or work coordination. CONCLUSION: Among the wide range of psychosocial risk factors, research has focused mainly on pain beliefs and coping skills, with disappointing results. Extended theoretical models integrating several psychosocial factors and multicomponent interventions are probably required to meet the challenge of LBP. © The Author 2014. Published by Oxford University Press. All rights reserved. For

permissions, please e-mail: journals.permissions@oup.com. PMID: 24632524 [PubMed - indexed for MEDLINE] 2. Disabil Rehabil. 2013 Jan;35(1):1-10. doi: 10.3109/09638288.2012.683848. Epub 2012 May 21. Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review. Brunner E(1), De Herdt A, Minguet P, Baldew SS, Probst M. Author information: (1)Faculty of Kinesiology and Rehabilitation Science, KU Leuven, Leuven, Belgium. PURPOSE: The primary purpose was to detect randomized controlled trials investigating cognitive behaviour therapy-based (CBT) treatments applied in acute/sub-acute low back pain (LBP). The secondary purpose was to analyse the methodological properties of the included studies, and to identify theory-based treatment strategies that are applicable for physiotherapists. METHOD: A systematic literature search was conducted using four databases. Risk of bias of included studies was assessed and the methodological properties summarized. In addition, content and treatment theory of detected CBT-based strategies were systematically analysed and classified into three distinctive concepts of CBT: operant, cognitive and respondent treatment. Finally, applicability of treatment strategies in physiotherapy practice was discussed. RESULTS: Eight studies were included in the present systematic review. Half of the studies suffered from high risk of bias, and study characteristics varied in all domains of methodology, particularly in terms of treatment design and outcome measures. Graded activity, an operant treatment approach based on principles of operant conditioning, was identified as a CBT-based strategy with traceable theoretical justification that can be applied by physiotherapists. CONCLUSION: Operant conditioning can be integrated in ambulant physiotherapy practice and is a promising CBT-based strategy for the prevention of chronic LBP. PMID: 22607157 [PubMed - indexed for MEDLINE] 3. Eur Spine J. 2011 Jul;20(7):1024-38. doi: 10.1007/s00586-010-1676-3. Epub 2011 Jan 13. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Lin CW(1), Haas M, Maher CG, Machado LA, van Tulder MW. Author information: (1)The George Institute for Global Health and Sydney Medical School, The University of Sydney, PO Box M201, Missenden Rd, Sydney, NSW 2050, Australia. clin@george.org.au

Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline. PMCID: PMC3176706 PMID: 21229367 [PubMed - indexed for MEDLINE]

Effectiveness and children and spinal manipulation 1. Chiropr Man Therap. 2015 Oct 27;23:30. doi: 10.1186/s12998-015-0075-6. eCollection 2015. The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Southerst D(1), Yu H(2), Randhawa K(3), Côté P(4), D'Angelo K(5), Shearer HM(2), Wong JJ(6), Sutton D(2), Varatharajan S(3), Goldgrub R(7), Dion S(5), Cox J(5), Menta R(5), Brown CK(5), Stern PJ(8), Stupar M(2), Carroll LJ(9), Taylor-Vaisey A(10). Author information: (1)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario Canada M5G 1X5. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (4)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (5)Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (7)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4. (8)Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (9)Injury Prevention Centre and School of Public Health, University of Alberta, 4075 Research Transition

Facility, 8308-114 St, Edmonton, Alberta Canada T6G 2E1. (10)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. BACKGROUND: Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI. RESULTS: We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults. CONCLUSIONS: The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009899. PMCID: PMC4623271 PMID: 26512315 [PubMed] 2. Ned Tijdschr Geneeskd. 2010;154:A1924. [Treatment of tension type headache: paracetamol and NSAIDs work: a systematic review]. [Article in Dutch] Verhagen AP(1), Damen L, Berger MY, Lenssinck ML, Passchier J, Kroes BW.

Author information: (1)Erasmus MC, Afd. Huisartsgeneeskunde, Rotterdam, the Netherlands. a.verhagen@erasmusmc.nl OBJECTIVE: Tension-type headache (TTH), also known as tension headache or muscle contraction headache is the most commonly experienced type of headache. Our aim was to evaluate the effectiveness of interventions in patients with TTH. METHOD: We performed a systematic review according to the guidelines of the Cochrane Collaboration. Randomised trials reporting conservative treatments in patients with TTH with headache as outcome were included. In the analysis studies were grouped according to type of intervention: acute pain medication, preventive medication, physiotherapy interventions, behavioural interventions and interventions in children. RESULTS: A total of 152 trials were included in this review with 17.523 patients, of which 37 studies (24.3%) were considered to be of high quality. Nine studies could not be included in one of the five subgroups. ACUTE MEDICATION: (41 trials). The pooled analyses showed that NSAIDs and acetaminophen are more effective than placebo. No significant differences could be found between different types of NSAIDs, but ibuprofen showed fewer short-term side effects when compared to other NSAIDs. There was a significant difference in favour of NSAIDs when compared to acetaminophen. PREVENTIVE MEDICATION: (44 trials). Overall, the use of antidepressants does not show to be more effective than placebo, and no significant differences between different types of antidepressants were found. Furthermore there is limited evidence concerning the negative effects of propranolol on depression in TTH patients, when compared to placebo or biofeedback. There is conflicting evidence about the effectiveness of benzodiazepines and vasodilator agents compared to placebo. There is no evidence concerning the effectiveness of muscle relaxants compared to placebo. BEHAVIOURAL THERAPY: (44 trials). Eight studies compared relaxation treatment with a waiting list or attention placebo control, and 11 studies compared EMG biofeedback with placebo and in both interventions we found inconsistent results. Most trials lack adequate power to show statistical significant differences, but frequently recovery/improvement rates did not reach clinical relevance. PHYSIOTHERAPEUTIC INTERVENTIONS: (12 trials). A wide variety of interventions were evaluated, such as spinal manipulations, exercise and physical applications. Overall the studies showed inconsistent results. CHILDREN: (11 trials). Eight studies evaluated the effectiveness of relaxation training. We found conflicting evidence for relaxation therapy compared with no treatment or other treatments. CONCLUSION: The evidence in this review suggests that NSAIDs and acetaminophen are both effective for short-term pain relief in patients with TTH. No specific type of NSAID was clearly more effective than others, but ibuprofen showed fewer side effects. There is insufficient evidence to either support or refute the effectiveness of preventive medication, physiotherapy, (spinal) manipulation, EMG biofeedback or cognitive behavioural treatment in patients with TTH. PMID: 20699021 [PubMed - indexed for MEDLINE] 3. J Altern Complement Med. 2007 Jun;13(5):491-512.

Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research. Hawk C(1), Khorsan R, Lisi AJ, Ferrance RJ, Evans MW. Author information: (1)Cleveland Chiropractic College, Kansas City, Missouri 64131, USA. cheryl.hawk@cleveland.edu Comment in J Altern Complement Med. 2007 Jun;13(5):479-80. OBJECTIVES: (1) To evaluate the evidence on the effect of chiropractic care, rather than spinal manipulation only, on patients with nonmusculoskeletal conditions; and (2) to identify shortcomings in the evidence base on this topic, from a Whole Systems Research perspective. DESIGN: Systematic review. METHODS: Databases included were PubMed, Ovid, Mantis, Index to Chiropractic Literature, and CINAHL. Search restrictions were human subjects, peer-reviewed journal, English language, and publication before May 2005. All randomized controlled trials (RCTs) were evaluated using the Scottish Intercollegiate Guidelines Network (SIGN) and Jadad checklists; a checklist developed from the CONSORT (Consolidated Standards of Reporting Trials) guidelines; and one developed by the authors to evaluate studies in terms of Whole Systems Research (WSR) considerations. RESULTS: The search yielded 179 papers addressing 50 different nonmusculoskeletal conditions. There were 122 case reports or case series, 47 experimental designs, including 14 RCTs, 9 systematic reviews, and 1 a large cohort study. The 14 RCTs addressed 10 conditions. Six RCTs were rated "high" on the 3 conventional checklists; one of these 6 was rated "high" in terms of WSR considerations. CONCLUSIONS: (1) Adverse effects should be routinely reported. For the few studies that did report, adverse effects of spinal manipulation for all ages and conditions were rare, transient, and not severe. (2) Evidence from controlled studies and usual practice supports chiropractic care (the entire clinical encounter) as providing benefit to patients with asthma, cervicogenic vertigo, and infantile colic. Evidence was promising for potential benefit of manual procedures for children with otitis media and elderly patients with pneumonia. (3) The RCT design is not necessarily incompatible with WSR. RCTs could improve generalizability by basing protocols on usual practice. (4) Case reports could contribute more to WSR by increasing their emphasis on patient characteristics and patient-based outcomes. (5) Chiropractic investigators, practitioners, and funding agencies should increase their attention to observational designs. PMID: 17604553 [PubMed - indexed for MEDLINE] 4. Pediatrics. 2007 Jan;119(1):e275-83. Epub 2006 Dec 18. Adverse events associated with pediatric spinal manipulation: a systematic review.

Vohra S(1), Johnston BC, Cramer K, Humphreys K. Author information: (1)CARE Program, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada T6G 2E1. svohra@ualberta.ca Erratum in Pediatrics. 2007 Jul;120(1):251. Pediatrics. 2007 Apr;119(4):867. Comment in Pediatrics. 2007 Jun;119(6):1261-4; author reply 1266-7. Pediatrics. 2007 Jun;119(6):1265-6; author reply 1266-7. Pediatrics. 2007 Jun;119(6):1264-5; author reply 1266-7. BACKGROUND: Spinal manipulation is a noninvasive manual procedure applied to specific body tissues with therapeutic intent. Although spinal manipulation is commonly used in children, there is limited understanding of the pediatric risk estimates. OBJECTIVE: Our goal was to systematically identify and synthesize available data on adverse events associated with pediatric spinal manipulation. METHODS: A comprehensive search was performed of 8 major electronic databases (eg, Medline, AMED, MANTIS) from inception to June 2004 irrespective of language. Reports were included if they (1) were a primary investigation of spinal manipulation (eg, observation studies, controlled trials, surveys), (2) included a study population of children who were aged 18 years or younger, and (3) reported data on adverse events. Data were summarized to demonstrate the nature and severity of adverse events that may result rather than their incidence. RESULTS: Thirteen studies (2 randomized trials, 11 observational reports) were identified for inclusion. We identified 14 cases of direct adverse events involving neurologic or musculoskeletal events. Nine cases involved serious adverse events (eg, subarachnoidal hemorrhage, paraplegia), 2 involved moderately adverse events that required medical attention (eg, severe headache), and 3 involved minor adverse events (eg, midback soreness). Another 20 cases of indirect adverse events involved delayed diagnosis (eg, diabetes, neuroblastoma) and/or inappropriate provision of spinal manipulation for serious medical conditions (ie, meningitis, rhabdomyosarcoma). CONCLUSIONS: Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric patients. PMID: 17178922 [PubMed - indexed for MEDLINE] 5. Ned Tijdschr Geneeskd. 2005 Mar 26;149(13):703-7. [Systematic review of the effects of therapy in infants with the KISS-syndrome (kinetic imbalance due to suboccipital strain)].

[Article in Dutch] Brand PL(1), Engelbert RH, Helders PJ, Offringa M. Author information: (1)Isala Klinieken, Amalia kinderafdeling, Postbus 10.500, 8000 GM Zwolle. p.l.p.brand@isala.nl Comment in Ned Tijdschr Geneeskd. 2006 May 13;150(19):1097-8; author reply 1098. Ned Tijdschr Geneeskd. 2005 May 28;149(22):1238-9; author reply 1239. Ned Tijdschr Geneeskd. 2005 May 28;149(22):1237; author reply 1237-8. OBJECTIVE: To establish the effects of manual therapy, chiropractic, or osteopathic treatment of the KISS-syndrome (kinetic imbalance due to suboccipital strain) in infants with positional preference, plagiocephaly, and colic. DESIGN: Systematic review of the literature. METHOD: PubMed, Embase and the Cochrane Library were searched for articles on the effects of manual therapy, chiropractic and osteopathy on the KISS-syndrome. Experts in the field of manual medicine and osteopathy were asked to provide relevant articles. The bibliography in a textbook of manual therapy for children was hand-searched for additional references to the KISS-syndrome. RESULTS: No clinical trials were found that evaluated the effects of manual therapy or osteopathy on either the KISS-syndrome or its symptoms. Pooled analysis of two randomised clinical trials on the effects of chiropractic in infantile colic showed no statistically significant difference between active and control treatments. In addition, we found that 22% of infants showed short episodes of apnoea during manual therapy of the spine, and that one case has been described in which such apnoea resulted in death. CONCLUSION: Given the absence of evidence of beneficial effects of spinal manipulation in infants and in view of its potential risks, manual therapy, chiropractic and osteopathy should not be used in infants with the KISS-syndrome, except within the context of randomised double-blind controlled trials. PMID: 15819137 [PubMed - indexed for MEDLINE]

Effectiveness and MT and ankle 1. Chiropr Man Therap. 2015 Oct 27;23:30. doi: 10.1186/s12998-015-0075-6. eCollection 2015. The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Southerst D(1), Yu H(2), Randhawa K(3), Côté P(4), D'Angelo K(5), Shearer HM(2), Wong JJ(6), Sutton D(2), Varatharajan S(3), Goldgrub R(7), Dion S(5), Cox J(5), Menta R(5), Brown CK(5), Stern PJ(8), Stupar M(2), Carroll LJ(9), Taylor-Vaisey A(10). Author information: (1)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario Canada M5G 1X5. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (4)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (5)Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (7)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4. (8)Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (9)Injury Prevention Centre and School of Public Health, University of Alberta, 4075 Research Transition Facility, 8308-114 St, Edmonton, Alberta Canada T6G 2E1. (10)UOIT-CMCC Centre for

the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. BACKGROUND: Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI. RESULTS: We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults. CONCLUSIONS: The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009899. PMCID: PMC4623271 PMID: 26512315 [PubMed] 2. J Orthop Sports Phys Ther. 2014 Nov;44(11):862-71, C1-23. doi: 10.2519/jospt.2014.5221. Epub 2014 Oct 9. Chronic complaints after ankle sprains: a systematic review on effectiveness of treatments. van Ochten JM(1), van Middelkoop M, Meuffels D, Bierma-Zeinstra SM. Author information:

(1)Department of General Practice, Erasmus University Medical Center, Rotterdam, the Netherlands. STUDY DESIGN: Systematic review. Objective To determine the effectiveness of treatments for patients with chronic complaints after ankle sprain. BACKGROUND: Though most people recover completely after a lateral inversion ankle injury, a considerable percentage have persistent complaints. Currently, it is still unclear which treatment options are best for these patients. METHODS: Major databases, including PubMed, Embase, CINAHL, and PEDro, were searched for randomized controlled trials and controlled clinical trials conducted from 1966 to October 2012. Due to clinical heterogeneity, the data were analyzed using a best-evidence synthesis. RESULTS: A total of 20 randomized controlled trials and 1 controlled clinical trial were included in the analysis. The included studies compared different treatments (training programs, physiotherapy, chiropractic/manual therapy, surgery, postoperative training, and functional treatment). For pain and function outcomes, limited to moderate evidence was found for effectiveness of a training program compared to conservative treatment. Two studies found a decrease of recurrences after a proprioceptive training program. Four studies showed good results for different surgical methods but did not include a nonsurgical control group for comparison. Limited evidence was found for the effectiveness of an early mobilization program after surgery. CONCLUSION: In chronic ankle complaints after an ankle sprain, a training program gives better results for pain and function, and a decrease of recurrent ankle sprains, than a wait-and-see policy. There was insufficient evidence to determine the most effective surgical treatment, but limited evidence suggests that postoperative, early mobilization was more effective than a plaster cast. LEVEL OF EVIDENCE: Therapy, level 1a-. PMID: 25299494 [PubMed - indexed for MEDLINE] 3. J Man Manip Ther. 2009;17(3):e80-9. Systematic review of efficacy for manual lymphatic drainage techniques in sports medicine and rehabilitation: an evidence-based practice approach. Vairo GL, Miller SJ, McBrier NM, Buckley WE. Manual therapists question integrating manual lymphatic drainage techniques (MLDTs) into conventional treatments for athletic injuries due to the scarcity of literature concerning musculoskeletal applications and established orthopaedic clinical practice guidelines. The purpose of this systematic review is to provide manual therapy clinicians with pertinent information regarding progression of MLDTs as well as to critique the evidence for efficacy of this method in sports medicine. We surveyed English-language publications from 1998 to 2008 by searching PubMed, PEDro, CINAHL, the Cochrane Library, and SPORTDiscus databases using the terms lymphatic system, lymph drainage, lymphatic therapy, manual lymph drainage, and lymphatic pump techniques. We selected articles investigating the effects of MLDTs on orthopaedic and athletic injury outcomes. Nine articles met inclusion criteria, of which 3 were randomized controlled trials (RCTs). We

evaluated the 3 RCTs using a validity score (PEDro scale). Due to differences in experimental design, data could not be collapsed for meta-analysis. Animal model experiments reinforce theoretical principles for application of MLDTs. When combined with concomitant musculoskeletal therapy, pilot and case studies demonstrate MLDT effectiveness. The best evidence suggests that efficacy of MLDT in sports medicine and rehabilitation is specific to resolution of enzyme serum levels associated with acute skeletal muscle cell damage as well as reduction of edema following acute ankle joint sprain and radial wrist fracture. Currently, there is limited high-ranking evidence available. Well-designed RCTs assessing outcome variables following implementation of MLDTs in treating athletic injuries may provide conclusive evidence for establishing applicable clinical practice guidelines in sports medicine and rehabilitation. PMCID: PMC2755111 PMID: 20046617 [PubMed]

Effectiveness and MT and cervical radiculopathy 1. J Man Manip Ther. 2011 Aug;19(3):135-42. doi: 10.1179/2042618611Y.0000000011. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. Boyles R(1), Toy P, Mellon J Jr, Hayes M, Hammer B. Author information: (1)Program of Physical Therapy, University of Puget Sound, Tacoma, WA, USA. STUDY DESIGN: Systematic review of randomized clinical trials. OBJECTIVE: Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy. BACKGROUND: Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population. RESULTS: Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising. CONCLUSION: Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR. PMCID: PMC3143012 PMID: 22851876 [PubMed]

Effectiveness and MT and groin pain 1. Br J Sports Med. 2015 Jun;49(12):813. doi: 10.1136/bjsports-2014-094256. Epub 2015 Jan 29. Study quality on groin injury management remains low: a systematic review on treatment of groin pain in athletes. Serner A(1), van Eijck CH(2), Beumer BR(2), Hölmich P(1), Weir A(3), de Vos RJ(4). Author information: (1)Aspetar Sports Groin Pain Center, Orthopaedic and Sports Medicine Hospital, Doha, Qatar Arthroscopic Center Amager, SORC-C, Copenhagen University Hospital, Amager-Hvidovre, Denmark. (2)Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands. (3)Aspetar Sports Groin Pain Center, Orthopaedic and Sports Medicine Hospital, Doha, Qatar. (4)Department of Orthopaedics, Erasmus University Medical Centre, Rotterdam, The Netherlands. BACKGROUND: Groin pain in athletes is frequent and many different treatment options have been proposed. The current level of evidence for the efficacy of these treatments is unknown. OBJECTIVE: Systematically review the literature on the efficacy of treatments for groin pain in athletes. METHODS: Nine medical databases were searched in May 2014. INCLUSION CRITERIA: treatment studies in athletes with groin pain; randomised controlled trials, controlled clinical trials or case series; n>10; outcome measures describing number of recovered athletes, patient satisfaction, pain scores or functional outcome scores. One author screened search results, and two authors independently assessed study quality. A best evidence synthesis was performed. Relationships between quality score and outcomes were evaluated. Review registration number CRD42014010262. RESULTS: 72 studies were included for quality analysis. Four studies were high quality. There is moderate evidence that, for adductor-related groin pain, active exercises compared with passive treatments improve success, multimodal treatment with a manual therapy technique shortens the time to return to sports compared with active exercises and adductor tenotomy improves treatment success over time. There is moderate evidence that for athletes with sportsman's hernia, surgery results in better treatment success then conservative treatment. There was a moderate and inverse correlation between study quality and treatment success (p<0.001, r=-0.41), but not between study quality and publication year (p=0.09, r=0.20). CONCLUSIONS: Only 6% of publications were high quality. Low-quality studies showed significantly higher treatment success and study quality has not improved since 1985. There is moderate evidence for the efficacy of conservative treatment (active exercises and multimodal treatments) and for surgery in patients with adductor-related groin pain. There is moderate evidence for efficacy of surgical treatment in sportsman's hernia. Published by the BMJ Publishing Group Limited. For permission to use (where not

already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. PMCID: PMC4484372 PMID: 25633830 [PubMed - in process]

Effectiveness and MT and headache 1. Cephalalgia. 2015 Jul 30. pii: 0333102415597889. [Epub ahead of print] Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis. Luedtke K(1), Allers A(1), Schulte LH(1), May A(2). Author information: (1)Department of Systems Neuroscience, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Germany. (2)Department of Systems Neuroscience, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Germany a.may@uke.de. AIM: We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH). METHODS: We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality. RESULTS: Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH (p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH (p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency (p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine (p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH (p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity (p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency (p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62). DISCUSSION: Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low. © International Headache Society 2015. PMID: 26229071 [PubMed - as supplied by publisher]

2. Neurologia. 2014 May 21. pii: S0213-4853(14)00011-5. doi: 10.1016/j.nrl.2014.01.002. [Epub ahead of print] Efficacy of manual therapy in the treatment of tension-type headache. A systematic review from 2000-2013. [Article in English, Spanish] Lozano López C(1), Mesa Jiménez J(2), de la Hoz Aizpurúa JL(1), Pareja Grande J(3), Fernández de Las Peñas C(4). Author information: (1)Máster en Dolor Orofacial y Disfunción Craneomandibular, Facultad de Medicina, Departamento de Fisioterapia, Universidad CEU San Pablo, Madrid, España. (2)Máster en Dolor Orofacial y Disfunción Craneomandibular, Facultad de Medicina, Departamento de Fisioterapia, Universidad CEU San Pablo, Madrid, España. Electronic address: jmesaj@ceu.es. (3)Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España. (4)Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad Rey Juan Carlos, Alcorcón, Madrid, España. OBJECTIVES: To study the efficacy of manual therapy in the treatment of tension-type headache (TTH) by assessing the quality of randomized control trials (RCTs) published from the year 2000 to April 2013. METHODS: A search was performed in the following databases: MEDLINE, EBSCO, CINAHL, SCOPUS, PEDRO and OVID. An analysis was made of RCT including patients with TTH receiving any manual therapy, and assessing outcome measures including the intensity, and frequency or duration of the headache. Two independent referees reviewed the methodological quality of RCTs using the Jadad scale. Data from the studies were extracted by two different reviewers. RESULTS: A total of fourteen RCTs were selected. Twelve studies showed acceptable quality (Jadad scale ≥3), and the remaining 2 had low quality (Jadad=2). The studies showed positive results, including reduction in headache intensity and/or frequency, reduction of medication consumption, and improvement in quality of life. CONCLUSIONS: The effectiveness of manual therapy for TTH cannot be completely assessed due to the heterogeneity in study design, outcome measures, and different treatments. Nevertheless, the results suggest patients with TTH receiving manual therapies showed better progress than those receiving conventional treatment or placebo. Further studies of high quality using manual therapy protocols, and also including standardized outcome measures, are now needed to clarify the efficacy of manual therapy in the management of TTH. Copyright © 2013 Sociedad Española de Neurología. Published by Elsevier Espana. All rights reserved. PMID: 24856370 [PubMed - as supplied by publisher] 3. Chiropr Man Therap. 2014 Mar 28;22(1):12. doi: 10.1186/2045-709X-22-12.

Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P(1). Author information: (1)Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, England. p.a.sutcliffe@warwick.ac.uk. BACKGROUND: This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report. METHODS: A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added. RESULTS: 25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive. CONCLUSIONS: Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted. PMCID: PMC3997823 PMID: 24679336 [PubMed] 4. Clin J Pain. 2006 Mar-Apr;22(3):278-85. Are manual therapies effective in reducing pain from tension-type headache?: a systematic review. Fernández-de-Las-Peñas C(1), Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA. Author information:

(1)Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, Madrid, Spain. cesarfdlp@yahoo.es OBJECTIVES: A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH). METHODS: Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence. RESULTS: Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8+/-2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited evidence (level 3). CONCLUSIONS: The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH. PMID: 16514329 [PubMed - indexed for MEDLINE]

Effectiveness and MT and hip 1. Br J Sports Med. 2015 Nov 26. pii: bjsports-2015-095255. doi: 10.1136/bjsports-2015-095255. [Epub ahead of print] Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis. Beumer L(1), Wong J(1), Warden SJ(2), Kemp JL(3), Foster P(1), Crossley KM(4). Author information: (1)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia. (2)School of Health and Rehabilitation Sciences, Indiana University, Indianapolis, Indiana, USA. (3)Australian Centre for Research into Injury and Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia. (4)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia. AIM: To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA). METHODS: A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0-3 months=short term; 4-12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores. RESULTS: 19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD -0.53, 95% CI -0.96 to -0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD -0.49, 95% CI -0.70 to -0.29). There were no medium (SMD -0.23, 95% CI -0.48 to 0.03) or long (SMD -0.22, 95% CI -0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD -0.38, 95% CI -0.88 to 0.13) when compared to minimal control. CONCLUSIONS: Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger high-quality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26612846 [PubMed - as supplied by publisher] 2. Reumatismo. 2013 May 27;65(2):63-74. doi: 10.4081/reumatismo.2013.63.

Manual therapy and therapeutic exercise in the treatment of osteoarthritis of the hip: a systematic review. Romeo A(1), Parazza S, Boschi M, Nava T, Vanti C. Author information: (1)Manual Therapy, University of Padova, Italy. This systematic review aimed at investigating the role of therapeutic exercise and/or manual therapy in the treatment of hip osteoarthritis (OA). Two independent reviewers (AR, CV) searched PubMed, Cinahl, Cochrane Library, PEDro and Scopus databases and a third one (SP) was consulted in case of disagreement. The research criteria were publication period (from May 2007 to April 2012) and publication language (English or Italian). Ten randomized controlled trials matched inclusion criteria, eight of which concerning therapeutic exercise and two manual therapy. Few good quality studies were found. At mid- and long-term follow-up land-based exercises showed insufficient evidence of effectiveness with respect to pain and quality of life, but positive results were found for physical function. Water exercises significantly reduced fall risk when combined with functional exercises. Programs containing progressive and gradual exposure of difficult activities, education and exercises promoted better outcomes, higher adherence to home program and increased amount of physical activity, especially walking. Manual therapy seemed to reduce pain and decrease disability at short-term. Less use of nonsteroidal anti-inflammatory drugs was statistically significant at long-term follow-up in patients treated with manual therapy. The relationship between clinical results and radiological grade of OA was not investigated. Encouraging results were found in recent literature for manual therapy and functional training. Further research is needed to elucidate this issue through high-quality trials, especially addressing the aspects that have not been thoroughly explored yet, for instance type, amount and scheduling of conservative treatment. PMID: 23877410 [PubMed - indexed for MEDLINE]

Effectiveness and MT and low back pain 1. BMC Musculoskelet Disord. 2013 Apr 9;14:129. doi: 10.1186/1471-2474-14-129. Osteopathic intervention in chronic non-specific low back pain: a systematic review. Orrock PJ(1), Myers SP. Author information: (1)School of Health and Human Sciences, Southern Cross University, PO Box 157, Lismore, NSW 2481, Australia. paul.orrock@scu.edu.au BACKGROUND: Chronic Non Specific Low Back Pain (CNSLBP) is a common, complex and disabling condition that has been present for longer than three months and is not caused by a serious pathology. Osteopaths are health practitioners who commonly diagnose and treat CNSLBP patients using a complex set of interventions that includes manual therapy. The study aimed to complete a Systematic Review of clinical research into osteopathic intervention in CNSLBP using a rigorous assessment of study quality. METHODS: The literature was searched to August 2011 using the following databases: AMED, CINAHL Plus, Cochrane Central Register of Clinical Trials, MEDLINE Plus, EMBASE, MANTIS, OSTMED, PEDro, ScienceDirect. Multiple search terms were used in various combinations: osteopathy/osteopathic, osteopathic manipulative technique, OMT, Spinal Manipulative Therapy, SMT, clinical trial, back pain, chronic back pain. The inclusion criteria were papers that: reported clinical trials; had adult participants; tested the effectiveness and/or efficacy of osteopathic manual therapy intervention applied by osteopaths, and had a study condition of CNSLBP. The quality of the papers was assessed using the Cochrane Back Review Risk of Bias criteria. A meta-analysis would proceed if the studies had adequate clinical and methodological homogeneity. RESULTS: Initial searches revealed 809 papers, 772 of which were excluded on the basis of abstract alone. The remaining 37 trial papers were subjected to a more detailed analysis of the full text, which resulted in 35 being excluded. The two remaining trials had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up. CONCLUSION: There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP. One trial concluded that the osteopathic intervention was similar in effect to a sham intervention, and the other suggests similarity of effect between osteopathic intervention, exercise and physiotherapy. Further clinical trials into this subject are required that have consistent and rigorous methods. These trials need to include an appropriate control and utilise an intervention that reflects actual practice. PMCID: PMC3623881 PMID: 23570655 [PubMed - indexed for MEDLINE]

2. Int J Sports Phys Ther. 2012 Dec;7(6):647-62. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Kuczynski JJ(1), Schwieterman B, Columber K, Knupp D, Shaub L, Cook CE. Author information: (1)Walsh University, North Canton, OH, USA. BACKGROUND CONTEXT: Low back pain (LBP) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses. A common intervention for LBP is spinal manipulation, a technique that is not specific to one scope of practice or profession. PURPOSE: The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain. METHODS: A search of the current literature was conducted using PubMed, CINAHL, SPORTDiscus, Pro Quest Nursing and Allied Health Source, Scopus, and Cochrane Controlled Trials Register. Studies were included if each involved: 1) individuals with LBP; 2) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations; 3) measurable clinical outcomes or efficiency of treatment measures, and 4) randomized control trials. The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Database (PEDro). RESULTS: Six randomized control trials met the inclusion criteria of this systematic review. The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported statistically significantly less medication use, health care utilization, and lost work time. CONCLUSION: Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain. PMCID: PMC3537457 PMID: 23316428 [PubMed] 3. Man Ther. 2012 Jun;17(3):201-12. doi: 10.1016/j.math.2012.01.006. Epub 2012 Mar 3. The effectiveness of sub-group specific manual therapy for low back pain: a systematic review. Slater SL(1), Ford JJ, Richards MC, Taylor NF, Surkitt LD, Hahne AJ.

Author information: (1)Low Back Research Team, Musculoskeletal Research Centre, Department of Physiotherapy, La Trobe University, Bundoora, Victoria 3083, Australia. slslater@internode.on.net BACKGROUND: Manual therapy is frequently used to treat low back pain (LBP), but evidence of its effectiveness is limited. One explanation may be sample heterogeneity and inadequate sub-grouping of participants in randomized controlled trials (RCTs) where manual therapy has not been targeted toward those likely to respond. OBJECTIVES: To determine the effectiveness of specific manual therapy provided to sub-groups of participants identified as likely to respond to manual therapy. DATA SOURCES: A systematic search of electronic databases of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled trials (CENTRAL). TRIAL ELIGIBILITY CRITERIA: RCTs on manual therapy for participants identified as belonging to a sub-group of LBP likely to respond to manual therapy were included. TRIAL APPRAISAL AND SYNTHESIS METHODS: Identified trials were assessed for eligibility. Data from included trials were extracted by two authors independently. Risk of bias in each trial was assessed using the PEDro scale and the overall quality of evidence rated according to the GRADE domains. Treatment effect sizes and 95% confidence intervals were calculated for pain and activity. RESULTS: Seven RCTs were included in the review. Clinical and statistical heterogeneity precluded meta-analysis. Significant treatment effects were found favouring sub-group specific manual therapy over a number of comparison treatments for pain and activity at short and intermediate follow-up. However, the overall GRADE quality of evidence was very low. CONCLUSIONS: This review found preliminary evidence supporting the effectiveness of sub-group specific manual therapy. Further high quality research on LBP sub-groups is required. Copyright © 2012 Elsevier Ltd. All rights reserved. PMID: 22386046 [PubMed - indexed for MEDLINE] 4. Phys Ther. 2009 Jan;89(1):9-25. doi: 10.2522/ptj.20080103. Epub 2008 Dec 4. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Macedo LG(1), Maher CG, Latimer J, McAuley JH. Author information: (1)The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Rd, Camperdown, Sydney, New South Wales, 2050 Australia. lmacedo@george.org.au BACKGROUND: Previous systematic reviews have concluded that the effectiveness of motor control exercise for persistent low back pain has not been clearly established. OBJECTIVE: The objective of this study was to systematically review randomized

controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain. METHODS: Electronic databases were searched to June 2008. Pain, disability, and quality-of-life outcomes were extracted and converted to a common 0 to 100 scale. Where possible, trials were pooled using Revman 4.2. RESULTS: Fourteen trials were included. Seven trials compared motor control exercise with minimal intervention or evaluated it as a supplement to another treatment. Four trials compared motor control exercise with manual therapy. Five trials compared motor control exercise with another form of exercise. One trial compared motor control exercise with lumbar fusion surgery. The pooling revealed that motor control exercise was better than minimal intervention in reducing pain at short-term follow-up (weighted mean difference=-14.3 points, 95% confidence interval [CI]=-20.4 to -8.1), at intermediate follow-up (weighted mean difference=-13.6 points, 95% CI=-22.4 to -4.1), and at long-term follow-up (weighted mean difference=-14.4 points, 95% CI=-23.1 to -5.7) and in reducing disability at long-term follow-up (weighted mean difference=-10.8 points, 95% CI=-18.7 to -2.8). Motor control exercise was better than manual therapy for pain (weighted mean difference=-5.7 points, 95% CI=-10.7 to -0.8), disability (weighted mean difference=-4.0 points, 95% CI=-7.6 to -0.4), and quality-of-life outcomes (weighted mean difference=-6.0 points, 95% CI=-11.2 to -0.8) at intermediate follow-up and better than other forms of exercise in reducing disability at short-term follow-up (weighted mean difference=-5.1 points, 95% CI=-8.7 to -1.4). CONCLUSIONS: Motor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise. PMID: 19056854 [PubMed - indexed for MEDLINE]

Effectiveness and MT and neck pain 1. Spine J. 2015 Dec 17. pii: S1529-9430(15)01234-6. doi: 10.1016/j.spinee.2015.08.024. [Epub ahead of print] Are manual therapies, passive physical modalities, or acupuncture effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? an update of the bone and joint decade task force on neck pain and its associated disorders by the optima collaboration. Wong JJ(1), Shearer HM(2), Mior S(3), Jacobs C(4), Côté P(5), Randhawa K(4), Yu H(4), Southerst D(6), Varatharajan S(4), Sutton D(4), van der Velde G(7), Carroll LJ(8), Ameis A(9), Ammendolia C(10), Brison R(11), Nordin M(12), Stupar M(13), Taylor-Vaisey A(13). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Department of Graduate Studies, Canadian Memorial Chiropractic College. Electronic address: jessica.wong@uoit.ca. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Division of Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC). (3)Division of Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC). (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Division of Clinical Education, Canadian Memorial Chiropractic College, Canada. (5)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT); Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT). (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital. (7)Toronto Health Economics and Technology Assessment (THETA) Collaborative; Leslie Dan Faculty of Pharmacy, University of Toronto; Institute for Work and Health. (8)Alberta Centre for Injury Control and Research and School of Public Health, University of Alberta. (9)Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal. (10)Institute for Work and Health; Institute for Health Policy, Management and Evaluation, University of Toronto. (11)Clinical Research, Kingston General Hospital; Department of Emergency Medicine, School of Medicine, Queen's University. (12)Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University. (13)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC). BACKGROUND CONTEXT: In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders (Neck Pain Task Force) found limited

evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). PURPOSE: To update findings of the Neck Pain Task Force examining the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. STUDY DESIGN/SETTING: Systematic review and best evidence synthesis. SAMPLE: Randomized controlled trials (RCTs), cohort studies, case-control studies comparing manual therapies, passive physical modalities, or acupuncture to other interventions, placebo/sham, or no intervention. OUTCOME MEASURES: Self-rated or functional recovery, pain intensity, health-related quality of life, psychological outcomes, or adverse events. METHODS: We systematically searched five databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Studies with a low risk of bias were stratified by the intervention's stage of development (exploratory versus evaluation) and synthesized following best evidence synthesis principles. Funding was provided by the Ministry of Finance. RESULTS: We screened 8551 citations, 38 studies were relevant, and 22 had a low risk of bias. Evidence from seven exploratory studies suggests that: 1) for recent but not persistent NAD I-II: thoracic manipulation offers short-term benefits; 2) for persistent NAD I-II: technical parameters of cervical mobilization (e.g., direction or site of manual contact) do not impact outcomes, while one session of cervical manipulation is similar to Kinesiotaping; and 3) for NAD I-II: strain-counterstrain treatment is no better than placebo. Evidence from 15 evaluation studies suggests that: 1) for recent NAD I-II: cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises; Swedish/clinical massage adds benefit to self-care advice; 2) for persistent NAD I-II: home-based cupping massage has similar outcomes to home-based muscle relaxation; low-level laser therapy (LLLT) does not offer benefits; Western acupuncture provides similar outcomes to non-penetrating placebo electroacupuncture; needle acupuncture provides similar outcomes to sham-penetrating acupuncture; 3) for WAD I-II: needle electroacupuncture offers similar outcomes as simulated electroacupuncture; and 4) for recent NAD III: a semi-rigid cervical collar with rest and graded strengthening exercises lead to similar outcomes; LLLT does not offer benefits. CONCLUSIONS: Our review adds new evidence to the Neck Pain Task Force and suggests that mobilization, manipulation, and clinical massage are effective interventions for the management of neck pain. It also suggests that electroacupuncture, strain-counterstrain, relaxation massage, and some passive physical modalities (heat, cold, diathermy, hydrotherapy, ultrasound) are not effective and should not be used to manage neck pain. Copyright © 2015 Elsevier Inc. All rights reserved. PMID: 26707074 [PubMed - as supplied by publisher] 2. Spine J. 2015 Nov 26. pii: S1529-9430(15)01235-8. doi: 10.1016/j.spinee.2015.08.025. [Epub ahead of print]

Which interventions are cost-effective for the management of whiplash-associated and neck pain-associated disorders? a systematic review of the health economic literature by the ontario protocol for traffic injury management (optima) collaboration. van der Velde G(1), Yu H(2), Paulden M(3), Côté P(4), Varatharajan S(2), Shearer HM(2), Wong JJ(5), Randhawa K(2), Southerst D(5), Mior S(6), Sutton D(2), Jacobs C(7), Taylor-Vaisey A(8). Author information: (1)Toronto Health Economics and Technology Assessment (THETA) Collaborative; Leslie Dan Faculty of Pharmacy, University of Toronto; Institute for Work and Health, Toronto. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Division of Graduate Education and Research, Canadian memorial Chiropractic College. (3)Faculty of Medicine and Dentistry, University of Alberta. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT); Canada Research Chair in Disability Prevention and Rehabilitation. Electronic address: Pierre.Cote@uoit.ca. (5)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Division of Undergraduate Education, Canadian Memorial Chiropractic College. (6)Division of Graduate Education and Research, Canadian memorial Chiropractic College; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT). (7)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC); Division of Clinical Education, Canadian Memorial Chiropractic College. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC). BACKGROUND CONTEXT: Whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) are prevalent conditions that impact society and impose a significant economic burden on health care systems. Health economic evidence on WAD and NAD interventions has been sparse: only three economic evaluations of interventions for NAD were identified by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (NPTF). An updated overview is needed to inform health care policy and guidelines. PURPOSE: To determine the cost-effectiveness of interventions for grade I-III WAD and NAD in children and adults. STUDY DESIGN: Systematic review of health economics literature, best-evidence synthesis. METHODS: We systematically searched CINAHL, the Cochrane economic databases (Health Technology Assessment, NHS Economic Evaluation Database), EconLit, EMBASE, MEDLINE, PsycINFO, and Tufts CEA Registry from 2000 to 2015 for economic evaluations of WAD and NAD interventions. We appraised relevant evaluations using the Scottish Intercollegiate Guidelines Network Methodology Criteria for Economic Evaluations. We extracted data, including mean costs [standardized to 2013

Canadian dollars (CAD)] and quality-adjusted life years (QALYs), from studies with adequate methodological quality. We recalculated cost-effectiveness statistics based on the standardized currency using a willingness-to-pay of CAD $50,000 per additional QALY. Funding was provided by the Ministry of Finance. RESULTS: Our search identified 1,616 citations. Six studies fulfilled our selection criteria, including three studies previously reviewed by the NPTF. Structured education appears cost-effective for adults with WAD. For adults with NAD, acupuncture added to routine medical care; manual therapy; multimodal care that includes manual therapy; advice and exercise; and psychological care using cognitive-behavioral therapy appear cost-effective. In contrast, adding manual therapy or diathermy to advice and exercise; multimodal care by a physiotherapist or physician; and behavioral-graded activity do not appear cost-effective for adults with NAD. CONCLUSIONS: Our review adds to the findings of the NPTF. Recent evidence suggests that structured education is cost-effective for WAD, while advice and exercise and multimodal care that includes manual therapy are cost-effective for NAD. Obtaining more robust health economic evidence for non-invasive interventions for WAD and NAD in children and adults remains an essential research priority. Copyright © 2015. Published by Elsevier Inc. PMID: 26631759 [PubMed - as supplied by publisher] 3. Spine J. 2014 Jul 8. pii: S1529-9430(14)00650-0. doi: 10.1016/j.spinee.2014.06.019. [Epub ahead of print] Is multimodal care effective for the management of patients with whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Sutton DA(1), Côté P(2), Wong JJ(3), Varatharajan S(3), Randhawa KA(3), Yu H(3), Southerst D(3), Shearer HM(3), van der Velde GM(4), Nordin MC(5), Carroll LJ(6), Mior SA(7), Taylor-Vaisey AL(8), Stupar M(3). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1. Electronic address: deborah.sutton@uoit.ca. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science Building, Room 3000, Oshawa, Ontario, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College St, Toronto, Ontario, Canada, M5S 3M2. (3)UOIT-CMCC

Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1. (4)Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College St, Toronto, Ontario, Canada, M5S 3M2; Faculty of Pharmacy, Leslie Dan Pharmacy Building, University of Toronto, 2nd Floor, 144 College St, Toronto, Ontario, Canada, M5S 3M2; Institute for Work and Health, 481 University Ave, Suite 800, Toronto, Ontario, Canada, M5G 2E9. (5)Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street, New York, NY, USA, 10014; Department of Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street, New York, NY, USA, 10014. (6)Department of Public Health Sciences and Alberta Centre for Injury Prevention and Research, School of Public Health, University of Alberta, 4075 RTG, 8308-114 Street, Edmonton, Alberta, Canada, T6G 2E1. (7)Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science Building, Room 3000, Oshawa, Ontario, Canada. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1. BACKGROUND CONTEXT: Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD). PURPOSE: To update findings of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD. STUDY DESIGN/SETTING: Systematic review and best-evidence synthesis. PATIENT SAMPLE: We included randomized controlled trials (RCTs), cohort studies, and case-control studies. OUTCOME MEASURES: Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events. METHODS: We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles. RESULTS: We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance,

advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD. CONCLUSIONS: Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 25014556 [PubMed - as supplied by publisher] 4. J Manipulative Physiol Ther. 2014 Jul-Aug;37(6):343-62. doi: 10.1016/j.jmpt.2014.05.001. Epub 2014 Jun 27. Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials. Tsertsvadze A(1), Clar C(1), Court R(2), Clarke A(3), Mistry H(4), Sutcliffe P(5). Author information: (1)Senior Research Fellow, Warwick Medical School, University of Warwick, Coventry, UK. (2)Information Specialist, Warwick Medical School, University of Warwick, Coventry, UK. (3)Professor, Warwick Medical School, University of Warwick, Coventry, UK. (4)Assistant Professor, Warwick Medical School, University of Warwick, Coventry, UK. (5)Associate Professor, Warwick Medical School, University of Warwick, Coventry, UK. Electronic address: p.a.sutcliffe@warwick.ac.uk. OBJECTIVES: The purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions. METHODS: A comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases. RESULTS: Twenty-five publications were included (11 trial-based economic evaluations). The studies compared cost-effectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (e.g., osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain. CONCLUSIONS: Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of

musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients. Copyright © 2014 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 24986566 [PubMed - indexed for MEDLINE] 5. Spine J. 2014 Feb 15. pii: S1529-9430(14)00210-1. doi: 10.1016/j.spinee.2014.02.014. [Epub ahead of print] Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Southerst D(1), Nordin MC(2), Côté P(3), Shearer HM(4), Varatharajan S(4), Yu H(4), Wong JJ(4), Sutton DA(4), Randhawa KA(4), van der Velde GM(5), Mior SA(6), Carroll LJ(7), Jacobs CL(8), Taylor-Vaisey AL(4). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1. Electronic address: danielle.southerst@uoit.ca. (2)Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street, New York, New York, USA, 10014. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College Street, Toronto, Ontario, Canada, M5S 3M2. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1. (5)Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College Street, Toronto, Ontario, Canada, M5S 3M2; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario, Canada, M5S 3M2; Institute for Work and Health, 481 University Ave, Toronto, Ontario, Canada, M5G 2E9. (6)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, Canada, L1H 7K4; (g)Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto,

Ontario, Canada, M2H 3J1. (7)Department of Public Health Sciences and Alberta Centre for Injury Prevention and Research, School of Public Health, University of Alberta, 4075 RTF, 8308-114 Street, Edmonton, Alberta, Canada, T6G 2E1. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1; Division of Clinical Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1. BACKGROUND CONTEXT: In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for Grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises. PURPOSE: To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III. STUDY DESIGN/SETTING: Systematic review and best evidence synthesis. SAMPLE: Studies comparing the effectiveness of exercise to other conservative interventions or no intervention. OUTCOME MEASURES: Outcomes of interest included self-rated recovery, functional recovery, pain intensity, health-related quality of life, psychological outcomes, and/or adverse events. METHODS: We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results of scientifically admissible studies were synthesized following best-evidence synthesis principles. RESULTS: We retrieved 4,761 articles, and 21 randomized controlled trials (RCTs) were critically appraised. Ten RCTs were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain Grade I/II, unsupervised range-of-motion exercises, nonsteroidal anti-inflammatory drugs and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain Grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD Grade I/II, supervised qigong and combined strengthening, range-of-motion, and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally, supervised high-dose strengthening is not superior to home exercises or advice. CONCLUSIONS: We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 24534390 [PubMed - as supplied by publisher] 6. Joint Bone Spine. 2013 Oct;80(5):508-15. doi: 10.1016/j.jbspin.2012.10.006. Epub

2012 Nov 16. Systematic review of manual therapies for nonspecific neck pain. Vincent K(1), Maigne JY, Fischhoff C, Lanlo O, Dagenais S. Author information: (1)Société franco-européenne de chiropratique (SOFEC), 25, avenue du Raincy, 93250 Villemomble, France. OBJECTIVE: To evaluate the effectiveness of manual therapies in the treatment of nonspecific neck pain. MATERIALS AND METHODS: Medline and the Cochrane Library were searched for randomized controlled trials of manual therapy or mobilization, used alone or with exercises to treat pain and functional impairment related to nonspecific neck pain. Cochrane Back Review Group criteria were used to assess the quality of the trials and the level of evidence (unclear, limited, moderate, or high) for short-, medium-, and long-term effects. RESULTS: Of 27 identified trials, 18 were of high quality. In acute neck pain, effective treatments were thoracic manipulation combined with electrothermal therapy in the short term and cervical manipulation in the long term. In chronic neck pain and neck pain of variable duration, both pain and function improved consistently at all follow-up time points. None of the manual therapies used alone or in combination was superior over the others. In the long term, exercises alone or combined with manual therapies were superior over manual therapies used alone. CONCLUSION: Manual therapies contribute usefully to the management of nonspecific neck pain. The level of evidence is moderate for short-term effects of upper thoracic manipulation in acute neck pain, limited for long-term effects of neck manipulation, and limited for all techniques and follow-up durations in chronic neck pain. Copyright © 2012 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved. PMID: 23165183 [PubMed - indexed for MEDLINE] 7. Eur Spine J. 2012 Aug;21(8):1441-50. doi: 10.1007/s00586-012-2272-5. Epub 2012 Mar 25. Cost-effectiveness of conservative treatments for neck pain: a systematic review on economic evaluations. Driessen MT(1), Lin CW, van Tulder MW. Author information: (1)Department of Health Sciences, The EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands. m.t.driessen@gmail.com

PURPOSE: Various conservative interventions have been used for the treatment of non-specific neck pain. The aim of this systematic review was to investigate the cost-effectiveness of conservative treatments for non-specific neck pain. METHODS: Clinical and economic electronic databases, reference lists and authors' databases were searched up to 13 January 2011. Two reviewers independently selected studies for inclusion, performed the risk of bias assessment and data extraction. RESULTS: A total of five economic evaluations met the inclusion criteria. All studies were conducted alongside randomised controlled trials and included a cost-utility analysis, and four studies also conducted a cost-effectiveness analysis. Most often, the economic evaluation was conducted from a societal or a health-care perspective. One study found that manual therapy was dominant over physiotherapy and general practitioner care, whilst behavioural graded activity was not cost-effective compared to manual therapy. The combination of advice and exercise with manual therapy was not cost-effective compared to advice and exercise only. One study found that acupuncture was cost-effective compared to a delayed acupuncture intervention, and another study found no differences on cost-effectiveness between a brief physiotherapy intervention compared to usual physiotherapy. Pooling of the data was not possible as heterogeneity existed between the studies on participants, interventions, controls, outcomes, follow-up duration and context related socio-political differences. CONCLUSION: At present, the limited number of studies and the heterogeneity between studies warrant no definite conclusions on the cost-effectiveness of conservative treatments for non-specific neck pain. PMCID: PMC3535241 PMID: 22447407 [PubMed - indexed for MEDLINE] 8. Spine J. 2009 Oct;9(10):859-71. doi: 10.1016/j.spinee.2009.04.019. Epub 2009 Jul 12. A Cochrane review of patient education for neck pain. Haines T(1), Gross AR, Burnie S, Goldsmith CH, Perry L, Graham N; Cervical Overview Group (COG). Author information: (1)Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada. BACKGROUND CONTEXT: Neck pain is common, disabling, and costly. The effectiveness of patient education strategies is unclear. PURPOSE: To assess whether patient education strategies are of benefit for pain, function/disability, global perceived effect, quality of life, or patient satisfaction, in adults with neck pain with or without radiculopathy. STUDY DESIGN: Cochrane systematic review. METHODS: Computerized bibliographic databases were searched from their start to May 31, 2008. Eligible studies were randomized trials investigating the effectiveness of patient education strategies for neck pain. Paired independent reviewers carried out study selection, data abstraction, and methodological

quality assessment. Relative risk and standardized mean differences were calculated. Because of differences in intervention type or disorder, no studies were considered appropriate to pool. RESULTS: Of the 10 selected trials, two (20%) were rated as of high quality. Patient education was assessed as follows: 1) eight trials of advice focusing on activation compared with no treatment, or to various active treatments, including therapeutic exercise, manual therapy, and cognitive behavioral therapy, showed either inferiority or no difference for pain, spanning a full range of follow-up periods, acuity and disorder types. When compared with rest, two trials that assessed acute whiplash-associated disorder showed moderate evidence of no difference for advice focusing on activation; 2) two trials studying advice focusing on pain and stress coping skills found moderate evidence of no benefit for chronic neck pain at intermediate- to long-term follow-up; and 3) one trial compared the effects of neck school to no treatment, yielding limited evidence of no benefit for pain, at intermediate-term follow-up in mixed acute/subacute/chronic neck pain. CONCLUSIONS: This review has not shown effectiveness for educational interventions for neck pain of various acuity stages and disorder types and at various follow-up periods, including advice to activate, advice on stress coping skills, and neck school. In future research, further attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of specific educational components. PMID: 19596214 [PubMed - indexed for MEDLINE] 9. Chiropr Osteopat. 2006 Apr 19;14:7. Comparative effectiveness of manipulation, mobilisation and the activator instrument in treatment of non-specific neck pain: a systematic review. Gemmell H(1), Miller P. Author information: (1)Department of Academic Affairs, Anglo-European College of Chiropractic, Bournemouth, UK. hgemmell@aecc.ac.uk BACKGROUND: Neck pain is a common problem and different forms of manual therapy are used in its treatment. The purpose of this systematic review was to critically appraise the literature that directly compared manipulation, mobilisation and the Activator instrument for non-specific neck pain. METHODS: Electronic databases (MEDLINE, MANTIS and CINAHL) were searched from their inception to October 2005 for all English language randomised clinical trials that directly compared manipulation, mobilisation and the Activator instrument. Inclusion and exclusion criteria were applied to select the studies and these studies were then evaluated using validated criteria. RESULTS: Five such studies were identified. The methodological quality was mostly poor. Findings from the studies were mixed and no one therapy was shown to be more effective than the others. CONCLUSION: Further high quality research has to be done before a recommendation

can be made as to the most effective manual method for non-specific neck pain. PMCID: PMC1459176 PMID: 16623934 [PubMed]

Effectiveness and MT and osteoarthritis 1. Br J Sports Med. 2015 Nov 26. pii: bjsports-2015-095255. doi: 10.1136/bjsports-2015-095255. [Epub ahead of print] Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis. Beumer L(1), Wong J(1), Warden SJ(2), Kemp JL(3), Foster P(1), Crossley KM(4). Author information: (1)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia. (2)School of Health and Rehabilitation Sciences, Indiana University, Indianapolis, Indiana, USA. (3)Australian Centre for Research into Injury and Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia. (4)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia. AIM: To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA). METHODS: A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0-3 months=short term; 4-12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores. RESULTS: 19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD -0.53, 95% CI -0.96 to -0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD -0.49, 95% CI -0.70 to -0.29). There were no medium (SMD -0.23, 95% CI -0.48 to 0.03) or long (SMD -0.22, 95% CI -0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD -0.38, 95% CI -0.88 to 0.13) when compared to minimal control. CONCLUSIONS: Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger high-quality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26612846 [PubMed - as supplied by publisher]

2. Reumatismo. 2013 May 27;65(2):63-74. doi: 10.4081/reumatismo.2013.63. Manual therapy and therapeutic exercise in the treatment of osteoarthritis of the hip: a systematic review. Romeo A(1), Parazza S, Boschi M, Nava T, Vanti C. Author information: (1)Manual Therapy, University of Padova, Italy. This systematic review aimed at investigating the role of therapeutic exercise and/or manual therapy in the treatment of hip osteoarthritis (OA). Two independent reviewers (AR, CV) searched PubMed, Cinahl, Cochrane Library, PEDro and Scopus databases and a third one (SP) was consulted in case of disagreement. The research criteria were publication period (from May 2007 to April 2012) and publication language (English or Italian). Ten randomized controlled trials matched inclusion criteria, eight of which concerning therapeutic exercise and two manual therapy. Few good quality studies were found. At mid- and long-term follow-up land-based exercises showed insufficient evidence of effectiveness with respect to pain and quality of life, but positive results were found for physical function. Water exercises significantly reduced fall risk when combined with functional exercises. Programs containing progressive and gradual exposure of difficult activities, education and exercises promoted better outcomes, higher adherence to home program and increased amount of physical activity, especially walking. Manual therapy seemed to reduce pain and decrease disability at short-term. Less use of nonsteroidal anti-inflammatory drugs was statistically significant at long-term follow-up in patients treated with manual therapy. The relationship between clinical results and radiological grade of OA was not investigated. Encouraging results were found in recent literature for manual therapy and functional training. Further research is needed to elucidate this issue through high-quality trials, especially addressing the aspects that have not been thoroughly explored yet, for instance type, amount and scheduling of conservative treatment. PMID: 23877410 [PubMed - indexed for MEDLINE]

Effectiveness and MT and pregnancy 1. J Orthop Sports Phys Ther. 2014 Jul;44(7):464-73, A1-15. doi: 10.2519/jospt.2014.5098. Epub 2014 May 10. Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review. van Benten E(1), Pool J, Mens J, Pool-Goudzwaard A. Author information: (1)University of Applied Sciences Utrecht, Utrecht, the Netherlands. Summary for patients in J Orthop Sports Phys Ther. 2014 Jul;44(7):474. STUDY DESIGN: Systematic review of the literature. OBJECTIVES: To review and assess the peer-reviewed literature on the effectiveness of physical therapy interventions in treating lumbopelvic pain during pregnancy. BACKGROUND: Current guidelines on interventions for lumbopelvic pain during pregnancy differ in their recommendations for assessment and intervention. Recent publications may allow revising current recommendations for the treatment of this complex problem. METHODS: An electronic search strategy was conducted in PubMed, PEDro, Scopus, and CINAHL of literature published from January 1992 to November 2013. Two authors independently assessed all abstracts for eligibility. Articles were independently rated for quality by 2 authors, using the Cochrane Back Review Group criteria for methodological quality. Where possible, effect sizes were calculated for the different interventions. RESULTS: A total of 22 articles (all randomized controlled trials) reporting on 22 independent studies were included. Overall, the methodological quality of the studies was moderate. Data for 4 types of interventions were considered: a combination of interventions (7 studies, n = 1202), exercise therapy (9 studies, n = 2149), manual therapy (5 studies, n = 360), and material support (1 study, n = 115). CONCLUSION: All included studies on exercise therapy, and most of the studies on interventions combined with patient education, reported a positive effect on pain, disability, and/or sick leave. Evidence-based recommendations can be made for the use of exercise therapy for the treatment of lumbopelvic pain during pregnancy. LEVEL OF EVIDENCE: Therapy, level 1a-. J Orthop Sports Phys Ther 2014;44(7):464-473. Epub 10 May 2014. doi:10.2519/jospt.2014.5098. PMID: 24816503 [PubMed - indexed for MEDLINE]

Effectiveness and MT and rotator cuff 1. Chiropr Man Therap. 2014 Mar 28;22(1):12. doi: 10.1186/2045-709X-22-12. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P(1). Author information: (1)Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, England. p.a.sutcliffe@warwick.ac.uk. BACKGROUND: This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report. METHODS: A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added. RESULTS: 25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive. CONCLUSIONS: Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted. PMCID: PMC3997823 PMID: 24679336 [PubMed] 2. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60. doi: 10.1016/j.jse.2008.06.004. Epub 2008 Oct 2. Exercise in the treatment of rotator cuff impingement: a systematic review and a

synthesized evidence-based rehabilitation protocol. Kuhn JE(1). Author information: (1)Vanderbilt Shoulder Center, Nashville, TN 37232, USA. j.kuhn@vanderbilt.edu Comment in J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):e33; author reply e33-4. J Athl Train. 2010 Sep-Oct;45(5):483-5. A systematic review of the literature was performed to evaluate the role of exercise in treating rotator cuff impingement and to synthesize a standard evidence-based rehabilitation protocol. Eleven randomized, controlled trials (level 1 and 2) evaluating the effect of exercise in the treatment of impingement were identified. Data regarding demographics, methodology, and outcomes of pain, range of motion, strength, and function were recorded. Individual components of each rehabilitation program were catalogued. Effectiveness was determined by statistical and clinical significance. Although many articles had methodologic concerns, the data demonstrate that exercise has statistically and clinically significant effects on pain reduction and improving function, but not on range of motion or strength. Manual therapy augments the effects of exercise, yet supervised exercise was not different than home exercise programs. Information regarding specific components of the exercise programs was synthesized into a gold standard rehabilitation protocol for future studies on the nonoperative treatment of rotator cuff impingement. PMID: 18835532 [PubMed - indexed for MEDLINE] 3. J Occup Rehabil. 2006 Mar;16(1):7-25. Treatment of impingement syndrome: a systematic review of the effects on functional limitations and return to work. Faber E(1), Kuiper JI, Burdorf A, Miedema HS, Verhaar JA. Author information: (1)Netherlands Expert Centre for Work Related Musculoskeletal Disorders, Erasmus MC, Rotterdam, The Netherlands. e.faber@erasmusmc.nl The goal of this systematic review is to evaluate the effectiveness of different treatments for impingement syndrome and rotator cuff tear on the improvement in functional limitations and concomitant duration of sick leave. A systematic search for clinical trials or controlled studies was conducted with the following text words: should*, rotator cuff, impingement, work, sick leave, disabilit*, function*. Nineteen articles were included in this review. For functional limitations, there is strong evidence that extracorporeal shock-wave therapy is not effective, moderate evidence that exercise combined with manual therapy is more effective than exercise alone, that ultrasound is not effective, and that open and arthroscopic acromioplasty are equally effective on the long term. For

all other interventions there is only limited evidence. We found many studies using range of motion and pain as outcome measures but functional limitations were less often used as an outcome measure in this type of research. Duration of sick leave was seldom included as an outcome measure. PMID: 16705497 [PubMed - indexed for MEDLINE] 4. Clin J Sport Med. 2003 May;13(3):176-82. Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Desmeules F(1), Côté CH, Frémont P. Author information: (1)Laval University Hospital Research Centre, Laval University, Quebec, Canada. OBJECTIVE: To review randomized controlled trials evaluating the effectiveness of therapeutic exercise and orthopedic manual therapy for the treatment of impingement syndrome. DATA SOURCE: Reports up to October 2002 were located from MEDLINE, the Cochrane Database of Systematic Reviews, the Physiotherapy Evidence Database (PEDro), the TRIP database, and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) using "shoulder" and "clinical trial"/"randomized controlled trial" as search terms. STUDY SELECTION: Studies were included if (1) they were a randomized controlled trial; (2) they were related to impingement syndrome, rotator cuff tendinitis, or bursitis; (3) one of the treatments included therapeutic exercise or manual therapy. DATA EXTRACTION: Two independent observers reviewed the methodological quality of the studies using an assessment tool developed by the Cochrane Musculoskeletal Injuries Group. Differences were resolved by consensus. DATA SYNTHESIS: Seven trials met our inclusion criteria. After consensus, the mean methodological score for all studies was 13.9 +/- 2.4 (of 24). Four studies of 7, including the 3 trials with the best methodological score (67%), suggested some benefit of therapeutic exercise or manual therapy compared with other treatments such as acromioplasty, placebo, or no intervention. CONCLUSIONS: There is limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome. More methodologically sound studies are needed to further evaluate these interventions. PMID: 12792213 [PubMed - indexed for MEDLINE]

Effectiveness and MT and TMJ disorders 1. Phys Ther. 2016 Jan;96(1):9-25. doi: 10.2522/ptj.20140548. Epub 2015 Aug 20. Effectiveness of Manual Therapy and Therapeutic Exercise for Temporomandibular Disorders: Systematic Review and Meta-Analysis. Armijo-Olivo S(1), Pitance L(2), Singh V(3), Neto F(4), Thie N(5), Michelotti A(6). Author information: (1)S. Armijo-Olivo, PT, BScPT, MScPT, PhD, Department of Physical Therapy, Faculty of Rehabilitation Medicine, 3-48 Corbett Hall, University of Alberta, Edmonton, Alberta, Canada T6G 2G4. sla4@ualberta.ca susanarmijo@gmail.com. (2)L. Pitance, PT, MT, PhD, Université Catholique de Louvain-Institute of Neuroscience, Brussels, Belgium, and Stomatology and Maxillofacial Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium. (3)V. Singh, DDS, MS, MSc, Department of Dentistry, Faculty of Medicine, TMD/Orofacial Pain Clinic, Kaye Edmonton Clinic, Edmonton, Alberta, Canada. (4)F. Neto, PT, FisioNeto-Terapia Manual Ortopédica and Pilates Clínico, Póvoa de Varzim, Portugal. (5)N. Thie, BSc, MSc, MMSc, DDS, School of Dentistry, Faculty of Medicine and Dentistry, TMD/Orofacial Pain Graduate Program, Edmonton Clinic Health Academy, Edmonton, Alberta, Canada. (6)A. Michelotti, BSc, DDS, Orthodontic Post-Graduate Program and TMD/Orofacial Pain Master Program, School of Medicine Federico II-Dental School, Naples, Italy. BACKGROUND: Manual therapy (MT) and exercise have been extensively used to treat people with musculoskeletal conditions such as temporomandibular disorders (TMD). The evidence regarding their effectiveness provided by early systematic reviews is outdated. PURPOSE: The aim of this study was to summarize evidence from and evaluate the methodological quality of randomized controlled trials that examined the effectiveness of MT and therapeutic exercise interventions compared with other active interventions or standard care for treatment of TMD. DATA SOURCES: Electronic data searches of 6 databases were performed, in addition to a manual search. STUDY SELECTION: Randomized controlled trials involving adults with TMD that compared any type of MT intervention (eg, mobilization, manipulation) or exercise therapy with a placebo intervention, controlled comparison intervention, or standard care were included. The main outcomes of this systematic review were pain, range of motion, and oral function. Forty-eight studies met the inclusion criteria and were analyzed. DATA EXTRACTION: Data were extracted in duplicate on specific study characteristics. DATA SYNTHESIS: The overall evidence for this systematic review was considered low. The trials included in this review had unclear or high risk of bias. Thus, the evidence was generally downgraded based on assessments of risk of bias. Most of the effect sizes were low to moderate, with no clear indication of superiority of exercises versus other conservative treatments for TMD. However, MT alone or in combination with exercises at the jaw or cervical level showed promising

effects. LIMITATIONS: Quality of the evidence and heterogeneity of the studies were limitations of the study. CONCLUSIONS: No high-quality evidence was found, indicating that there is great uncertainty about the effectiveness of exercise and MT for treatment of TMD. © 2016 American Physical Therapy Association. PMID: 26294683 [PubMed - in process] 2. J Oral Rehabil. 2015 Nov;42(11):847-61. doi: 10.1111/joor.12321. Epub 2015 Jun 7. Manual therapy for the management of pain and limited range of motion in subjects with signs and symptoms of temporomandibular disorder: a systematic review of randomised controlled trials. Calixtre LB(1), Moreira RF(1), Franchini GH(1), Alburquerque-Sendín F(2), Oliveira AB(1). Author information: (1)Department of Physiotherapy, Federal University of São Carlos (UFSCar), São Carlos, Brazil. (2)Department of Nursing and Physiotherapy, Salamanca University, Salamanca, Spain. There is a lack of knowledge about the effectiveness of manual therapy (MT) on subjects with temporomandibular disorders (TMD). The aim of this systematic review is to synthetise evidence regarding the isolated effect of MT in improving maximum mouth opening (MMO) and pain in subjects with signs and symptoms of TMD. MEDLINE(®) , Cochrane, Web of Science, SciELO and EMBASE(™) electronic databases were consulted, searching for randomised controlled trials applying MT for TMD compared to other intervention, no intervention or placebo. Two authors independently extracted data, PEDro scale was used to assess risk of bias, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) was applied to synthetise overall quality of the body of evidence. Treatment effect size was calculated for pain, MMO and pressure pain threshold (PPT). Eight trials were included, seven of high methodological quality. Myofascial release and massage techniques applied on the masticatory muscles are more effective than control (low to moderate evidence) but as effective as toxin botulinum injections (moderate evidence). Upper cervical spine thrust manipulation or mobilisation techniques are more effective than control (low to high evidence), while thoracic manipulations are not. There is moderate-to-high evidence that MT techniques protocols are effective. The methodological heterogeneity across trials protocols frequently contributed to decrease quality of evidence. In conclusion, there is widely varying evidence that MT improves pain, MMO and PPT in subjects with TMD signs and symptoms, depending on the technique. Further studies should consider using standardised evaluations and better study designs to strengthen clinical relevance. © 2015 John Wiley & Sons Ltd.

PMID: 26059857 [PubMed - in process] 3. Phys Ther. 2006 Jul;86(7):955-73. A systematic review of the effectiveness of exercise, manual therapy, electrotherapy, relaxation training, and biofeedback in the management of temporomandibular disorder. Medlicott MS(1), Harris SR. Author information: (1)Lion's Gate Hospital, North Vancouver, British Columbia, Canada. mmedlicott@hotmail.com Comment in Evid Based Dent. 2007;8(4):110-1. Phys Ther. 2006 Jul;86(7):910-1. BACKGROUND AND PURPOSE: This systematic review analyzed studies examining the effectiveness of various physical therapy interventions for temporomandibular disorder. METHODS: Studies met 4 criteria: (1) subjects were from 1 of 3 groups identified in the first axis of the Research Diagnostic Criteria for Temporomandibular Disorders, (2) the intervention was within the realm of physical therapist practice, (3) an experimental design was used, and (4) outcome measures assessed one or more primary presenting symptoms. Thirty studies were evaluated using Sackett's rules of evidence and 10 scientific rigor criteria. Four randomly selected articles were classified independently by 2 raters (interrater agreement of 100% for levels of evidence and 73.5% for methodological rigor). RESULTS: The following recommendations arose from the 30 studies: (1) active exercises and manual mobilizations may be effective; (2) postural training may be used in combination with other interventions, as independent effects of postural training are unknown; (3) mid-laser therapy may be more effective than other electrotherapy modalities; (4) programs involving relaxation techniques and biofeedback, electromyography training, and proprioceptive re-education may be more effective than placebo treatment or occlusal splints; and (5) combinations of active exercises, manual therapy, postural correction, and relaxation techniques may be effective. DISCUSSION AND CONCLUSION: These recommendations should be viewed cautiously. Consensus on defining temporomandibular joint disorder, inclusion and exclusion criteria, and use of reliable and valid outcome measures would yield more rigorous research. PMID: 16813476 [PubMed - indexed for MEDLINE] 4. Phys Ther. 2006 May;86(5):710-25. A systematic review of the effectiveness of physical therapy interventions for temporomandibular disorders.

McNeely ML(1), Armijo Olivo S, Magee DJ. Author information: (1)Department of Physical Therapy, 2-50 Corbett Hall, University of Alberta, Edmonton, Alberta, Canada T6G 2G4. Comment in Phys Ther. 2006 Jul;86(7):910-1. BACKGROUND AND PURPOSE: The purpose of this qualitative systematic review was to assess the evidence concerning the effectiveness of physical therapy interventions in the management of temporomandibular disorders. METHODS: A literature search of published and unpublished articles resulted in the retrieval of 36 potential articles. RESULTS: Twelve studies met all selection criteria for inclusion in the review: 4 studies addressed the use of therapeutic exercise interventions, 2 studies examined the use of acupuncture, and 6 studies examined electrophysical modalities. Two studies provided evidence in support of postural exercises to reduce pain and to improve function and oral opening. One study provided evidence for the use of manual therapy in combination with active exercises to reduce pain and to improve oral opening. One study provided evidence in support of acupuncture to reduce pain when compared with no treatment; however, in another study no significant differences in pain outcomes were found between acupuncture and sham acupuncture. Significant improvements in oral opening were found with muscular awareness relaxation therapy, biofeedback training, and low-level laser therapy treatment. DISCUSSION AND CONCLUSION: Most of the studies included in this review were of very poor methodological quality; therefore, the findings should be interpreted with caution. PMID: 16649894 [PubMed - indexed for MEDLINE]

Exercise and Ankle 1. Clin Sports Med. 2015 Apr;34(2):329-46. doi: 10.1016/j.csm.2014.12.001. Epub 2015 Feb 14. Supervised rehabilitation versus home exercise in the treatment of acute ankle sprains: a systematic review. Feger MA(1), Herb CC(1), Fraser JJ(2), Glaviano N(1), Hertel J(3). Author information: (1)Department of Kinesiology, University of Virginia, 210 Emmet Street South, Charlottesville, VA 22904-4407, USA. (2)Department of Kinesiology, University of Virginia, 210 Emmet Street South, Charlottesville, VA 22904-4407, USA; US Navy Medicine Professional Development Center, Bethesda, MD, USA. (3)Department of Kinesiology, University of Virginia, 210 Emmet Street South, Charlottesville, VA 22904-4407, USA. Electronic address: jhertel@virginia.edu. In competitive sports medicine, supervised rehabilitation is the standard of care; in the general population, unsupervised home exercise is more common. We systematically reviewed randomized, controlled trials comparing outcomes for supervised rehabilitation versus home exercise programs. Supervised rehabilitation programs resulted in (1) less pain and subjective instability, (2) greater gains in ankle strength and joint position sense, and (3) inconclusive results regarding prevention of recurrent ankle sprains. We recommend supervised rehabilitation over home exercise programs owing to the improved short-term patient-recorded evidence with a strength-of-recommendation taxonomy level of evidence of 2B. Copyright © 2015 Elsevier Inc. All rights reserved. PMID: 25818717 [PubMed - indexed for MEDLINE] 2. Chiropr Man Therap. 2015 Oct 27;23:30. doi: 10.1186/s12998-015-0075-6. eCollection 2015. The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Southerst D(1), Yu H(2), Randhawa K(3), Côté P(4), D'Angelo K(5), Shearer HM(2), Wong JJ(6), Sutton D(2), Varatharajan S(3), Goldgrub R(7), Dion S(5), Cox J(5), Menta R(5), Brown CK(5), Stern PJ(8), Stupar M(2), Carroll LJ(9), Taylor-Vaisey A(10). Author information: (1)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario Canada M5G 1X5. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College

(CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (4)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (5)Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (7)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4. (8)Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (9)Injury Prevention Centre and School of Public Health, University of Alberta, 4075 Research Transition Facility, 8308-114 St, Edmonton, Alberta Canada T6G 2E1. (10)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. BACKGROUND: Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI. RESULTS: We screened 6047 articles. Seven RCTs were critically appraised and

three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults. CONCLUSIONS: The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009899. PMCID: PMC4623271 PMID: 26512315 [PubMed] 3. J Orthop Sports Phys Ther. 2014 Sep;44(9):690-701, C1-7. doi: 10.2519/jospt.2014.5294. Epub 2014 Aug 6. Early ankle movement versus immobilization in the postoperative management of ankle fracture in adults: a systematic review and meta-analysis. Keene DJ(1), Williamson E, Bruce J, Willett K, Lamb SE. Author information: (1)Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK. STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: To compare early ankle movement versus ankle immobilization after surgery for ankle fracture on clinical and patient-reported outcomes. BACKGROUND: A significant proportion of patients undergoing surgery for ankle fracture experience postoperative complications and delayed return to function. The risks and benefits of movement of the ankle in the first 6 weeks after surgery are not known, and clinical practice varies widely. METHODS: We searched bibliographic databases and reference lists to identify eligible trials. Two independent reviewers conducted data extraction and risk-of-bias assessments. RESULTS: Fourteen trials (705 participants) were included in the review, 11 of which were included in the meta-analysis. The quality of the trials was universally poor. The pooled effect of early ankle movement on function at 9 to 12 weeks after surgery compared to immobilization was inconclusive (standardized mean difference, 0.46; 95% confidence interval: -0.02, 0.93; P = .06; I(2) = 72%), and no differences were observed between groups at 1 year. The odds of venous thromboembolism were significantly lower with early ankle movement

compared to immobilization (Peto odds ratio = 0.12; 95% confidence interval: 0.02, 0.71; P = .02; I(2) = 0%). Deep surgical site infection (Peto odds ratio = 7.08; 95% confidence interval: 1.39, 35.99; P = .02; I(2) = 0%), superficial surgical site infection, fixation failure, and reoperation to remove metalwork were more common after early ankle movement compared to immobilization. CONCLUSION: The quality of evidence is poor. The effects of early movement after ankle surgery on short-term functional outcomes are unclear, but there is no observable difference in the longer term. There is a small reduction in risk of postoperative thromboembolism with early ankle movement. Current evidence suggests that deep and superficial surgical site infections, fixation failure, and the need to remove metalwork are more common after early ankle movement. Level of Evidence Therapy, level 1a-. PMID: 25098197 [PubMed - indexed for MEDLINE] 4. J Am Podiatr Med Assoc. 2013 Nov-Dec;103(6):534-47. Effectiveness of foot and ankle exercise programs on reducing the risk of falling in older adults: a systematic review and meta-analysis of randomized controlled trials. Schwenk M(1), Jordan ED, Honarvararaghi B, Mohler J, Armstrong DG, Najafi B. Author information: (1)Interdisciplinary Consortium on Advanced Motion Performance College of Medicine, University of Arizona, Tucson, AZ. BACKGROUND: Foot and ankle (FA) exercise programs might reduce the risk of falling in older adults. We sought to systematically review the current literature on FA exercise programs targeted at reducing the risk of falling in older adults. METHODS: A systematic literature search was performed in the PubMed database, the Physiotherapy Evidence Database, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials. Articles were included based on the following criteria: 1) randomized controlled trial, 2) FA exercise program, and 3) use of fall risk-related motor outcomes (strength, balance, flexibility, and functional ability) or use of falls as an outcome. Weighted effect sizes (d) were calculated across studies for estimating the overall effect of FA exercises on the most frequently reported motor outcome parameters. RESULTS: Eight publications met the inclusion criteria. Small to moderate overall effects were found for balance (d = 0.46, P < .001) and ankle flexibility (d = 0.29, P = .006). No significant overall effects were found for ankle plantarflexor strength (d = 0.11, P = .223) and walking performance (d = -0.05, P = .404). Controversial results were reported for other functional measures. Effects varied depending on the type of intervention. Only one study reported improved ankle evertor strength and a significant reduction in falls. CONCLUSIONS: Evidence suggests that FA exercise can improve certain fall risk-related motor outcomes and reduce falls. Limited effects on strength and functional ability might be related to insufficient training intensity and lack

of adherence. Further studies that include progressive strength and flexibility training are necessary to validate which FA exercise programs are most effective at preventing falls. PMID: 24297989 [PubMed - indexed for MEDLINE] 5. J Athl Train. 2013 Sep-Oct;48(5):696-709. doi: 10.4085/1062-6050-48.4.11. Epub 2013 Aug 5. Therapeutic interventions for increasing ankle dorsiflexion after ankle sprain: a systematic review. Terada M(1), Pietrosimone BG, Gribble PA. Author information: (1)Musculoskeletal Health and Movement Science Laboratory, University of Toledo, OH. CONTEXT: Clinicians perform therapeutic interventions, such as stretching, manual therapy, electrotherapy, ultrasound, and exercises, to increase ankle dorsiflexion. However, authors of previous studies have not determined which intervention or combination of interventions is most effective. OBJECTIVE: To determine the magnitude of therapeutic intervention effects on and the most effective therapeutic interventions for restoring normal ankle dorsiflexion after ankle sprain. DATA SOURCES: We performed a comprehensive literature search in Web of Science and EBSCO HOST from 1965 to May 29, 2011, with 19 search terms related to ankle sprain, dorsiflexion, and intervention and by cross-referencing pertinent articles. STUDY SELECTION: Eligible studies had to be written in English and include the means and standard deviations of both pretreatment and posttreatment in patients with acute, subacute, or chronic ankle sprains. Outcomes of interest included various joint mobilizations, stretching, local vibration, hyperbaric oxygen therapy, electrical stimulation, and mental-relaxation interventions. DATA EXTRACTION: We extracted data on dorsiflexion improvements among various therapeutic applications by calculating Cohen d effect sizes with associated 95% confidence intervals (CIs) and evaluated the methodologic quality using the Physiotherapy Evidence Database (PEDro) scale. DATA SYNTHESIS: In total, 9 studies (PEDro score = 5.22 ± 1.92) met the inclusion criteria. Static-stretching interventions with a home exercise program had the strongest effects on increasing dorsiflexion in patients 2 weeks after acute ankle sprains (Cohen d = 1.06; 95% CI = 0.12, 2.42). The range of effect sizes for movement with mobilization on ankle dorsiflexion among individuals with recurrent ankle sprains was small (Cohen d range = 0.14 to 0.39). CONCLUSIONS: Static-stretching intervention as a part of standardized care yielded the strongest effects on dorsiflexion after acute ankle sprains. The existing evidence suggests that clinicians need to consider what may be the limiting factor of ankle dorsiflexion to select the most appropriate treatments and interventions. Investigators should examine the relationship between improvements in dorsiflexion and patient progress using measures of patient

self-reported functional outcome after therapeutic interventions to determine the most appropriate forms of therapeutic interventions to address ankle-dorsiflexion limitation. PMCID: PMC3784372 PMID: 23914912 [PubMed - indexed for MEDLINE] 6. Med Sci Sports Exerc. 2013 Aug;45(8):1534-44. doi: 10.1249/MSS.0b013e318289d821. Immediate effect of exercise on achilles tendon properties: systematic review. Obst SJ(1), Barrett RS, Newsham-West R. Author information: (1)School of Rehabilitation Sciences and Center for Musculoskeletal Research, Griffith Health Institute, Griffith University, Queensland, Australia. s.obst@griffith.edu.au INTRODUCTION: Understanding the mechanical and morphological adaptation of the Achilles tendon (AT) in response to acute exercise could have important implications for athletic performance, injury prevention, and rehabilitation. The purpose of this study was to conduct a systematic review and critical evaluation of the literature to determine the immediate effect of a single bout of exercise on the mechanical and morphological properties of the AT in vivo. METHODS: Five electronic research databases were systematically searched for intervention-based studies reporting mechanical and morphological properties of the AT after a single bout of exercise. RESULTS: Searches revealed 3292 possible articles; 21 met the inclusion criteria. There is evidence that maximal isometric contractions and prolonged static stretching (>5 min) of the triceps surae complex cause an immediate decrease in AT stiffness, whereas prolonged running and hopping have minimal effect. Limited but consistent evidence exists, indicating that AT hysteresis is reduced after prolonged static stretching. Consistent evidence supports a reduction in free AT diameter (anterior-posterior) after dynamic ankle exercise, and this change appears most pronounced in the healthy tendon and after eccentric exercise. CONCLUSIONS: The mechanical and morphological properties of the AT in vivo are affected by acute exercise in a mode- and dose-dependent manner. Transient changes in AT stiffness, hysteresis, and diameter after unaccustomed exercise modes and doses may expose the tendon to increased risk of strain injury and impact on the mechanical function of the triceps surae muscle-tendon unit. PMID: 23439426 [PubMed - indexed for MEDLINE] 7. Man Ther. 2012 Aug;17(4):285-91. doi: 10.1016/j.math.2012.02.016. Epub 2012 Mar 27. Effectiveness of proprioceptive exercises for ankle ligament injury in adults: a systematic literature and meta-analysis.

Postle K(1), Pak D, Smith TO. Author information: (1)School of Allied Health Professions, Faculty of Medicine and Health Science, University of East Anglia, Queen's Building, Norwich NR4 7TJ, UK. K.Postle1@uea.ac.uk The purpose of this study was to assess the effectiveness of such proprioceptive exercise following ankle ligament injury. A systematic review of the databases MEDLINE, EMBASE, CINHAL, AMED, the Cochrane library database and the PEDro database, in addition to unpublished literature databases was conducted to July 2011. When appropriate, meta-analysis was conducted to pool results from homogeneous studies. The methodological quality of the literature was reviewed using the Critical Appraisal Skills Programme tool. The results indicated that there is no statistically significant difference in recurrent injury between the addition of proprioceptive exercises during the rehabilitation of patients following ankle ligament injury (p = 0.68). The addition of proprioceptive training demonstrated a significant reduction in subjective instability and functional outcomes (p < 0.05). There was no consensus on the advantages of including proprioceptive training in the rehabilitation of this population for swelling, postural sway, joint position sense, ankle range of motion or return to sport outcomes. Further study is warranted to develop the rigour of the evidence-base and to determine the optimal proprioceptive training programme following ankle ligament injury with different populations. Copyright © 2012 Elsevier Ltd. All rights reserved. PMID: 22459604 [PubMed - indexed for MEDLINE] 8. Eur J Phys Rehabil Med. 2009 Sep;45(3):431-41. Epub 2008 Dec 16. Effects of rehabilitation after ankle fracture: a Cochrane systematic review. Lin CW(1), Moseley AM, Refshauge KM. Author information: (1)George Institute for International Health, University of Sydney, NSW, Australia. clin@george.org.au BACKGROUND: Ankle fracture is one of the most common lower limb fractures. People experience limitations in activities after ankle fracture. OBJECTIVES: The aim of this review was to evaluate the effects of rehabilitation interventions after ankle fracture in adults. METHODS: Electronic databases, reference lists of included studies and relevant systematic reviews, and clinical trials registers were searched for randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture. The primary outcomes were activity limitation and adverse events. Two reviewers independently screened search results, assessed methodological quality, and extracted data. RESULTS: Thirty-one studies were included. Clinical and statistical

heterogeneity, or the low number of studies in the comparison, prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation but also led to a higher rate of adverse events (relative risk 2.61, 95% CI 1.72 to 3.97). Most other rehabilitation interventions did not show an effect in improving activity limitation. CONCLUSIONS: There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period for improving activity limitation. Because of the potential increased risk, the patient's ability to comply with this treatment regimen is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence. PMID: 19078904 [PubMed - indexed for MEDLINE] 9. Sports Med. 2008;38(7):553-63. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review. Loudon JK(1), Santos MJ, Franks L, Liu W. Author information: (1)Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas, USA. jloudon@kumc.edu Functional ankle instability (FAI) is a term used to describe an ankle that easily 'gives way' with activity. There have been many proposed causes of FAI including joint proprioceptive deficiency, muscle weakness, balance control impairments, and delayed muscle reaction time, none of which has proven to be the exclusive cause of FAI. Treatment becomes difficult when the causative factor of the injury is obscure. This systematic review evaluates the clinical trials involving conservative exercise interventions in FAI and examines the changes induced by the exercise treatments to the various potential FAI factors. Sixteen articles describing the active exercise treatment of FAI were analysed using Sackett's levels of evidence and were examined for scientific rigor. From this review, it can be concluded that conservative treatment interventions including balance, proprioceptive and muscle strengthening exercises are effective for patients with FAI in decreasing the incidence of giving-way episodes, improving balance stability, and improving function. PMID: 18557658 [PubMed - indexed for MEDLINE] 10. Aust J Physiother. 2006;52(1):27-37. Effectiveness of exercise therapy and manual mobilisation in ankle sprain and functional instability: a systematic review. van der Wees PJ(1), Lenssen AF, Hendriks EJ, Stomp DJ, Dekker J, de Bie RA.

Author information: (1)Department of Epidemiology, Maastricht University, The Netherlands. philip.vanderwees@epid.unimaas.nl This study critically reviews the effectiveness of exercise therapy and manual mobilisation in acute ankle sprains and functional instability by conducting a systematic review of randomised controlled trials. Trials were searched electronically and manually from 1966 to March 2005. Randomised controlled trials that evaluated exercise therapy or manual mobilisation of the ankle joint with at least one clinically relevant outcome measure were included. Internal validity of the studies was independently assessed by two reviewers. When applicable, relative risk (RR) or standardised mean differences (SMD) were calculated for individual and pooled data. In total 17 studies were included. In thirteen studies the intervention included exercise therapy and in four studies the effects of manual mobilisation of the ankle joint was evaluated. Average internal validity score of the studies was 3.1 (range 1 to 7) on a 10-point scale. Exercise therapy was effective in reducing the risk of recurrent sprains after acute ankle sprain: RR 0.37 (95% CI 0.18 to 0.74), and with functional instability: RR 0.38 (95% CI 0.23 to 0.62). No effects of exercise therapy were found on postural sway in patients with functional instability: SMD: 0.38 (95% CI -0.15 to 0.91). Four studies demonstrated an initial positive effect of different modes of manual mobilisation on dorsiflexion range of motion. It is likely that exercise therapy, including the use of a wobble board, is effective in the prevention of recurrent ankle sprains. Manual mobilisation has an (initial) effect on dorsiflexion range of motion, but the clinical relevance of these findings for physiotherapy practice may be limited. PMID: 16515420 [PubMed - indexed for MEDLINE]

Exercise and Asthma 1. BMC Pediatr. 2016 Apr 18;16:50. doi: 10.1186/s12887-016-0571-4. Childhood asthma and physical activity: a systematic review with meta-analysis and Graphic Appraisal Tool for Epidemiology assessment. Lochte L(1), Nielsen KG(2), Petersen PE(3), Platts-Mills TA(4). Author information: (1)Department of Odontology, University of Copenhagen, Copenhagen, 1014, Denmark. rkb664@alumni.ku.dk. (2)Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, 2100, Denmark. (3)Department of Odontology, University of Copenhagen, Copenhagen, 1014, Denmark. (4)Department of Medicine, Division of Allergy and Clinical Immunology, University of Virginia, Charlottesville, 22908, VA, USA. BACKGROUND: Childhood asthma is a global problem affecting the respiratory health of children. Physical activity (PA) plays a role in the relationship between asthma and respiratory health. We hypothesized that a low level of PA would be associated with asthma in children and adolescents. The objectives of our study were to (1) summarize the evidence available on associations between PA and asthma prevalence in children and adolescents and (2) assess the role of PA in new-onset or incident asthma among children and adolescents. METHODS: We searched Medline, the Cochrane Library, and Embase and extracted data from original articles that met the inclusion criteria. Summary odds ratios (ORs) and confidence intervals (CIs) were used to express the results of the meta-analysis (forest plot). We explored heterogeneity using funnel plots and the Graphic Appraisal Tool for Epidemiology (GATE). RESULTS: We retrieved 1,571 titles and selected 11 articles describing three cohort and eight cross-sectional studies for inclusion. A meta-analysis of the cohort studies revealed a risk of new-onset asthma in children with low PA (OR [95 % CI] 1.32 [0.95; 1.84] [random effects] and 1.35 [1.13; 1.62] [fixed effects]). Three cross-sectional studies identified significant positive associations between childhood asthma or asthma symptoms and low PA. CONCLUSIONS: Children and adolescents with low PA levels had an increased risk of new-onset asthma, and some had a higher risk of current asthma/or wheezing; however, there was some heterogeneity among the studies. This review reveals a critical need for future longitudinal assessments of low PA, its mechanisms, and its implications for incident asthma in children. The systematic review was prospectively registered at PROSPERO (registration number: CRD42014013761; available at: http://www.crd.york.ac.uk/PROSPERO [accessed: 24 March 2016]). PMCID: PMC4836150 PMID: 27091126 [PubMed - in process] 2. J Sch Nurs. 2015 Feb;31(1):70-6. doi: 10.1177/1059840514523295. Epub 2014 Feb 12. A systematic review of the literature on screening for exercise-induced asthma: considerations for school nurses.

Worrell K(1), Shaw MR(2), Postma J(3), Katz JR(3). Author information: (1)Providence Medical Research Center, Sacred Heart Medical Center and Children's Hospital, Spokane, WA, USA. (2)College of Nursing, Washington State University, Spokane, WA, USA michele_shaw@wsu.edu. (3)College of Nursing, Washington State University, Spokane, WA, USA. Asthma is a major cause of illness, missed school days, and hospitalization in children. One type of asthma common in children is exercise-induced asthma (EIA). EIA causes airway narrowing with symptoms of cough and shortness of breath during exercise. The purpose of this article is to review the literature relevant to screening children and adolescents for EIA and to inform development of a school nurse-led EIA screening program. A systematic review of EIA screening tests was conducted by searching PUBMED for key terms. Sixty-seven articles were identified; after review only seven met the inclusion criteria. The most common screening test was the 6-min exercise challenge. School-based screening programs have the potential to identify EIA among undiagnosed children and adolescents. School nurses are health professionals with the knowledge and skills necessary to develop successful screening programs in the school setting. Based on results of the literature review, we present implications for developing screening programs in schools to identify children with undiagnosed EIA. © The Author(s) 2014. PMID: 24526571 [PubMed - in process] 3. Br J Sports Med. 2014 Jul;48(13):1024-31. doi: 10.1136/bjsports-2012-091347. Epub 2013 Mar 23. Exercise training in children with asthma: a systematic review. Wanrooij VH(1), Willeboordse M(1), Dompeling E(1), van de Kant KD(1). Author information: (1)Department of Paediatric Pulmonology, School for Public Health and Primary Care (CAPHRI), Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands. Exercise can provoke asthma symptoms, such as dyspnoea, in children with asthma. Exercise-induced bronchoconstriction (EIB) is prevalent in 40-90% of children with asthma. Conversely, exercise can improve physical fitness. The purpose of this paper is to provide a systematic review of the literature regarding the effects of exercise training in children with asthma, particularly in relation to: EIB, asthma control, pulmonary function, cardiorespiratory parameters and parameters of underlying pathophysiology. A systematic search in several databases was performed. Controlled trials that undertook a physical training programme in children with asthma (aged 6-18 years) were selected. Twenty-nine studies were included. Training had positive effects on several cardiorespiratory

fitness parameters. A few studies demonstrated that training could improve EIB, especially in cases where there was sufficient room for improvement. Peak expiratory flow was the only lung function parameter that could be improved substantially by training. The effects of training on asthma control, airway inflammation and bronchial hyper-responsiveness were barely studied. Owing to the overall beneficial effects of training and the lack of negative effects, it can be concluded that physical exercise is safe and can be recommended in children with asthma. A training programme should have a minimum duration of 3 months, with at least two 60 min training sessions per week, and a training intensity set at the (personalised) ventilatory threshold. Further research is recommended regarding the effects of exercise on underlying pathophysiological mechanisms and asthma control in children with asthma. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. PMID: 23525551 [PubMed - indexed for MEDLINE] 4. Sports Med. 2013 Nov;43(11):1157-70. doi: 10.1007/s40279-013-0077-2. Effects of exercise training on airway hyperreactivity in asthma: a systematic review and meta-analysis. Eichenberger PA(1), Diener SN, Kofmehl R, Spengler CM. Author information: (1)Exercise Physiology Lab, Institute of Human Movement Sciences, ETH Zurich, Winterthurerstrasse 190, 8057, Zurich, Switzerland. BACKGROUND: Although physical exercise is recommended for asthmatics, evidence on the effects of exercise on clinical key factors is still missing. OBJECTIVES: We performed a systematic review and meta-analysis to determine the effect of exercise training (EXT) on quality of life (QoL), bronchial hyperresponsiveness (BHR), exercise-induced bronchoconstriction (EIB), lung function and exercise capacity, plus the factors affecting changes in QoL and exercise capacity in asthmatics after a period of EXT. DATA SOURCES: A computerized search was conducted in MEDLINE, EMBASE, and CINAHL (last search on 15 November 2012), without language restriction, and references of original studies and reviews were searched for further relevant studies. STUDY SELECTION: Two independent investigators screened full-text studies with asthmatic subjects undertaking EXT (defined as training for ≥7 days, ≥2 times per week, ≥5 training sessions in total) that assessed at least one of the following outcomes: QoL, airway hyperreactivity, forced expiratory volume in one second (FEV₁), peak expiratory flow (PEF), inflammatory parameters, exercise capacity, or exercise endurance. Potentially relevant studies were excluded if only respiratory muscle training, breathing exercises or yoga was performed, if asthmatic subjects with co-morbidities were investigated, if only data of mixed patient groups without separate results for asthmatics were presented, if training regimens were not sufficiently specified, if no numerical outcome data

were presented, and if new long-term medication was introduced in addition to physical training. Of 500 potentially relevant articles, 13.4 % (67 studies including 2,059 subjects) met the eligibility criteria and were included for further analyses. STUDY APPRAISAL AND SYNTHESIS METHODS: Data extraction and risk of bias assessment was performed according to the Cochrane Handbook for Systematic Reviews of Interventions. A meta-analysis of all randomized controlled trials (RCTs) was performed to determine the effect of EXT on asthma symptoms, BHR, EIB, FEV₁, exercise capacity and exercise endurance compared with control training. In addition, relative pre/post changes were analysed in all RCTs and controlled trials. Finally, multiple linear regression models were used to identify effects of relative changes in airway hyperreactivity (BHR or EIB), lung function (FEV₁ or PEF) and training hours on QoL and exercise performance. RESULTS: In a total of 17 studies including 599 subjects, meta-analyses showed a significant improvement in days without asthma symptoms, FEV1 and exercise capacity while BHR only tended to improve. The analysis of relative within-group changes after EXT showed, however, significant improvements in QoL (17 %), BHR (53 %), EIB (9 %), and FEV1 (3 %) compared with control conditions. Multiple linear regression models revealed that changes in airway hyperreactivity and lung function significantly contributed to the change in QoL, while mainly the changes in airway hyperreactivity contributed to the change in exercise capacity. CONCLUSION: EXT was shown to improve asthma symptoms, QoL, exercise capacity, BHR, EIB, and FEV1 in asthmatics and improvements in BHR explained part of the improvement in QoL and exercise capacity. Thus, physical activity should be recommended as a supplementary therapy to medication. However, more well controlled studies should be performed assessing the relationship of physical activity, QoL, airway hyperreactivity, lung function and especially airway inflammation as well as medication intake. PMID: 23846823 [PubMed - indexed for MEDLINE] 5. Physiother Theory Pract. 2013 May;29(4):271-7. doi: 10.3109/09593985.2012.731626. Epub 2012 Oct 22. Effect of diaphragmatic breathing exercise on quality of life in subjects with asthma: A systematic review. Prem V(1), Sahoo RC, Adhikari P. Author information: (1)Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal Hospital, Bangalore, India. Prem.v@manipal.edu The aim of this systematic review was to determine if diaphragmatic breathing exercise improves quality of life (QoL) in asthma. Electronic databases were searched for randomized controlled trials (RCTs). Data were extracted and risk of bias was assessed by two independent reviewers. Three RCTs were eligible for inclusion (254 subjects). Two studies compared diaphragmatic breathing exercise to asthma education, and one compared with asthma medication. Meta-analysis was not possible due to clinical heterogeneity of the studies. All three studies had

a low risk of bias. All studies reported short-term effects, and long-term effects of breathing exercise on asthma quality life. There is a moderate evidence of improvement in QoL following diaphragmatic breathing both in short-term and long-term basis. PMID: 23088703 [PubMed - indexed for MEDLINE] 6. J Asthma. 2012 Jun;49(5):487-95. doi: 10.3109/02770903.2012.680636. Epub 2012 May 3. Exercise-related quality of life in subjects with asthma: a systematic review. Pacheco DR(1), Silva MJ, Alexandrino AM, Torres RM. Author information: (1)School of Allied Health Professions, Polytechnic Institute of Oporto, Oporto, Portugal. ftdianapacheco@gmail.com OBJECTIVE: The purpose of this review was to analyze, based on a review of the current literature, the effects of physical activity on the quality of life (QoL) of subjects with asthma. METHODS: The authors conducted a search of randomized controlled trials (RCTs) between January 2000 and August 2010 in a group of major databases of health sciences (Academic Search Complete, Directory of Open Access Journals, Elsevier--Science Direct, Highwire Press, PubMed, Scielo Global, Scirus, Scopus, SpringerLink, Taylor & Francis, and Wiley Interscience) with the keywords asthma, QoL, physical activity, exercise, training, and program in all possible combinations. Citations and references of each study selected were also examined. RESULTS: Of the 1075 studies identified, only 11 were included. Five of these studies were performed in children between the ages of 7 and 15 and the remaining studies were performed on adults. Intervention programs were divided into aerobic training programs and breathing exercises programs. All aerobic training programs showed improvements in QoL, demonstrating a positive influence of aerobic training on asthma. CONCLUSIONS: There is a noticeable trend in the benefit of aerobic training programs in the QoL for individuals with asthma. The breathing exercises programs were few and heterogeneous, making it difficult to reach a positive conclusion on whether it could be recommended for the improvement of QoL in this pathology. There is a great need for more RCTs with methodological rigor. PMID: 22554022 [PubMed - indexed for MEDLINE] 7. PLoS One. 2012;7(12):e50775. doi: 10.1371/journal.pone.0050775. Epub 2012 Dec 20. Physical activity and asthma: a systematic review and meta-analysis. Eijkemans M(1), Mommers M, Draaisma JM, Thijs C, Prins MH. Author information:

(1)Department of Pediatrics, Radboud University Medical Centre, Nijmegen, The Netherlands. m.eijkemans@cukz.umcn.nl INTRODUCTION: This review aims to give an overview of available published evidence concerning the association between physical activity and asthma in children, adolescents and adults. METHODS: We included all original articles in which both physical activity and asthma were assessed in case-control, cross-sectional or longitudinal (cohort) studies. Excluded were studies concerning physical fitness, studies in athletes, therapeutic or rehabilitation intervention studies such as physical training or exercise in asthma patients. Methodological quality of the included articles was assessed according to the Newcastle-Ottawa Scale (NOS). RESULTS: A literature search was performed until June 2011 and resulted in 6,951 publications derived from PubMed and 1,978 publications from EMBASE. In total, 39 studies met the inclusion criteria: 5 longitudinal studies (total number of subjects n = 85,117) with physical activity at baseline as exposure, and asthma incidence as outcome. Thirty-four cross-sectional studies (n = 661,222) were included. Pooling of the longitudinal studies showed that subjects with higher physical activity levels had lower incidence of asthma (odds ratio 0.88 (95% CI: 0.77-1.01)). When restricting pooling to the 4 prospective studies with moderate to good study quality (defined as NOS≥5) the pooled odds ratio only changed slightly (0.87 (95% CI: 0.77-0.99)). In the cross-sectional studies, due to large clinical variability and heterogeneity, further statistical analysis was not possible. CONCLUSIONS: The available evidence indicates that physical activity is a possible protective factor against asthma development. The heterogeneity suggests that possible relevant effects remain hidden in critical age periods, sex differences, or extremes of levels of physical activity (e.g. sedentary). Future longitudinal studies should address these issues. PMCID: PMC3527462 PMID: 23284646 [PubMed - indexed for MEDLINE] 8. J Asthma Allergy. 2012;5:21-6. doi: 10.2147/JAA.S32232. Epub 2012 Jun 7. Asthma and obesity: does weight loss improve asthma control? a systematic review. Juel CT(1), Ali Z, Nilas L, Ulrik CS. Author information: (1)Respiratory Section, Internal Medicine Unit, Hvidovre Hospital and University of Copenhagen, Hvidovre, Denmark. AIM AND METHODS: Obesity is a major health problem, and obesity is associated with a high incidence of asthma and poor asthma control. The aim of the present paper is to systematically review the current knowledge of the effect on overall asthma control of weight reduction in overweight and obese adults with asthma. RESULTS: Weight loss in obese individuals with doctor-diagnosed asthma is associated with a 48%-100% remission of asthma symptoms and use of asthma medication. Published studies, furthermore, reveal that weight loss in obese

asthmatics improves asthma control, and that especially surgically induced weight loss results in significant improvements in asthma severity, use of asthma medication, dyspnoea, exercise tolerance, and acute exacerbations, including hospitalizations due to asthma. Furthermore, weight loss in obese asthmatics is associated with improvements in level of lung function and airway responsiveness to inhaled methacholine, whereas no significant improvements have been observed in exhaled nitric oxide or other markers of eosinophilic airway inflammation. CONCLUSION: Overweight and obese adults with asthma experience a high symptomatic remission rate and significant improvements in asthma control, including objective measures of disease activity, after weight loss. Although these positive effects of weight loss on asthma-related health outcomes seem not to be accompanied by remission or improvements in markers of eosinophilic airway inflammation, it has potentially important implications for the future burden of asthma. PMCID: PMC3392696 PMID: 22791994 [PubMed] 9. Drugs. 2009 Aug 20;69(12):1533-53. doi: 10.2165/11316720-000000000-00000. Exercise-induced bronchoconstriction in asthmatic children: a comparative systematic review of the available treatment options. Grzelewski T(1), Stelmach I. Author information: (1)N. Copernicus Hospital, Department of Pediatrics and Allergy, Medical University of Lodz, 65 Pabianicka Str., Lodz, Poland. tomaszgrzelew@wp.pl The aim of this article is to critically review the efficacy and safety data from randomized controlled trials (RCTs) using inhaled corticosteroids (ICSs), long- or short-acting beta(2)-adrenoceptor agonists (LABAs, SABAs), parasympatholytics and oral leukotriene receptor antagonists in the management of exercise-induced bronchoconstriction (EIB) in children with persistent asthma (EIA). The studies with sufficient information on patient characteristics and outcomes were chosen using a MEDLINE search. Results from the individual searches were combined and repeated. Studies were also found by reviewing the reference lists of the articles not included in this review. Studies focusing solely on individuals with asthma and other allergic co-morbidities (i.e. a degree of bronchial reversibility) were considered in this review. To make the paper evidence-based, the design and the quality of different studies were assessed employing the Sign criteria (evidence level [EL] and grades of recommendation [GR]). No additional statistical analyses were performed. Most of studies included paediatric patients with underlying EIA. We need to distinguish children with recurrent asthma symptoms in whom EIB is also present (patients with EIA) from asthmatic subjects whose symptoms appear only as a result of exercise (patients with EIB). Further controller treatment is indicated in patients with EIA and further reliever treatment in patients with EIB. ICSs are the first-choice controller drugs for EIA in children with persistent asthma (Sign grade of recommendation [GR]:A). In children with EIA without complete control with ICSs, SABAs (GR:A), leukotriene

receptor antagonists (LTRAs) [GR:A] or LABAs (GR:A) may be added to gain control. Treatment with relievers such as SABAs (GR:A), parasympatholytics (GR:B) or, eventually, LABAs (GR:A), administered 10-15 minutes before exercise is the most preferable method of preventing EIB symptoms in children; however, not as monotherapy in children with EIA. The disadvantages and controversy relating to inhaled beta(2)-adrenoceptor agonist use lie in the development of tolerance to their effect when they are used on a regular basis, and the possibility of a resulting underuse of ICSs in patients with EIA. Researchers and guidelines recommend that if any patient requires treatment with a beta(2)-adrenoceptor agonist more than twice weekly, a low dose of ICSs should be administered. Inhaled parasympatholytics may be effective as preventive relievers in some children with EIB or EIA, especially among those with increased vagal activity. LTRAs have a well balanced efficacy-safety profile in preventing the occurrence of EIB symptoms in children. Compared with LABAs, LTRAs produce persistent attenuation of EIB and possess an additional effect with rescue SABA therapy in persistent asthmatic patients with EIA. A disadvantage of LTRAs is a non-response phenomenon. There are still insufficient data on the efficacy-safety profiles of ICS/LABA combination drugs in the treatment of EIA in children to recommend this treatment without caution. Safety profiles of inhaled SABAs, anticholinergics and montelukast in approved dosages seem sufficient enough to recommend use of these drugs in the prevention of EIB symptoms in children. Many researchers agree that treatment of EIA in children should always be individualized. PMID: 19678711 [PubMed - indexed for MEDLINE]

Exercise and Carpal tunnel 1. Chiropr Man Therap. 2016 Mar 7;24:8. doi: 10.1186/s12998-016-0089-8. eCollection 2016. Multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Sutton D(1), Gross DP(2), Côté P(3), Randhawa K(4), Yu H(1), Wong JJ(5), Stern P(6), Varatharajan S(4), Southerst D(7), Shearer HM(1), Stupar M(8), Goldgrub R(9), van der Velde G(10), Nordin M(11), Carroll LJ(12), Taylor-Vaisey A(8). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (2)Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, 8205 114 St, 3-28 Corbett Hall, Edmonton, AB Canada T6G 2G4 ; Rehabilitation Research Centre, University of Alberta, 8205 114 St, 3-48 Corbett Hall, Edmonton, AB Canada T6G 2G4. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (5)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (6)Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (7)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, Ontario Canada M5T 3L9. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation,

University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (9)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, L1H 7L7 Ontario Canada. (10)Toronto Health Economics and Technology Assessment (THETA) Collaborative, 6th Floor, Room 658, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Institute for Work and Health, 481 University Avenue, Toronto, Ontario Canada M5G 2E9. (11)Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue, New York, NY 10016 USA. (12)School of Public Health and Injury Prevention Centre, University of Alberta, 3-300 Edmonton Clinic Health Academy 11405 - 87 Ave, Edmonton, Alberta Canada T6G 1C9. BACKGROUND: Musculoskeletal disorders of the elbow, forearm, wrist and hand are associated with pain, functional impairment and decreased productivity in the general population. Combining several interventions in a multimodal program of care is reflective of current clinical practice; however there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand on self-rated recovery, functional recovery, or clinical outcomes in adults or children. METHODS: We conducted a systematic review of the literature and best evidence synthesis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1990 to March 2015. Randomized controlled trials, cohort studies, and case-control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 5989 articles, and critically appraised eleven articles. Of those, seven had a low risk of bias; one addressed carpal tunnel syndrome and six addressed lateral epicondylitis. Our search did not identify any low risk of bias studies examining the effectiveness of multimodal care for the management of other musculoskeletal disorders of the elbow, forearm, wrist or hand. The evidence suggests that multimodal care for the management of lateral epicondylitis may include education, exercise (strengthening, stretching, occupational exercise), manual therapy (manipulation) and soft tissue therapy (massage). The evidence does not support the use of multimodal care for the management of carpal tunnel syndrome. CONCLUSIONS: The current evidence on the effectiveness of multimodal care for musculoskeletal disorders of the elbow, forearm, wrist and hand is limited. The available evidence suggests that there may be a role for multimodal care in the management of patients with persistent lateral epicondylitis. Future research is needed to examine the effectiveness of multimodal care and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009093. PMCID: PMC4780149 PMID: 26955466 [PubMed]

2. J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):143-201. doi: 10.1016/j.jmpt.2013.04.001. Epub 2013 May 20. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Brantingham JW(1), Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C. Author information: (1)Murdoch University, Murdoch, Australia. jimbrant2002@yahoo.com OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence. Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 23697915 [PubMed - indexed for MEDLINE] 3. Clin Rehabil. 2007 Apr;21(4):299-314. A systematic review of conservative treatment of carpal tunnel syndrome.

Piazzini DB(1), Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L. Author information: (1)Department of Physical Medicine and Rehabilitation, Catholic University, Rome, Italy. OBJECTIVE: To assess the effectiveness of conservative therapy in carpal tunnel syndrome. DATA SOURCES: A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. REVIEW METHODS: RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). RESULTS: Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. CONCLUSION: There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective. PMID: 17613571 [PubMed - indexed for MEDLINE] 4. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD003471. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. Verhagen AP, Karels C, Bierma-Zeinstra SM, Burdorf L, Feleus A, Dahaghin S, de Vet HC, Koes BW. Update in Cochrane Database Syst Rev. 2009;(3):CD003471.

Update of Cochrane Database Syst Rev. 2004;(1):CD003471. BACKGROUND: Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS). OBJECTIVES: This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied. SELECTION CRITERIA: We included randomised and non-randomised controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence. MAIN RESULTS: For this update we included six additional studies; 21 trials in total. Seventeen trials included people with chronic non-specific neck or shoulder complaints, or non-specific upper extremity disorders. Over 25 interventions were evaluated; five main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, and energised splint. Overall, the quality of the studies was poor. In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome. AUTHORS' CONCLUSIONS: There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage; breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy; and manual therapy as an add-on treatment to exercises. PMID: 16856010 [PubMed - indexed for MEDLINE] 5. J Clin Epidemiol. 2007 Feb;60(2):110-7. Epub 2006 Sep 7. Exercise proves effective in a systematic review of work-related complaints of

the arm, neck, or shoulder. Verhagen AP(1), Karels C, Bierma-Zeinstra SM, Feleus A, Dahaghin S, Burdorf A, Koes BW. Author information: (1)Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands. a.verhagen@erasmusmc.nl OBJECTIVE: Interventions such as physiotherapy and ergonomic adjustments play a major role in the treatment of most work-related complaints of the arm, neck, and/or shoulder (CANS). We evaluated whether conservative interventions have a significant impact on outcomes for work-related CANS. STUDY DESIGN AND SETTING: A systematic review was conducted. Only (randomized) trials studying interventions for patients suffering from work-related CANS were included. Interventions may include exercises, relaxation, physical applications, and workplace adjustments. Two authors independently selected the trials, assessed methodological quality, and extracted data. RESULTS: We included 26 studies (in total 2,376 patients); 23 studies included patients with chronic nonspecific complaints. Over 30 interventions were evaluated and 7 main subgroups of interventions could be determined, of which the subgroup "exercises" was the largest one. Overall, the quality of the studies appeared to be poor. CONCLUSION: There is limited evidence for the effectiveness of exercises when compared to massage, adding breaks during computer work, massage as add-on treatment to manual therapy, manual therapy as add-on treatment to exercises, and some keyboards in people with carpal tunnel syndrome when compared to other keyboards or placebo. For other interventions no clear effectiveness could be demonstrated.

Exercise and cervical radiculopathy 1. J Man Manip Ther. 2011 Aug;19(3):135-42. doi: 10.1179/2042618611Y.0000000011. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. Boyles R(1), Toy P, Mellon J Jr, Hayes M, Hammer B. Author information: (1)Program of Physical Therapy, University of Puget Sound, Tacoma, WA, USA. STUDY DESIGN: Systematic review of randomized clinical trials. OBJECTIVE: Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy. BACKGROUND: Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population. RESULTS: Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising. CONCLUSION: Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR.

Exercise and Diabetes 1. BMJ Open. 2016 Apr 20;6(4):e008986. doi: 10.1136/bmjopen-2015-008986. Improving management of type 2 diabetes in South Asian patients: a systematic review of intervention studies. Bhurji N(1), Javer J(2), Gasevic D(1), Khan NA(3). Author information: (1)College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK. (2)Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada. (3)Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada Center for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada. OBJECTIVES: Optimal control of type 2 diabetes is challenging in many patient populations including in South Asian patients. We systematically reviewed studies on the effect of diabetes management interventions targeted at South Asian patients with type 2 diabetes on glycaemic control. DESIGN: Systematic review of MEDLINE, EMBASE and CINAHL databases for randomised controlled trials (RCTs) and pre-post-test studies (January 1990 to February 2014). Studies were stratified by where interventions were conducted (South Asia vs Western countries). PARTICIPANTS: Patients originating from Pakistan, Bangladesh or India with type 2 diabetes. PRIMARY OUTCOME: Change in glycated haemoglobin (HbA1c). Secondary end points included change in blood pressure, lipid levels, anthropomorphics and knowledge. RESULTS: 23 studies (15 RCTs) met criteria for analysis with 7 from Western countries (n=2532) and 16 from South Asia (n=1081). Interventions in Western countries included translated diabetes education, additional clinical care, written materials, visual aids, and bilingual community-based peers and/or health professionals. Interventions conducted in South Asia included yoga, meditation or exercise, community-based peers, health professionals and dietary education (cooking exercises). Among RCTs in India (5 trials; n=390), 4 demonstrated significant reductions in HbA1c in the intervention group compared with usual care (yoga and exercise interventions). Among the 4 RCTs conducted in Europe (n=2161), only 1 study, an education intervention of 113 patients, reported a significant reduction in HbA1c with the intervention. Lipids, blood pressure and knowledge improved in both groups with studies from India more often reporting reductions in body mass index and waist circumference. CONCLUSIONS: Overall, there was little improvement in HbA1c level in diabetes management interventions targeted at South Asians living in Europe compared with usual care, although other outcomes did improve. The smaller studies in India demonstrated significant improvements in glycaemic and other end points. Novel

strategies are needed to improve glycaemic control in South Asians living outside of India. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMCID: PMC4838706 PMID: 27098819 [PubMed - in process] 2. Eur J Intern Med. 2016 Jan;27:37-47. doi: 10.1016/j.ejim.2015.11.016. Epub 2015 Dec 3. Efficacy of lifestyle interventions in patients with type 2 diabetes: A systematic review and meta-analysis. Huang XL(1), Pan JH(2), Chen D(2), Chen J(2), Chen F(2), Hu TT(2). Author information: (1)Department of Nephrology, The First Hospital of Wuhan, China. Electronic address: 5051huangxiaoli@163.com. (2)Department of Nephrology, The First Hospital of Wuhan, China. BACKGROUND: The current meta-analysis evaluated the outcomes of various lifestyle interventions, including diet modifications (DIET), physical activity (PA), and patient education (EDU) in reducing the risk of cardiovascular disease in patients with type 2 diabetes. METHODS: Randomized clinical trials comparing lifestyle intervention with "usual care" (control) in type 2 diabetes patients were hand-searched from medical databases by two independent reviewers using the terms "diabetes, cardiovascular risk, lifestyle, health education, dietary, exercise/physical activities, and behavior intervention". RESULTS: Of the 235 studies identified, 17 were chosen for the meta-analysis. The average age of patients ranged from 50-67.3 years. Results reveal no significant difference between the groups, with respect to BMI, while PA and DIET yielded a greater reduction in HbA1c. Significant reduction in both systolic and diastolic pressures in the DIET group, and diastolic pressure in the PA group, was observed. HDL-c in the DIET group was significantly higher than the control group, while no change in LDL-c levels, was seen in all three intervention subtypes. There was no difference between the EDU vs. the control group in terms of HbA1c, blood pressure or HDL-c and LDL-c. CONCLUSION: DIET intervention showed an improvement in HbA1c, systolic/diastolic blood pressure and HDL-c, with an exception of LDL-c and BMI, suggesting that nutritional intervention had a significant impact on the quality of life by

reducing the cardiovascular risk in type 2 diabetes patients. Copyright © 2015 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved. PMID: 26655787 [PubMed - in process] 3. Atherosclerosis. 2015 Nov;243(1):131-7. doi: 10.1016/j.atherosclerosis.2015.09.016. Epub 2015 Sep 11. Cardiorespiratory fitness and risk of type 2 diabetes mellitus: A 23-year cohort study and a meta-analysis of prospective studies. Zaccardi F(1), O'Donovan G(2), Webb DR(3), Yates T(2), Kurl S(4), Khunti K(3), Davies MJ(3), Laukkanen JA(5). Author information: (1)Diabetes Research Centre, University of Leicester, Leicester, UK. Electronic address: frazac@fastwebnet.it. (2)Diabetes Research Centre, University of Leicester, Leicester, UK; NIHR Leicester-Loughborough Diet, Lifestyle, and Physical Activity Biomedical Research Unit, UK. (3)Diabetes Research Centre, University of Leicester, Leicester, UK. (4)Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland. (5)Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland; Central Finland Hospital, Jyväskylä, Finland; Department of Medicine, University of Helsinki, Helsinki, Finland. AIMS: To investigate the association between cardiorespiratory fitness (CRF) and type 2 diabetes mellitus (T2DM) in a cohort of middle-age Finnish men and to summarise the current evidence in a meta-analysis of prospective studies. METHODS: CRF was measured at baseline in a random population-based sample of 2520 subjects by assessing oxygen uptake during maximal exercise. Cox regression analysis was used to estimate the association between CRF, expressed as metabolic equivalents (METs), and the risk of T2DM adjusted for potential confounders; this estimate was then pooled with the results of other prospective studies in a meta-analysis. RESULTS: Mean (SD) baseline age and CRF were 53 (5) years and 8.7 (2.1) METs, respectively. During 23 years of follow-up, 153 (6.1%) participants developed T2DM. The hazard ratio per 1-MET higher CRF, adjusted for age, body mass index, systolic blood pressure, serum HDL-cholesterol, and family history of T2DM, was 0.93 (95% confidence interval (CI): 0.84, 1.02; p = 0.109); further adjustment for smoking, education, and socioeconomic status did not materially change the estimate. In a random-effects meta-analysis of eight studies (92,992 participants and 8564 T2DM cases) combining maximally adjusted estimates, the pooled risk

ratio of T2DM per 1-MET higher CRF level was 0.95 (95% CI: 0.93, 0.98; p = 0.003; I(2) = 81%), corresponding to 23 fewer cases per 100,000 person-years based on the assumption of a causal link between CRF and T2DM. CONCLUSIONS: These data suggest that there is an inverse relationship between CRF and T2DM that is largely independent of other risk factors. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved. PMID: 26386209 [PubMed - in process] 4. Curr Diabetes Rev. 2015 Aug 17. [Epub ahead of print] The effect of exercise on vascular function and stiffness in type 2 diabetes: A systematic review and meta-analysis. Way KL(1), Keating SE, Baker MK, Chuter VH, Johnson NA. Author information: (1)Faculty of Health Sciences, Lidcombe. Charles Perkins Centre, Camperdown, University of Sydney NSW 2006, Australia. kway2744@uni.sydney.edu.au. Deterioration of the structure and function of the vascular system is the underlying feature in cardiovascular disease (CVD), which is the highest cause of mortality in type 2 diabetes (T2D). Studies assessing the effect of exercise on vascular function and stiffness have used different measurement techniques and small cohorts, making it difficult to conclude on the overall efficacy of exercise on these outcomes. The aim of this study was to assess the effect of exercise on vascular function and stiffness in T2D. Electronic database searches were performed in AMED, MEDLINE, MEDLINE Daily Update, PREMEDLINE, SPORTDiscus, CINAHL, EMBASE and Web of Science. The effect size (ES), and 95% confidence intervals (CIs) of eligible studies were calculated. Pooled estimates of the effect of aerobic exercise (AEx) on vascular function and stiffness, using ES, were obtained. Results show that AEx led to a near-significant reduction in PWV (ES = -0.402, 95% CI: -0.716 to -0.088; P = 0.052), a significant reduction in EID (ES =0.416, 95% CI: 0.062 to 0.769; P= 0.021), and a non-significant benefit in FMD measures. There were limited studies using resistance training or in combination with aerobic exercise, to assess a pooled effect on vascular function or stiffness. These data suggest that aerobic exercise training should be used as a primary treatment strategy for improving vascular smooth muscle function as measured by EID in individuals with T2D. There is currently insufficient evidence concerning the efficacy of regular exercise for improving vascular function and stiffness as measured by FMD and PWV. PMID: 26279493 [PubMed - as supplied by publisher]

5. Eur J Epidemiol. 2015 Jul;30(7):529-42. doi: 10.1007/s10654-015-0056-z. Epub 2015 Jun 20. Physical activity and the risk of type 2 diabetes: a systematic review and dose-response meta-analysis. Aune D(1), Norat T, Leitzmann M, Tonstad S, Vatten LJ. Author information: (1)Department of Public Health and General Practice, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway, d.aune@imperial.ac.uk. We investigated the association between specific types of physical activity and the risk of type 2 diabetes in a systematic review and meta-analysis of published studies. PubMed, Embase and Ovid databases were searched for prospective studies and randomized trials up to 2nd of March 2015. Summary relative risks (RRs) were calculated using a random effects model. Eighty-one studies were included. The summary RRs for high versus low activity were 0.65 (95 % CI 0.59-0.71, I(2) = 18 %, n = 14) for total physical activity, 0.74 (95 % CI 0.70-0.79, I(2) = 84 %, n = 55) for leisure-time activity, 0.61 (95 % CI 0.51-0.74, I(2) = 73 %, n = 8) for vigorous activity, 0.68 (95 % CI 0.52-0.90, I(2) = 93 %, n = 5) for moderate activity, 0.66 (95 % CI 0.47-0.94, I(2) = 47 %, n = 4) for low intensity activity, and 0.85 (95 % CI 0.79-0.91, I(2) = 0 %, n = 7) for walking. Inverse associations were also observed for increasing activity over time, resistance exercise, occupational activity and for cardiorespiratory fitness. Nonlinear relations were observed for leisure-time activity, vigorous activity, walking and resistance exercise (p nonlinearity < 0.0001 for all), with steeper reductions in type 2 diabetes risk at low activity levels than high activity levels. This meta-analysis provides strong evidence for an inverse association between physical activity and risk of type 2 diabetes, which may partly be mediated by reduced adiposity. All subtypes of physical activity appear to be beneficial. Reductions in risk are observed up to 5-7 h of leisure-time, vigorous or low intensity physical activity per week, but further reductions cannot be excluded beyond this range. PMID: 26092138 [PubMed - indexed for MEDLINE] 6. Nutr Hosp. 2015 Apr 1;31(4):1465-72. doi: 10.3305/nh.2015.31.4.7907. [Glycemic control through physical exercise in type 2 diabetes systematic review].

[Article in Spanish; Abstract available in Spanish from the publisher] Quílez Llopiz P(1), Reig García-Galbis M(2). Author information: (1)Ph. D. Departamento de Enfermería, Facultad de Ciencias de la Salud de la Universidad de Alicante. España.. pablotuno@hotmail.com. (2)Ph. D. Departamento de Enfermería, Facultad de Ciencias de la Salud de la Universidad de Alicante. España.. manuel.reig@ua.es. INTRODUCTION: In Spain, nearly 14% of the population is diabetic, 95% corresponds to Type 2 Diabetes Mellitus patients. Poor glycemic control increases morbidity and mortality. There are three pillars in the treatment of type 2 diabetes: diet, medication and exercise. However, the potential for prescribing exercise training has not been fully exploited. OBJECTIVE: To analyze the effect of different exercise modalities (AE, RT, Combo, HIIT) on glycemic control in patients with type 2 diabetes mellitus. METHODS: The reserch was performed in 3 electronic databases (Pubmed, Scopus and Proquest), including publications from 2011 to the present, publications undertaking interventions with AE, RT, Combo or HIIT, and those that measured capillary glucose, CGMS or HbA1c. RESULTS: Of the 386 articles found, 14 met the inclusion criteria. These items were classified according to exercise intervention modality (AE, RT, Combo, HIIT) and whether glycemic control was measured as a result of continued training or 24-48h post-workout. CONCLUSIONS: EA, RT, Combo and HIIT show efficacy in glycemic control in both the continuous training and 24-48h post-training. To achieve certain benefits in glycemic control, prescribing a structured frequency, volume and intensity training is required. Combo is the modality that gets better results through continued training. Publisher: Abstract available from the publisher. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved. PMID: 25795929 [PubMed - in process] 7. Sports Med. 2015 Apr;45(4):587-99. doi: 10.1007/s40279-015-0302-2. Quantifying the acute changes in glucose with exercise in type 1 diabetes: a systematic review and meta-analysis. García-García F(1), Kumareswaran K, Hovorka R, Hernando ME.

Author information: (1)Bioengineering and Telemedicine Group, Universidad Politécnica de Madrid, Madrid, Spain, fgarcia@gbt.tfo.upm.es. BACKGROUND: The acute impact of different types of physical activity on glycemic control in type 1 diabetes has not been well quantified. OBJECTIVES: Our objective was to estimate the rate of change (RoC) in glucose concentration induced acutely during the performance of structured exercise and at recovery in subjects with type 1 diabetes. METHODS: We searched for original articles in the PubMed, MEDLINE, Scopus, and Cochrane databases. Search terms included type 1 diabetes, blood glucose, physical activity, and exercise. Eligible studies (randomized controlled trials and non-randomized experiments) encompassed controlled physical activity sessions (continuous moderate [CONT], intermittent high intensity [IHE], resistance [RESIST], and/or a resting reference [REST]) and reported excursions in glucose concentration during exercise and after its cessation. Data were extracted by graph digitization to compute two RoC measures from population profiles: RoCE during exercise and RoCR in recovery. RESULTS: Ten eligible studies were found from 540 publications. Meta-analyses of exercise modalities versus rest yielded the following: RoCE -4.43 mmol/L h(-1) (p < 0.00001, 95% confidence interval [CI] -6.06 to -2.79) and RoCR +0.70 mmol/L h(-1) (p = 0.46, 95% CI -1.14 to +2.54) for CONT vs. REST; RoCE -5.25 mmol/L·h(-1) (p < 0.00001, 95 % CI -7.02 to -3.48) and RoCR +0.72 mmol/L h(-1) (p = 0.71, 95% CI -3.10 to +4.54) for IHE vs. REST; RoCE -2.61 mmol/L h(-1) (p = 0.30, 95% CI -7.55 to +2.34) and RoCR -0.02 mmol/L h(-1) (p = 1.00, 95% CI -7.58 to +7.53) for RESIST vs. REST. CONCLUSIONS: Novel RoC magnitudes RoCE, RoCR reflected rapid decays of glycemia during CONT exercise and gradual recoveries immediately afterwards. RESIST showed more constrained decays, whereas discrepancies were found for IHE. PMID: 25616852 [PubMed - indexed for MEDLINE] 8. Diabetes Res Clin Pract. 2015 Mar;107(3):320-31. doi: 10.1016/j.diabres.2015.01.027. Epub 2015 Jan 21. Preventing the progression to type 2 diabetes mellitus in adults at high risk: a systematic review and network meta-analysis of lifestyle, pharmacological and surgical interventions. Stevens JW(1), Khunti K(2), Harvey R(3), Johnson M(3), Preston L(3), Woods HB(3), Davies M(2), Goyder E(3). Author information:

(1)University of Sheffield, UK. Electronic address: J.W.Stevens@sheffield.ac.uk. (2)University of Leicester, UK. (3)University of Sheffield, UK. AIMS: Individuals with impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) have an increased risk of progression to Type 2 diabetes mellitus. The objective of this review was to quantify the effectiveness of lifestyle, pharmacological and surgical interventions in reducing the progression to Type 2 diabetes mellitus in people with IFG or IGT. METHODS: A systematic review was carried out. A network meta-analysis (NMA) of log-hazard ratios was performed. Results are presented as hazard ratios and the probabilities of treatment rankings. RESULTS: 30 studies were included in the NMA. There was a reduced hazard of progression to Type 2 diabetes mellitus associated with all interventions versus standard lifestyle advice; glipizide, diet plus pioglitazone, diet plus exercise plus metformin plus rosiglitazone, diet plus exercise plus orlistat, diet plus exercise plus pedometer, rosiglitazone, orlistat and diet plus exercise plus voglibose produced the greatest effects. CONCLUSIONS: Lifestyle and some pharmacological interventions are beneficial in reducing the risk of progression to Type 2 diabetes mellitus. Lifestyle interventions require significant behaviour changes that may be achieved through incentives such as the use of pedometers. Adverse events and cost of pharmacological interventions should be taken into account when considering potential risks and benefits. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved. PMID: 25638454 [PubMed - indexed for MEDLINE] 9. Obstet Gynecol. 2015 Mar;125(3):576-82. doi: 10.1097/AOG.0000000000000691. Physical activity interventions in pregnancy and risk of gestational diabetes mellitus: a systematic review and meta-analysis. Russo LM(1), Nobles C, Ertel KA, Chasan-Taber L, Whitcomb BW. Author information: (1)Division of Biostatistics and Epidemiology, University of Massachusetts, Amherst, Massachusetts. Comment in J Midwifery Womens Health. 2015 Jul-Aug;60(4):472. OBJECTIVE: Gestational diabetes mellitus (GDM) is a common complication of pregnancy associated with an increased incidence of pregnancy complications,

adverse pregnancy outcomes, and maternal and fetal risks of chronic health conditions later in life. Physical activity has been proposed to reduce the risk of GDM and is supported by observational studies, but experimental research assessing its effectiveness is limited and conflicting. We aimed to use meta-analysis to synthesize existing randomized controlled studies of physical activity and GDM. DATA SOURCES: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov for eligible studies. METHODS OF STUDY SELECTION: The following combination of keywords was used: (pregnant or pregnancy or gestation or gestate or gestational or maternity or maternal or prenatal) AND (exercise or locomotion or activity or training or sports) AND (diabetes or insulin sensitivity or glucose tolerance) AND (random* or trial). Eligibility was restricted to studies that randomized participants to an exercise-only-based intervention (ie, separate from dietary interventions) and presented data regarding GDM risk. Two authors performed the database search, assessment of eligibility, and abstraction of data from included studies, and a third resolved any discrepancies. A total of 469 studies was retrieved, of which 10 met inclusion criteria and could be used for analysis (3,401 participants). TABULATION, INTEGRATION, AND RESULTS: Fixed-effects models were used to estimate summary relative risk (RR) and 95% confidence interval (CI) and I to assess heterogeneity. There was a 28% reduced risk (95% CI 9-42%) in the intervention group compared with the control group (RR 0.72, P=.005). Heterogeneity was low (I=12%) and nonsignificant (P=.33). CONCLUSION: The results from this meta-analysis suggest that physical activity in pregnancy provides a slight protective effect against the development of GDM. Studies evaluating type, timing, duration, and compliance of physical activity regimens are warranted to best inform obstetric guidelines. PMID: 25730218 [PubMed - indexed for MEDLINE] 10. Maturitas. 2015 Jan;80(1):14-23. doi: 10.1016/j.maturitas.2014.09.008. Epub 2014 Sep 29. A systematic review and meta-analysis of tai chi for treating type 2 diabetes. Lee MS(1), Jun JH(2), Lim HJ(3), Lim HS(4). Author information: (1)Medical Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea. Electronic address: drmslee@gmail.com. (2)Medical Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea. (3)Department of Nursing, Chodang University, Muan, South Korea. (4)Department of Nursing, Howon University, Kunsan, South Korea.

The aim of this review was to update and critically evaluate the evidence from randomised clinical trials (RCTs) of tai chi for patients with type 2 diabetes mellitus (T2DM). Twelve databases were searched by August 2014. Fifteen RCTs met all of the inclusion criteria. One RCT compared the effects of tai chi with sham exercise and failed to show the effectiveness of tai chi on fasting blood glucose (FBG), or HbA1c. The other four RCTs tested the effects of tai chi compared with various types of exercise and the meta-analysis failed to show an FBG-lowering effect. Five RCTs compared the effects of tai chi with an anti-diabetic medication and the meta-analysis showed favourable effects of tai chi on FBG. One RCT showed the positive effects of tai chi plus standard care on HbA1c and FBG compared with standard care alone. Four RCTs compared the effects of tai chi to no treatment and the meta-analysis failed to show the positive effects of tai chi on HbA1c. Three RCTs reported superior effects of tai chi on quality of life. In conclusion, the existing trial evidence is not convincing enough to suggest that tai chi is effective for managing patients with T2DM. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. PMID: 25449822 [PubMed - indexed for MEDLINE] 11. Diabetes Res Clin Pract. 2014 Dec;106(3):393-400. doi: 10.1016/j.diabres.2014.09.038. Epub 2014 Oct 7. A systematic review and meta-analysis of exercise interventions in adults with type 1 diabetes. Yardley JE(1), Hay J(2), Abou-Setta AM(3), Marks SD(4), McGavock J(5). Author information: (1)Manitoba Institute of Child Health, University of Manitoba, Winnipeg, MB, Canada; University of Alberta, Augustana Campus, Camrose, AB, Canada. (2)Manitoba Institute of Child Health, University of Manitoba, Winnipeg, MB, Canada. (3)George & Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada; Winnipeg Regional Health Authority, Winnipeg, MB, Canada. (4)Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada. (5)Manitoba Institute of Child Health, University of Manitoba, Winnipeg, MB, Canada. Electronic address: jmcgavock@mich.ca. AIMS: Conflicting evidence exists regarding the benefits of physical activity for long-term blood glucose control in adults with type 1 diabetes (T1D). The object of this systematic review was to determine the effects of physical activity on long-term blood glucose control in T1D adults. METHODS: PubMed/Medline, Embase, CENTRAL, SPORTdiscus, Global Health and ICTRP were searched up to October 2013 for randomized trials of aerobic or resistance

exercise training in T1D adults. Exercises had to be performed at least twice weekly for a minimum of two months. The primary outcome was glycated hemoglobin (HbA1c). Secondary outcomes included cardiorespiratory fitness and insulin dose. RESULTS: Six randomized trials were identified (323 adults); sample sizes ranged from n=6 to n=148 participants receiving the intervention. Five trials had an unknown risk of bias; one trial was deemed to be at high risk of bias. Exercise frequency varied from twice weekly to daily, with intensities (50-90% VO2peak), and session durations (20-120 min) varying widely. Four trials reported HbA1c, which decreased with exercise training (mean difference [MD] -0.78% (-9 mmol/mol), 95% CI -1.14 (-13 mmol/mol) to -0.41 (-5 mmol/mol); p<0.0001; I(2) 0%) compared with controls. Exercise training improved cardiorespiratory fitness by 3.45 ml/kg/min (95% CI 0.59 to 6.31, p=0.02, I(2) 0%) compared with controls. One trial reported an effect on insulin dose (MD -0.4U/kg, 95% CI -0.53 to -0.27, p<0.00001) compared to controls. CONCLUSION: There are currently insufficient well-designed studies to ascertain the true effect of exercise training on HbA1c in individuals with T1D, but current results are promising. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. PMID: 25451913 [PubMed - indexed for MEDLINE] 12. Sports Med. 2014 Nov;44(11):1557-72. doi: 10.1007/s40279-014-0226-2. Association between physical activity advice only or structured exercise training with blood pressure levels in patients with type 2 diabetes: a systematic review and meta-analysis. Figueira FR(1), Umpierre D, Cureau FV, Zucatti AT, Dalzochio MB, Leitão CB, Schaan BD. Author information: (1)Exercise Pathophysiology Research Laboratory, Hospital de Clinicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, Brazil. BACKGROUND: Diabetes is associated with marked cardiovascular morbidity and mortality. However, the association between different types of exercise training and blood pressure (BP) changes is not fully clear in type 2 diabetes. OBJECTIVE: The aim of this systematic review and meta-analysis of randomized controlled clinical trials (RCTs) was to determine the effects of structured exercise training (aerobic [AER], resistance [RES], or combined [COMB]) and physical activity (PA) advice only on BP changes in patients with type 2 diabetes. METHODS: Searches in five electronic databases were conducted to retrieve studies

published from 1980 to 2013. Eligible studies were RCTs consisting of structured exercise training or PA advice versus no intervention in patients with type 2 diabetes. We used random effect models to derive weighted mean differences (WMDs) of exercises on absolute changes in systolic BP (SBP) and diastolic BP (DBP). RESULTS: A total of 30 RCTs of structured training (2,217 patients) and 21 of PA advice (7,323 patients) were included. Data were extracted independently in duplicate. Structured exercise was associated with reductions in SBP (WMD -4.22 mmHg; 95% confidence interval [CI] -5.89 to -2.56) and DBP (WMD -2.07 mmHg; 95% CI -3.03 to -1.11) versus controls. In structured exercise interventions, AER and RES were associated with declines in BP, and COMB was not associated with BP changes. However, in sensitivity analysis, a high-intensity protocol within COMB was associated with declines in SBP (WMD -3.30 mmHg; 95% CI -4.71 to -1.89). Structured exercise longer than 150 min/week was associated with greater BP reductions. PA advice only was associated with reduction in SBP (WMD -2.97 mmHg; 95% CI -4.52 to -1.43) and DBP (WMD -1.41 mmHg; 95% CI -1.94 to -0.88) versus controls. CONCLUSIONS: AER, RES, and high-intensity combined training are associated with BP reduction in patients with type 2 diabetes, especially in exercise programs lasting more than 150 min/week. PA advice only is also associated with lower BP levels. PMID: 25047852 [PubMed - indexed for MEDLINE] 13. Diabetologia. 2014 Sep;57(9):1789-97. doi: 10.1007/s00125-014-3303-z. Epub 2014 Jul 5. Impact of different training modalities on glycaemic control and blood lipids in patients with type 2 diabetes: a systematic review and network meta-analysis. Schwingshackl L(1), Missbach B, Dias S, König J, Hoffmann G. Author information: (1)Department of Nutritional Sciences, Faculty of Life Sciences, University of Vienna, Althanstraße 14 (UZAII), 1090, Vienna, Austria, lukas.schwingshackl@univie.ac.at. AIMS/HYPOTHESIS: This study aimed to systematically review randomised controlled trials comparing the effects of aerobic exercise training (AET), resistance training (RT) and combined training (CT) on glycaemic control and blood lipids in patients with type 2 diabetes mellitus. METHODS: Searches were performed in MEDLINE, EMBASE and the Cochrane Library. Inclusion criteria were: type 2 diabetes mellitus, adult, supervised training and a minimum intervention period of 8 weeks. Pooled effects were calculated by fixed/random effect pairwise and Bayesian fixed/random effects network

meta-analyses. RESULTS: A total of 14 trials enrolling 915 participants were included. AET was more effective than RT in improving HbA1c levels (mean difference [MD] -0.20% [-2.2 mmol/mol]; 95% CI -0.32, -0.08; p = 0.0007, 10 trials/515 participants) and fasting glucose (MD -0.9 mmol/l; 95% CI -1.71, -0.09; p = 0.03, 8 trials/245 participants). Compared with AET, CT resulted in a significantly more pronounced reduction in HbA1c (MD -0.17% [-1.87 mmol/mol]; 95% CI -0.31, -0.03; p = 0.02, 9 trials/493 participants). Compared with RT, the MD of the change in HbA1c (MD -0.62%, [-6.82 mmol/mol]; 95% CI -0.95, -0.30; p = 0.0002, 5 trials/362 participants], fasting glucose (MD -1.99 mmol/l; 95% CI -3.07, -0.90; p = 0.0003, 3 trials/99 participants) and triacylglycerols (MD -0.28 mmol/l; 95% CI -0.46, -0.10; p = 0.003, 4 trials/213 participants) were all in favour of CT. The exclusion of trials with a high risk of bias yielded only non-significant results. CONCLUSIONS/INTERPRETATION: The present data suggest that CT might be the most efficacious exercise modality to improve glycaemic control and blood lipids. Interpretation with respect to clinical relevance is limited by the low quality of the studies included and the limited information on the clinically important outcomes or adverse effects of exercise. PMID: 24996616 [PubMed - indexed for MEDLINE] 14. Sports Med. 2014 Apr;44(4):487-99. doi: 10.1007/s40279-013-0128-8. Resistance exercise versus aerobic exercise for type 2 diabetes: a systematic review and meta-analysis. Yang Z(1), Scott CA, Mao C, Tang J, Farmer AJ. Author information: (1)Division of Epidemiology, The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China, zuyaoyang@cuhk.edu.hk. BACKGROUND: Resistance and aerobic exercises are both recommended as effective treatments for people with type 2 diabetes. However, the optimum type of exercise for the disease remains to be determined to inform clinical decision-making and facilitate personalized exercise prescription. OBJECTIVES: Our objective was to investigate whether resistance exercise is comparable to aerobic exercise in terms of effectiveness and safety in people with type 2 diabetes. DATA SOURCES: PubMed, EMBASE, CENTRAL, CINAHL, and SPORTdiscus were systematically searched up to March 2013. The reference lists of eligible studies and relevant reviews were also checked.

STUDY SELECTION: We used the following criteria to select studies for inclusion in the review: (i) the study was a randomized controlled trial; (ii) the participants were people with type 2 diabetes aged 18 years or more; (iii) the trial compared resistance exercise with aerobic exercise for a duration of at least 8 weeks, with pre-determined frequency, intensity, and duration; and (iv) the trial provided relevant data on at least one of the following: glycaemic control, blood lipids, anthropometric measures, blood pressure, fitness, health status, and adverse events. STUDY APPRAISAL AND SYNTHESIS METHODS: The assessment of study quality was based on the Cochrane Risk of Bias tool. For effectiveness measures, differences (resistance group minus aerobic group) in the changes from baseline with the two exercises were combined, using a random-effects model wherever possible. For adverse events, the relative risks (resistance group vs. aerobic group) were combined. RESULTS: Twelve trials (n = 626) were included. Following the exercise interventions, there was a greater reduction of glycosylated hemoglobin with aerobic exercise than with resistance exercise (difference 0.18% (1.97 mmol/mol), 95% confidence interval (CI) 0.01, 0.36). This difference became non-significant with sensitivity analysis (p = 0.14). The differences in changes from baseline were also statistically significant for body mass index (difference 0.22, 95% CI 0.06, 0.39), peak oxygen consumption (difference -1.84 mL/kg/min, 95% CI -3.07, -0.62), and maximum heart rate (difference 3.44 beats per minute, 95% CI 2.49, 4.39). Relative risks for adverse events (all) and serious adverse events were 1.17 (95% CI 0.77, 1.79) and 0.89 (95% CI 0.18, 4.39), respectively. LIMITATIONS: Most included trials were short term (8 weeks to 6 months), and seven had important methodological limitations. Additionally, the meta-analyses for some of the secondary outcomes had a small number of participants or substantial statistical heterogeneity. CONCLUSIONS: Although differences in some diabetic control and physical fitness measures between resistance exercise and aerobic exercise groups reached statistical significance, there is no evidence that they are of clinical importance. There is also no evidence that resistance exercise differs from aerobic exercise in impact on cardiovascular risk markers or safety. Using one or the other type of exercise for type 2 diabetes may be less important than doing some form of physical activity. Future long-term studies focusing on patient-relevant outcomes are warranted. PMID: 24297743 [PubMed - indexed for MEDLINE] 15. Metabolism. 2014 Mar;63(3):431-40. doi: 10.1016/j.metabol.2013.08.018. Epub 2013 Nov 23. Effects of exercise on C-reactive protein, inflammatory cytokine and adipokine in patients with type 2 diabetes: a meta-analysis of randomized controlled trials.

Hayashino Y(1), Jackson JL(2), Hirata T(3), Fukumori N(3), Nakamura F(3), Fukuhara S(3), Tsujii S(4), Ishii H(4). Author information: (1)Department of Endocrinology, Tenri Hospital, Nara, Japan; Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan. Electronic address: hayasino-y@umin.net. (2)Department of General Medicine, Zablocki VA Medical Center, Milwaukee, WI, USA. (3)Department of Epidemiology and Healthcare Research, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan. (4)Department of Endocrinology, Tenri Hospital, Nara, Japan. OBJECTIVE: C-reactive protein (CRP), inflammatory cytokines, and adipokines contribute to atherosclerosis, insulin resistance, and development of late-onset complication in patients with type 2 diabetes. We performed a systematic review to assess effects of exercise interventions on inflammatory markers/cytokines and adipokines. MATERIALS/METHODS: We searched electronic databases (MEDLINE, EMBASE, and Cochrane Controlled Trials Registry) and reference lists in relevant papers for articles published in 1966-2013. We selected studies that evaluated the effects of exercise intervention on inflammatory markers/cytokines and adipokines in adult patients with type 2 diabetes. Weighted mean differences of exercise on outcomes were derived using fixed or random effect models; factors influencing heterogeneity were identified using meta-regression analysis. RESULTS: Fourteen randomized controlled trials (824 patients) were included in our meta-analysis. Exercise was associated with a significant in CRP=-0.66mg/l (95% CI, -1.09 to -0.23mg/l; -14% from baseline) and interleukin-6 (IL-6)=-0.88pg/ml (95% CI, -1.44 to -0.32pg/ml; -18% from baseline) but did not alter adiponectin or resistin levels; aerobic exercise program was associated with a significant change in leptin=-3.72ng/ml (95% CI, -6.26 to -1.18ng/ml; -24% from baseline). For IL-6, exercise was more effective in those with a longer duration in the program and larger number of sessions during study (p=0.001). CONCLUSIONS: Exercise decreases inflammatory cytokine (CRP and IL-6) in patients with type 2 diabetes. Exercise could be a therapeutic option for improving abnormalities in inflammation levels in patients with diabetes. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 24355625 [PubMed - indexed for MEDLINE] 16. PLoS One. 2014 Nov 25;9(11):e113667. doi: 10.1371/journal.pone.0113667. eCollection 2014.

Dietary restriction and exercise for diabetic patients with chronic kidney disease: a systematic review. Van Huffel L(1), Tomson CR(2), Ruige J(3), Nistor I(4), Van Biesen W(5), Bolignano D(6). Author information: (1)Department of Endocrinology, Ghent University Hospital, Ghent, Belgium; European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium. (2)The Richard Bright Kidney Unit, Southmead Hospital, Bristol, United Kingdom. (3)Department of Endocrinology, Ghent University Hospital, Ghent, Belgium. (4)European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium; Nephrology Department, "Dr. C.I. Parhon" University Hospital, University of Medicine and Pharmacy "Gr. T. Popa," Iasi, Romania. (5)European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium; Renal Division, Ghent University Hospital, Ghent, Belgium. (6)European Renal Best Practice (ERBP), Ghent University Hospital, Ghent, Belgium; CNR-Institute of Clinical Physiology, Reggio Calabria, Italy. BACKGROUND: Obesity and sedentary lifestyle are major health problems and key features to develop cardiovascular disease. Data on the effects of lifestyle interventions in diabetics with chronic kidney disease (CKD) have been conflicting. STUDY DESIGN: Systematic review. POPULATION: Diabetes patients with CKD stage 3 to 5. SEARCH STRATEGY AND SOURCES: Medline, Embase and Central were searched to identify papers. INTERVENTION: Effect of a negative energy balance on hard outcomes in diabetics with CKD. OUTCOMES: Death, cardiovascular events, glycaemic control, kidney function, metabolic parameters and body composition. RESULTS: We retained 11 studies. There are insufficient data to evaluate the effect on mortality to promote negative energy balance. None of the studies reported a difference in incidence of Major Adverse Cardiovascular Events. Reduction of energy intake does not alter creatinine clearance but significantly reduces proteinuria (mean difference from -0.66 to -1.77 g/24 h). Interventions with combined exercise and diet resulted in a slower decline of eGFR (-9.2 vs. -20.7 mL/min over two year observation; p<0.001). Aerobic and resistance exercise reduced HbA1c (-0.51 (-0.87 to -0.14); p = 0.007 and -0.38 (-0.72 to -0.22); p = 0.038, respectively). Exercise interventions improve the overall functional status and quality of life in this subgroup. Aerobic exercise reduces BMI (-0.74% (-1.29 to -0.18); p = 0.009) and body weight (-2.2 kg (-3.9 to -0.6); p = 0.008). Resistance exercise reduces trunk fat mass (-0,7±0,1 vs. +0,8 kg ±0,1 kg; p = 0,001-0,005). In none of the studies did the intervention cause an increase in adverse events. LIMITATIONS: All studies used a different intervention type and mixed patient

groups. CONCLUSIONS: There is insufficient evidence to evaluate the effect of negative energy balance interventions on mortality in diabetic patients with advanced CKD. Overall, these interventions have beneficial effects on glycaemic control, BMI and body composition, functional status and quality of life, and no harmful effects were observed. PMCID: PMC4244158 PMID: 25423489 [PubMed - indexed for MEDLINE] 17. Int J Behav Nutr Phys Act. 2014 Jan 15;11:2. doi: 10.1186/1479-5868-11-2. Efficacy of interventions that include diet, aerobic and resistance training components for type 2 diabetes prevention: a systematic review with meta-analysis. Aguiar EJ, Morgan PJ, Collins CE, Plotnikoff RC, Callister R(1). Author information: (1)Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan Campus, University Dr, Callaghan, NSW 2308, Australia. Robin.Callister@newcastle.edu.au. Current recommendations for the prevention of type 2 diabetes advise modification of diet and exercise behaviors including both aerobic and resistance training. However, the efficacy of multi-component interventions involving a combination of these three components has not been established. The aims of this review were to systematically review and meta-analyze the evidence on multi-component (diet + aerobic exercise + resistance training) lifestyle interventions for type 2 diabetes prevention. Eight electronic databases (Medline, Embase, SportDiscus, Web of Science, CINAHL, Informit health collection, Cochrane library and Scopus) were searched up to June 2013. Eligible studies 1) recruited prediabetic adults or individuals at risk of type 2 diabetes; 2) conducted diet and exercise [including both physical activity/aerobic and resistance training] programs; and 3) reported weight and plasma glucose outcomes. In total, 23 articles from eight studies were eligible including five randomized controlled trials, one quasi-experimental, one two-group comparison and one single-group pre-post study. Four studies had a low risk of bias (score ≥ 6/10). Median intervention length was 12 months (range 4-48 months) with a follow-up of 18 months (range 6.5-48 months). The diet and exercise interventions varied slightly in terms of their specific prescriptions. Meta-analysis favored interventions over controls for weight loss (-3.79 kg [-6.13, -1.46; 95% CI], Z = 3.19, P = 0.001) and fasting plasma glucose (-0.13 mmol.L⁻¹ [-0.24, -0.02; 95% CI], Z = 2.42, P = 0.02). Diabetes incidence was only reported in two studies, with reductions of 58% and

56% versus control groups. In summary, multi-component lifestyle type 2 diabetes prevention interventions that include diet and both aerobic and resistance exercise training are modestly effective in inducing weight loss and improving impaired fasting glucose, glucose tolerance, dietary and exercise outcomes in at risk and prediabetic adult populations. These results support the current exercise guidelines for the inclusion of resistance training in type 2 diabetes prevention, however there remains a need for more rigorous studies, with long-term follow-up evaluating program efficacy, muscular fitness outcomes, diabetes incidence and risk reduction. PMCID: PMC3898566 PMID: 24423095 [PubMed - indexed for MEDLINE] 18. Diabetes Metab Res Rev. 2013 Nov;29(8):593-603. doi: 10.1002/dmrr.2461. Exercise lowers postprandial glucose but not fasting glucose in type 2 diabetes: a meta-analysis of studies using continuous glucose monitoring. MacLeod SF(1), Terada T, Chahal BS, Boulé NG. Author information: (1)Faculty of Physical Education and Recreation and the Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada. Exercise has repeatedly been shown to improve glycemic control as assessed by glycated hemoglobin. However, changes in glycated hemoglobin do not provide information regarding which aspects of glycemic control have been altered. The purpose of this systematic review was to examine the effect of exercise as assessed by continuous glucose monitoring systems (CGMS) in type 2 diabetes. Databases (PubMed, Medline, EMBASE) were searched up to February 2013. Eligible studies had participants with type 2 diabetes complete standardized exercise protocols and used CGMS to measure changes in glycemic control. Randomized controlled trials, crossover trials and studies with pre-post designs were included. Average glucose concentration, daily time spent in hyperglycemia or hypoglycemia, and fasting glucose concentration were compared between exercise and control conditions. Eleven studies met the inclusion criteria and were included in the review. Eight studies had short-term (≤2 weeks) exercise interventions, whereas three studies had a longer-term intervention (all >2 months). The types of exercises utilized included aerobic, resistance and a combination of the two. The eight short-term studies were included in quantitative analysis. Exercise significantly decreased average glucose concentrations (-0.8 mmol/L, p < 0.01) and daily time spent in hyperglycemia (-129 minutes, p < 0.01), but did not significantly affect daily time spent in hypoglycemia (-3 minutes, p = 0.47) or fasting glucose (-0.3 mmol/L, p = 0.13).

The four randomized crossover trials had similar findings compared to studies with pre-post designs. Exercise consistently reduced average glucose concentrations and time spent in hyperglycemia despite not significantly affecting outcomes such as fasting glucose and hypoglycemia. Copyright © 2013 John Wiley & Sons, Ltd. PMID: 24038928 [PubMed - indexed for MEDLINE] 19. Sports Med. 2013 Nov;43(11):1191-9. doi: 10.1007/s40279-013-0085-2. Effects of exercise training on arterial function in type 2 diabetes mellitus: a systematic review and meta-analysis. Montero D(1), Walther G, Benamo E, Perez-Martin A, Vinet A. Author information: (1)Avignon University, LAPEC EA4278, 84000, Avignon, France, david.montero.barril@gmail.com. BACKGROUND AND OBJECTIVE: Controversy exists among trials assessing whether exercise can improve arterial function in type 2 diabetes mellitus (T2DM) subjects. Therefore the aim of this study was to systematically review and quantify the effects of exercise on arterial function in T2DM subjects. METHODS: MEDLINE, Cochrane, Scopus and Web of Science were searched up until January 2013 for randomized controlled trials evaluating the effects of exercise interventions lasting 4 weeks or more on arterial function in T2DM subjects. Flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) of the brachial conduit artery were considered for assessment of arterial endothelial function and smooth muscle function, respectively. RESULTS: Five randomized trials comparing exercise and control groups (overall n = 217) met the inclusion criteria. The mean exercise characteristics were as follows: 3.6 sessions per week, 67.5 min per session, intensity at 74.4 % of the maximum heart rate (HR(max)), for 14 weeks. The post-intervention mean difference in FMD favoured the exercise groups over the control groups (2.23 %; P < 0.0001). No significant post-intervention mean difference in NMD (1.22 %; P = 0.29) was found between the groups. Neither heterogeneity nor publication bias was detected among the trials. CONCLUSION: Exercise training alone improved FMD, showing its capacity to restore arterial endothelial function in T2DM subjects. However, further research is needed to determine whether longer and/or more intense exercise interventions could enhance arterial smooth muscle function in this population. PMID: 23912806 [PubMed - indexed for MEDLINE]

20. Ann Intern Med. 2013 Oct 15;159(8):543-51. doi: 10.7326/0003-4819-159-8-201310150-00007. Lifestyle interventions for patients with and at risk for type 2 diabetes: a systematic review and meta-analysis. Schellenberg ES, Dryden DM, Vandermeer B, Ha C, Korownyk C. BACKGROUND: The effect of multifaceted lifestyle interventions on clinically oriented outcomes across a spectrum of metabolic risk factors and abnormal glucose is unclear. PURPOSE: To systematically review the effectiveness of lifestyle interventions on minimizing progression to diabetes in high-risk patients or progression to clinical outcomes (such as cardiovascular disease and death) in patients with type 2 diabetes. DATA SOURCES: 5 electronic databases (1980 to June 2013), reference lists, and gray literature. STUDY SELECTION: Two reviewers independently identified randomized, controlled trials of lifestyle interventions (≥3 months' duration) that included exercise, diet, and at least 1 other component; the comparator was standard care. DATA EXTRACTION: One reviewer extracted and a second verified data. Two reviewers independently assessed methodological quality. DATA SYNTHESIS: Nine randomized, controlled trials with patients who were at risk for diabetes and 11 with patients who had diabetes were included. Seven studies reported that lifestyle interventions decreased the risk for diabetes from the end of intervention up to 10 years after it. In patients with diabetes, 2 randomized, controlled trials (which included pharmacotherapy) reported no improvement in all-cause mortality (risk ratio, 0.75 [95% CI, 0.53 to 1.06]). Composite outcomes for cardiovascular disease were too heterogeneous to pool. One trial reported improvement in microvascular outcomes at 13-year follow-up. LIMITATION: Most trials focused on surrogate measures (such as weight change, blood pressure, and lipids) for which clinical relevance was unclear. CONCLUSION: Comprehensive lifestyle interventions effectively decrease the incidence of type 2 diabetes in high-risk patients. In patients who already have type 2 diabetes, there is no evidence of reduced all-cause mortality and insufficient evidence to suggest benefit on cardiovascular and microvascular outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. PMID: 24126648 [PubMed - indexed for MEDLINE] 21. Eur J Cardiovasc Nurs. 2013 Aug;12(4):320-9. doi: 10.1177/1474515112471002. Epub

2013 Jan 8. Multi-component weight-loss interventions for people with cardiovascular disease and/or type 2 diabetes mellitus: a systematic review. Gallagher R(1), Armari E, White H, Hollams D. Author information: (1)University of Technology, Sydney, Australia. Robyn.Gallagher@uts.edu.au OBJECTIVES: To determine whether weight loss interventions, which combine dietary, exercise and behaviour change strategies, result in reduced weight, body mass index (BMI) and waist circumference in people with coronary heart disease (CHD), hypertension (HTN) and/or type 2 diabetes mellitus (T2DM). DESIGN: A systematic review of studies published 1997 to 2010. DATA SOURCES: The electronic databases MEDLINE, PsycINFO, COCHRANE, CINAHL and EMBASE. REVIEW METHODS: Studies were included if samples were: ≥ 18 years old, overweight or obese (BMI 26-39.99 kg/m(2)), and diagnosed with CHD, T2DM and/or HTN. Only randomised controlled trials (RCTs) or systematic reviews of RCTs reporting group-based interventions that combined dietary, exercise and behavioural change strategies and outcomes for weight, BMI and/or waist circumference up to 12 months were included. Two researchers extracted data and appraised quality, with a third making final decisions. RESULTS: Eight RCTs were included (total n = 1428). Participants' mean age was 60.4 years and 61% were female. Interventions varied by contact time, content and delivery. Mean weight loss ranged from -2 kg to -4 kg (SD 4 kg) at 3-4 months, -1.3 kg to -8.2 kg (SD 4 kg) at 5-6 months and -0.87 (SD 0.57 kg) to -6.9 kg (SD 4 kg) at 12 months. Of the few studies that measured waist circumference the mean reduction was -3.1 cm at three and 12 months. CONCLUSIONS: Weight loss interventions that combine exercise, diet and behaviour change strategies result in minor weight loss at 3-12 months in people with CHD, T2DM or HTN. Further research is required to determine the most effective and efficient methods. PMID: 23303770 [PubMed - indexed for MEDLINE] 22. Diabetologia. 2013 Jun;56(6):1210-25. doi: 10.1007/s00125-013-2871-7. Epub 2013 Mar 23. Effects of exercise training on quality of life, symptoms of depression, symptoms of anxiety and emotional well-being in type 2 diabetes mellitus: a systematic review.

van der Heijden MM(1), van Dooren FE, Pop VJ, Pouwer F. Author information: (1)Department of Medical and Clinical Psychology, Center of Research on Psychology in Somatic Diseases, Tilburg University, PO Box 90153, 5000 LE Tilburg, the Netherlands. AIMS/HYPOTHESIS: Psychological problems are relatively common in people with type 2 diabetes. It is unclear whether exercise training exerts an effect on quality of life, symptoms of depression, symptoms of anxiety and emotional well-being in people with type 2 diabetes. The aim of this study was to conduct a systematic review to assess the effects of exercise training on these outcomes in people with type 2 diabetes. METHODS: MEDLINE, PsycINFO, Embase and ClinicalTrials.gov databases were searched. The review included randomised controlled trials (RCTs) of at least 4 weeks' duration in people with type 2 diabetes that evaluated the effect of exercise training on quality of life, symptoms of depression, symptoms of anxiety and/or emotional well-being compared with usual care. RESULTS: Of 1,261 retrieved articles, 20 RCTs were included with a total of 1,719 participants. Quality of life was assessed in 16 studies. Between-group comparisons showed no significant results for aerobic training with the exception of one study, and mixed results for resistance and combined training. Symptoms of depression were assessed in four studies. In only one study did the intervention decrease symptoms of depression. Emotional well-being was evaluated in four studies, which also showed conflicting results. Symptoms of anxiety were evaluated in one study, which showed a significant improvement. CONCLUSIONS/INTERPRETATION: The effects of exercise training on psychological outcomes in people with type 2 diabetes are conflicting. Therefore, there is a need for further high-quality RCTs in order to gain greater insight into the role of exercise training in people with type 2 diabetes. PMID: 23525683 [PubMed - indexed for MEDLINE] 23. Curr Diab Rep. 2013 Jun;13(3):372-80. doi: 10.1007/s11892-013-0373-0. Exercise and diabetes-related cardiovascular disease: systematic review of published evidence from observational studies and clinical trials. Koivula RW(1), Tornberg AB, Franks PW. Author information: (1)Department of Clinical Sciences, Genetic and Molecular Epidemiology Unit, Lund University, SE-205 02 Malmö, Sweden.

The cost of treating cardiovascular disease (CVD) and diabetes is enormous and is set to rise in the coming years. Physical inactivity and sedentary behaviors are major risk factors for these diseases and are estimated to account for several million global deaths annually. Lifestyle interventions, particularly those aimed at enhancing physical activity levels, have a substantial favorable impact on diabetes progression in people at high risk of the disease. Although observational studies and small intervention studies suggest that physical activity might also prevent CVD in people with diabetes, this is not supported by the results of larger randomized controlled trials of lifestyle intervention. The purpose of this review is to provide an overview of the published studies focused on the role of physical activity in CVD prevention in persons with diabetes, and to discuss the implications of these studies' findings. Our review identified almost 100 studies published in the past decade relevant to this topic. PMID: 23494754 [PubMed - indexed for MEDLINE] 24. Diabetologia. 2013 Feb;56(2):242-51. doi: 10.1007/s00125-012-2774-z. Epub 2012 Nov 16. Volume of supervised exercise training impacts glycaemic control in patients with type 2 diabetes: a systematic review with meta-regression analysis. Umpierre D(1), Ribeiro PA, Schaan BD, Ribeiro JP. Author information: (1)Exercise Pathophysiology Research Laboratory, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, Centro de Pesquisa Clínica-LaFiex, Porto Alegre, RS, Brazil. daniel.umpierre@gmail.com AIMS/HYPOTHESIS: Supervised exercise programmes improve glycaemic control in type 2 diabetes, but training characteristics associated with reduction in HbA(1c) remain unclear. We conducted a systematic review with meta-regression analysis of randomised clinical trials (RCTs) assessing the association between intensity and volume of exercise training (aerobic, resistance or combined) and HbA(1c) changes in patients with type 2 diabetes. METHODS: Five electronic databases were searched (1980-2012) to retrieve RCTs of at least 12 weeks' duration, consisting of supervised exercise training vs no intervention, that reported HbA(1c) changes and exercise characteristics. Two independent reviewers conducted study selection and data extraction. RESULTS: Twenty-six RCTs (2,253 patients) met the inclusion criteria. In multivariate analysis, baseline HbA(1c) and exercise frequency explained nearly 58% of between-study variance. Baseline HbA(1c) was inversely correlated with HbA(1c) reductions after the three types of exercise training. In aerobic training, exercise volume (represented by frequency of sessions) was associated

with changes in HbA(1c) (weighted r = -0.64), while no variables were correlated with glycaemic control induced by resistance training. In combined training, weekly volume of resistance exercise explained heterogeneity in multivariate analysis and was associated with changes in HbA(1c) levels (weighted r = -0.70). CONCLUSIONS/INTERPRETATION: Reduction in HbA(1c) is associated with exercise frequency in supervised aerobic training, and with weekly volume of resistance exercise in supervised combined training. Therefore, exercise volume is a major determinant of glycaemic control in patients with type 2 diabetes. PMID: 23160642 [PubMed - indexed for MEDLINE] 25. PLoS One. 2013;8(3):e58861. doi: 10.1371/journal.pone.0058861. Epub 2013 Mar 15. Does exercise improve glycaemic control in type 1 diabetes? A systematic review and meta-analysis. Kennedy A(1), Nirantharakumar K, Chimen M, Pang TT, Hemming K, Andrews RC, Narendran P. Author information: (1)School of Clinical & Experimental Medicine, University of Birmingham, Birmingham, United Kingdom. OBJECTIVE: Whilst regular exercise is advocated for people with type 1 diabetes, the benefits of this therapy are poorly delineated. Our objective was to review the evidence for a glycaemic benefit of exercise in type 1 diabetes. RESEARCH DESIGN AND METHODS: Electronic database searches were carried out in MEDLINE, Embase, Cochrane's Controlled Trials Register and SPORTDiscus. In addition, we searched for as yet unpublished but completed trials. Glycaemic benefit was defined as an improvement in glycosylated haemoglobin (HbA1c). Both randomised and non-randomised controlled trials were included. RESULTS: Thirteen studies were identified in the systematic review. Meta-analysis of twelve of these (including 452 patients) demonstrated an HbA1c reduction but this was not statistically significant (standardised mean difference (SMD) -0.25; 95% CI, -0.59 to 0.09). CONCLUSIONS: This meta-analysis does not reveal evidence for a glycaemic benefit of exercise as measured by HbA1c. Reasons for this finding could include increased calorie intake, insulin dose reductions around the time of exercise or lack of power. We also suggest that HbA1c may not be a sensitive indicator of glycaemic control, and that improvement in glycaemic variability may not be reflected in this measure. Exercise does however have other proven benefits in type 1 diabetes, and remains an important part of its management. PMCID: PMC3598953

PMID: 23554942 [PubMed - indexed for MEDLINE] 26. Diabetes Care. 2012 Dec;35(12):2681-9. doi: 10.2337/dc11-2452. Changing physical activity behavior in type 2 diabetes: a systematic review and meta-analysis of behavioral interventions. Avery L(1), Flynn D, van Wersch A, Sniehotta FF, Trenell MI. Author information: (1)Institute of Cellular Medicine, Newcastle University, Newcastle Upon Tyne, UK. leah.avery@ncl.ac.uk Comment in Evid Based Med. 2013 Dec;18(6):213-4. OBJECTIVE: Behavioral interventions targeting "free-living" physical activity (PA) and exercise that produce long-term glycemic control in adults with type 2 diabetes are warranted. However, little is known about how clinical teams should support adults with type 2 diabetes to achieve and sustain a physically active lifestyle. RESEARCH DESIGN AND METHODS: We conducted a systematic review of randomized controlled trials (RCTs) (published up to January 2012) to establish the effect of behavioral interventions (compared with usual care) on free-living PA/exercise, HbA(1c), and BMI in adults with type 2 diabetes. Study characteristics, methodological quality, practical strategies for increasing PA/exercise (taxonomy of behavior change techniques), and treatment fidelity strategies were captured using a data extraction form. RESULTS: Seventeen RCTs fulfilled the review criteria. Behavioural interventions showed statistically significant increases in objective (standardized mean difference [SMD] 0.45, 95% CI 0.21-0.68) and self-reported PA/exercise (SMD 0.79, 95% CI 0.59-0.98) including clinically significant improvements in HbA(1c) (weighted mean difference [WMD] -0.32%, 95% CI -0.44% to -0.21%) and BMI (WMD -1.05 kg/m(2), 95% CI -1.31 to -0.80). Few studies provided details of treatment fidelity strategies to monitor/improve provider training. Intervention features (e.g., specific behavior change techniques, interventions underpinned by behavior change theories/models, and use of ≥10 behaviour change techniques) moderated effectiveness of behavioral interventions. CONCLUSIONS: Behavioral interventions increased free-living PA/exercise and produced clinically significant improvements in long-term glucose control. Future studies should consider use of theory and multiple behavior change techniques associated with clinically significant improvements in HbA(1c), including structured training for care providers on the delivery of behavioural interventions.

PMCID: PMC3507564 PMID: 23173137 [PubMed - indexed for MEDLINE] 27. Diabetes Res Clin Pract. 2012 Dec;98(3):349-60. doi: 10.1016/j.diabres.2012.10.004. Epub 2012 Oct 29. Effects of supervised exercise on lipid profiles and blood pressure control in people with type 2 diabetes mellitus: a meta-analysis of randomized controlled trials. Hayashino Y(1), Jackson JL, Fukumori N, Nakamura F, Fukuhara S. Author information: (1)Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto 606-8501, Japan. hayasino-y@umin.net AIMS: Our study's purpose was to perform a systematic review to assess the effect of supervised exercise interventions on lipid profiles and blood pressure control. METHODS: We searched electronic databases and selected studies that evaluated the effect of supervised exercise intervention on cardiovascular risk factors in adult people with type 2 diabetes. We used random effect models to derive weighted mean differences of exercise on lipid profiles and blood pressure control. RESULTS: Forty-two RCTs (2808 subjects) met inclusion criteria and are included in our meta-analysis. Structured exercise was associated with a change in systolic blood pressure (SBP) of -2.42 mmHg (95% CI, -4.39 to -0.45 mmHg), diastolic blood pressure (DBP) of -2.23 mmHg (95% CI, -3.21 to -1.25 mmHg), high-density lipoprotein cholesterol (HDL-C) of 0.04 mmol/L (95% CI, 0.02-0.07 mmol/L), and low-density lipoprotein cholesterol (LDL-C) of -0.16 mmol/L (95% CI, -0.30 to -0.01 mmol/L). Heterogeneity was partially explained by age, dietary co-intervention and the duration and intensity of the exercise. CONCLUSIONS: Supervised exercise is effective in improving blood pressure control, lowering LDL-C, and elevating HDL-C levels in people with diabetes. Physicians should recommend exercise for their adult patients with diabetes who can safely do so. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved. PMID: 23116535 [PubMed - indexed for MEDLINE] 28. Diabetes Res Clin Pract. 2012 Nov;98(2):187-98. doi:

10.1016/j.diabres.2012.08.004. Epub 2012 Sep 14. Combined exercise for people with type 2 diabetes mellitus: a systematic review. Oliveira C(1), Simões M, Carvalho J, Ribeiro J. Author information: (1)Polytechnic Institute of Viana do Castelo, Portugal. cesarchaves@esdl.ipvc.pt Type 2 diabetes mellitus has emerged as a major non-communicable chronic diseases in many countries. The importance of exercise in the prevention and management of this disease is evident. This paper briefly reviews the effects of combining aerobic and resistance exercises on glycemic control, and details the training and characteristics of various interventions in adults with type 2 diabetes mellitus. Literature searches were performed using electronic databases between the 1st of January 1950 and the 15th of September 2011. Of the 403 articles retrieved, 28 studies met our inclusion criteria. Combined exercise protocols seem to improve glycemic control to a greater extent than isolated forms of exercise. Nevertheless, length, duration, intensity, mode, number of exercises, sets and repetitions varied markedly among studies. Supervised training sessions, recommended structured exercises, and splitting aerobic and resistance training in separate sessions may be relevant for best results. Future studies should analyze the effects of different aerobic and resistance training modes, different training and progression methods, and whether one type of exercise is optimal, as these issues are likely to convey greater knowledge on type 2 diabetes mellitus management through combined exercise. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved. PMID: 22981711 [PubMed - indexed for MEDLINE] 29. Diabetes Res Clin Pract. 2012 Aug;97(2):206-16. doi: 10.1016/j.diabres.2012.02.001. Epub 2012 Mar 3. Exercise training in high-risk ethnic populations with type 2 diabetes: a systematic review of clinical trials. Sukala WR(1), Page R, Cheema BS. Author information: (1)School of Health and Human Sciences, Southern Cross University, Lismore, NSW, Australia. BACKGROUND: To review clinical trials that have prescribed exercise training in

high-risk, ethnic populations with type 2 diabetes mellitus (T2DM) and delineate areas for future research. METHOD: A systematic review using computerized databases was performed. RESULTS: The systematic review located nine trials, including four uncontrolled trials, and five randomized controlled trials (RCTs) that included 521 participants. Cohorts studied included African, Indian, Polynesian, Hispanic, Arabian, and Chinese peoples and interventions included aerobic training, resistance training or a combination thereof. Several trials documented improvements in HbA1c, insulin action, body composition, blood lipids and systolic and diastolic blood pressure. In general, a longer duration and greater frequency of training resulted in greater adaptation. Studies demonstrating no effect were generally limited by an inadequate intervention. There was evidence of differential training responses between Caucasians and non-Caucasians in two studies drawing such comparisons. CONCLUSIONS: Robust RCTs prescribing appropriate, targeted interventions and investigating relevant outcomes may be required to stimulate greater advocacy for exercise as a therapeutic adjunct for diabetes management in these populations. Investigations should be extended to other high-risk populations, particularly indigenous peoples who suffer an extreme burden of T2DM. Translation of research into clinical application should remain the overall objective. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved. PMID: 22385831 [PubMed - indexed for MEDLINE] 30. Chin J Integr Med. 2011 Oct;17(10):789-93. doi: 10.1007/s11655-011-0812-1. Epub 2011 Jul 30. Tai chi for management of type 2 diabetes mellitus: a systematic review. Lee MS(1), Choi TY, Lim HJ, Ernst E. Author information: (1)Division of Standard Research, Korea Institute of Oriental Medicine, Daejeon, 305-811, South Korea. drmslee@gmail.com OBJECTIVE: Tai chi has been recommended for treating type 2 diabetes mellitus. The purpose of this systematic review was to evaluate evidence from controlled clinical trials testing the effectiveness of tai chi in treating type 2 diabetes mellitus. METHODS: Systematic searches were conducted on 14 electronic databases without restrictions on either population characteristics or language of publication. The outcome measures considered for inclusion were changes in fasting blood glucose (FBG), glycosylated haemoglobin A1c (HbA1c) and quality of life (QOL).

RESULTS: Eight randomised clinical trials (RCTs) and two controlled clinical trials (CCTs) met all inclusion criteria. Three RCTs from 1 trial compared the effects of tai chi with sham exercise and failed to show effectiveness of tai chi on FBG, HbA1c, or QOL. The other 3 RCTs tested the effects of tai chi compared with other types of exercise on FBG. The meta-analysis failed to show an FBG-lowering effect of tai chi [n=118, weighted mean difference (WMD): -0.14 mmol/L, 95% CI: -0.86 to 0.58, P=0.70]. Four studies (2 RCTs and 2 CCT) compared tai chi with no treatment or self-management programme and failed to report significant differences between the experimental and control groups except for QOL from 1 RCT and 1 CCT. CONCLUSION: The existing evidence does not suggest that tai chi is an effective therapy for type 2 diabetes. Currently, there are few high-quality trials on which to make definitive judgements. PMID: 21805298 [PubMed - indexed for MEDLINE] 31. JAMA. 2011 May 4;305(17):1790-9. doi: 10.1001/jama.2011.576. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. Umpierre D(1), Ribeiro PA, Kramer CK, Leitão CB, Zucatti AT, Azevedo MJ, Gross JL, Ribeiro JP, Schaan BD. Author information: (1)Exercise Pathophysiology Research Laboratory, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. Comment in JAMA. 2011 Aug 10;306(6):607-8; author reply 608-10. JAMA. 2011 May 4;305(17):1808-9. Praxis (Bern 1994). 2011 Sep 7;100(18):1125-6. JAMA. 2011 Aug 10;306(6):607; author reply 608-9. CONTEXT: Regular exercise improves glucose control in diabetes, but the association of different exercise training interventions on glucose control is unclear. OBJECTIVE: To conduct a systematic review and meta-analysis of randomized controlled clinical trials (RCTs) assessing associations of structured exercise training regimens (aerobic, resistance, or both) and physical activity advice with or without dietary cointervention on change in hemoglobin A(1c) (HbA(1c)) in type 2 diabetes patients. DATA SOURCES: MEDLINE, Cochrane-CENTRAL, EMBASE, ClinicalTrials.gov, LILACS, and SPORTDiscus databases were searched from January 1980 through February 2011.

STUDY SELECTION: RCTs of at least 12 weeks' duration that evaluated the ability of structured exercise training or physical activity advice to lower HbA(1c) levels as compared with a control group in patients with type 2 diabetes. DATA EXTRACTION: Two independent reviewers extracted data and assessed quality of the included studies. DATA SYNTHESIS: Of 4191 articles retrieved, 47 RCTs (8538 patients) were included. Pooled mean differences in HbA(1c) levels between intervention and control groups were calculated using a random-effects model. Overall, structured exercise training (23 studies) was associated with a decline in HbA(1c) level (-0.67%; 95% confidence interval [CI], -0.84% to -0.49%; I(2), 91.3%) compared with control participants. In addition, structured aerobic exercise (-0.73%; 95% CI, -1.06% to -0.40%; I(2), 92.8%), structured resistance training (-0.57%; 95% CI, -1.14% to -0.01%; I(2), 92.5%), and both combined (-0.51%; 95% CI, -0.79% to -0.23%; I(2), 67.5%) were each associated with declines in HbA(1C) levels compared with control participants. Structured exercise durations of more than 150 minutes per week were associated with HbA(1c) reductions of 0.89%, while structured exercise durations of 150 minutes or less per week were associated with HbA(1C) reductions of 0.36%. Overall, interventions of physical activity advice (24 studies) were associated with lower HbA(1c) levels (-0.43%; 95% CI, -0.59% to -0.28%; I(2), 62.9%) compared with control participants. Combined physical activity advice and dietary advice was associated with decreased HbA(1c) (-0.58%; 95% CI, -0.74% to -0.43%; I(2), 57.5%) as compared with control participants. Physical activity advice alone was not associated with HbA(1c) changes. CONCLUSIONS: Structured exercise training that consists of aerobic exercise, resistance training, or both combined is associated with HbA(1c) reduction in patients with type 2 diabetes. Structured exercise training of more than 150 minutes per week is associated with greater HbA(1c) declines than that of 150 minutes or less per week. Physical activity advice is associated with lower HbA(1c), but only when combined with dietary advice. PMID: 21540423 [PubMed - indexed for MEDLINE] 32. Diabetes Care. 2011 May;34(5):1228-37. doi: 10.2337/dc10-1881. Effects of exercise on cardiovascular risk factors in type 2 diabetes: a meta-analysis. Chudyk A(1), Petrella RJ. Author information: (1)Aging, Rehabilitation, and Geriatric Care Research Centre, The Lawson Health Research Institute, Parkwood Hospital, London, Ontario, Canada.

OBJECTIVE: Exercise is a cornerstone of diabetes management and the prevention of incident diabetes. However, the impact of the mode of exercise on cardiovascular (CV) risk factors in type 2 diabetes is unclear. RESEARCH DESIGN AND METHODS: We conducted a systematic review of the literature between 1970 and October 2009 in representative databases for the effect of aerobic or resistance exercise training on clinical markers of CV risk, including glycemic control, dyslipidemia, blood pressure, and body composition in patients with type 2 diabetes. RESULTS: Of 645 articles retrieved, 34 met our inclusion criteria; most investigated aerobic exercise alone, and 10 reported combined exercise training. Aerobic alone or combined with resistance training (RT) significantly improved HbA(1c) -0.6 and -0.67%, respectively (95% CI -0.98 to -0.27 and -0.93 to -0.40, respectively), systolic blood pressure (SBP) -6.08 and -3.59 mmHg, respectively (95% CI -10.79 to -1.36 and -6.93 to -0.24, respectively), and triglycerides -0.3 mmol/L (95% CI -0.48 to -0.11 and -0.57 to -0.02, respectively). Waist circumference was significantly improved -3.1 cm (95% CI -10.3 to -1.2) with combined aerobic and resistance exercise, although fewer studies and more heterogeneity of the responses were observed in the latter two markers. Resistance exercise alone or combined with any other form of exercise was not found to have any significant effect on CV markers. CONCLUSIONS: Aerobic exercise alone or combined with RT improves glycemic control, SBP, triglycerides, and waist circumference. The impact of resistance exercise alone on CV risk markers in type 2 diabetes remains unclear. PMCID: PMC3114506 PMID: 21525503 [PubMed - indexed for MEDLINE] 33. Health Promot Int. 2009 Dec;24(4):416-27. doi: 10.1093/heapro/dap031. Epub 2009 Sep 30. Barriers to regular exercise among adults at high risk or diagnosed with type 2 diabetes: a systematic review. Korkiakangas EE(1), Alahuhta MA, Laitinen JH. Author information: (1)Finnish Institute of Occupational Health, Oulu, Finland. eveliina.korkiakangas@ttl.fi The aim of this systematic review was to identify the reported barriers to regular exercise among adults either at high risk or already diagnosed with type 2 diabetes (T2D), because of the importance of exercise in the prevention of T2D. We searched the MEDLINE, Cinahl and PsycINFO databases. All potentially relevant articles were reviewed by two researchers, and 67 titles were found, of which 13

papers met inclusion criteria. Internal and external barriers to exercise were identified among adults either at high risk of T2D or already diagnosed. Internal barriers were factors which were influenced by the individual's own decision-making, and external barriers included factors which were outside of the individual's own control. It is important for counselling to identify the internal and external barriers to regular exercise. In this way, the content of counselling can be developed, and solutions to the barriers can be discussed and identified. Further research on the barriers to regular exercise is needed. PMID: 19793763 [PubMed - indexed for MEDLINE] 34. Aust J Physiother. 2009;55(4):237-46. Progressive resistance exercise improves glycaemic control in people with type 2 diabetes mellitus: a systematic review. Irvine C(1), Taylor NF. Author information: (1)Physiotherapy, Peter James Centre, Eastern Health, Melbourne, Victoria 3131, Australia. Casey.Peiris@easternhealth.org.au QUESTION: Is progressive resistance exercise a safe and effective form of exercise to improve glycaemic control in people with type 2 diabetes? DESIGN: Systematic review with meta-analysis of randomised controlled trials. PARTICIPANTS: People with type 2 diabetes mellitus. INTERVENTION: Progressive resistance exercise. OUTCOME MEASURES: The primary outcome was glycaemic control measured as percentage glycosylated haemoglobin (HbA1c). Secondary outcomes were body composition (lean body and fat free mass in kg), and muscle strength (% change in 1RM, dynamometry, change in maximum weight lifted). RESULTS: The search yielded nine relevant trials that evaluated 372 people with type 2 diabetes. Compared to not exercising, progressive resistance exercise led to small and statistically significant absolute reductions in HbA1c of 0.3% (SMD -0.25, 95% CI -0.47 to -0.03). When compared to aerobic exercise there were no significant differences in HbA1c. Progressive resistance exercise resulted in large improvements in strength when compared to aerobic (SMD 1.44, 95% CI 0.83 to 2.05) or no exercise (SMD 0.95, 95% CI 0.58 to 1.31). There were no significant changes in body composition. CONCLUSIONS: Progressive resistance exercise increases strength and leads to small reductions in glycosylated haemoglobin that are likely to be clinically significant for people with type 2 diabetes. Progressive resistance exercise is a feasible option in the management of glycaemia for this population.

PMID: 19929766 [PubMed - indexed for MEDLINE] 35. Diabetes Metab Res Rev. 2009 Jan;25(1):13-40. doi: 10.1002/dmrr.928. Adaptations to exercise training within skeletal muscle in adults with type 2 diabetes or impaired glucose tolerance: a systematic review. Wang Y(1), Simar D, Fiatarone Singh MA. Author information: (1)Exercise, Health and Performance Faculty Research Group, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia. The aim of this investigation was to review morphological and metabolic adaptations within skeletal muscle to exercise training in adults with type 2 diabetes mellitus (T2DM) or impaired glucose tolerance (IGT). A comprehensive, systematic database search for manuscripts was performed from 1966 to March 2008 using computerized databases, including Medline, Premedline, CINAHL, AMED, EMBASE and SportDiscus. Three reviewers independently assessed studies for potential inclusion (exposure to exercise training, T2DM or IGT, muscle biopsy performed). A total of 18 exercise training studies were reviewed. All morphological and metabolic outcomes from muscle biopsies were collected. The metabolic outcomes were divided into six domains: glycogen, glucose facilitated transporter 4 (GLUT4) and insulin signalling, enzymes, markers of inflammation, lipids metabolism and so on. Beneficial adaptations to exercise were seen primarily in muscle fiber area and capillary density, glycogen, glycogen synthase and GLUT4 protein expressions. Few randomized controlled trials including muscle biopsy data existed, with a small number of subjects involved. More trials, especially robustly designed exercise training studies, are needed in this field. Future research should focus on the insulin signalling pathway to better understand the mechanism of the improvements in insulin sensitivity and glucose homeostasis in response to various modalities and doses of exercise in this cohort. Copyright 2009 John Wiley & Sons, Ltd. PMID: 19143033 [PubMed - indexed for MEDLINE] 36. Diabetes Educ. 2007 Nov-Dec;33(6):962-88; discussion 989-90. Interventions for being active among individuals with diabetes: a systematic review of the literature. Kavookjian J(1), Elswick BM, Whetsel T.

Author information: (1)Department of Pharmacy Care Systems, Harrison School of Pharmacy, 128 Miller Hall, Auburn, AL 36849-5501, USA. kavooja@auburn.edu Comment on Diabetes Educ. 2007 Nov-Dec;33(6):989-90. PURPOSE: The purpose of this systematic review is to assess and summarize evidence and gaps in the literature regarding the intervention for being active (exercise) among individuals with diabetes. METHODS: Twelve electronic databases were searched. Publications eligible for inclusion specifically studied learning, behavioral, clinical, and humanistic outcomes for exercise interventions in adult patients with type 1 and type 2 diabetes. RESULTS: Seven reviews (2 systematic reviews, 3 meta-analyses, 2 technical reviews) and 34 individual, nonreview studies (18 randomized controlled trials, 16 nonrandomized trials) met inclusion criteria. For type 2 diabetes, findings suggested that exercise had a positive effect on glycemic control and decreased cardiovascular risk, but the impact of exercise on behavioral and humanistic outcomes was unclear; long-term outcomes and adherence to exercise interventions is unknown because most studies were of short duration. The overall impact of varied types of exercise in type 1 diabetes was unclear, especially regarding glycemic control. Potential benefits of exercise in type 1 may include improved cardiovascular health. CONCLUSION: The review did not identify specific successful intervention details because of the heterogeneity of studies, subjects, and research gaps. General findings suggest that physical activity is better than no exercise at all; intensive regimens, if tolerated by patients, achieved better clinical outcomes than less intensive regimens. Reviewed studies using structured exercise regimens exhibited a more significant impact on outcomes. Substantial gaps in the literature include studies measuring direct effects of exercise in the US minority populations most affected by type 2 diabetes and economic evaluations of exercise interventions. Interventions must be tailored to individual patient needs to succeed. PMID: 18057265 [PubMed - indexed for MEDLINE]

Exercise and Elbow 1. Chiropr Man Therap. 2016 Mar 7;24:8. doi: 10.1186/s12998-016-0089-8. eCollection 2016. Multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Sutton D(1), Gross DP(2), Côté P(3), Randhawa K(4), Yu H(1), Wong JJ(5), Stern P(6), Varatharajan S(4), Southerst D(7), Shearer HM(1), Stupar M(8), Goldgrub R(9), van der Velde G(10), Nordin M(11), Carroll LJ(12), Taylor-Vaisey A(8). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (2)Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, 8205 114 St, 3-28 Corbett Hall, Edmonton, AB Canada T6G 2G4 ; Rehabilitation Research Centre, University of Alberta, 8205 114 St, 3-48 Corbett Hall, Edmonton, AB Canada T6G 2G4. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (5)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (6)Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (7)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, Ontario Canada M5T 3L9. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation,

University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (9)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, L1H 7L7 Ontario Canada. (10)Toronto Health Economics and Technology Assessment (THETA) Collaborative, 6th Floor, Room 658, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Institute for Work and Health, 481 University Avenue, Toronto, Ontario Canada M5G 2E9. (11)Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue, New York, NY 10016 USA. (12)School of Public Health and Injury Prevention Centre, University of Alberta, 3-300 Edmonton Clinic Health Academy 11405 - 87 Ave, Edmonton, Alberta Canada T6G 1C9. BACKGROUND: Musculoskeletal disorders of the elbow, forearm, wrist and hand are associated with pain, functional impairment and decreased productivity in the general population. Combining several interventions in a multimodal program of care is reflective of current clinical practice; however there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand on self-rated recovery, functional recovery, or clinical outcomes in adults or children. METHODS: We conducted a systematic review of the literature and best evidence synthesis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1990 to March 2015. Randomized controlled trials, cohort studies, and case-control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 5989 articles, and critically appraised eleven articles. Of those, seven had a low risk of bias; one addressed carpal tunnel syndrome and six addressed lateral epicondylitis. Our search did not identify any low risk of bias studies examining the effectiveness of multimodal care for the management of other musculoskeletal disorders of the elbow, forearm, wrist or hand. The evidence suggests that multimodal care for the management of lateral epicondylitis may include education, exercise (strengthening, stretching, occupational exercise), manual therapy (manipulation) and soft tissue therapy (massage). The evidence does not support the use of multimodal care for the management of carpal tunnel syndrome. CONCLUSIONS: The current evidence on the effectiveness of multimodal care for musculoskeletal disorders of the elbow, forearm, wrist and hand is limited. The available evidence suggests that there may be a role for multimodal care in the management of patients with persistent lateral epicondylitis. Future research is needed to examine the effectiveness of multimodal care and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009093. PMCID: PMC4780149 PMID: 26955466 [PubMed]

2. J Manipulative Physiol Ther. 2015 Sep;38(7):507-20. doi: 10.1016/j.jmpt.2015.06.002. Epub 2015 Jun 27. The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Menta R(1), Randhawa K(2), Côté P(3), Wong JJ(4), Yu H(5), Sutton D(6), Varatharajan S(7), Southerst D(8), D'Angelo K(1), Cox J(1), Brown C(1), Dion S(1), Mior S(9), Stupar M(10), Shearer HM(11), Lindsay GM(12), Jacobs C(13), Taylor-Vaisey A(14). Author information: (1)Graduate Student, Department of Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (2)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. Electronic address: Kristi.randhawa@uoit.ca. (3)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Oshawa, Ontario, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, Ontario, Canada. (4)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Instructor, Department of Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (5)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (6)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (7)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (8)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto,

Ontario, Canada; Research Coordinator, Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada. (9)Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Adjunct Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada. (10)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, Ontario, Canada. (11)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, Ontario, Canada. (12)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada. (13)Assistant Clinical Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Director, Division of Clinical Education and Patient Care, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (14)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada. OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 26130104 [PubMed - in process] 3. Br J Sports Med. 2013 Nov;47(17):1112-9. doi: 10.1136/bjsports-2012-091990. Epub 2013 May 24. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Hoogvliet P(1), Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Author information: (1)Department of Rehabilitation Medicine and Physical Therapy, Erasmus MC-University Medical Center Rotterdam, , Rotterdam, The Netherlands. BACKGROUND: Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and mobilisation are considered for its treatment. OBJECTIVE: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis. METHODS: Searches in PubMed, Embase, Cinahl and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. RESULTS: One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and mid-term effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found. CONCLUSIONS: Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis. PMID: 23709519 [PubMed - indexed for MEDLINE] 4. Clin Rehabil. 2014 Jan;28(1):3-19. doi: 10.1177/0269215513491974. Epub 2013 Jul 23. Is eccentric exercise an effective treatment for lateral epicondylitis? A

systematic review. Cullinane FL(1), Boocock MG, Trevelyan FC. Author information: (1)AUT University, Auckland, New Zealand. OBJECTIVE: To establish the effectiveness of eccentric exercise as a treatment intervention for lateral epicondylitis. DATA SOURCES: ProQuest, Medline via EBSCO, AMED, Scopus, Web of Science, CINAHL. REVIEW METHODS: A systematic review was undertaken to identify randomized and controlled clinical trials incorporating eccentric exercise as a treatment for patients diagnosed with lateral epicondylitis. Studies were included if: they incorporated eccentric exercise, either in isolation or as part of a multimodal treatment protocol; they assessed at least one functional or disability outcome measure; and the patients had undergone diagnostic testing. The methodological quality of each study was assessed using the Modified Cochrane Musculoskeletal Injuries Group score sheet. RESULTS: Twelve studies met the inclusion criteria. Three were deemed 'high' quality, seven were 'medium' quality, and two were 'low' quality. Eight of the studies were randomized trials investigating a total of 334 subjects. Following treatment, all groups inclusive of eccentric exercise reported decreased pain and improved function and grip strength from baseline. Seven studies reported improvements in pain, function, and/or grip strength for therapy treatments inclusive of eccentric exercise when compared with those excluding eccentric exercise. Only one low-quality study investigated the isolated effects of eccentric exercise for treating lateral epicondylitis and found no significant improvements in pain when compared with other treatments. CONCLUSION: The majority of consistent findings support the inclusion of eccentric exercise as part of a multimodal therapy programme for improved outcomes in patients with lateral epicondylitis. PMID: 23881334 [PubMed - indexed for MEDLINE] 5. J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):143-201. doi: 10.1016/j.jmpt.2013.04.001. Epub 2013 May 20. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Brantingham JW(1), Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C. Author information: (1)Murdoch University, Murdoch, Australia. jimbrant2002@yahoo.com OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing

Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence.

Exercise and Frozen shoulder 1. Health Technol Assess. 2012;16(11):1-264. doi: 10.3310/hta16110. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E(1), Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G, Robertson J, McDaid C. Author information: (1)Centre for Reviews and Dissemination, University of York, York, UK. BACKGROUND: Frozen shoulder is condition in which movement of the shoulder becomes restricted. It can be described as either primary (idiopathic) whereby the aetiology is unknown, or secondary, when it can be attributed to another cause. It is commonly a self-limiting condition, of approximately 1 to 3 years' duration, though incomplete resolution can occur. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of treatments for primary frozen shoulder, identify the most appropriate intervention by stage of condition and highlight any gaps in the evidence. DATA SOURCES: A systematic review was conducted. Nineteen databases and other sources including the Cumulative Index to Nursing and Allied Health (CINAHL), Science Citation Index, BIOSIS Previews and Database of Abstracts of Reviews of Effects (DARE) were searched up to March 2010 and EMBASE and MEDLINE up to January 2011, without language restrictions. MEDLINE, CINAHL and PsycINFO were searched in June 2010 for studies of patients' views about treatment. REVIEW METHODS: Randomised controlled trials (RCTs) evaluating physical therapies, arthrographic distension, steroid injection, sodium hyaluronate injection, manipulation under anaesthesia, capsular release or watchful waiting, alone or in combination were eligible for inclusion. Patients with primary frozen shoulder (with or without diabetes) were included. Quasi-experimental studies were included in the absence of RCTs and case series for manipulation under anaesthesia (MUA) and capsular release only. Full economic evaluations meeting the intervention and population inclusion criteria of the clinical review were included. Two researchers independently screened studies for relevance based on the inclusion criteria. One reviewer extracted data and assessed study quality; this was checked by a second reviewer. The main outcomes of interest were pain, range of movement, function and disability, quality of life and adverse events. The analysis comprised a narrative synthesis and pair-wise meta-analysis. A mixed-treatment comparison (MTC) was also undertaken. An economic decision model was intended, but was found to be implausible because of a lack of available evidence. Resource use was estimated from clinical advisors and combined with quality-adjusted life-years obtained through mapping to present tentative cost-effectiveness results. RESULTS: Thirty-one clinical effectiveness studies and one economic evaluation were included. The clinical effectiveness studies evaluated steroid injection, sodium hyaluronate, supervised neglect, physical therapy (mainly physiotherapy), acupuncture, MUA, distension and capsular release. Many of the studies identified were at high risk of bias. Because of variation in the interventions and comparators few studies could be pooled in a meta-analysis. Based on single RCTs,

and for some outcomes only, short-wave diathermy may be more effective than home exercise. High-grade mobilisation may be more effective than low-grade mobilisation in a population in which most patients have already had treatment. Data from two RCTs showed that there may be benefit from adding a single intra-articular steroid injection to home exercise in patients with frozen shoulder of < 6 months' duration. The same two trials showed that there may be benefit from adding physiotherapy (including mobilisation) to a single steroid injection. Based on a network of nine studies the MTC found that steroid combined with physiotherapy was the only treatment showing a statistically and clinically significant beneficial treatment effect compared with placebo for short-term pain (standardised mean difference -1.58, 95% credible interval -2.96 to -0.42). This analysis was based on only a subset of the evidence, which may explain why the findings are only partly supportive of the main analysis. No studies of patients' views about the treatments were identified. Average costs ranged from £36.16 for unguided steroid injections to £2204 for capsular release. The findings of the mapping suggest a positive relationship between outcome and European Quality of Life-5 Dimensions (EQ-5D) score: a decreasing visual analogue scale score (less pain) was accompanied by an increasing (better) EQ-5D score. The one published economic evaluation suggested that low-grade mobilisation may be more cost-effective than high-grade mobilisation. Our tentative cost-effectiveness analysis suggested that steroid alone may be more cost-effective than steroid plus physiotherapy or physiotherapy alone. These results are very uncertain. LIMITATIONS: The key limitation was the lack of data available. It was not possible to undertake the planned synthesis exploring the influence of stage of frozen shoulder or the presence of diabetes on treatment effect. As a result of study diversity and poor reporting of outcome data there were few instances where the planned quantitative synthesis was possible or appropriate. Most of the included studies had a small number of participants and may have been underpowered. The lack of available data made the development of a decision-analytic model implausible. We found little evidence on treatment related to stage of condition, treatment pathways, the impact on quality of life, associated resource use and no information on utilities. Without making a number of questionable assumptions modelling was not possible. CONCLUSIONS: There was limited clinical evidence on the effectiveness of treatments for primary frozen shoulder. The economic evidence was so limited that no conclusions can be made about the cost-effectiveness of the different treatments. High-quality primary research is required. PMCID: PMC4781571 PMID: 22405512

Exercise and Groin pain 1. J Manipulative Physiol Ther. 2016 Feb;39(2):110-120.e1. doi: 10.1016/j.jmpt.2016.01.003. The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Brown CK(1), Southerst D(2), Côté P(3), Shearer HM(4), Randhawa K(5), Wong JJ(6), Yu H(7), Varatharajan S(7), Sutton D(7), Stern PJ(8), D'Angelo K(1), Dion S(1), Cox J(1), Goldgrub R(9), Stupar M(10), Carroll LJ(11), Taylor-Vaisey A(12). Author information: (1)Graduate Student, Department of Graduate Studies, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (2)Research Coordinator, Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, Toronto, ON, Canada. (3)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Oshawa, ON, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (4)Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Senior Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (5)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (6)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Associate Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Instructor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (7)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (8)Director, Graduate Education Program, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Assistant Clinical Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (9)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada.

(10)Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (11)Professor, Injury Prevention Centre and School of Public Health, University of Alberta, Edmonton, AB, Canada. (12)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. RESULTS: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a "wait and see" approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. CONCLUSION: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed. Copyright © 2016 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 26976374 [PubMed - in process] 2. J Manipulative Physiol Ther. 2016 Feb;39(2):95-109.e2. doi: 10.1016/j.jmpt.2016.01.004. The Effectiveness of Multimodal Care for Soft Tissue Injuries of the Lower Extremity: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Sutton DA(1), Nordin M(2), Côté P(3), Randhawa K(4), Yu H(5), Wong JJ(6), Stern

P(7), Varatharajan S(4), Southerst D(8), Shearer HM(9), Stupar M(10), Chung C(11), Goldgrub R(12), Carroll LJ(13), Taylor-Vaisey A(14). Author information: (1)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. Electronic address: deborah.sutton@uoit.ca. (2)Professor, Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York, NY; Professor, Department of Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York, NY. (3)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), Oshawa, ON, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, ON, Canada. (4)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (5)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (6)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Associate Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Instructor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (7)Director, Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Assistant Clinical Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (8)Research Coordinator, Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Toronto, ON, Canada. (9)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Senior Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (10)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (11)Assistant Professor, Division of Clinical Education, Canadian

Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (12)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), Oshawa, ON, Canada. (13)Professor, Injury Prevention Centre and School of Public Health, University of Alberta, Edmonton, AB, Canada. (14)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the lower extremity. METHODS: We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Random pairs of independent reviewers screened studies for relevance and critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. We included studies with a low risk of bias in our best evidence synthesis. RESULTS: We screened 6794 articles. Six studies had a low risk of bias and addressed the following: plantar heel pain (n = 2), adductor-related groin pain (n = 1), and patellofemoral pain (n = 3). The evidence suggests that multimodal care for the management of persistent plantar heel pain may include mobilization and stretching exercise. An intensive, clinic-based, group exercise program (strengthening, stretching, balance, agility) is more effective than multimodal care for the management of adductor-related groin pain in male athletes. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Our search did not identify any low risk of bias studies examining multimodal care for the management of other soft tissue injuries of the lower extremity. CONCLUSION: A multimodal program of care for the management of persistent plantar heel pain may include mobilization and stretching exercise. Multimodal care for adductor-related groin pain is not recommended based on the current evidence. There is inconclusive evidence to support the use of multimodal care for the management of persistent patellofemoral pain. Copyright © 2016 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 26976373 [PubMed - in process] 3. Br J Sports Med. 2015 Nov;49(22):1447-51. doi: 10.1136/bjsports-2014-093715. Epub 2015 Jun 30. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. King E(1), Ward J(2), Small L(3), Falvey E(4), Franklyn-Miller A(5). Author information: (1)Department of Sports Medicine, Sports Surgery Clinic, Dublin, Ireland Department of Life Sciences, Roehampton University, London, UK. (2)Department of Sports Medicine, Sports Surgery Clinic, Dublin, Ireland. (3)School of

Mathematical Sciences and Insight Research Centre, University College Dublin, Dublin, Ireland. (4)Department of Sports Medicine, Sports Surgery Clinic, Dublin, Ireland Centre for Health, Exercise and Sports Medicine, University of Melbourne, Melbourne, Australia Department of Medicine, University College Cork, Ireland Irish Rugby Football Union, Dublin, Ireland. (5)Department of Sports Medicine, Sports Surgery Clinic, Dublin, Ireland Centre for Health, Exercise and Sports Medicine, University of Melbourne, Melbourne, Australia. BACKGROUND: Athletic groin pain (AGP) is an encompassing term for the multitude of chronic conditions presenting as pain in the inguinal region. The purpose of this review was to compare the return to play rates (RTPrate) and return to play times (RTPtime) between surgical and rehabilitation interventions in the treatment of AGP. METHODS: A systematic review of English language peer review journals was carried out between 1980 to June 2013 using PubMed, Embase, CINHAL and Google Scholar searching for all papers relating to AGP (and its various pseudonyms) and all surgical and rehabilitative interventions which reported RTPrate and/or RTPtime. AGP literature has been subdivided by many eponymous diagnoses but anatomical diagnostic groupings of (1) abdominal wall, (2) adductor and (3) pubic related pain were used in this review. Meta-analysis was then carried out on the data to compare results between the surgical and rehabilitation groups. RESULTS: Fifty-six papers out of the 561 discovered in the initial search were included in the review with 3332 athletes included. Evidence was mostly level IV. Using the Black and Downs checklist we found poor study quality overall with a high risk of bias especially among surgical studies. The results showed comparable RTPrate between surgical and rehabilitative interventions within the three diagnostic groups. Rehabilitation had significantly quicker RTPtime for pubic related groin pain compared to surgery (10.5 weeks and 23.1 weeks respectively). The abdominal group had the fastest return of the three groups for the rehabilitation and surgery. CONCLUSIONS: The review suggested better outcomes with rehabilitation for pubic-related groin pain with no difference between the adductor and abdominal groups. The review highlighted the poor quality and risk of bias in the literature making accurate comparison difficult. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26130700 [PubMed - in process] 4. Sports Med Arthrosc Rehabil Ther Technol. 2009 Mar 31;1(1):5. doi: 10.1186/1758-2555-1-5. A systematic review of the literature on the effectiveness of exercise therapy for groin pain in athletes. Machotka Z(1), Kumar S, Perraton LG. Author information:

(1)Centre for Allied Health Evidence, University of South Australia, North Terrace, Adelaide, South Australia, 5000, Australia. zuzana.machotka@unisa.edu.au BACKGROUND: Athletes competing in sports that require running, changes in direction, repetitive kicking and physical contact are at a relatively higher risk of experiencing episodes of athletic groin pain. To date, there has been no systematic review that aims to inform clinicians about the best available evidence on features of exercise interventions for groin pain in athletes. The primary aim of this systematic review was to evaluate the available evidence on the effectiveness of exercise therapy for groin pain in athletes. The secondary aim of this review was to identify the key features of exercise interventions used in the management of groin pain in an athletic population. METHODS: MEDLINE, CINAHL, PubMed, SPORTSDiscus, Embase, AMED, Ovid, PEDro, Cochrane Controlled Trials Register and Google Scholar databases were electronically searched. Data relating to research design, sample population, type of sport and exercise intervention was extracted. The methodological evaluation of included studies was conducted by using a modified quantitative critical appraisal tool. RESULTS: The search strategy identified 468 studies, 12 of which were potentially relevant. Ultimately five studies were included in this review. Overall the quality of primary research literature was moderate, with only one randomised controlled trial identified. All included studies provided evidence that an exercise intervention may lead to favourable outcomes in terms of return to sport. Four of the five studies reviewed included a strengthening component and most utilised functional, standing positions similar to those required by their sport. No study appropriately reported the intensity of their exercise interventions. Duration of intervention ranged from 3.8 weeks to 16 weeks. All five studies reported the use of one or more co-intervention. CONCLUSION: Best available evidence to date, with its limitations, continues to support common clinical practice of exercise therapy as a key component of rehabilitation for groin pain in athletes. Overall, the available evidence suggests that exercise, particularly strengthening exercise of the hip and abdominal musculature could be an effective intervention for athletes with groin pain. Literature provides foundational evidence that this may need to be in the form of progressive exercises (static to functional) and performed through range. There is currently no clear evidence regarding the most effective intensity and frequency of exercise, because of a lack of reporting in the primary literature. PMCID: PMC2674034 PMID: 19331695 [PubMed] 5. Scand J Med Sci Sports. 2008 Jun;18(3):263-74. doi: 10.1111/j.1600-0838.2008.00790.x. Epub 2008 Apr 6. Treatment of longstanding groin pain in athletes: a systematic review. Jansen JA(1), Mens JM, Backx FJ, Kolfschoten N, Stam HJ. Author information: (1)UMC Utrecht, Department of Rehabilitation and Sports Medicine, Heidelberglaan,

Utrecht, The Netherlands. jjansen4@umcutrecht.nl The aims of this study were to determine (1) the kinds of treatments applied for longstanding groin pain (LGP) in athletes; (2) the results; and (3) the levels of evidence for the interventions. Digital databases P were searched for articles describing the effects of interventions for LGP in athletes. Treatment of LGP in athletes can consist of conservative measures such as rest or restricted activity, active or passive physical therapy, steroid injections or dextrose prolotherapy. Studies describing surgery generally mention failure of conservative measures, although a description of these conservative measures is mostly lacking. During surgery, a reinforcement of the abdominal wall is applied in most cases, using an open or laparoscopic approach. There is level I evidence that physical therapy aiming at strengthening and coordinating the muscles stabilizing hip and pelvis has superior results compared with passive physical therapy. For patients with a positive herniography and/or positive ilioinguinal or iliohypogastric nerve block tests, there are indications (level II) that surgery results in earlier return to sport compared with exercise therapy. Possibly, laparoscopic intervention might result in an earlier return to sport compared with open approach surgery (level III). For different clinical diagnoses, the same or similar surgical interventions were performed. PMID: 18397195 [PubMed - indexed for MEDLINE]

Exercise and Headaches 1. Cephalalgia. 2016 Mar 2. pii: 0333102416636096. [Epub ahead of print] Effectiveness of preventive and treatment interventions for primary headaches in the workplace: A systematic review of the literature. Lardon A(1), Girard MP(2), Zaïm C(3), Lemeunier N(4), Descarreaux M(5), Marchand AA(6). Author information: (1)Université du Québec à Trois-Rivières, Canada Institut Franco-Européen de Chiropraxie, France. (2)Université du Québec à Trois-Rivières, Canada Université de Montréal, Canada. (3)Université de Montréal, Canada. (4)Institut Franco-Européen de Chiropraxie, France University of Ontario Institute of Technology, Canada. (5)Université du Québec à Trois-Rivières, Canada. (6)Université du Québec à Trois-Rivières, Canada andree-anne.marchand@uqtr.ca. AIM: The purpose of this systematic literature review is to assess the benefits of workplace-based occupational therapies and interventions, including acute and preventive medication, on headache intensity and frequency, related disability as well as work-related outcomes. METHODS: A search of the literature was conducted in PubMed, MEDLINE, Cochrane library, CINAHL and Embase using terms related to headache, workplace and occupational health. The Cochrane Collaboration's risk of bias assessment tool was used on individual studies to assess internal validity and the Grading of Recommendations Assessment, Development, and Evaluation system was applied to studies by clinical outcome and used to rate quality of evidence. RESULTS: Fifteen articles were included in the systematic review. None of them were classified as low risk of bias according to the Cochrane Collaboration's tool for assessing risk of bias. This systematic review found preliminary low-quality evidence suggesting that exercise and acupuncture can reduce workers' headache pain intensity, frequency and related disability. CONCLUSION: Although this systematic review provided preliminary low evidence in favour of work-based intervention, studies with more rigorous designs and methodologies are needed to provide further evidence of the effectiveness of workplace-based headache management strategies. © International Headache Society 2016. PMID: 26935099 [PubMed - as supplied by publisher] 2. Eur Spine J. 2016 Feb 6. [Epub ahead of print] Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Varatharajan S(1,)(2,)(3), Ferguson B(4), Chrobak K(4), Shergill Y(5), Côté P(6,)(7,)(8), Wong JJ(1,)(2), Yu H(1,)(2), Shearer HM(1,)(2), Southerst D(1,)(9),

Sutton D(1,)(2), Randhawa K(1,)(2,)(3), Jacobs C(1,)(10), Abdulla S(4), Woitzik E(4), Marchand AA(11), van der Velde G(12,)(13,)(14), Carroll LJ(15), Nordin M(16), Ammendolia C(17,)(14,)(18), Mior S(2,)(17), Ameis A(19), Stupar M(1), Taylor-Vaisey A(1). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (2)Division of Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (3)Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (4)Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (5)University of Ottawa Centre for Interdisciplinary Pain Research, Ottawa Hospital Research Institute, The Ottawa Hospital General Campus, 501 Smyth Rd, Box 249-B, Ottawa, ON, K1H 8L6, Canada. (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. pierre.cote@uoit.ca. (7)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada. pierre.cote@uoit.ca. (8)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada. pierre.cote@uoit.ca. (9)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, ON, M5T 3L9, Canada. (10)Division of Clinical Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (11)Département d'anatomie, Université du Québec à Trois-Rivières, 3351 Boul. des Forges, C.P. 500, Trois-Rivières, QUÉBEC, G9A 5H7, Canada. (12)Toronto Health Economics and Technology Assessment (THETA) Collaborative, 6th Floor, Room 658, 144 College Street, Toronto, ON, M5S 3M2, Canada. (13)Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada. (14)Institute for Work and Health, 481 University Avenue, Toronto, ON, M5G 2E9, Canada. (15)Injury Prevention Centre and School of Public Health, University of Alberta, 3-300 ECHA, 11405-87 Ave, Edmonton, AB, T6G 1C9, Canada. (16)Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue, New York, NY, 10016, USA. (17)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada. (18)Institute for Health Policy, Management and Evaluation, University of Toronto, 4th Flodior, 155 College St, Toronto, ON, M5T 3M6, Canada. (19)Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada. PURPOSE: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients

with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches). METHODS: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful. CONCLUSIONS: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy. PMID: 26851953 [PubMed - as supplied by publisher] 3. Cephalalgia. 2016 Apr;36(5):474-92. doi: 10.1177/0333102415597889. Epub 2015 Jul 30. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis. Luedtke K(1), Allers A(1), Schulte LH(1), May A(2). Author information: (1)Department of Systems Neuroscience, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Germany. (2)Department of Systems Neuroscience, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Germany a.may@uke.de. AIM: We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH). METHODS: We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality. RESULTS: Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB

in >1 domain. Meta-analyses of all trials indicated a reduction of TTH ( ITALIC! p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH ( ITALIC! p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency ( ITALIC! p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine ( ITALIC! p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH ( ITALIC! p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity ( ITALIC! p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency ( ITALIC! p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62). DISCUSSION: Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low. © International Headache Society 2015. PMID: 26229071 [PubMed - in process] 4. Chiropr Man Therap. 2014 Mar 28;22(1):12. doi: 10.1186/2045-709X-22-12. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P(1). Author information: (1)Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, England. p.a.sutcliffe@warwick.ac.uk. BACKGROUND: This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report. METHODS: A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated,

or new categories not assessed by Bronfort were added. RESULTS: 25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive. CONCLUSIONS: Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted. PMCID: PMC3997823 PMID: 24679336 [PubMed] 5. Headache. 2014 Jan;54(1):40-53. doi: 10.1111/head.12204. Epub 2013 Aug 28. A systematic review of behavioral headache interventions with an aerobic exercise component. Baillie LE(1), Gabriele JM, Penzien DB. Author information: (1)Department of Psychology, G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS, USA; Department of Psychiatry, The University of Mississippi Medical Center, Jackson, MS, USA. BACKGROUND: Behavioral approaches have been found to be effective in managing chronic headache. Recently, attention has been given to the role of exercise in chronic headache management, although much of the literature addresses it as a monotherapy. The current review assesses the effectiveness of exercise as an adjunct to other behavioral treatments for chronic headache. OBJECTIVE: To evaluate the methodology and outcomes of studies using behavioral headache interventions with an aerobic exercise component. METHODS: A systematic literature review was conducted on PubMed and PsychInfo to identify studies that offered or recommended aerobic exercise as part of a multicomponent treatment for headaches. The search included only those articles that were written in English and published in academic journals. RESULTS: Nine studies met inclusion criteria, of which 2 were randomized controlled trials. Despite methodological limitations, results of existing studies suggest that the behavioral headache interventions that include aerobic exercise may be associated with positive outcomes for headache variables. Four single-group studies reported statistically significant improvements in at least 1 headache variable at the end of treatment. Both randomized controlled trials and 1 non-randomized trial reported statistically significant post-treatment improvement in at least 1 headache outcome variable in the intervention group

compared with control groups. CONCLUSIONS: Incorporating exercise into behavioral headache treatments appears to be promising, but as studies to date have not evaluated the individual contribution of exercise, its role in managing headache symptoms is unclear. Further work is needed to evaluate the unique role of exercise in such treatment programs. Recommendations for future research include adhering to published guidelines for clinical trial design and reporting, adhering to existing guidelines for headache research (such as reporting outcome data for multiple headache variables), developing exercise prescriptions based on public health recommendations, and reporting all aspects of exercise prescriptions. © 2013 American Headache Society. PMID: 23992549 [PubMed - indexed for MEDLINE] 6. Curr Pain Headache Rep. 2009 Dec;13(6):413-9. Does exercise therapy improve headache? a systematic review with meta-analysis. Fricton J(1), Velly A, Ouyang W, Look JO. Author information: (1)Department of Diagnostic and Surgical Science, University of Minnesota School of Dentistry, 515 Delaware Street SE, Minneapolis, MN 55455, USA. frict001@umn.edu PMID: 19889280 [PubMed - indexed for MEDLINE]

Exercise and hip 1. J Manipulative Physiol Ther. 2016 Feb;39(2):110-120.e1. doi: 10.1016/j.jmpt.2016.01.003. The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Brown CK(1), Southerst D(2), Côté P(3), Shearer HM(4), Randhawa K(5), Wong JJ(6), Yu H(7), Varatharajan S(7), Sutton D(7), Stern PJ(8), D'Angelo K(1), Dion S(1), Cox J(1), Goldgrub R(9), Stupar M(10), Carroll LJ(11), Taylor-Vaisey A(12). Author information: (1)Graduate Student, Department of Graduate Studies, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (2)Research Coordinator, Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, Toronto, ON, Canada. (3)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Oshawa, ON, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (4)Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Senior Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (5)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (6)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Associate Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Instructor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (7)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (8)Director, Graduate Education Program, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Assistant Clinical Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (9)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada. (10)Adjunct Professor, Graduate Education and Research Programs, Canadian

Memorial Chiropractic College, Toronto, ON, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (11)Professor, Injury Prevention Centre and School of Public Health, University of Alberta, Edmonton, AB, Canada. (12)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip, thigh, and knee. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. RESULTS: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a "wait and see" approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. CONCLUSION: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed. Copyright © 2016 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 26976374 [PubMed - in process] 2. Clin Rehabil. 2015 Dec 22. pii: 0269215515622670. [Epub ahead of print] The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: A systematic review and meta-analysis. Sampath KK(1), Mani R(2), Miyamori T(2), Tumilty S(2). Author information: (1)Centre for Health, Activity, and Rehabilitation Research, School of

Physiotherapy, University of Otago, New Zealand kesava.kovanur-sampath@otago.ac.nz. (2)Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand. OBJECTIVE: To determine whether manual therapy or exercise therapy or both is beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life. METHODS: Databases such as Medline, AMED, EMBASE, CINAHL, SPORTSDiscus, PubMed, Cochrane Library, Web of Science, Physiotherapy Evidence Database, and SCOPUS were searched from their inception till September 2015. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures (pain, physical function and quality of life) were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for assessing the quality of the body of evidence for each outcome of interest. RESULTS: Seven trials (886 participants) that met the inclusion criteria were included in the meta-analysis. There was high quality evidence that exercise therapy was beneficial at post-treatment (pain-SMD-0.27,95%CI-0.5to-0.04;physical function-SMD-0.29,95%CI-0.47to-0.11) and follow-up (pain-SMD-0.24,95%CI- 0.41to-0.06; physical function-SMD-0.33,95%CI-0.5to-0.15). There was low quality evidence that manual therapy was beneficial at post-treatment (pain-SMD-0.71,95%CI-1.08to-0.33; physical function-SMD-0.71,95%CI-1.08to-0.33) and follow-up (pain-SMD-0.43,95%CI-0.8to-0.06; physical function-SMD-0.47,95%CI-0.84to-0.1). Low quality evidence indicated that combined treatment was beneficial at post-treatment (pain-SMD-0.43,95%CI-0.78to-0.08; physical function-SMD-0.38,95%CI-0.73to-0.04) but not at follow-up (pain-SMD0.25,95%CI-0.35to0.84; physical function-SMD0.09,95%CI-0.5to0.68). There was no effect of any interventions on quality of life. CONCLUSION: An Exercise therapy intervention provides short-term as well as long-term benefits in terms of reduction in pain, and improvement in physical function among people with hip osteoarthritis. The observed magnitude of the treatment effect would be considered small to moderate. © The Author(s) 2015. PMID: 26701903 [PubMed - as supplied by publisher] 3. Br J Sports Med. 2016 Apr;50(8):458-63. doi: 10.1136/bjsports-2015-095255. Epub 2015 Nov 26. Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis. Beumer L(1), Wong J(1), Warden SJ(2), Kemp JL(3), Foster P(1), Crossley KM(4). Author information: (1)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia. (2)School of Health and Rehabilitation Sciences, Indiana University, Indianapolis, Indiana, USA. (3)Australian Centre for Research

into Injury and Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia. (4)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia. AIM: To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA). METHODS: A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0-3 months=short term; 4-12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores. RESULTS: 19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD -0.53, 95% CI -0.96 to -0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD -0.49, 95% CI -0.70 to -0.29). There were no medium (SMD -0.23, 95% CI -0.48 to 0.03) or long (SMD -0.22, 95% CI -0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD -0.38, 95% CI -0.88 to 0.13) when compared to minimal control. CONCLUSIONS: Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger high-quality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26612846 [PubMed - in process] 4. J Am Med Dir Assoc. 2016 Mar 1;17(3):200-5. doi: 10.1016/j.jamda.2015.10.004. Epub 2015 Nov 25. Rehabilitation Interventions for Older Individuals With Cognitive Impairment Post-Hip Fracture: A Systematic Review. Resnick B(1), Beaupre L(2), McGilton KS(3), Galik E(4), Liu W(5), Neuman MD(6), Gruber-Baldini AL(7), Orwig D(7), Magaziner J(7). Author information: (1)Organizational Systems and Adult Health, University of Maryland, School of Nursing, Baltimore, MD. Electronic address: resnick@son.umaryland.edu. (2)Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada. (3)Toronto Rehabilitation Institute, University Health Network, Lawrence

S. Bloomberg Faculty of Nursing Toronto, Ontario, Canada. (4)Organizational Systems and Adult Health, University of Maryland, School of Nursing, Baltimore, MD. (5)University of Iowa, Iowa City, IA. (6)Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. (7)Division of Gerontology, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD. PURPOSE: Currently, most rehabilitation services for individuals who sustain a hip fracture are not designed to meet the complex needs of those who also have cognitive impairment. The goal of this review was to identify current best practices for rehabilitation in long-term care settings and approaches to optimize outcomes among individuals with dementia and other cognitive impairments post-hip fracture. PROCEDURES: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement was used to guide the review. Five electronic databases, including PubMed, EMBASE, CINAHL (EBSCO), Medline (EBSCO), and PsycINFO (EBSCO), were searched for intervention studies published in English language journals. Studies were eligible if they focused on rehabilitation interventions post-hip fracture among older individuals (≥65 years) with cognitive impairment who were living in or transferred to long-term care or postacute/rehabilitation settings post-hip fracture. Studies were excluded if they did not enroll individuals with cognitive impairment, the study was descriptive without any intervention content, or the intervention components were only medication, surgical approach or medical treatment. MAIN FINDINGS: A total of 4478 records were identified, 1915 of which were duplicative, 2563 were relevant based on title, and after careful review 7 studies were included. Two included studies were randomized controlled trials, one was a single group pre- and post-test, one a descriptive comparison between those with and without cognitive impairment, one a case controlled matched trial, one a nonequivalent groups trial, and one a case report. The interventions varied between manipulating the type and amount of exercise or testing multifactorial issues including environmental interventions and the use of an interdisciplinary team to address psychosocial factors, medication management, use of assistive devices, and specific preferences or concerns of the individuals. CONCLUSIONS: The evidence summarized in this review suggests that it is feasible to implement rehabilitation programs focused on individuals with cognitive impairment in postacute care settings. Moreover, there was evidence to suggest that intensive rehabilitation and exercise activities are beneficial, although innovative approaches may be needed to engage individuals with cognitive impairment. Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved. PMCID: PMC4769900 [Available on 2017-03-01] PMID: 26612482 [PubMed - in process] 5. Clin Rehabil. 2015 Sep 23. pii: 0269215515606198. [Epub ahead of print] Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise

in the management of hip osteoarthritis. Brosseau L(1), Wells GA(2), Pugh AG(3), Smith CA(2), Rahman P(4), Àlvarez Gallardo IC(5), Toupin-April K(6), Loew L(7), De Angelis G(2), Cavallo S(8), Taki J(9), Marcotte R(10), Fransen M(11), Hernandez-Molina G(12), Kenny GP(10), Regnaux JP(13), Lefevre-Colau MM(14), Brooks S(15), Laferriere L(16), McLean L(7), Longchamp G(17). Author information: (1)School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada Lucie.Brosseau@uottawa.ca. (2)School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada. (3)Department of Public Health Sciences, Queens University, Canada. (4)Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. (5)Department of Physical Education and Sport, University of Granada, Granada, Spain. (6)Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada. (7)School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada. (8)School of Public Health, Option Epidemiology, University of Montreal, Montreal, Quebec, Canada. (9)Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada. (10)School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada. (11)Faculty of Health Sciences, University of Sydney, Sydney, Australia. (12)Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Canada. (13)Centre de recherche Epidémiologie et Biostatistique, Hôpital Hôtel-Dieu, Paris, France. (14)Department of Medicine and Rehabilitation, Institute of Rheumatology, Cochin Hospital, Paris, France. (15)The Arthritis Society, Ontario Division, Ontario, Canada. (16)Canadian Forces Health Services Group Headquarters, National Defense, Ottawa, Ontario, Canada. (17)Consumer expert. OBJECTIVES: The primary objective is to identify effective land-based therapeutic exercise interventions and provide evidence-based recommendations for managing hip osteoarthritis. A secondary objective is to develop an Ottawa Panel evidence-based clinical practice guideline for hip osteoarthritis. METHODS: The search strategy and modified selection criteria from a Cochrane review were used. Studies included hip osteoarthritis patients in comparative controlled trials with therapeutic exercise interventions. An Expert Panel arrived at a Delphi survey consensus to endorse the recommendations. The Ottawa Panel hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) considered the study design (level I: randomized controlled trial and level II: controlled clinical trial), statistical significance (p < 0.5), and clinical importance (⩾15% improvement). RESULTS: Four high-quality studies were included, which demonstrated that variations of strength training, stretching, and flexibility exercises are generally effective for improving the management of hip osteoarthritis. Strength training exercises displayed the greatest improvements for pain (Grade A), disability (Grades A and C+), physical function (Grade A), stiffness (Grade A), and range of motion (Grade A) within a short time period (8-24 weeks). Stretching also greatly improved physical function (Grade A), and flexibility exercises improved pain (Grade A), range of motion (Grade A), physical function (Grade A), and stiffness (Grade C+).

CONCLUSION: The Ottawa Panel recommends land-based therapeutic exercise, notably strength training, for management of hip osteoarthritis in reducing pain, stiffness and self-reported disability, and improving physical function and range of motion. © The Author(s) 2015. PMID: 26400851 [PubMed - as supplied by publisher] 6. Br J Sports Med. 2016 Mar;50(6):346-55. doi: 10.1136/bjsports-2014-094465. Epub 2015 Jun 2. Structured exercise improves mobility after hip fracture: a meta-analysis with meta-regression. Diong J(1), Allen N(2), Sherrington C(3). Author information: (1)Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia. (2)Faculty of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia. (3)The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia. OBJECTIVES: To determine the effect of structured exercise on overall mobility in people after hip fracture. To explore associations between trial-level characteristics and overall mobility. DESIGN: Systematic review, meta-analysis and meta-regression. DATA SOURCES: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register and the Physiotherapy Evidence Database to May 2014. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS: Randomised controlled trials of structured exercise, which aimed to improve mobility compared with a control intervention in adult participants after surgery for hip fracture were included. DATA EXTRACTION AND SYNTHESIS: Data were extracted by one investigator and checked by an independent investigator. Standardised mean differences (SMD) of overall mobility were meta-analysed using random effects models. Random effects meta-regression was used to explore associations between trial-level characteristics and overall mobility. RESULTS: 13 trials included in the meta-analysis involved 1903 participants. The pooled Hedges' g SMD for overall mobility was 0.35 (95% CI 0.12 to 0.58, p=0.002) in favour of the intervention. Meta-regression showed greater treatment effects in trials that included progressive resistance exercise (change in SMD=0.58, 95% CI 0.17 to 0.98, p=0.008, adjusted R(2)=60%) and delivered interventions in settings other than hospital alone (change in SMD=0.50, 95% CI 0.08 to 0.93, p=0.024, adjusted R(2)=49%). CONCLUSIONS AND IMPLICATIONS: Structured exercise produced small improvements on overall mobility after hip fracture. Interventions that included progressive resistance training and were delivered in other settings were more effective, although the latter may have been confounded by duration of interventions.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26036676 [PubMed - in process] 7. Physiotherapy. 2015 Sep;101(3):252-65. doi: 10.1016/j.physio.2014.12.003. Epub 2015 Jan 16. Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review. Lowe CJ(1), Davies L(2), Sackley CM(3), Barker KL(4). Author information: (1)Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Hospital, Windmill Road, Headington, Oxford, UK. Electronic address: catherine.minnslowe@ouh.nhs.uk. (2)Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Hospital, Windmill Road, Headington, Oxford, UK. (3)School of Rehabilitation Sciences, University of East Anglia, Norwich Research Park, Norwich, UK. (4)Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Hospital, Windmill Road, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals NHS Trust, Oxford, UK. BACKGROUND: Existing review required updating. OBJECTIVE: To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis. DESIGN: Systematic review from January 2007 to November 2013. DATA SOURCES: AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied. ELIGIBILITY CRITERIA: Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed. OUTCOMES: Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion. STUDY APPRAISAL: Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered. RESULTS: 11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening.

LIMITATIONS: The overall quality and quantity of trials, and their diversity, prevented meta-analyses. CONCLUSIONS: Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required. Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 25724323 [PubMed - indexed for MEDLINE] 8. Open Rheumatol J. 2014 Nov 28;8:89-95. doi: 10.2174/1874312901408010089. eCollection 2014. Physical exercise and weight loss for hip and knee osteoarthritis in very old patients: a systematic review of the literature. Quintrec JL(1), Verlhac B(2), Cadet C(3), Bréville P(4), Vetel JM(5), Gauvain JB(6), Jeandel C(7), Maheu E(8). Author information: (1)Service de Médecine Gériatrique 3 [Department of Geriatric Medicine 3], Hôpital Sainte-Périne (A.P-H.P), Paris, France. (2)Pôle Vieillissement, réadaptation et Accompagnement [Centre for the Aged, Rehabilitation and Support], Hôpital Paul Brousse (A.P-H.P) Villejuif, France. (3)Medical Office, Paris, France. (4)Service de Rhumatologie [Department of Rheumatology], Groupe Hospitalier Paris Saint Joseph, Paris, France. (5)Centre Hospitalier, Le Mans, France. (6)Centre de Médecine Interne Gériatrique [Centre for Geriatric Internal Medicine], Centre Hospitalier régional, Orléans, France. (7)Service de Médecine interne et Gériatrie [Department of Internal and Geriatric Medicine], Montpellier, France. (8)Service de Rhumatologie, Rheumatology Department, Medical Office / Hôpital Saint Antoine -A.P-H.P, Paris, France. BACKGROUND: Rheumatologic and geriatric scholarly organisations recommendations for the management of hip and knee osteoarthritis, which emphasise the usefulness of non-pharmacological therapies, are not scaled according to patient's age and physical condition. We conducted a systematic review of clinical trials on exercise and weight loss in hip and knee osteoarthritis in very old patients. METHODS: Electronic search in MEDLINE, EMBASE, PASCAL database, systematic search of the Cochrane Reviews, manual search in guidelines, meta-analyses and identified relevant articles. RESULTS: We identified 83 trials, with only 2 on patients aged ≥ 75 years; we therefore lowered the mean age threshold to 70 years and found 15 trials, mainly performed in knee osteoarthritis and outpatients. PHYSICAL EXERCISE 8 TRIALS: was effective on pain and function (4 controlled trials), with a persistent effect only in case of self-rehabilitation. AQUATIC EXERCISE 5 TRIALS: was as effective as land-based exercise. WEIGHT LOSS 2 TRIALS: only patients under diet + exercise had significant improvement on symptoms.

CONCLUSION: Our systematic review confirms that international recommendations on exercise for knee osteoarthritis also apply to subjects aged 70-80 years. Long-term effectiveness requires a maintenance strategy. Specific trials on very old patients with various comorbidities are mandatory, given that these subjects are more exposed to drug-related iatrogenesis. PMCID: PMC4258698 PMID: 25489352 [PubMed] 9. Clin Rehabil. 2015 Jan;29(1):14-29. doi: 10.1177/0269215514537093. Epub 2014 Jul 3. Progressive resistance training before and after total hip and knee arthroplasty: a systematic review. Skoffer B(1), Dalgas U(2), Mechlenburg I(3). Author information: (1)Institute of Clinical Medicine, Aarhus University, Denmark Department of Physical and Occupational Therapy, Aarhus University Hospital, Denmark bss@mph.au.dk. (2)Section of Sport Science, Department of Public Health, Aarhus University, Denmark. (3)Orthopaedic Research Centre, Aarhus University Hospital, Denmark. OBJECTIVE: To investigate the effect of progressive resistance training (PRT) on muscle strength and functional capacity before and/or after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The effects of THA and TKA upon quality of life and the rate of adverse events were also investigated. DATA SOURCES: Literature from nine databases. REVIEW METHODS: Studies were included if 1) the effect of a PRT intervention was compared with no intervention or another type of intervention; 2) the outcomes included muscle strength and/or functional capacity; 3) all participants were scheduled for or had just undergone THA or TKA; 4) they were randomized, controlled trials (RCT); and 5) only full-length papers in English were studied. Data on patient characteristics, training regime, controls, and outcome measures were extracted. RESULTS: Four RCT studies on PRT and THA including 136 patients and three RCT studies on PRT and TKA including 284 patients were identified and rated according to the PEDro scale. The general methodological quality of the studies was low. No adverse events were reported in any of the studies. Weak evidence of a beneficial effect of PRT before and/or after THA on muscle strength and functional capacity was found. No effect of PRT before TKA on muscle strength and functional capacity was found. The results of postoperative PRT were too heterogeneous to allow conclusions. CONCLUSION: PRT is safe and feasible before and/or after THA. PRT is safe, but the methodological quality of existing evidence permits no conclusion on the effectiveness of PRT before and/or after TKA. © The Author(s) 2014.

PMID: 24994766 [PubMed - indexed for MEDLINE] 10. Semin Arthritis Rheum. 2014 Jun;43(6):701-12. doi: 10.1016/j.semarthrit.2013.11.012. Epub 2013 Dec 4. A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Nelson AE(1), Allen KD(2), Golightly YM(3), Goode AP(4), Jordan JM(5). Author information: (1)Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC. Electronic address: aenelson@med.unc.edu. (2)Department of Medicine, Duke University Medical Center & Health Services Research & Development, VA Medical Center, Durham, NC. (3)Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC. (4)Department of Community and Family Medicine, Duke University Medical Center, Durham, NC. (5)Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Department of Orthopaedics, University of North Carolina, Chapel Hill, NC. PURPOSE: Although a number of osteoarthritis (OA) management guidelines exist, uptake has been suboptimal. Our aim was to review and critically evaluate existing OA management guidelines to better understand potential issues and barriers. METHODS: A systematic review of the literature in MEDLINE published from January 1, 2000 to April 1, 2013 was performed and supplemented by bibliographic reviews, following PRISMA guidelines and a written protocol. Following initial title and abstract screening, 2 authors independently reviewed full-text articles; a third settled disagreements. Two independent reviewers extracted data into a standardized form. Two authors independently assessed guideline quality using the AGREE II instrument; three generated summary recommendations based on the extracted guideline data. RESULTS: Overall, 16 articles were included in the final review. There was broad agreement on recommendations by the various organizations. For non-pharmacologic modalities, education/self-management, exercise, weight loss if overweight, walking aids as indicated, and thermal modalities were widely recommended. For appropriate patients, joint replacement was recommended; arthroscopy with debridement was not recommended for symptomatic knee OA. Pharmacologic modalities most recommended included acetaminophen/paracetamol (first line) and NSAIDs (topical or oral, second line). Intra-articular corticosteroids were generally recommended for hip and knee OA. Controversy remains about the use of acupuncture, knee braces, heel wedges, intra-articular hyaluronans, and glucosamine/chondroitin.

CONCLUSIONS: The relative agreement on many OA management recommendations across organizations indicates a problem with dissemination and implementation rather than a lack of quality guidelines. Future efforts should focus on optimizing implementation in primary care settings, where the majority of OA care occurs. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 24387819 [PubMed - indexed for MEDLINE] 11. J Physiother. 2013 Dec;59(4):219-26. doi: 10.1016/S1836-9553(13)70198-X. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait speed and cadence after elective total hip replacement: a systematic review. Coulter CL(1), Scarvell JM, Neeman TM, Smith PN. Author information: (1)Australian National University Medical School, Australia; Physiotherapy Department, Canberra Hospital, Australia. Electronic address: corinne.coulter@act.gov.au. QUESTION: In people who have been discharged from hospital after a total hip replacement, do rehabilitation exercises directed by a physiotherapist improve strength, gait, function and quality of life? Are these exercises as effective in an unsupervised home-based setting as they are in a supervised outpatient setting? DESIGN: Systematic review with meta-analysis of randomised trials. PARTICIPANTS: Adult patients after elective total hip replacement. INTERVENTION: Physiotherapist-directed rehabilitation exercises after discharge from hospital following total hip replacement. OUTCOME MEASURES: Hip and knee strength, gait parameters, functional measures, and quality of life. RESULTS: Five studies comprising 234 participants were included in the review. Sufficient data for meta-analysis were only obtained for hip and knee strength, gait speed and cadence. Physiotherapy rehabilitation improved hip abductor strength by a mean of 16Nm (95% CI 10 to 22), gait speed by 6 m/min (95% CI 1 to 11) and cadence by 20 steps/min (95% CI 8 to 32). Favourable but non-significant improvements in strength were noted for other muscle groups at the hip and knee. Function and quality of life could not be meta-analysed due to insufficient data and heterogeneity of measures, but functional measures tended to favour the physiotherapy rehabilitation group. Most outcomes were similar between outpatient and home-based exercise programs. CONCLUSION: Physiotherapy rehabilitation improves hip abductor strength, gait speed and cadence in people who have been discharged from hospital after total hip replacement. Physiotherapist-directed rehabilitation exercises appear to be similarly effective whether they are performed unsupervised at home or supervised by a physiotherapist in an outpatient setting. Copyright © 2013 Australian Physiotherapy Association. Published by Elsevier B.V.

All rights reserved. PMID: 24287215 [PubMed - indexed for MEDLINE] 12. Eur J Phys Rehabil Med. 2013 Dec;49(6):893-907, quiz 921-3. Epub 2013 Oct 30. Which type of exercise therapy is effective after hip arthroplasty? A systematic review of randomized controlled trials. Di Monaco M(1), Castiglioni C. Author information: (1)Division of Physical Medicine and Rehabilitation and Osteoporosis Research Center Presidio Sanitario San Camillo, Turin, Italy - marco.di.monaco@alice.it. BACKGROUND: Early multidisciplinary rehabilitation can improve the recovery after total hip arthroplasty (THA). However, optimal exercise therapy has not been defined. We aimed to answer the question: "Which type and/or timing of exercise therapy is effective following THA?" DESIGN: Systematic review. METHODS: We searched four databases: MEDLINE, PEDro, Cochrane Library, and Cinahl since January 2008 till December 2012. Literature before 2008 was not searched for, because it was previously analyzed by two systematic reviews. Eligible criteria for studies were: Randomized Controlled Trials (RCTs); English language; interventions on type and/or timing of physical exercise initiating after THA; outcome measures including at least one among impairment, activity, participation, quality of life, or length of stay in hospital. RESULTS: Eleven papers on nine RCTs were identified. Trial quality was mixed. PEDro scores ranged from four to eight. Exercise therapy varied greatly in type and timing. Each of the nine RCTs addressed a specific issue and overall the results were sparse. In the early postoperative phase favorable outcomes were due to ergometer cycling and maximal strength training. Inconclusive results were reported for aquatic exercises, bed exercises without external resistance or without its progressive increase according to the overload principle, and timing. In the late postoperative phase (> 8 weeks postoperatively) advantages were due to weight-bearing exercises. CONCLUSION: Insufficient evidence exists to build up a detailed evidence-based exercise protocol after THA. Sparse results from few RCTs support specific exercise types which should be added to the usual mobility training in THA patients. PMID: 24172644 [PubMed - indexed for MEDLINE] 13. Reumatismo. 2013 May 27;65(2):63-74. doi: 10.4081/reumatismo.2013.63. Manual therapy and therapeutic exercise in the treatment of osteoarthritis of the hip: a systematic review. Romeo A(1), Parazza S, Boschi M, Nava T, Vanti C.

Author information: (1)Manual Therapy, University of Padova, Italy. This systematic review aimed at investigating the role of therapeutic exercise and/or manual therapy in the treatment of hip osteoarthritis (OA). Two independent reviewers (AR, CV) searched PubMed, Cinahl, Cochrane Library, PEDro and Scopus databases and a third one (SP) was consulted in case of disagreement. The research criteria were publication period (from May 2007 to April 2012) and publication language (English or Italian). Ten randomized controlled trials matched inclusion criteria, eight of which concerning therapeutic exercise and two manual therapy. Few good quality studies were found. At mid- and long-term follow-up land-based exercises showed insufficient evidence of effectiveness with respect to pain and quality of life, but positive results were found for physical function. Water exercises significantly reduced fall risk when combined with functional exercises. Programs containing progressive and gradual exposure of difficult activities, education and exercises promoted better outcomes, higher adherence to home program and increased amount of physical activity, especially walking. Manual therapy seemed to reduce pain and decrease disability at short-term. Less use of nonsteroidal anti-inflammatory drugs was statistically significant at long-term follow-up in patients treated with manual therapy. The relationship between clinical results and radiological grade of OA was not investigated. Encouraging results were found in recent literature for manual therapy and functional training. Further research is needed to elucidate this issue through high-quality trials, especially addressing the aspects that have not been thoroughly explored yet, for instance type, amount and scheduling of conservative treatment. PMID: 23877410 [PubMed - indexed for MEDLINE] 14. Arch Phys Med Rehabil. 2013 Jan;94(1):164-76. doi: 10.1016/j.apmr.2012.08.211. Epub 2012 Sep 4. Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Gill SD(1), McBurney H. Author information: (1)Department of Physiotherapy, Barwon Health, Geelong, Australia. steveg@barwonhealth.org.au OBJECTIVE: To investigate the preoperative effects of exercise-based interventions on pain and physical function for people awaiting joint replacement surgery of the hip or knee. DATA SOURCES: Four computer databases (CINAHL, MEDLINE, Embase, and Cochrane Library) were searched until July 4, 2012. Search terms included knee, hip, joint replacement, arthroplasty, physiotherapy, physical therapy, exercise, hydrotherapy, rehabilitation, and preoperative. Reference lists of retrieved

articles were also screened. STUDY SELECTION: Randomized or quasi-randomized studies comparing an exercise-based intervention with a no-intervention group for people awaiting hip or knee joint replacement surgery were included. Outcomes were pain and physical function including self-reported function, walking speed, and muscle strength. One of 2 reviewers determined that 18 studies met the inclusion criteria. DATA EXTRACTION: The methodologic quality of each study was independently assessed by 2 reviewers using the PEDro scale, and a final PEDro score was determined by discussion and consensus between the reviewers. Participants' characteristics, content and design of the interventions, and data for quantitative synthesis were extracted by 1 reviewer. DATA SYNTHESIS: For participants awaiting knee replacement surgery, quantitative data synthesis found no significant differences between the exercise and no-intervention groups for pain, self-reported function, walking speed, or muscle strength. For participants awaiting hip replacement surgery, quantitative data synthesis found a significant difference between the groups, with standardized mean differences (SMDs) indicating a medium-sized effect in favor of intervention for both pain (SMD=.45; 95% confidence interval .15-.75) and self-reported function (SMD=.46; 95% confidence interval .20-.72). CONCLUSIONS: Exercise-based interventions can reduce pain and improve physical function for people awaiting hip replacement surgery but not knee replacement surgery. Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. PMID: 22960276 [PubMed - indexed for MEDLINE] 15. Phys Ther. 2012 Nov;92(11):1437-51. doi: 10.2522/ptj.20110274. Epub 2012 Jul 19. Extended exercise rehabilitation after hip fracture improves patients' physical function: a systematic review and meta-analysis. Auais MA(1), Eilayyan O, Mayo NE. Author information: (1)School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, Quebec, Canada. mohammad.auais@mail.mcgill.ca BACKGROUND: Although the principal goal of hip fracture management is a return to the pre-event functional level, most survivors fail to regain their former levels of autonomy. One of the most effective strategies to mitigate the fracture's consequences is therapeutic exercise. PURPOSE: The purpose of this study was to review and quantify the reported effects of an extended exercise rehabilitation program offered beyond the regular rehabilitation period on improving physical functioning for patients with hip fractures. SOURCES: The Cochrane libraries, PubMed, CINAHL, PEDro, and EMBASE were searched to April 2012. STUDY SELECTION: All randomized controlled trials comparing extended exercise

programs with usual care for community-dwelling people after hip fracture were included in the review. DATA EXTRACTION AND SYNTHESIS: Two reviewers conducted each step independently. The data from the included studies were summarized, and pooled estimates were calculated for 11 functional outcomes. RESULTS: Thirteen trials were included in the review and 11 in the meta-analysis. The extended exercise program showed modest effect sizes (ESs), which reached significance, under random theory, for knee extension strength for the affected and nonaffected sides (ES=0.47, 95% confidence interval [CI]=0.27-0.66, and ES=0.45, 95% CI=0.16-0.74, respectively), balance (ES=0.32, 95% CI=0.15-0.49), physical performance-based tests (ES=0.53, 95% CI=0.27-0.78), Timed "Up & Go" Test (ES=0.83, 95% CI=0.28-1.4), and fast gait speed (ES=0.42, 95% CI=0.11-0.73). Effects on normal gait speed, Six-Minute Walk Test, activities of daily living and instrumental activities of daily living, and physical function subscale of the 36-Item Short-Form Health Survey (SF-36-PF) did not reach significance. Community-based programs had larger ESs compared with home-based programs. CONCLUSIONS: To the authors' knowledge, this is the first meta-analysis to provide evidence that an extended exercise rehabilitation program for patients with hip fractures has a significant impact on various functional abilities. The focus of future research should go beyond just effectiveness and study the cost-effectiveness of extended programs. PMID: 22822235 [PubMed - indexed for MEDLINE] 16. Value Health. 2012 Jan;15(1):1-12. doi: 10.1016/j.jval.2011.09.003. Epub 2011 Nov 29. Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review. Pinto D(1), Robertson MC, Hansen P, Abbott JH. Author information: (1)Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand. daniel-pinto@northwestern.edu OBJECTIVE: To investigate the cost-effectiveness of nonpharmacological, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. METHODS: We identified economic evaluations or cost studies associated with randomized or quasi-randomized controlled trials that assessed nonpharmacologic, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. Medline, Embase, PubMed, National Health Service Economic Evaluation Database, CENTRAL, EconLit, and OpenSIGLE were searched up to October 1, 2010. Study characteristics extracted include study population, health outcomes, and economic analysis elements. Economic analyses were assessed by using the Quality of Health Economic Studies instrument, and the methodological quality of the randomized controlled trials was graded by using an internal validity checklist. All costs were converted to 2008 US dollars. RESULTS: Ten economic evaluations and one randomized controlled trial reporting health-care costs met our inclusion criteria. Interventions included exercise

programs, acupuncture, rehabilitation programs, and lifestyle interventions. Six of the 11 studies exhibited high risks of bias for the cost and/or effect components of their cost-effectiveness estimate. Six studies used comparators of unknown cost-effectiveness. Four studies reported cost-effectiveness estimates lower than $50,000 per quality-adjusted life-year. All studies evaluating exercise interventions found the programs to be cost saving. CONCLUSIONS: There is only limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. More high-quality economic evaluations of conservative interventions are needed to further inform practice. Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved. PMID: 22264966 [PubMed - indexed for MEDLINE] 17. BMC Musculoskelet Disord. 2011 Jun 2;12:123. doi: 10.1186/1471-2474-12-123. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes. Batterham SI(1), Heywood S, Keating JL. Author information: (1)Department of Physiotherapy, Monash University Peninsula Campus, McMahons Rd, Frankston, Australia. BACKGROUND: Aquatic and land based exercise are frequently prescribed to maintain function for people with arthritis. The relative efficacy of these rehabilitation strategies for this population has not been established.This review investigated the effects of aquatic compared to land based exercise on function, mobility or participants' perception of programs for people with arthritis. METHODS: Medline, CINAHL, AMED and the Cochrane Central Register of Controlled Clinical Trials were searched up to July 2010. Ten randomised, controlled clinical trials that compared land to aquatic exercise for adults with arthritis were included. Study quality was assessed with the PEDro scale. Data relevant to the review question were systematically extracted by two independent reviewers. Standardised mean differences between groups for key outcomes were calculated. Meta-analyses were performed for function, mobility and indices that pooled health outcomes across multiple domains. RESULTS: No differences in outcomes were observed for the two rehabilitation strategies in meta-analysis. There was considerable variability between trials in key program characteristics including prescribed exercises and design quality. Components of exercise programs were poorly reported by the majority of trials. No research was found that examined participant preferences for aquatic compared to land based exercise, identifying this as an area for further research. CONCLUSION: Outcomes following aquatic exercise for adults with arthritis appear comparable to land based exercise. When people are unable to exercise on land, or find land based exercise difficult, aquatic programs provide an enabling

alternative strategy. PMCID: PMC3141607 PMID: 21635746 [PubMed - indexed for MEDLINE] 18. BMC Musculoskelet Disord. 2009 Aug 4;10:98. doi: 10.1186/1471-2474-10-98. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. Minns Lowe CJ(1), Barker KL, Dewey ME, Sackley CM. Author information: (1)Department of Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, UK. catherine.minnslowe@noc.anglox.nhs.uk BACKGROUND: Physiotherapy has long been a routine component of patient rehabilitation following hip joint replacement. The purpose of this systematic review was to evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for osteoarthritic patients following elective primary total hip arthroplasty. METHODS: DESIGN: Systematic review, using the Cochrane Collaboration Handbook for Systematic Reviews of Interventions and the Quorom Statement. Database searches: AMED, CINAHL, EMBASE, KingsFund, MEDLINE, Cochrane library (Cochrane reviews, Cochrane Central Register of Controlled Trials, DARE), PEDro, The Department of Health National Research Register. Handsearches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. No language restrictions were applied. SELECTION: Trials comparing physiotherapy exercise versus usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed. OUTCOMES: Functional activities of daily living, walking, quality of life, muscle strength and range of hip joint motion. Trial quality was extensively evaluated. Narrative synthesis plus meta-analytic summaries were performed to summarise the data. RESULTS: 8 trials were identified. Trial quality was mixed. Generally poor trial quality, quantity and diversity prevented explanatory meta-analyses. The results were synthesised and meta-analytic summaries were used where possible to provide a formal summary of results. Results indicate that physiotherapy exercise after discharge following total hip replacement has the potential to benefit patients. CONCLUSION: Insufficient evidence exists to establish the effectiveness of physiotherapy exercise following primary hip replacement for osteoarthritis. Further well designed trials are required to determine the value of post discharge exercise following this increasingly common surgical procedure. PMCID: PMC2734755 PMID: 19653883 [PubMed - indexed for MEDLINE]

19. Arthritis Res Ther. 2009;11(3):R98. doi: 10.1186/ar2743. Epub 2009 Jun 25. Exercise therapy for the management of osteoarthritis of the hip joint: a systematic review. McNair PJ(1), Simmonds MA, Boocock MG, Larmer PJ. Author information: (1)Health and Rehabilitation Research Centre, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand. peter.mcnair@aut.ac.nz INTRODUCTION: Recent guidelines pertaining to exercise for individuals with osteoarthritis have been released. These guidelines have been based primarily on studies of knee-joint osteoarthritis. The current study was focused on the hip joint, which has different biomechanical features and risk factors for osteoarthritis and has received much less attention in the literature. The purpose was to conduct a systematic review of the literature to evaluate the exercise programs used in intervention studies focused solely on hip-joint osteoarthritis, to decide whether their exercise regimens met the new guidelines, and to determine the level of support for exercise-therapy interventions in the management of hip-joint osteoarthritis. METHODS: A systematic literature search of 14 electronic databases was undertaken to identify interventions that used exercise therapy as a treatment modality for hip osteoarthritis. The quality of each article was critically appraised and graded according to standardized methodologic approaches. A 'pattern-of-evidence' approach was used to determine the overall level of evidence in support of exercise-therapy interventions for treating hip osteoarthritis. RESULTS: More than 4,000 articles were identified, of which 338 were considered suitable for abstract review. Of these, only 6 intervention studies met the inclusion criteria. Few well-designed studies specifically investigated the use of exercise-therapy management on hip-joint osteoarthritis. Insufficient evidence was found to suggest that exercise therapy can be an effective short-term management approach for reducing pain levels, improving joint function and the quality of life. CONCLUSIONS: Limited information was available on which conclusions regarding the efficacy of exercise could be clearly based. No studies met the level of exercise recommended for individuals with osteoarthritis. High-quality trials are needed, and further consideration should be given to establishing the optimal exercises and exposure levels necessary for achieving long-term gains in the management of osteoarthritis of the hip. PMCID: PMC2714154 PMID: 19555502 [PubMed - indexed for MEDLINE] 20. Eur J Phys Rehabil Med. 2009 Sep;45(3):303-17. Epub 2009 Feb 23. Rehabilitation after total hip arthroplasty: a systematic review of controlled trials on physical exercise programs.

Di Monaco M(1), Vallero F, Tappero R, Cavanna A. Author information: (1)Osteoporosis Research Center, San Camillo Hospital, Turin, Italy. medici@h-sancamillo.to.it Total hip arthroplasty (THA) has revolutionized the care of patients with end-stage joint disease, leading to pain relief, functional recovery, and substantial improvement in quality of life. However, long-term studies indicate persistence of impairment and functional limitation after THA, and the optimal rehabilitation protocols are largely unknown. The aim of this paper was to systematically review the controlled trials published on the effectiveness of physical exercise programs after THA. Nine studies were retrieved from MEDLINE and reviewed. Results show that the physical exercise protocols most frequently used after THA in the early postoperative phase are neither supported nor denied by clinical controlled trials. Convincing evidence for the effectiveness of single interventions in addition to usual exercise programs exists for each of the three following options: treadmill training with partial body-weight support, unilateral resistance training of the quadriceps muscle (operated side), and arm-interval exercises with an arm ergometer. In the late postoperative phase (operation interval > 8 weeks) exercise programs consistently improve both impairment and ability to function. Weight-bearing exercises with hip-abductor eccentric strengthening may be the crucial component of the late-phase protocols. Substantial limitations were found in the nine studies, including small sample size, patient selection, heterogeneity of outcome assessments, and potential sources of variability not investigated. Despite limitations, we conclude that three main suggestions emerge from controlled trials on physical exercise after THA: early postoperative protocols should include additive interventions whose effectiveness has been shown. Late postoperative programs are useful and should comprise weight-bearing exercises with hip-abductor eccentric strengthening. PMID: 19238130 [PubMed - indexed for MEDLINE] 21. Arch Phys Med Rehabil. 2009 Feb;90(2):246-62. doi: 10.1016/j.apmr.2008.06.036. Systematic review of hip fracture rehabilitation practices in the elderly. Chudyk AM(1), Jutai JW, Petrella RJ, Speechley M. Author information: (1)Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada. achudyk@uwo.ca OBJECTIVE: To address the need for a research synthesis on the effectiveness of the full range of hip fracture rehabilitation interventions for older adults and make evidence based conclusions. DATA SOURCES: Medline, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials were searched from 1980 to 2007 for studies published in English. The terms rehabilitation and hip fracture were exploded in order to

obtain related search terms and categories. STUDY SELECTION: In the initial search of the databases, a combined total of 1031 articles was identified. Studies that did not focus on hip fracture rehabilitation, did not include persons over the age of 50 years, and/or did not include measures of physical outcome were excluded. DATA EXTRACTION: Only studies with an Oxford Center for Evidence-Based Medicine Levels of Evidence level of I (randomized controlled trial, RCT) or II (cohort) were reviewed. The methodologic quality of both types of studies was assessed using a modified version of the Downs and Black checklist. DATA SYNTHESIS: There were 55 studies that met our selection criteria: 30 RCTs and 25 nonrandomized trials. They were distributed across 6 categories for rehabilitation intervention (care pathways, early rehabilitation, interdisciplinary care, occupational and physical therapy, exercise, intervention not specified) and 3 settings (acute care hospital, postacute care/rehabilitation, postrehabilitation). CONCLUSIONS: When looking across all of the intervention types, the most frequently reported positive outcomes were associated with measures of ambulatory ability. Eleven intervention categories across 3 settings were associated with improved ambulatory outcomes. Seven intervention approaches were related to improved functional recovery, while 6 intervention approaches were related to improved strength and balance recovery. Decreased length of stay and increased falls self-efficacy were associated with 2 interventions, while 1 intervention had a positive effect on lower-extremity power generation. PMID: 19236978 [PubMed - indexed for MEDLINE] 22. Arthritis Rheum. 2007 Oct 15;57(7):1245-53. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review. Pisters MF(1), Veenhof C, van Meeteren NL, Ostelo RW, de Bakker DH, Schellevis FG, Dekker J. Author information: (1)Netherlands Institute for Health Services Research, Utrecht, The Netherlands. m.pisters@nivel.nl OBJECTIVE: To determine the long-term effectiveness (>/=6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee. METHODS: We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long-term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings. RESULTS: Five high-quality and 6 low-quality randomized clinical trials were

included. Strong evidence was found for no long-term effectiveness on pain and self-reported physical function, moderate evidence for long-term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term effectiveness on pain, self-reported physical function, and observed physical function. CONCLUSION: The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long-term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term. PMID: 17907210 [PubMed - indexed for MEDLINE] 23. Osteoarthritis Cartilage. 2007 Sep;15(9):981-1000. Epub 2007 Aug 27. OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Zhang W(1), Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. Author information: (1)University of Edinburgh, Osteoarticular Research Group, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom. PURPOSE: As a prelude to developing updated, evidence-based, international consensus recommendations for the management of hip and knee osteoarthritis (OA), the Osteoarthritis Research Society International (OARSI) Treatment Guidelines Committee undertook a critical appraisal of published guidelines and a systematic review (SR) of more recent evidence for relevant therapies. METHODS: Sixteen experts from four medical disciplines (primary care two, rheumatology 11, orthopaedics one and evidence-based medicine two), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. Three additional experts were invited to take part in the critical appraisal of existing guidelines in languages other than English. MEDLINE, EMBASE, Science Citation Index, CINAHL, AMED, Cochrane Library, seven Guidelines Websites and Google were searched systematically to identify guidelines for the management of hip and/or knee OA. Guidelines which met the inclusion/exclusion criteria were assigned to four groups of four appraisers. The quality of the guidelines was assessed using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument and standardised percent scores (0-100%) for scope, stakeholder involvement, rigour, clarity, applicability and editorial independence, as well as overall quality, were calculated. Treatment modalities addressed and recommended by the guidelines were summarised. Agreement (%) was estimated and the best level of evidence to support

each recommendation was extracted. Evidence for each treatment modality was updated from the date of the last SR in January 2002 to January 2006. The quality of evidence was evaluated using the Oxman and Guyatt, and Jadad scales for SRs and randomised controlled trials (RCTs), respectively. Where possible, effect size (ES), number needed to treat, relative risk (RR) or odds ratio and cost per quality-adjusted life year gained (QALY) were estimated. RESULTS: Twenty-three of 1462 guidelines or consensus statements retrieved from the literature search met the inclusion/exclusion criteria. Six were predominantly based on expert opinion, five were primarily evidence based and 12 were based on both. Overall quality scores were 28%, 41% and 51% for opinion-based, evidence-based and hybrid guidelines, respectively (P=0.001). Scores for aspects of quality varied from 18% for applicability to 67% for scope. Thirteen guidelines had been developed for specific care settings including five for primary care (e.g., Prodigy Guidance), three for rheumatology (e.g., European League against Rheumatism recommendations), three for physiotherapy (e.g., Dutch clinical practice guidelines for physical therapy) and two for orthopaedics (e.g., National Institutes of Health consensus guidelines), whereas 10 did not specify the target users (e.g., Ontario guidelines for optimal therapy). Whilst 14 guidelines did not separate hip and knee, eight were specific for knee but only one for hip. Fifty-one different treatment modalities were addressed by these guidelines, but only 20 were universally recommended. Evidence to support these modalities ranged from Ia (meta-analysis/SR of RCTs) to IV (expert opinion). The efficacy of some modalities of therapy was confirmed by the results of RCTs published between January 2002 and 2006. These included exercise (strengthening ES 0.32, 95% confidence interval (CI) 0.23, 0.42, aerobic ES 0.52, 95% CI 0.34, 0.70 and water-based ES 0.25, 95% CI 0.02, 0.47) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ES 0.32, 95% CI 0.24, 0.39). Examples of other treatment modalities where recent trials failed to confirm efficacy included ultrasound (ES 0.06, 95% CI -0.39, 0.52), massage (ES 0.10, 95% CI -0.23, 0.43) and heat/ice therapy (ES 0.69, 95% CI -0.07, 1.45). The updated evidence on adverse effects also varied from treatment to treatment. For example, while the evidence for gastrointestinal (GI) toxicity of non-selective NSAIDs (RR=5.36, 95% CI 1.79, 16.10) and for increased risk of myocardial infarction associated with rofecoxib (RR=2.24, 95% CI 1.24, 4.02) were reinforced, evidence for other potential drug related adverse events such as GI toxicity with acetaminophen or myocardial infarction with celecoxib remained inconclusive. CONCLUSION: Twenty-three guidelines have been developed for the treatment of hip and/or knee OA, based on opinion alone, research evidence or both. Twenty of 51 modalities of therapy are universally recommended by these guidelines. Although this suggests that a core set of recommendations for treatment exists, critical appraisal shows that the overall quality of existing guidelines is sub-optimal, and consensus recommendations are not always supported by the best available evidence. Guidelines of optimal quality are most likely to be achieved by combining research evidence with expert consensus and by paying due attention to issues such as editorial independence, stakeholder involvement and applicability. This review of existing guidelines provides support for the development of new guidelines cognisant of the limitations in existing guidelines. Recommendations should be revised regularly following SR of new research evidence as this becomes available. PMID: 17719803 [PubMed - indexed for MEDLINE]

24. J Rheumatol. 2002 Aug;29(8):1737-45. Therapeutic exercise for people with osteoarthritis of the hip or knee. A systematic review. Fransen M(1), McConnell S, Bell M. Author information: (1)Institute for International Health, University of Sydney, Australia. mfransen@iih.usyd.edu.au OBJECTIVE: To determine whether land based therapeutic exercise is beneficial for people with osteoarthritis (OA) of the hip or knee in terms of reduced joint pain, improved physical function, and/or the patient's global assessment of therapeutic effectiveness. METHODS: Five databases were searched for randomized clinical trials. Standardized mean differences (SMD) with their 95% confidence intervals (CI) were calculated for each study and then combined using a fixed effects model. RESULTS: Only 2 studies, totaling about 100 participants, could potentially provide data on people with hip OA. Fourteen studies provided data on 1633 participants with knee OA. Nine of these studies were considered of high methodological quality. For pain, combining the results revealed a mean moderate beneficial effect (SMD 0.46, 95% Cl 0.35, 0.57), while for self-reported physical function a mean small beneficial effect (SMD 0.33, 95% CI 0.23, 0.43) was found. These results appeared to be sensitive to blinding of outcome assessor and choice of control group. CONCLUSION: Land based therapeutic exercise was shown to reduce pain and improve physical function for people with OA of the knee. PMID: 12180738 [PubMed - indexed for MEDLINE] 25. Arthritis Rheum. 1999 Jul;42(7):1361-9. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. van Baar ME(1), Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW. Author information: (1)Netherlands Institute of Primary Health Care, Utrecht. OBJECTIVE: To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee. METHODS: A computerized literature search of Medline, Embase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was

systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power. RESULTS: Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect. CONCLUSION: There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions. PMID: 10403263 [PubMed - indexed for MEDLINE]

Exercise and Hypertension 1. Hypertension. 2016 May 23. pii: HYPERTENSIONAHA.116.07431. [Epub ahead of print] Will Exercise Advice Be Sufficient for Treatment of Young Adults With Prehypertension and Hypertension? A Systematic Review and Meta-Analysis. Williamson W(1), Foster C(2), Reid H(2), Kelly P(2), Lewandowski AJ(2), Boardman H(2), Roberts N(2), McCartney D(2), Huckstep O(2), Newton J(2), Dawes H(2), Gerry S(2), Leeson P(2). Author information: (1)From the Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine (W.W., A.J.L., H.B., O.H., P.L.), British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health (C.F., H.R.), Bodleian Health Care Libraries (N.R.), Department of Primary Care Health Sciences (D.M.C.), Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (J.N.), and Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (S.G.), University of Oxford, Oxford, United Kingdom; Institute for Sport, Physical Education and Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (P.K.); and Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom (H.D.). wilby.williamson@cardiov.ox.ac.uk. (2)From the Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine (W.W., A.J.L., H.B., O.H., P.L.), British Heart Foundation Centre on Population Approaches for Non-Communicable Disease Prevention, Nuffield Department of Population Health (C.F., H.R.), Bodleian Health Care Libraries (N.R.), Department of Primary Care Health Sciences (D.M.C.), Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences (J.N.), and Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (S.G.), University of Oxford, Oxford, United Kingdom; Institute for Sport, Physical Education and Health Sciences, University of Edinburgh, Edinburgh, United Kingdom (P.K.); and Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, United Kingdom (H.D.). Previous studies report benefits of exercise for blood pressure control in middle age and older adults, but longer-term effectiveness in younger adults is not well established. We performed a systematic review and meta-analysis of published randomized control trials with meta-regression of potential effect modifiers. An information specialist completed a comprehensive search of available data sources, including studies published up to June 2015. Authors applied strict inclusion and exclusion criteria to screen 9524 titles. Eligible studies recruited younger adults with a cardiovascular risk factor (with at least 25% of cohort aged 18-40 years); the intervention had a defined physical activity

strategy and reported blood pressure as primary or secondary outcome. Meta-analysis included 14 studies randomizing 3614 participants, mean age 42.2±6.3 (SD) years. At 3 to 6 months, exercise was associated with a reduction in systolic blood pressure of -4.40 mm Hg (95% confidence interval, -5.78 to -3.01) and in diastolic blood pressure of -4.17 mm Hg (95% confidence interval, -5.42 to -2.93). Intervention effect was not significantly influenced by baseline blood pressure, body weight, or subsequent weight loss. Observed intervention effect was lost after 12 months of follow-up with no reported benefit over control, mean difference in systolic blood pressure -1.02 mm Hg (95% confidence interval, -2.34 to 0.29), and in diastolic blood pressure -0.91 mm Hg (95% confidence interval, -1.85 to 0.02). Current exercise guidance provided to reduce blood pressure in younger adults is unlikely to benefit long-term cardiovascular risk. There is need for continued research to improve age-specific strategies and recommendations for hypertension prevention and management in young adults. © 2016 The Authors. PMID: 27217408 [PubMed - as supplied by publisher] 2. J Sci Med Sport. 2016 May;19(5):424-31. doi: 10.1016/j.jsams.2015.05.009. Epub 2015 Jun 5. The blood pressure response to acute and chronic aerobic exercise: A meta-analysis of candidate gene association studies. Bruneau ML Jr(1), Johnson BT(2), Huedo-Medina TB(3), Larson KA(3), Ash GI(4), Pescatello LS(5). Author information: (1)Department of Exercise Science and Sports Studies, Springfield College, Springfield, MA, United States; Department of Kinesiology, University of Connecticut, Storrs, CT, United States. Electronic address: mbruneaujr@springfieldcollege.edu. (2)Department of Psychology, University of Connecticut, Storrs, CT, United States. (3)Department of Allied Health Sciences, University of Connecticut, Storrs, CT, United States. (4)Department of Kinesiology, University of Connecticut, Storrs, CT, United States. (5)Department of Kinesiology, University of Connecticut, Storrs, CT, United States; Institute for Systems Genomics, University of Connecticut, Storrs, CT, United States. OBJECTIVES: To meta-analyze candidate gene association studies on the change in blood pressure beyond the immediate post-exercise phase after versus before aerobic exercise. DESIGN: Meta-analysis. METHODS: A systematic search was conducted. Studies retrieved included acute

(short-term or postexercise hypotension) or chronic (long-term or training) aerobic exercise interventions; and blood pressure measured before and after aerobic exercise training, or before and after exercise or control under ambulatory conditions by genotype. Effect sizes were determined for genotype and adjusted for sample features. RESULTS: Qualifying studies (k=17, n=3524) on average included middle-aged, overweight men (44.2%) and women (55.8%) with prehypertension (134.9±11.7/78.6±9.5mmHg). Training interventions (k=12) were performed at 60.4±12.9% of maximum oxygen consumption (VO2max) for 41.9±12.5minsession(-1), 3.6±1.2daysweek(-1) for 15.7±7.6week; and post-exercise hypotension interventions (k=5) were performed at 53.5±14.4% VO2max for 38.5±5.4minsession(-1). Sample characteristics explained 54.2-59.0% of the variability in the blood pressure change after versus before acute exercise or control under ambulatory conditions, and 57.4-67.1% of the variability in the blood pressure change after versus before training (p<0.001). Only angiotensinogen M235T (rs699) associated with the change in diastolic blood pressure after versus before training (R(2)=0.1%, p=0.05), but this association did not remain statistically significant after adjustment for multiple comparisons. CONCLUSIONS: Sample characteristics explained most of the variability in the change of BP beyond the immediate post-exercise phase after versus before acute and chronic aerobic exercise. Angiotensinogen M235T (rs699) was the only genetic variant that associated with the change in diastolic blood pressure after versus before training, accounting for <1% of the variance. Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved. PMID: 26122461 [PubMed - in process] 3. Heart Lung Circ. 2016 Apr;25(4):333-41. doi: 10.1016/j.hlc.2015.10.015. Epub 2015 Nov 18. Effects of Exercise Training on Exercise Capacity in Pulmonary Arterial Hypertension: A Systematic Review of Clinical Trials. Babu AS(1), Padmakumar R(2), Maiya AG(3), Mohapatra AK(4), Kamath RL(5). Author information: (1)Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal - 576104, Karnataka, India. Electronic address: abrahambabu@gmail.com. (2)Department of Cardiology, Kasturba Medical College, Manipal University, Manipal-576104, Karnataka, India. (3)Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal - 576104, Karnataka, India. (4)Department of Pulmonary Medicine, Kasturba Medical

College, Manipal University, Manipal-576104, Karnataka, India. (5)Department of Cardiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India. BACKGROUND: Pulmonary arterial hypertension (PAH) causes profound functional limitations and poor quality of life. Yet, there is only a limited literature available on the role of exercise training. This paper systematically reviews the effects of exercise training on exercise capacity in PAH. METHODS: A systematic search of databases (PubMed, CINAHL, CENTRAL, Web of Science and PEDRo) was undertaken for English language articles published between 1(st) January 1980 and 31(st) March 2015. Quality rating for all articles was done using the Downs and Black scoring system. RESULTS: Fifteen articles of good (n=4), moderate (n=6) and poor (n=5) quality were included in the review. Exercise interventions included aerobic, resistance, inspiratory muscle training or a combination, for 6-18 weeks. Improvements were seen in exercise capacity (six minute walk distance (6MWD) and peak VO2) by 17-96m and 1.1-2.1ml/Kg/min, functional class by one class and quality of life, with minimal adverse events. CONCLUSIONS: There is evidence to recommend the use of exercise training as an adjunct to medical treatment in PAH. More clinical trials and research are required to assess the effects of different types of exercise programs in patients with PAH, while focussing on strong exercise endpoints to quantify the improvements seen with exercise training. Copyright © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved. PMID: 26703447 [PubMed - in process] 4. Pharmacoeconomics. 2016 Mar 7. [Epub ahead of print] Systematic Review of Health-Related Quality of Life in Patients with Pulmonary Arterial Hypertension. Gu S(1), Hu H(1,)(2), Dong H(3). Author information: (1)Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, Zhejiang Province, 310058, China. (2)Department of Public Health, Zhejiang Medical College, Hangzhou, Zhejiang Province, China. (3)Center for Health Policy Studies, School of Public Health, Zhejiang University School of Medicine, 866 Yuhangtang Road, Hangzhou, Zhejiang Province, 310058, China. donghj@zju.edu.cn.

BACKGROUND: The increasing survival of patients with pulmonary arterial hypertension (PAH) has shifted attention towards the disease burden that PAH imposes on patients and healthcare systems. Most studies emphasize epidemiology and medications, while large observational studies reporting on the health-related quality of life (HRQOL) of patients with PAH are lacking. OBJECTIVE: Our objective was to study the HRQOL of patients with PAH and to summarize the factors that influence it. METHODS: We conducted systematic literature searches in English (PubMed, Web of Knowledge, ScienceDirect and OVID) and Chinese (China National Knowledge Infrastructure, Wanfang Data, Chongqing VIP and SinoMed) databases to identify studies published from 2000 to 2015 assessing the HRQOL of patients with PAH. Search results were independently reviewed and extracted by two reviewers. RESULTS: Of 3392 records identified in the initial search, 20 eligible papers (19 English, 1 Chinese) were finally included. Studies used a range of instruments; the generic 36-item Short Form Survey (SF-36) was the most widely used, and the disease-specific Cambridge Pulmonary Hypertension Outcome Survey (CAMPHOR) was the second mostly widely used. Mean HRQOL scores assessed via the SF-36 (physical component summary [PCS] 25.4-80.1; mental component summary [MCS] 33.2-76.0) and CAMPHOR (symptom scores 3.1-17; total HRQOL 2.8-12.6; activity scores 3.8-18.1) varied across studies, reporting decreased HRQOL in patients. Mental health (depression, anxiety, stress), physical health (exercise capacity, symptoms) and medical therapies were reported to affect HRQOL. CONCLUSION: We found that PAH places a substantial burden on patients, particularly in terms of HRQOL; however, the paucity of large observational studies in this area requires the attention of researchers, especially in China. PMID: 26951248 [PubMed - as supplied by publisher] 5. Circ Heart Fail. 2015 Nov;8(6):1032-43. doi: 10.1161/CIRCHEARTFAILURE.115.002130. Epub 2015 Jul 16. Efficacy and Safety of Exercise Training in Chronic Pulmonary Hypertension: Systematic Review and Meta-Analysis. Pandey A(1), Garg S(1), Khunger M(1), Garg S(1), Kumbhani DJ(1), Chin KM(1), Berry JD(2). Author information: (1)From the Division of Cardiology, Department of Internal Medicine (A.P., Sonia Garg, D.J.K., J.D.B.), Division of Pulmonary Medicine, Department of Internal Medicine (K.M.C.), and Department of Clinical Sciences (J.D.B.), University of Texas Southwestern Medical Center, Dallas; Department of Internal Medicine, University of Minnesota School of Medicine, Minneapolis (Sushil Garg); and

Department of Internal Medicine, Cleveland Clinic, OH (M.K.). (2)From the Division of Cardiology, Department of Internal Medicine (A.P., Sonia Garg, D.J.K., J.D.B.), Division of Pulmonary Medicine, Department of Internal Medicine (K.M.C.), and Department of Clinical Sciences (J.D.B.), University of Texas Southwestern Medical Center, Dallas; Department of Internal Medicine, University of Minnesota School of Medicine, Minneapolis (Sushil Garg); and Department of Internal Medicine, Cleveland Clinic, OH (M.K.). jarett.berry@utsouthwestern.edu. Erratum in Circ Heart Fail. 2015 Nov;8(6):1143. BACKGROUND: Exercise training has been shown to improve cardiorespiratory fitness, physical capacity, and quality of life in patients with cardiopulmonary conditions, such as heart failure and chronic obstructive pulmonary disease. However, its role in management of pulmonary hypertension is not well defined. In this study, we aim to evaluate the efficacy and safety of exercise training in patients with pulmonary hypertension. METHODS AND RESULTS: We included all prospective intervention studies that evaluated the efficacy and safety of exercise training in patients with pulmonary hypertension. Primary outcome of this meta-analysis was a change in 6-minute walk distance. We also assessed the effect of exercise on peak oxygen uptake, resting pulmonary arterial systolic pressure, peak exercise heart rate, and quality of life. A total of 469 exercise-training participants enrolled in 16 separate training studies were included. In the pooled analysis, exercise training was associated with significant improvement in 6-minute walk distance (weighted mean difference, 53.3 m; 95% confidence interval, 39.5-67.2), peak oxygen uptake (weighted mean difference, 1.8 mL/kg per minute; 95% confidence interval, 1.4-2.3), pulmonary arterial systolic pressure (weighted mean difference, -3.7 mm Hg; 95% confidence interval, -5.4 to -1.9), peak exercise heart rate (weighted mean difference, 10 beats per min; 95% confidence interval, 6-15), and quality of life as measured on SF-36 questionnaire subscale scores. Furthermore, exercise training was well tolerated with a low dropout rate, and no major adverse events were related to exercise training. CONCLUSIONS: Exercise training in patients with pulmonary hypertension appears safe and is associated with a significant improvement in exercise capacity, pulmonary arterial pressure, and quality of life. © 2015 American Heart Association, Inc. PMID: 26185169 [PubMed - indexed for MEDLINE] 6. Maturitas. 2015 Apr;80(4):370-8. doi: 10.1016/j.maturitas.2015.01.002. Epub 2015 Jan 9.

Effect of Baduanjin exercise for hypertension: a systematic review and meta-analysis of randomized controlled trials. Xiong X(1), Wang P(2), Li S(3), Zhang Y(4), Li X(5). Author information: (1)Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China. Electronic address: xiongxingjiangtcm@163.com. (2)Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China. (3)Department of Biological Science and Technology, School of Life Sciences, Tsinghua University, Beijing, China. (4)Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. (5)Bio-organic and Natural Products Laboratory, McLean Hospital, Harvard Medical School, Belmont, MA, USA. This study aims to evaluate the efficacy of Baduanjin exercise for hypertension. Cochrane Library, PubMed, EMBASE, CNKI, VIP, CBM and Wanfang databases were searched. Eight randomized controlled trials (RCTs) were identified. Baduanjin significantly lowered systolic blood pressure (SBP) (WMD=-13.00 mmHg; 95% CI: -21.24 to -4.77; P=0.002), diastolic blood pressure (DBP) (WMD=-6.13 mmHg; 95% CI: -11.20 to -1.07; P=0.02), body mass index, blood glucose, triglyceride, and low-density lipoprotein-cholesterol, and improved high-density lipoprotein-cholesterol and quality of life compared to no intervention. No significant difference between Baduanjin and antihypertensive drugs on SBP (WMD=1.05 mmHg; 95% CI: -2.07 to 4.17; P=0.51) or DBP (WMD=1.90 mmHg; 95% CI: -1.22 to 5.02; P=0.23) was identified. Baduanjin plus antihypertensive drugs significantly reduced SBP (WMD=-7.49 mmHg; 95% CI: -11.39 to -3.59; P=0.0002), DBP (WMD=-3.55 mmHg; 95% CI: -5.25 to -1.85; P<0.0001), blood glucose, and total cholesterol compared to antihypertensive drugs. Baduanjin is an effective therapy for hypertension. However, further rigorously designed RCTs are still warranted. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved. PMID: 25636242 [PubMed - indexed for MEDLINE] 7. BMC Pulm Med. 2015 Apr 22;15:40. doi: 10.1186/s12890-015-0031-1. Exercise training improves physical fitness in patients with pulmonary arterial hypertension: a systematic review and meta-analysis of controlled trials. Buys R(1), Avila A(2), Cornelissen VA(3). Author information: (1)Department of Rehabilitation Sciences, Tervuursevest 101, B 1501, B-3001,

Leuven, Belgium. roselien.buys@faber.kuleuven.be. (2)Department of Rehabilitation Sciences, Tervuursevest 101, B 1501, B-3001, Leuven, Belgium. andrea.avila@faber.kuleuven.be. (3)Department of Rehabilitation Sciences, Tervuursevest 101, B 1501, B-3001, Leuven, Belgium. veronique.cornelissen@med.kuleuven.be. BACKGROUND: Pulmonary arterial hypertension (PAH) is a progressive disorder characterized by hypertension in the pulmonary arteries. PAH leads to symptoms such as shortness of breath, dizziness, leg edema and chest pain, impacting heavily on quality of life. The aim of this systematic review and meta-analysis was to determine the effect of exercise training to improve physical fitness and functionality in patients with PAH. METHODS: A search was conducted for controlled trials using the databases Medline, Embase, SPORT Discus and Cochrane Central Register of Controlled Trials. Studies were included if at least 80% of the participants presented with group 1 PAH and if the intervention consisted of an exercise training program of at least 3 weeks duration. Data were extracted on study quality, participant and exercise intervention characteristics, and outcomes. Data were pooled by the generic inverse variance method using random effect models and were expressed as weighted means and 95% confidence intervals (CI). RESULTS: Of 110 identified abstracts, 5 studies with 106 patients (exercise: 53; control: 53; mean age 49.7 years) were included. Disease severity ranged from mild to severe; 96 patients suffered from PAH, 10 patients had chronic thromboembolic pulmonary hypertension. Exercise training led to an increase in 6 minute walk distance (72.5 m; 95% CI 46.0 m to 99.1 m; p < 0.0001) and peak oxygen uptake (2.16 mL/kg/min; 95% CI 2.16 to 3.93; p = 0.02). No severe adverse events during exercise were reported. CONCLUSIONS: Our findings suggest that an exercise training program positively influences exercise tolerance and functional capacity in patients with PAH. PMCID: PMC4423624 PMID: 25896259 [PubMed - in process] 8. J Thorac Dis. 2015 Mar;7(3):309-19. doi: 10.3978/j.issn.2072-1439.2015.02.08. Therapy in stable chronic obstructive pulmonary disease patients with pulmonary hypertension: a systematic review and meta-analysis. Chen X(1), Tang S(1), Liu K(1), Li Q(1), Kong H(1), Zeng X(1), Xie W(1), Wang H(1). Author information: (1)1 Department of Respiratory, First Affiliated Hospital with Nanjing Medical University, Nanjing 210029, China ; 2 Department of Epidemiology & Biostatistics,

School of Public Health, Nanjing Medical University, Nanjing 210029, China ; 3 Department of Respiratory, Xuzhou No. 1 Hospital, Xuzhou 221002, China. Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD) without effective drugs to treat. We conducted a systematic review and meta-analysis in order to evaluate whether PH specific therapies were effective for stable COPD patients. Data were extracted from PubMed, Cochrane Central Register of Controlled Trials and China Knowledge Resource Integrated Database. Randomized controlled trials (RCTs) with PH specific therapy treated more than 4 weeks in COPD were selected. The main outcome was exercise capacity; meanwhile pulmonary arterial pressure (PAP), hypoxemia and health related life quality were also measured. We included nine trials involving 365 subjects, among which two were treated with bosentan and seven with sildenafil. The study time varied from 4 weeks to 18 months and mostly it was 12 weeks. In a pooled analysis of nine trials, exercise capacity of COPD patients was improved by PH-specific therapy [mean difference (MD) 66.39 m, 95% confidence intervals (CI): 59.44-73.34]. COPD with severe PH (mean PAP >35 mmHg by right heart catheterization or systolic PAP >50 mmHg by echocardiography) improved the exercise capacity (MD 67.24 m, 95% CI: 60.26-74.23), but COPD without PH at rest did not (MD -9.24 m, 95% CI: -75.08 to 56.31). Meanwhile PAP was decreased (MD -9.02 mmHg, 95% CI: -10.71 to -7.34 mmHg). Although hypoxemia and life quality were not improved, the dyspnea was alleviated or at least not aggravated (Borg dyspnea index, MD -0.86, 95% CI: -1.86 to 0.14). In conclusion, PH specific drugs (especially sildenafil) could improve exercise capacity and decrease PAP in COPD patients with severe PH. PMCID: PMC4387388 PMID: 25922708 [PubMed] 9. Int J Cardiol. 2015 Jan 15;178:142-6. doi: 10.1016/j.ijcard.2014.10.161. Epub 2014 Oct 27. Exercise training for pulmonary hypertension: a systematic review and meta-analysis. Yuan P(1), Yuan XT(2), Sun XY(3), Pudasaini B(1), Liu JM(4), Hu QH(5). Author information: (1)Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China. (2)Department of Gastroenterology, Weifang Traditional Chinese Hospital, Shandong, China. (3)Department of Rheumatology, Weifang Traditional Chinese Hospital, Shandong, China. (4)Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China. Electronic

address: jinmingliu2007@163.com. (5)Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China. Electronic address: qinghuaa@yahoo.com. PMID: 25464238 [PubMed - indexed for MEDLINE] 10. Medicine (Baltimore). 2015 Jan;94(1):e352. doi: 10.1097/MD.0000000000000352. Qigong for hypertension: a systematic review. Xiong X(1), Wang P, Li X, Zhang Y. Author information: (1)From the Department of Cardiology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences (XX); Bio-organic and Natural Products Laboratory, McLean Hospital, Harvard Medical School, Belmont, MA, USA (XL); Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences (PW), Beijing, China; Bio-organic and Natural Products Laboratory, McLean Hospital, Harvard Medical School, Belmont, MA; and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada (YZ). The purpose of this review was to evaluate the efficacy and safety of qigong for hypertension.A systematic literature search was performed in 7 databases from their respective inceptions until April 2014, including the Cochrane Library, EMBASE, PubMed, Chinese Scientific Journal Database, Chinese Biomedical Literature Database, Wanfang database, and Chinese National Knowledge Infrastructure. Randomized controlled trials of qigong as either monotherapy or adjunctive therapy with antihypertensive drugs versus no intervention, exercise, or antihypertensive drugs for hypertension were identified. The risk of bias was assessed using the tool described in Cochrane Handbook for Systematic Review of Interventions, version 5.1.0.Twenty trials containing 2349 hypertensive patients were included in the meta-analysis. The risk of bias was generally high. Compared with no intervention, qigong significantly reduced systolic blood pressure (SBP) (weighted mean difference [WMD] = -17.40 mm Hg, 95% confidence interval [CI] -21.06 to -13.74, P < 0.00001) and diastolic blood pressure (DBP) (WMD = -10.15 mm Hg, 95% CI -13.99 to -6.30, P < 0.00001). Qigong was inferior to exercise in decreasing SBP (WMD = 6.51 mm Hg, 95% CI 2.81 to 10.21, P = 0.0006), but no significant difference between the effects of qigong and exercise on DBP (WMD = 0.67 mm Hg, 95% CI -1.39 to 2.73, P = 0.52) was identified. Compared with antihypertensive drugs, qigong produced a clinically meaningful but not statistically significant reduction in SBP (WMD = -7.91 mm Hg, 95% CI -16.81 to 1.00, P = 0.08), but appeared to be more effective in lowering DBP (WMD = -6.08 mm Hg, 95% CI -9.58 to -2.58, P = 0.0007). Qigong plus antihypertensive drugs significantly lowered both SBP (WMD = -11.99 mm Hg, 95% CI

-15.59 to -8.39, P < 0.00001) and DBP (WMD = -5.28 mm Hg, 95% CI, -8.13 to -2.42, P = 0.0003) compared with antihypertensive drugs alone. No serious adverse events were reported.The meta-analysis suggests that qigong is an effective therapy for hypertension. However, more rigorously designed randomized controlled trials with long-term follow-up focusing on hard clinical outcomes are required to confirm the results. PMCID: PMC4602820 PMID: 25569652 [PubMed - indexed for MEDLINE] 11. Am J Hypertens. 2014 Sep;27(9):1146-51. doi: 10.1093/ajh/hpu078. Epub 2014 May 2. A systematic review and meta-analysis of yoga for hypertension. Cramer H(1), Haller H(2), Lauche R(2), Steckhan N(3), Michalsen A(3), Dobos G(2). Author information: (1)Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany; h.cramer@kliniken-essen-mitte.de. (2)Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany; (3)Immanuel Hospital Berlin, Department of Internal and Complementary Medicine, Berlin, Germany; Charité - Universitätsmedizin Berlin, Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie, Berlin, Germany. BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate the quality of evidence and the strength of recommendation for yoga as a therapeutic means in the management of prehypertension and hypertension. METHODS: MEDLINE/Pubmed, Scopus, CENTRAL, and IndMED were screened through February 2014 for randomized controlled trials (RCTs) on the effects of yoga interventions (≥8 weeks) compared with usual care or any active control intervention on blood pressure in patients with prehypertension (120-139/80-89 mm Hg) or hypertension (≥140/≥90 mm Hg). Risk of bias was assessed using the Cochrane risk of bias tool; quality of evidence was assessed according to the GRADE recommendations. RESULTS: Seven RCTs with a total of 452 patients were included. Compared with usual care, very low-quality evidence was found for effects of yoga on systolic (6 RCTs, n = 278; mean difference (MD) = -9.65 mm Hg, 95% confidence interval (CI) = -17.23 to -2.06, P = 0.01; heterogeneity: I (2) = 90%, χ(2) = 48.21, P < 0.01) and diastolic blood pressure (6 RCTs, n = 278; MD = -7.22 mm Hg, 95% CI = -12.83 to -1.62, P = 0.01; heterogeneity: I (2) = 92%, χ(2) = 64.84, P < 0.01). Subgroup analyses revealed effects for RCTs that included hypertensive patients but not for RCTs that included both hypertensive and prehypertensive patients, as

well as for RCTs that allowed antihypertensive comedication but not for those that did not. More adverse events occurred during yoga than during usual care. Compared with exercise, no evidence was found for effects of yoga on systolic or diastolic blood pressure. CONCLUSIONS: Larger studies are required to confirm the emerging but low-quality evidence that yoga may be a useful adjunct intervention in the management of hypertension. © American Journal of Hypertension, Ltd 2014. All rights reserved. For Permissions, please email: journals.permissions@oup.com. PMID: 24795403 [PubMed - indexed for MEDLINE] 12. Int J Cardiol. 2014 May 15;173(3):361-8. doi: 10.1016/j.ijcard.2014.03.072. Epub 2014 Mar 20. The impact of aerobic exercise training on arterial stiffness in pre- and hypertensive subjects: a systematic review and meta-analysis. Montero D(1), Roche E(2), Martinez-Rodriguez A(2). Author information: (1)Applied Biology Department, Institute of Bioengineering, Miguel Hernandez University, Elche, Spain; Department of Internal Medicine, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands. Electronic address: david.montero.barril@gmail.com. (2)Applied Biology Department, Institute of Bioengineering, Miguel Hernandez University, Elche, Spain. BACKGROUND: Debate concerning aerobic exercise decreasing arterial stiffness in pre- and hypertensive individuals still exists. We sought to systematically review and quantify the effect of aerobic exercise training on arterial stiffness in pre- and hypertensive subjects. METHODS: MEDLINE, Cochrane, Scopus and Web of Science were searched up until August 2013 for trials assessing the effect of aerobic exercise interventions lasting 4 or more weeks on arterial stiffness in (pre)hypertensive subjects. Standardized mean difference (SMD) in arterial stiffness parameters (PWV, B-stiffness, Compliance, AIx) was calculated using a random-effects model. Subgroup and meta-regression analyses were used to study potential moderating factors. RESULTS: Fourteen trials comprising a total of 472 (pre)hypertensive subjects met the inclusion criteria. Arterial stiffness was not significantly reduced by aerobic training in (pre)hypertensive subjects (14 trials, SMD=-0.19; P=.06). Likewise, post-intervention arterial stiffness was similar between the aerobic

exercise-trained and control (pre)hypertensive subjects (8 trials, SMD=-0.10; P=.43). Neither heterogeneity nor publication bias was detected in either of these analyses. In the subgroup analyses, arterial stiffness was significantly reduced in aerobic exercise-trained (pre)hypertensive subgroups below the median value in post minus pre-intervention systolic blood pressure (SBP) (SMD=-0.38, P=.04) and in subgroups above the median value in the duration of the intervention (SMD=-0.28, P=.03). Similar results were obtained in the meta-regression analysis. CONCLUSIONS: Arterial stiffness is not reduced in (pre)hypertensive subjects in response to aerobic training unless associated with a substantial reduction in SBP and/or prolonged duration. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. PMID: 24698257 [PubMed - indexed for MEDLINE] 13. Int J Cardiol. 2014 May 1;173(2):170-83. doi: 10.1016/j.ijcard.2014.02.017. Epub 2014 Feb 25. Effects of yoga on cardiovascular disease risk factors: a systematic review and meta-analysis. Cramer H(1), Lauche R(2), Haller H(2), Steckhan N(3), Michalsen A(4), Dobos G(2). Author information: (1)Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany. Electronic address: h.cramer@kliniken-essen-mitte.de. (2)Department of Internal and Integrative Medicine, Kliniken Essen-Mitte, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany. (3)Immanuel Hospital Berlin, Department of Internal and Complementary Medicine, Berlin, Germany. (4)Immanuel Hospital Berlin, Department of Internal and Complementary Medicine, Berlin, Germany; Charité-Universitätsmedizin Berlin, Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie, Germany. BACKGROUND: The aim of this review was to systematically assess and meta-analyze the effects of yoga on modifiable biological cardiovascular disease risk factors in the general population and in high-risk disease groups. METHODS: MEDLINE/PubMed, Scopus, the Cochrane Library, and IndMED were screened through August 2013 for randomized controlled trials (RCTs) on yoga for predefined cardiovascular risk factors in healthy participants, non-diabetic participants with high risk for cardiovascular disease, or participants with type 2 diabetes mellitus. Risk of bias was assessed using the Cochrane risk of bias tool.

RESULTS: Forty-four RCTs with a total of 3168 participants were included. Risk of bias was high or unclear for most RCTs. Relative to usual care or no intervention, yoga improved systolic (mean difference (MD)=-5.85 mm Hg; 95% confidence interval (CI)=-8.81, -2.89) and diastolic blood pressure (MD=-4.12 mm Hg; 95%CI=-6.55, -1.69), heart rate (MD=-6.59 bpm; 95%CI=-12.89, -0.28), respiratory rate (MD=-0.93 breaths/min; 95%CI=-1.70, -0.15), waist circumference (MD=-1.95 cm; 95%CI=-3.01, -0.89), waist/hip ratio (MD=-0.02; 95%CI=-0.03, -0.00), total cholesterol (MD=-13.09 mg/dl; 95%CI=-19.60, -6.59), HDL (MD=2.94 mg/dl; 95%CI=0.57, 5.31), VLDL (MD=-5.70 mg/dl; 95%CI=-7.36, -4.03), triglycerides (MD=-20.97 mg/dl; 95%CI=-28.61, -13.32), HbA1c (MD=-0.45%; 95%CI=-0.87, -0.02), and insulin resistance (MD=-0.19; 95%CI=-0.30, -0.08). Relative to exercise, yoga improved HDL (MD=3.70 mg/dl; 95%CI=1.14, 6.26). CONCLUSIONS: This meta-analysis revealed evidence for clinically important effects of yoga on most biological cardiovascular disease risk factors. Despite methodological drawbacks of the included studies, yoga can be considered as an ancillary intervention for the general population and for patients with increased risk of cardiovascular disease. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved. PMID: 24636547 [PubMed - indexed for MEDLINE] 14. Altern Ther Health Med. 2014 Mar-Apr;20(2):32-59. Yoga and hypertension: a systematic review. Tyagi A, Cohen M. Lifestyle modification is a cornerstone of hypertension (HPT) treatment, yet most recommendations currently focus on diet and exercise and do not consider stress reduction strategies. Yoga is a spiritual path that may reduce blood pressure (BP) through reducing stress, increasing parasympathetic activation, and altering baroreceptor sensitivity; however, despite reviews on yoga and cardiovascular disease, diabetes, metabolic syndrome, and anxiety that suggest yoga may reduce BP, no comprehensive review has yet focused on yoga and HPT. A systematic review of all published studies on yoga and HPT was performed revealing 39 cohort studies, 30 nonrandomized, controlled trials (NRCTs), 48 randomized, controlled trials (RCTs), and 3 case reports with durations ranging from 1 wk to 4 y and involving a total of 6693 subjects. Most studies reported that yoga effectively reduced BP in both normotensive and hypertensive populations. These studies suggest that yoga is an effective adjunct therapy for HPT and worthy of inclusion in clinical guidelines, yet the great heterogeneity of yoga practices and the variable quality of the research makes it difficult to recommend any specific yoga practice for HPT. Future research needs to focus on high quality clinical

trials along with studies on the mechanisms of action of different yoga practices. PMID: 24657958 [PubMed - indexed for MEDLINE] 15. Pulm Med. 2014;2014:528783. doi: 10.1155/2014/528783. Epub 2014 Nov 16. Effect of PAH specific therapy on pulmonary hemodynamics and six-minute walk distance in portopulmonary hypertension: a systematic review and meta-analysis. Faisal M(1), Siddiqi F(1), Alkaddour A(2), Bajwa AA(1), Shujaat A(1). Author information: (1)Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Jacksonville, FL 32209, USA. (2)Department of Medicine, University of Florida, Jacksonville, FL 32209, USA. BACKGROUND: Little is known about the effect of pulmonary arterial hypertension (PAH) specific therapy on pulmonary hemodynamics and exercise capacity in patients with portopulmonary hypertension (PoPH) because such patients are usually excluded from randomized clinical trials (RCT) of such therapy. METHODS: We searched PUBMED using the terms "(Therapy/Broad (filter)) AND (portopulmonary hypertension)." We included studies that met the following criteria: ≥5 patients, AND PoPH confirmed by right heart catheterization (RHC), AND follow-up RHC data, AND/OR baseline and follow-up 6MWD available. RESULTS: 12 studies met our inclusion criteria. None was a RCT. The baseline mPAP was 48.6 ± 4.4 mmHg, cardiac output (CO) 5.6 ± 0.9 L/min, and pulmonary vascular resistance (PVR) 668.6 ± 219.1 dynes.sec/cm(5). The baseline 6MWD was 348.2 ± 35.6 meters. The use of PAH specific therapy improved mPAP by 7.54 mmHg (95% CI 10.2 to 4.9), CO by 1.77 L/min (95% CI 1.1 to 2.4), and PVR by 253 dynes.sec/cm(5) (95% CI 291.4 to 214.6) (n = 135) and 6MWD by 61.8 meters (95% CI 47.5 to 76) (n = 122). CONCLUSIONS: The use of PAH specific therapy in PoPH results in significant improvement in both pulmonary hemodynamics and 6MWD. PMCID: PMC4248336 PMID: 25478223 [PubMed - indexed for MEDLINE] 16. J Korean Med Sci. 2013 Aug;28(8):1200-6. doi: 10.3346/jkms.2013.28.8.1200. Epub 2013 Jul 31. Systematic review and meta-analysis of pulmonary hypertension specific therapy for exercise capacity in chronic obstructive pulmonary disease.

Park J(1), Song JH, Park DA, Lee JS, Lee SD, Oh YM. Author information: (1)Department of Pulmonary and Critical Care Medicine Wonkwang University, Sanbon Hospital, Gunpo, Korea. Some patients with chronic obstructive pulmonary disease (COPD) have pulmonary hypertension (PH) that adversely affects survival. We performed a systematic review and meta-analysis to assess whether PH-specific therapies have an effect for stable COPD. Data sources were Medline, EMBASE, Cochrane Central Register of Controlled Trials, Korea med and references from relevant publications. Randomized prospective trials that compared PH specific therapy in COPD for more than 6 weeks with placebo were included. The outcomes were the exercise capacity and adverse events. Four randomized controlled trials involving 109 subjects were included in the analysis. Two trials involved bosentan, one sildenafil and one beraprost. The studies varied in duration of treatment from 3 to 18 months. In a pooled analysis of four trials, exercise-capacity was not significantly improved with PH-specific treatment for COPD (risk ratio, -5.1; 95% CI, -13.0 to 2.8). COPD with overt PH significantly improved the exercise capacity (mean difference, 111.6; 95% CI, 63.3 to 159.9) but COPD with PH unknown did not (mean difference, 26.6; 95% CI, -24.3 to 77.5). There was no significant difference in hypoxemia (mean difference, 2.6; 95% CI, -3.7 to 8.8). PH specific treatments have a significant effect in improving exercise capacity in COPD with overt PH. PMCID: PMC3744709 PMID: 23960448 [PubMed - indexed for MEDLINE] 17. J Hypertens. 2013 Apr;31(4):639-48. doi: 10.1097/HJH.0b013e32835ca964. Endurance exercise beneficially affects ambulatory blood pressure: a systematic review and meta-analysis. Cornelissen VA(1), Buys R, Smart NA. Author information: (1)Department of Rehabilitation Sciences, Research Center for Cardiovascular Rehabilitation, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium. Veronique.cornelissen@faber.kuleuven.be Exercise is widely recommended as one of the key preventive lifestyle changes to reduce the risk of hypertension and to manage high blood pressure (BP), but individual studies investigating the effect of exercise on ambulatory BP have remained inconclusive. Therefore, the primary purpose of this systematic review

and meta-analysis was to determine the effect of aerobic endurance training on daytime and night-time BP in healthy adults. A systematic literature search was conducted using PubMed and Cochrane Controlled Clinical trial registry from their inception to May 2012. Randomized controlled trials of at least 4 weeks investigating the effects of aerobic endurance training on ambulatory BP in healthy adults were included. Inverse weighted random effects models were used for analyses, with data reported as weighted means and 95% confidence limits. We included 15 randomized controlled trials, involving 17 study groups and 633 participants (394 exercise participants and 239 control participants). Overall, endurance training induced a significant reduction in daytime SBP [-3.2 mmHg, 95% confidence interval (CI), -5.0 to-1.3] and daytime DBP (-2.7 mmHg, 95% CI, -3.9 to -1.5). No effect was observed on night-time BP. The findings from this meta-analysis suggest that aerobic endurance exercise significantly decreases daytime, but not night-time, ambulatory BP. PMID: 23325392 [PubMed - indexed for MEDLINE] 18. Am J Hypertens. 2013 Mar;26(3):357-66. doi: 10.1093/ajh/hps053. Epub 2012 Dec 27. Exercise-induced hypertension, cardiovascular events, and mortality in patients undergoing exercise stress testing: a systematic review and meta-analysis. Schultz MG(1), Otahal P, Cleland VJ, Blizzard L, Marwick TH, Sharman JE. Author information: (1)Menzies Research Institute Tasmania, University of Tasmania, Hobart, Tasmania, Australia. BACKGROUND: The prognostic relevance of a hypertensive response to exercise (HRE) is ill-defined in individuals undergoing exercise stress testing. The study described here was intended to provide a systematic review and meta-analysis of published literature to determine the value of exercise-related blood pressure (BP) (independent of office BP) for predicting cardiovascular (CV) events and mortality. METHODS: Online databases were searched for published longitudinal studies reporting exercise-related BP and CV events and mortality rates. RESULTS: We identified for review 12 longitudinal studies with a total of 46,314 individuals without significant coronary artery disease, with total CV event and mortality rates recorded over a mean follow-up of 15.2±4.0 years. After adjustment for age, office BP, and CV risk factors, an HRE at moderate exercise intensity carried a 36% greater rate of CV events and mortality (95% CI, 1.02-1.83, P = 0.039) than that of subjects without an HRE. Additionally, each 10mm Hg increase in systolic BP during exercise at moderate intensity was accompanied by a 4% increase in CV events and mortality, independent of office

BP, age, or CV risk factors (95% CI, 1.01-1.07, P = 0.02). Systolic BP at maximal workload was not significantly associated with the outcome of an increased rate of CV, whether analyzed as a categorical (HR=1.49, 95% CI, 0.90-2.46, P = 0.12) or a continuous (HR=1.01, 95% CI, 0.98-1.04, P = 0.53) variable. CONCLUSIONS: An HRE at moderate exercise intensity during exercise stress testing is an independent risk factor for CV events and mortality. This highlights the need to determine underlying pathophysiological mechanisms of exercise-induced hypertension. PMID: 23382486 [PubMed - indexed for MEDLINE] 19. J Am Heart Assoc. 2013 Feb 1;2(1):e004473. doi: 10.1161/JAHA.112.004473. Exercise training for blood pressure: a systematic review and meta-analysis. Cornelissen VA(1), Smart NA. Author information: (1)Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium. BACKGROUND: We conducted meta-analyses examining the effects of endurance, dynamic resistance, combined endurance and resistance training, and isometric resistance training on resting blood pressure (BP) in adults. The aims were to quantify and compare BP changes for each training modality and identify patient subgroups exhibiting the largest BP changes. METHODS AND RESULTS: Randomized controlled trials lasting ≥4 weeks investigating the effects of exercise on BP in healthy adults (age ≥18 years) and published in a peer-reviewed journal up to February 2012 were included. Random effects models were used for analyses, with data reported as weighted means and 95% confidence interval. We included 93 trials, involving 105 endurance, 29 dynamic resistance, 14 combined, and 5 isometric resistance groups, totaling 5223 participants (3401 exercise and 1822 control). Systolic BP (SBP) was reduced after endurance (-3.5 mm Hg [confidence limits -4.6 to -2.3]), dynamic resistance (-1.8 mm Hg [-3.7 to -0.011]), and isometric resistance (-10.9 mm Hg [-14.5 to -7.4]) but not after combined training. Reductions in diastolic BP (DBP) were observed after endurance (-2.5 mm Hg [-3.2 to -1.7]), dynamic resistance (-3.2 mm Hg [-4.5 to -2.0]), isometric resistance (-6.2 mm Hg [-10.3 to -2.0]), and combined (-2.2 mm Hg [-3.9 to -0.48]) training. BP reductions after endurance training were greater (P<0.0001) in 26 study groups of hypertensive subjects (-8.3 [-10.7 to -6.0]/-5.2 [-6.8 to -3.4] mm Hg) than in 50 groups of prehypertensive subjects (-2.1 [-3.3 to -0.83]/-1.7 [-2.7 to -0.68]) and 29 groups of subjects with normal BP levels (-0.75 [-2.2 to +0.69]/-1.1 [-2.2 to -0.068]). BP reductions after dynamic resistance training were largest for prehypertensive participants (-4.0 [-7.4 to

-0.5]/-3.8 [-5.7 to -1.9] mm Hg) compared with patients with hypertension or normal BP. CONCLUSION: Endurance, dynamic resistance, and isometric resistance training lower SBP and DBP, whereas combined training lowers only DBP. Data from a small number of isometric resistance training studies suggest this form of training has the potential for the largest reductions in SBP. PMCID: PMC3603230 PMID: 23525435 [PubMed - indexed for MEDLINE] 20. Int J Nurs Stud. 2010 Dec;47(12):1545-61. doi: 10.1016/j.ijnurstu.2010.08.008. Epub 2010 Sep 21. The effect of walking intervention on blood pressure control: a systematic review. Lee LL(1), Watson MC, Mulvaney CA, Tsai CC, Lo SF. Author information: (1)Department of Nursing, Tzu Chi College of Technology, and School of Nursing, Tzu Chi University, Hualien, Taiwan. lllee666@gmail.com BACKGROUND: Hypertension is a major public health problem and a key risk factor of cardiovascular diseases. Increased physical activity has been recommended as an important lifestyle modification for the prevention and control of hypertension. However the optimal characteristics for a physical activity programme remain open to debate. Walking is recommended by healthcare professionals as a form of exercise for controlling hypertension and nurses find it difficult to provide advice about this form of physical activity. Studies testing the effect of walking on blood pressure have produced inconsistent findings. OBJECTIVES: To systematically review the evidence for the effectiveness of walking intervention on blood pressure. METHODS: A systematic search of the literature was conducted using a range of electronic and evidence-based databases to identify studies. Criteria for study inclusion were a randomised controlled trial design with a non-intervention control group; study samples were aged 16 years and over; the intervention was predominantly focused on walking and blood pressure was an outcome. Data extraction and quality appraisal were carried out independently by two reviewers; a third reviewer was consulted when needed. RESULTS: A total of 27 randomised controlled trials were included and nine of the 27 trials found an effect of walking intervention on blood pressure control. Walking intervention tends to be effective from studies with larger sample size. A beneficial effect of walking on blood pressure tended to employ moderate to

high-intensity walking and a longer intervention period than those trials not showing the effect. CONCLUSIONS: The results of this review provide evidence of the beneficial effects of walking on lowering blood pressure. Recommendations on lowering blood pressure with a walking activity should address the issue of walking intensity to achieve a beneficial effect on lowering blood pressure. Future research investigating the effect of walking intensity on blood pressure levels and rigorous design of walking interventions to achieve better adherence and methodological quality is required. Copyright © 2010 Elsevier Ltd. All rights reserved. PMID: 20863494 [PubMed - indexed for MEDLINE] 21. J Cardiopulm Rehabil Prev. 2009 May-Jun;29(3):152-60. doi: 10.1097/HCR.0b013e3181a33379. Tai chi exercise for patients with cardiovascular conditions and risk factors: A SYSTEMATIC REVIEW. Yeh GY(1), Wang C, Wayne PM, Phillips R. Author information: (1)Division for Research and Education in Complementary and Integrative Medical Therapies, Harvard Medical School, Boston, Massachusetts 02215, USA. gyeh@hms.harvard.edu PURPOSE: To conduct a systematic review of the literature evaluating tai chi exercise as an intervention for patients with cardiovascular disease (CVD) or with CVD risk factors (CVDRF). METHODS: We searched (1) MEDLINE, CAB Alt HealthWatch, BIOSIS previews, Science Citation Index, EMBASE, and Social Science Citation Index from inception through October 2007; (2) Chinese Medical Database, China Hospital Knowledge, China National Knowledge Infrastructure, and China Traditional Chinese Medicine Database from inception through June 2005; and (3) the medical libraries of Beijing and Nanjing Universities. Clinical studies published in English and Chinese including participants with established CVD or CVDRF were included. Data were extracted in a standardized manner; 2 independent investigators assessed methodological quality, including the Jadad score for randomized controlled trials (RCTs). RESULTS: Twenty-nine studies met inclusion criteria: 9 RCTs, 14 nonrandomized studies, and 6 observational trials. Three studies examined subjects with coronary heart disease, 5 in subjects with heart failure, and 10 in heterogeneous populations that included those with CVD. Eleven studies examined subjects with

CVDRF (hypertension, dyslipidemia, impaired glucose metabolism). Study duration ranged from 8 weeks to 3 years. Most studies included fewer than 100 subjects (range, 5-207). Six of 9 RCTs were of adequate quality (Jadad >or= 3). Most studies reported improvements with tai chi, including blood pressure reductions and increases in exercise capacity. No adverse effects were reported. CONCLUSION: Preliminary evidence suggests that tai chi exercise may be a beneficial adjunctive therapy for some patients with CVD and CVDRF. Further research is needed. PMCID: PMC2755083 PMID: 19471133 [PubMed - indexed for MEDLINE] 22. J Hypertens. 2007 Aug;25(8):1525-32. Qigong for hypertension: a systematic review of randomized clinical trials. Lee MS(1), Pittler MH, Guo R, Ernst E. Author information: (1)Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK. drmslee@gmail.com OBJECTIVES: To assess systematically the clinical evidence of qigong for hypertension. METHODS: Databases were searched up to August 2006. All randomized clinical trials (RCTs) testing qigong in patients with hypertension of any origin and assessing clinically relevant outcomes were considered. Trials using any type of control intervention were included. The selection of studies, data extraction and quality assessment were performed independently by at least two reviewers. Methodological quality was evaluated using the Jadad score. RESULTS: A total of 121 potentially relevant articles were identified and 12 RCTs were included. Seven RCTs tested qigong in combination with antihypertensive drugs compared with antihypertensive drugs alone. The meta-analysis of two trials reporting adequate data suggested beneficial effects in favour of qigong [weighted mean difference, systolic blood pressure (SBP) -12.1 mmHg, 95% confidence interval (CI) -17.1 to -7.0; diastolic blood pressure -8.5 mmHg, 95% CI -12.6 to -4.4]. Qigong was compared with waiting list control in two RCTs and was found to reduce SBP significantly (weighted mean difference -18.5 mmHg, 95% CI -23.1 to -13.9). In three further RCTs the comparisons made were: qigong combined with conventional therapy versus muscle relaxation combined with conventional therapy; qigong as a sole treatment versus exercise. All reported positive results in at least some of the relevant outcome measures. The methodological quality of the studies was low. CONCLUSION: There is some encouraging evidence of qigong for lowering SBP, but

the conclusiveness of these findings is limited. Rigorously designed trials are warranted to confirm these results. PMID: 17620944 [PubMed - indexed for MEDLINE] 23. J Public Health Med. 1998 Dec;20(4):441-8. Lowering blood pressure: a systematic review of sustained effects of non-pharmacological interventions. Ebrahim S(1), Smith GD. Author information: (1)Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine, London. BACKGROUND: Risk factors for raised blood pressure include obesity, physical inactivity, high dietary salt intake, stress, and high alcohol consumption. Much less is known about the effects on blood pressure of modification of these risk factors for the purposes of disease prevention. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to estimate the effects of various non-pharmacological interventions on blood pressure. METHODS: RCTs of single interventions aimed at altering these risk factors among adults aged 45 or older with and without hypertension, and with at least six months follow-up were included. MEDLINE was the primary source and the boundaries of the study were from 1966 to April 1995. RESULTS: The majority of RCTs were of short duration and did not provide guidance on the sustainability of effects and were excluded. Totals of eight RCTs of salt restriction, eight RCTs of weight reduction, eight of stress management, eight of exercise, and one of alcohol reduction of longer than six months duration were found. Net (i.e. intervention - control group) systolic blood pressure changes, mean mm Hg (with 95 per cent confidence intervals in parentheses), in hypertensives were as follows: salt restriction -2.9 (-5.8,0.0), weight loss -5.2 (-8.3,-2.0), stress control -1.0 (-2.3,+0.3), and exercise -0.8 (-5.9,+4.2). Smaller changes were found in normotensive participants: salt restriction -1.3 (-2.7,+0.1), weight loss -2.8 (-3.9,-1.8), exercise -0.2 (-2.8,+2.4), and alcohol reduction -2.1 (-4.1,-0.1). Some interventions (e.g. stress control in normotensives) were not examined in either hypertensives or normotensives. The majority of RCTs were of low methodological quality and bias often tended to increase the changes observed. Few of the trials controlled for the confounding effects of concurrent changes in other blood pressure risk factors. CONCLUSION: These net changes are probably overestimates of the effects that might be achieved by non-pharmacological interventions. There is a need for large-scale, long duration trials of these non-pharmacological interventions in

both hypertensive patients and normotensive people to determine effect sizes more accurately. PMID: 9923952 [PubMed - indexed for MEDLINE] 24. Prev Cardiol. 2008 Spring;11(2):82-9. The effect of tai chi exercise on blood pressure: a systematic review. Yeh GY(1), Wang C, Wayne PM, Phillips RS. Author information: (1)Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School Osher Institute, Boston, MA 02215, USA. gyeh@hms.harvard.edu A systematic review of the literature on the effect of tai chi exercise on blood pressure (BP) was performed. The authors searched Medline, CAB, Alt HealthWatch, BIOSIS previews, Science Citation Index, and EMBASE systems (inception through January 2007); researched Chinese Medical, China Hospital Knowledge, China National Knowledge Infrastructure, and China Traditional Chinese Medicine databases (inception to June 2005); and performed hand searches at the medical libraries of Beijing and Nanjing Universities. Clinical studies of tai chi examining BP as an outcome published in English or Chinese were included. Studies reporting only acute exercise effects were excluded. Data were extracted in a standardized manner and 2 independent investigators assessed methodologic quality. Twenty-six studies examining patients with and without cardiovascular conditions met inclusion criteria: 9 randomized controlled trials, 13 nonrandomized studies, and 4 observational studies. Study heterogeneity precluded formal meta-analyses. Twenty-two studies (85%) reported reductions in BP with tai chi (3-32 mm Hg systolic and 2-18 mm Hg diastolic BP reductions). Five randomized controlled trials were of adequate quality (Jadad score > or = 3). No adverse effects were reported. Tai chi exercise may reduce BP and serve as a practical, nonpharmacologic adjunct to conventional hypertension management. PMID: 18401235 [PubMed - indexed for MEDLINE] 25. J Hypertens. 2006 Feb;24(2):215-33. Lifestyle interventions to reduce raised blood pressure: a systematic review of randomized controlled trials. Dickinson HO(1), Mason JM, Nicolson DJ, Campbell F, Beyer FR, Cook JV, Williams

B, Ford GA. Author information: (1)University of Newcastle upon Tyne, Centre for Health Services Research, Newcastle upon Tyne, UK. Comment in J Hypertens. 2006 Oct;24(10):2115-6; author reply 2116-7. PURPOSE: To quantify effectiveness of lifestyle interventions for hypertension. DATA SOURCES: Electronic bibliographic databases from 1998 onwards, existing guidelines, systematic reviews. STUDY SELECTION AND DATA ABSTRACTION: We included randomized, controlled trials with at least 8 weeks' follow-up, comparing lifestyle with control interventions, enrolling adults with blood pressure at least 140/85 mmHg. Primary outcome measures were systolic and diastolic blood pressure. Two independent reviewers selected trials and abstracted data; differences were resolved by discussion. RESULTS: We categorized trials by type of intervention and used random effects meta-analysis to combine mean differences between endpoint blood pressure in treatment and control groups in 105 trials randomizing 6805 participants. Robust statistically significant effects were found for improved diet, aerobic exercise, alcohol and sodium restriction, and fish oil supplements: mean reductions in systolic blood pressure of 5.0 mmHg [95% confidence interval (CI): 3.1-7.0], 4.6 mmHg (95% CI: 2.0-7.1), 3.8 mmHg (95% CI: 1.4-6.1), 3.6 mmHg (95% CI: 2.5-4.6) and 2.3 mmHg (95% CI: 0.2-4.3), respectively, with corresponding reductions in diastolic blood pressure. Relaxation significantly reduced blood pressure only when compared with non-intervention controls. We found no robust evidence of any important effect on blood pressure of potassium, magnesium or calcium supplements. CONCLUSIONS: Patients with elevated blood pressure should follow a weight-reducing diet, take regular exercise, and restrict alcohol and salt intake. Available evidence does not support relaxation therapies, calcium, magnesium or potassium supplements to reduce blood pressure. PMID: 16508562 [PubMed - indexed for MEDLINE]

Exercise and Hypothyroidism 1. Res Q Exerc Sport. 2014 Sep;85(3):365-89. doi: 10.1080/02701367.2014.930405. Impact of overt and subclinical hypothyroidism on exercise tolerance: a systematic review. Lankhaar JA(1), de Vries WR, Jansen JA, Zelissen PM, Backx FJ. Author information: (1)a University Medical Center Utrecht . PURPOSE: This systematic review describes the state of the art of the impact of hypothyroidism on exercise tolerance and physical performance capacity in untreated and treated patients with hypothyroidism. METHOD: A systematic computer-aided search was conducted using biomedical databases. Relevant studies in English, German, and Dutch, published from the earliest date of each database up to December 2012, were identified. RESULTS: Out of 116 studies, a total of 38 studies with 1,379 patients fulfilled the inclusion criteria. These studies emphasize the multifactorial causes of exercise intolerance in untreated patients by the impact of limitations in different functional systems, with cardiovascular, cardiopulmonary, musculoskeletal, neuromuscular, and cellular metabolic systems acting in concert. Moreover, the studies affirm that exercise intolerance in patients is not always reversible during adequate hormone replacement therapy. As a consequence, despite a defined euthyroid status, there remains a significant group of treated patients with persistent complaints related to exercise intolerance who are suffering from limitations in daily and sport activities, as well as an impaired quality of life. An explanation for this phenomenon is lacking. Only 2 studies investigated the effects of a physical training program, and they showed inconsistent effects on the performance capacity in untreated patients with subclinical hypothyroidism. CONCLUSIONS: A limited body of knowledge exists concerning exercise tolerance in treated patients with hypothyroidism, and there is an insufficient amount of quantitative studies on the effects of a physical training program. To enhance exercise and sports participation for this specific group, more research in this forgotten area is warranted. PMID: 25141089 [PubMed - indexed for MEDLINE]

Exercise and Knee 1. Physiotherapy. 2016 Jun;102(2):136-44. doi: 10.1016/j.physio.2015.11.001. Epub 2015 Nov 17. What is the effect of sensori-motor training on functional outcome and balance performance of patients' undergoing TKR? A systematic review. Moutzouri M(1), Gleeson N(2), Billis E(3), Panoutsopoulou I(3), Gliatis J(4). Author information: (1)Department of Physiotherapy, Technological Educational Institute (TEI) of Western Greece, Aigion, Greece. Electronic address: moutzouri_marie@yahoo.com. (2)School of Health Sciences Queen Margaret University, UK. (3)Department of Physiotherapy, Technological Educational Institute (TEI) of Western Greece, Aigion, Greece. (4)Orthopedic Surgery Department, University Hospital of Patras, Greece. OBJECTIVES: Total knee replacement (TKR) has a beneficial effect on patients' functional ability; however, incidence of falls and deficits on proprioception are not restored even 1-year after surgery. Early and intensive exercise post-TKR has received limited endorsement in the literature. The aim of this review was to systemically identify and critically appraise clinical studies investigating the effect of sensori-motor training on functional and balance performance in TKR patients. DATA SOURCES: The electronic databases Cochrane Library, MEDLINE, EMBASE, CINAHL, PEDro and the register of current controlled trials were searched up to September 2014. REVIEW METHODS: Two independent reviewers used predefined inclusion and exclusion criteria to identify all eligible articles. Eligible articles were summarized and critically reviewed, using the PEDro scale. RESULTS: Two hundred and seventy six articles were screened, six were included. The studies, presented the results of 409 patients (269 intervention, 140 control). A range of rehabilitation protocols were defined by components of proprioception, postural control, balance perturbation and coordination. All studies supported the use of sensori-motor training as an additional element in patients' rehabilitation protocols. Clinical performance-based tests (more than relevant patient-reported measures) showed that functional ability and balance were improved compared to controls. The robustness of evidence was compromised because most of the studies were underpowered. CONCLUSIONS: Limited robust (Ia) evidence supports the equal effectiveness of functional rehabilitation program as a functional rehabilitation enhanced with sensori-motor elements in patients post-TKR. However, dose-response parameters of exercise eliciting improvement warrant further investigation. Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 26712529 [PubMed - in process]

2. Ann Phys Rehabil Med. 2016 Apr 11. pii: S1877-0657(16)00040-3. doi: 10.1016/j.rehab.2016.01.013. [Epub ahead of print] Isokinetic muscle strengthening for knee osteoarthritis: A systematic review of randomized controlled trials with meta-analysis. Coudeyre E(1), Jegu AG(2), Giustanini M(3), Marrel JP(3), Edouard P(4), Pereira B(5). Author information: (1)Service de médecine physique et de réadaptation, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France; Université Clermont Auvergne, 63000 Clermont-Ferrand, France; INRA, unité de nutrition humaine (UNH, UMR 1019), CRNH Auvergne, 63000 Clermont-Ferrand, France. Electronic address: ecoudeyre@chu-clermontferrand.fr. (2)Service de médecine physique et de réadaptation, site du Tampon, CHU Sud Réunion, CHU Réunion, 97448 Saint-Pierre, France. (3)Service de médecine physique et de réadaptation, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France. (4)Laboratoire de physiologie de l'exercice (LPE EA 4338), hôpital de Bellevue, faculté de médecine Jacques-Lisfranc, université Jean-Monnet, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France. (5)CHU Clermont-Ferrand, Biostatistics Unit, délégation recherche clinique & innovation (DRCI), Villa annexe IFSI, 63003 Clermont-Ferrand, France. OBJECTIVE: To assess the level of scientific evidence and the place in the rehabilitation framework of isokinetic muscle strengthening (IMS) for knee osteoarthritis (OA). METHODS: A systematic review of the English literature in MEDLINE via PubMed, the Cochrane Library, and PEDro databases for only randomized comparative trials. Data that were sufficiently homogeneous underwent comprehensive meta-analysis. Methodological assessment was done by using the CLEAR scale for non-pharmacologic trials. RESULTS: We identified articles for 9 trials (696 patients). All trials were of low to moderate quality. Tolerance of IMS was considered good. Improvement in muscle strength was better with an IMS program than no treatment or an isometric exercise but did not differ with an aerobic program. We found an important effect for pain (standardized mean difference 1.218 [95% CI 0.899-1.54], P<0.001) and functional Lequesne index (1.61 [0.40-2.81], P=0.009) and a moderate effect for the Western Ontario and McMaster Universities Osteoarthritis Index subscore C for disability (0.58 [0.04-1.11], P=0.03). CONCLUSIONS: IMS is an effective way to propose dynamic muscle strengthening for knee OA rehabilitation and has a significant effect on pain and disability. Because of the weak methodology and the great heterogeneity of studies, particularly in IMS protocol and outcome measures, insufficient data are available to provide guidelines about efficacy and strategy. Future clinical trials are needed, but more attention should be paid to the methods of such studies to clarify the role of IMS in the therapeutic armamentarium of knee OA. Copyright © 2016 Elsevier Masson SAS. All rights reserved. PMID: 27079585 [PubMed - as supplied by publisher]

3. Ann Phys Rehabil Med. 2016 Apr 1. pii: S1877-0657(16)00043-9. doi: 10.1016/j.rehab.2016.02.005. [Epub ahead of print] Educating patients about the benefits of physical activity and exercise for their hip and knee osteoarthritis. Systematic literature review. Gay C(1), Chabaud A(2), Guilley E(3), Coudeyre E(4). Author information: (1)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France; Université Clermont Auvergne, 63003 Clermont-Ferrand, France; Unité de Nutrition Humaine, INRA, UMR 1019, CRNH Auvergne, 63000 Clermont-Ferrand, France. (2)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France; Université Clermont Auvergne, 63003 Clermont-Ferrand, France. (3)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France. (4)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France; Université Clermont Auvergne, 63003 Clermont-Ferrand, France; Unité de Nutrition Humaine, INRA, UMR 1019, CRNH Auvergne, 63000 Clermont-Ferrand, France. Electronic address: ecoudeyre@chu-clermontferrand.fr. OBJECTIVES: Highlight the role of patient education about physical activity and exercise in the treatment of hip and knee osteoarthritis (OA). METHODS: Systematic literature review from the Cochrane Library, PubMed and Wiley Online Library databases. A total of 125 items were identified, including 11 recommendations from learned societies interested in OA and 45 randomized controlled trials addressing treatment education and activity/exercise for the treatment of hip and knee osteoarthritis. RESULTS: In the end, 13 randomized controlled trials and 8 recommendations were reviewed (1b level of evidence). Based on the analysis, it was clear that education, exercise and weight loss are the pillars of non-pharmacological treatments. These treatments have proven to be effective but require changes in patient behaviour that are difficult to obtain. Exercise and weight loss improve function and reduce pain. Education potentiates compliance to exercise and weight loss programs, thereby improving their long-term benefits. Cost efficiency studies have found a reduction in medical visits and healthcare costs after 12 months because of self-management programs. CONCLUSION: Among non-surgical treatment options for hip and knee osteoarthritis, the most recent guidelines focus on non-pharmacological treatment. Self-management for general physical activity and exercise has a critical role. Programs must be personalized and adjusted to the patient's phenotype. This development should help every healthcare professional adapt the care they propose to each patient. Registration number for the systematic review: CRD42015032346. Copyright © 2016 Elsevier Masson SAS. All rights reserved. PMID: 27053003 [PubMed - as supplied by publisher]

4. J Sci Med Sport. 2016 Apr 20. pii: S1440-2440(16)30030-5. doi: 10.1016/j.jsams.2016.04.003. [Epub ahead of print] Effectiveness of exercise therapy for meniscal lesions in adults: A systematic review and meta-analysis. Swart NM(1), van Oudenaarde K(2), Reijnierse M(2), Nelissen RG(3), Verhaar JA(4), Bierma-Zeinstra SM(5), Luijsterburg PA(6). Author information: (1)Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands. Electronic address: n.m.swart@erasmusmc.nl. (2)Department of Radiology, Leiden University Medical Center, The Netherlands. (3)Department of Orthopedics, Leiden University Medical Center, The Netherlands. (4)Department of Orthopedics, Erasmus MC, University Medical Center Rotterdam, The Netherlands. (5)Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands; Department of Orthopedics, Erasmus MC, University Medical Center Rotterdam, The Netherlands. (6)Department of General Practice, Erasmus MC, University Medical Center Rotterdam, The Netherlands. OBJECTIVES: This study evaluated the effectiveness of exercise therapy in patients with meniscal lesions. DESIGN: Systematic review and meta-analysis. METHODS: Nine databases were searched up to July 2015, including EMBASE and Medline OvidSP. Randomized and controlled clinical trials in adults with traumatic or degenerative meniscal lesions were considered for inclusion. Interventions had to consist of exercise therapy in non-surgical patients or after meniscectomy, and had to be compared with meniscectomy, no exercise therapy, or to a different type of exercise therapy. Primary outcomes were pain and function on short term (≤3 months) and long term (>3 months). Two researchers independently selected the studies, assessed the risk of bias, and extracted data. RESULTS: Of the 1415 identified articles 14 articles describing 12 studies were included; all had some concerns about the risk of bias. There was no significant difference between exercise therapy and meniscectomy for pain (MD 0.27 [-4.30,4.83]) and function (SMD -0.32 [-0.68,0.03]). After meniscectomy, there was conflicting evidence for the effectiveness of exercise therapy when compared to no exercise therapy for pain and function. There was no significant difference between various types of exercise therapy for pain (MD 19.30 [-6.60,45.20]) and function (SMD 0.01 [-0.27,0.28]). CONCLUSIONS: Exercise therapy and meniscectomy yielded comparable results on pain and function. Exercise therapy compared to no exercise therapy after meniscectomy showed conflicting evidence at short term, but was more effective on function at long term. The preferable type/frequency/intensity of exercise therapy remains unclear. The strength of the evidence was low to very low. Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

PMID: 27129638 [PubMed - as supplied by publisher] 5. Sports Med. 2016 Mar;46(3):353-64. doi: 10.1007/s40279-015-0418-4. Effects of Resistance Training on Lower-Extremity Muscle Power in Middle-Aged and Older Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Straight CR(1), Lindheimer JB(2), Brady AO(3), Dishman RK(2), Evans EM(2). Author information: (1)Department of Kinesiology, University of Georgia, 330 River Road, Athens, GA, 30602, USA. cstraight@umass.edu. (2)Department of Kinesiology, University of Georgia, 330 River Road, Athens, GA, 30602, USA. (3)Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, NC, USA. BACKGROUND: Resistance training (RT) has been investigated as a potential intervention strategy for improving muscle function, but the effects on lower-extremity muscle power in middle-aged and older adults have not been systematically reviewed. OBJECTIVE: The aim of this meta-analysis is to provide a quantitative estimate of the effect of RT on lower-extremity muscle power in middle-aged and older adults and to examine independent moderators of this relationship. METHODS: Randomized controlled trials that examined the effects of RT on either leg press (LP) or knee extension (KE) muscle power in adults aged ≥50 years were included. Data were aggregated with meta-analytic techniques, and multi-level modeling was used to adjust for nesting effects. A total of 52 effects from 12 randomized controlled trials were analyzed with a random-effects model to estimate the effect of RT on lower-extremity muscle power. A multiple-regression analysis was conducted to examine independent moderators of the mean effect. RESULTS: The adjusted aggregated results from all studies indicate that RT has a small-to-moderate effect on lower-extremity muscle power (Hedges' d = 0.34, 95 % confidence interval [CI] 0.25-0.43), which translated to 54.90 watts (95 % CI 40.37-69.43). Meta-regression analyses indicated that high-velocity RT was superior to traditional RT (Δ = 0.62 vs. 0.20, respectively) for increasing lower-extremity muscle power. In addition, training volume significantly moderated the effect of RT on muscle power. CONCLUSION: The findings from this meta-analysis indicate that RT is an efficacious intervention strategy for improving LP and KE muscle power in adults aged ≥50 years. Training mode and volume independently moderate the effect of RT on lower-extremity muscle power, and should be considered when prescribing RT exercise for middle-aged and older adults. PMID: 26545362 [PubMed - in process] 6. Clin Rehabil. 2016 Feb 15. pii: 0269215516628617. [Epub ahead of print] The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: A systematic

review. Alshewaier S(1), Yeowell G(2), Fatoye F(3). Author information: (1)Department of Health Professions, Manchester Metropolitan University, UK Department of Physical Therapy, Majmaah University, Kingdom of Saudi Arabia. (2)Department of Health Professions, Manchester Metropolitan University, UK g.yeowell@mmu.ac.uk. (3)Department of Health Professions, Manchester Metropolitan University, UK. OBJECTIVE: To evaluate the effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury. METHODS: The following databases were searched: PubMed, Ovid, The Cochrane Library and Web of Science. Studies published between the inception of the databases and December 2015 were sought using appropriate keywords in various combinations. This search was supplemented with a manual search of the references of selected studies. Studies were assessed for methodological quality using the Physiotherapy Evidence Database scale. RESULTS: A total of 500 studies were identified, of which eight studies met the inclusion criteria and were included in the present review. The average Physiotherapy Evidence Database score for the studies included was 5.8, which reflects an overall moderate methodological quality.The eight studies investigated a total of 451 subjects of which 71% (n=319) were males. The age of the participants in the eight studies ranged from 15 to 57 years. The duration of the intervention in the studies ranged from 3 to 24 weeks. This review found that pre-operative physiotherapy rehabilitation is effective for improving the outcomes of treatment following anterior cruciate ligament injury, including increasing knee-related function and improving muscle strength. However, whilst there was a significant improvement in quality of life from baseline following intervention, no significant difference in quality of life was found between the control and intervention groups. CONCLUSIONS: There is evidence to suggest that pre-operative physiotherapy rehabilitation is beneficial to patients with anterior cruciate ligament injury. © The Author(s) 2016. PMID: 26879746 [PubMed - as supplied by publisher] 7. J Manipulative Physiol Ther. 2016 Feb;39(2):110-120.e1. doi: 10.1016/j.jmpt.2016.01.003. The Effectiveness of Exercise on Recovery and Clinical Outcomes in Patients With Soft Tissue Injuries of the Hip, Thigh, or Knee: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Brown CK(1), Southerst D(2), Côté P(3), Shearer HM(4), Randhawa K(5), Wong JJ(6), Yu H(7), Varatharajan S(7), Sutton D(7), Stern PJ(8), D'Angelo K(1), Dion S(1), Cox J(1), Goldgrub R(9), Stupar M(10), Carroll LJ(11), Taylor-Vaisey A(12).

Author information: (1)Graduate Student, Department of Graduate Studies, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (2)Research Coordinator, Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, Toronto, ON, Canada. (3)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Oshawa, ON, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (4)Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Senior Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (5)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (6)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Associate Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Instructor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (7)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (8)Director, Graduate Education Program, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Assistant Clinical Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (9)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada. (10)Adjunct Professor, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, ON, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (11)Professor, Injury Prevention Centre and School of Public Health, University of Alberta, Edmonton, AB, Canada. (12)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. OBJECTIVE: The purpose of this systematic review was to determine the effectiveness of exercise for the management of soft tissue injuries of the hip,

thigh, and knee. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL Plus with Full Text from January 1, 1990, to April 8, 2015, for randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effect of exercise on pain intensity, self-rated recovery, functional recovery, health-related quality of life, psychological outcomes, and adverse events. Random pairs of independent reviewers screened titles and abstracts and assessed risk of bias using the Scottish Intercollegiate Guidelines Network criteria. Best evidence synthesis methodology was used. RESULTS: We screened 9494 citations. Eight RCTs were critically appraised, and 3 had low risk of bias and were included in our synthesis. One RCT found statistically significant improvements in pain and function favoring clinic-based progressive combined exercises over a "wait and see" approach for patellofemoral pain syndrome. A second RCT suggests that supervised closed kinetic chain exercises may lead to greater symptom improvement than open chain exercises for patellofemoral pain syndrome. One RCT suggests that clinic-based group exercises may be more effective than multimodal physiotherapy in male athletes with persistent groin pain. CONCLUSION: We found limited high-quality evidence to support the use of exercise for the management of soft tissue injuries of the lower extremity. The evidence suggests that clinic-based exercise programs may benefit patients with patellofemoral pain syndrome and persistent groin pain. Further high-quality research is needed. Copyright © 2016 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 26976374 [PubMed - in process] 8. Eur J Phys Rehabil Med. 2016 Feb;52(1):110-33. Epub 2015 Jul 9. Exercise for treating patellofemoral pain syndrome: an abridged version of Cochrane systematic review. VAN DER Heijden RA(1), Lankhorst NE, VAN Linschoten R, Bierma-Zeinstra SM, Marienke VAN Middelkoop M. Author information: (1)Department of General Practice, Erasmu MC, University Medical Center Rotterdam, The Netherlands - m.vanmiddelkoop@erasmusmc.nl. BACKGROUND: Patellofemoral pain syndrome (PFPS) is a common knee problem characterised by retropatellar or peripatellar pain, which particularly affects adolescents and young adults. Exercise therapy is often prescribed. AIM: To assess the effects of exercise therapy in people with PFPS. DESIGN: Systematic review. SETTING: All settings. POPULATION: Adolescents and adults with PFPS. METHODS: A search was performed in nine databases up to May 2014, including the

Cochrane Register, MEDLINE and EMBASE. Randomised and quasi-randomised trials evaluating the effect of exercise therapy in adolescents and adults with PFPS were considered for inclusion. Two review authors independently selected trials, extracted data and assessed risk of bias. RESULTS: In total, 31 trials including 1690 participants were included in this review, of which most were at high risk of performance bias and detection bias due to lack of blinding. The included studies provided evidence for: exercise therapy versus control; exercise therapy versus other conservative interventions (e.g. taping); and different exercises or exercise programmes. Pooled data favoured exercise therapy over control for pain during activity (short term MD -1.46 [-2.39, -0.54]), usual pain (short term estimated MD -1.44 [-2.48,-0.39]), functional ability; (short term estimated MD 12.21 [6.44, 18.09] and long term recovery (RR 1.35 [0.99, 1.84]). Pooled data favoured hip and knee exercise over knee exercises alone for pain during activity (short-term MD -2.20 [3.80, -0.60]) and usual pain (short term MD-1.77 [-2.78,-0.76]). CONCLUSION: This review found very low quality but consistent evidence that exercise therapy for PFPS may result in clinically important reduction in pain and improvement in functional ability, as well as enhancing long-term recovery. There is some very low quality evidence that hip plus knee exercises may be more effective in reducing pain than knee exercise alone. CLINICAL REHABILITATION IMPACT: Very low quality evidence but consistent evidence indicates that exercise therapy benefits patients with PFP. However, there is insufficient evidence to determine the best form of exercise therapy and it is unknown whether this result would apply to all people with PFPS. PMID: 26158920 [PubMed - in process] 9. J Geriatr Phys Ther. 2016 Jan-Mar;39(1):38-48. doi: 10.1519/JPT.0000000000000045. Effect of Home Exercise Program in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis. Anwer S(1), Alghadir A, Brismée JM. Author information: (1)1Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Kingdom of Saudi Arabia. 2Padmashree Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. 3Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock. BACKGROUND: The Osteoarthritis Research Society International recommended that nonpharmacological methods include patient education programs, weight reduction, coping strategies, and exercise programs for the management of knee osteoarthritis (OA). However, neither a systematic review nor a meta-analysis has been published regarding the effectiveness of home exercise programs for the management of knee OA. PURPOSE: The purpose of this systematic review was to examine the evidence regarding the effect of home exercise programs with and without supervised clinic-based exercises in the management of knee OA.

METHODS: We searched PubMed, CINAHL, Embase, Scopus, and PEDro for research articles published prior to September 2014 using key words such as pain, exercise, home exercise program, rehabilitation, supervised exercise program, and physiotherapy in combination with Medical Subject Headings "Osteoarthritis knee." We selected randomized and case-controlled trials published in English language. To verify the quality of the selected studies, we applied the PEDro Scale. Two evaluators individually selected the studies based on titles, excluding those articles that were not related to the objectives of this review. One evaluator extracted data from the included studies. A second evaluator independently verified extracted data for accuracy. RESULTS: A total of 31 studies were found in the search. Of these, 19 studies met the inclusion criteria and were further analyzed. Seventeen of these 19 studies reached high methodological quality on the PEDro scale. Although the methods and home exercise program interventions varied widely in these studies, most found significant improvements in pain and function in individuals with knee OA. DISCUSSIONS: The analysis indicated that both home exercise programs with and without supervised clinic-based exercises were beneficial in the management of knee OA. CONCLUSIONS: The large evidence of high-quality trials supports the effectiveness of home exercise programs with and without supervised clinic-based exercises in the rehabilitation of knee OA. In addition, small but growing evidence supports the effectiveness of other types of exercise such as tai chi, balance, and proprioceptive training for individuals with knee OA. PMID: 25695471 [PubMed - in process] 10. Clin Rehabil. 2016 Jan;30(1):36-52. doi: 10.1177/0269215515570098. Epub 2015 Feb 17. Effects of exercise therapy on walking ability in individuals with knee osteoarthritis: a systematic review and meta-analysis of randomised controlled trials. Tanaka R(1), Ozawa J(2), Kito N(2), Moriyama H(3). Author information: (1)Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Japan r-tanaka@hs.hirokoku-u.ac.jp. (2)Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Japan. (3)Department of Rehabilitation Science, Graduate School of Health Sciences, Kobe University, Japan. OBJECTIVE: To examine the effect of exercise therapy on the walking ability of individuals with knee osteoarthritis. DATA SOURCES: Randomised clinical trials (RCTs) were identified by searching through PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature. All literature published to October 2014 were included in the search. REVIEW METHODS: Data were collected from RCTs that compared the effects of exercise therapy on walking ability with the effects of no intervention or

psychoeducational intervention in participants with knee osteoarthritis. The outcome data on the total distance walked (6-minute walk test); the amount of time spent walking (the time to walk arbitrary distances); and gait velocity were obtained and analysed. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated. RESULTS: Twenty-eight RCTs were identified. Meta-analysis provided very-low-quality evidence that exercise therapy increased the total distance walked in the 6-minute walk test, in comparison with the effects of the control interventions (SMD = 0.44, 95% CI 0.27 to 0.60). Meta-analysis also provided low- or moderate-quality evidence that the amount of time spent walking and gait velocity were improved more by exercise therapy than by the control interventions (the amount of time spent walking: SMD = -0.50, 95% CI -0.70 to -0.30; gait velocity: SMD = 1.78, 95% CI 0.98 to 2.58). CONCLUSION: In individuals with knee osteoarthritis, exercise therapy can improve the amount of time spent walking, gait velocity, and maybe the total distance walked. © The Author(s) 2015. PMID: 25691583 [PubMed - in process] 11. Br J Sports Med. 2015 Dec;49(24):1554-7. doi: 10.1136/bjsports-2015-095424. Epub 2015 Sep 24. Exercise for osteoarthritis of the knee: a Cochrane systematic review. Fransen M(1), McConnell S(2), Harmer AR(1), Van der Esch M(3), Simic M(1), Bennell KL(4). Author information: (1)Faculty of Health Sciences, Clinical and Rehabilitation Sciences Research Group and Discipline of Physiotherapy, University of Sydney, Sydney, Australia. (2)Department of Medicine, St Joseph's Health Care Centre, Toronto, Canada. (3)Department of Rehabilitation, Reade, Centre for Rehabilitation and Rheumatology, Amsterdam, The Netherlands. (4)Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, Australia. OBJECTIVE: To determine whether land-based therapeutic exercise is beneficial for people with knee osteoarthritis (OA) in terms of reduced joint pain or improved physical function and quality of life. METHODS: Five electronic databases were searched, up until May 2013. Randomised clinical trials comparing some form of land-based therapeutic exercise with a non-exercise control were selected. Three teams of two review authors independently extracted data and assessed risk of bias for each study. Standardised mean differences immediately after treatment and 2-6 months after cessation of formal treatment were separately pooled using a random effects model. RESULTS: In total, 54 studies were identified. Overall, 19 (35%) studies reported adequate random sequence generation, allocation concealment and adequately

accounted for incomplete outcome data. However, research results may be vulnerable to selection, attrition and detection bias. Pooled results from 44 trials indicated that exercise significantly reduced pain (12 points/100; 95% CI 10 to 15) and improved physical function (10 points/100; 95% CI 8 to 13) to a moderate degree immediately after treatment, while evidence from 13 studies revealed that exercise significantly improved quality of life immediately after treatment with small effect (4 points/100; 95% CI 2 to 5). In addition, 12 studies provided 2-month to 6-month post-treatment sustainability data which showed significantly reduced knee pain (6 points/100; 95% CI 3 to 9) and 10 studies which showed improved physical function (3 points/100; 95% CI 1 to 5). CONCLUSIONS: Among people with knee osteoarthritis, land-based therapeutic exercise provides short-term benefit that is sustained for at least 2-6 months after cessation of formal treatment. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26405113 [PubMed - in process] 12. Clin Rehabil. 2015 Oct 15. pii: 0269215515610039. [Epub ahead of print] The effects of resistance exercise in patients with knee osteoarthritis: A systematic review and meta-analysis. Li Y(1), Su Y(2), Chen S(1), Zhang Y(1), Zhang Z(1), Liu C(1), Lu M(1), Liu F(1), Li S(1), He Z(1), Wang Y(1), Sheng L(1), Wang W(1), Zhan Z(1), Wang X(1), Zheng N(1). Author information: (1)Department of Rehabilitation Medicine College, Fujian University of Traditional Chinese Medicine, Fujian, China. (2)Department of Rehabilitation Medicine College, Fujian University of Traditional Chinese Medicine, Fujian, China suyouxin777@hotmail.com. OBJECTIVE: To analyze the effectiveness of resistance exercise in the treatment of knee osteoarthritis on pain, stiffness, and physical function. DESIGN: Systematic review and meta-analysis of randomized controlled trials. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, the Web of Science, and Chinese Biomedical Literature Database were searched from the date of inception to August 2015. METHODS: Trials comparing effects of resistance exercise intervention with either non-intervention or psycho-educational intervention were selected by two reviewers independently. The risk of bias was assessed and studies with similar outcomes were pooled using a fixed or random effects model. RESULTS: Data from 17 randomized clinical trials including 1705 patients were integrated. The main source of methodological bias in the selected studies was lack of double blinding. The meta-analysis results suggested that resistance exercise training relieved pain (standard mean difference [SMD]: -0.43; 95% confidence interval [CI]: -0.57 to -0.29; P < 0.001), alleviated stiffness (SMD:

-0.31; 95%: CI -0.56 to -0.05; P = 0.02), and improved physical function (SMD -0.53; 95% CI: -0.70 to -0.37; P < 0.001). CONCLUSION: Resistance exercise is beneficial in terms of reducing pain, alleviating stiffness, and improving physical function in patients with knee osteoarthritis. © The Author(s) 2015. PMID: 26471972 [PubMed - as supplied by publisher] 13. J Phys Ther Sci. 2015 Oct;27(10):3309-14. doi: 10.1589/jpts.27.3309. Epub 2015 Oct 30. Does exercise therapy improve the health-related quality of life of people with knee osteoarthritis? A systematic review and meta-analysis of randomized controlled trials. Tanaka R(1), Ozawa J(1), Kito N(1), Moriyama H(2). Author information: (1)Department of Rehabilitation, Hiroshima International University, Japan. (2)Department of Rehabilitation Science, Graduate School of Health Sciences, Kobe University, Japan. [Purpose] The aim of this study was to examine the effects of exercise therapy on the health-related QOL of people with knee osteoarthritis. [Subjects] Four databases (PubMed, Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature) were searched for randomized controlled trials that evaluated the effects of exercise therapy on health-related QOL assessed by the SF-36 for inclusion in our systematic review. The methodological qualities of the trials were assessed independently by two reviewers using the PEDro scale. Pooled analyses with a random-effects model or a fixed-effects model were used in the meta-analyses to calculate the standardized mean differences and 95% confidence intervals. [Results] Twelve studies met the inclusion criteria. Our meta-analysis provides high-quality evidence that exercise therapy increases the summary score, physical functioning score, and role-physical score of knee osteoarthritis sufferers. Our meta-analysis also provides moderate-quality evidence that the physical component summary and mental component summary scores were improved to a greater extent by exercise therapy than by control interventions. [Conclusion] Exercise therapy can improve health-related QOL, as assessed by the SF-36, of knee osteoarthritis sufferers. PMCID: PMC4668190 PMID: 26644699 [PubMed] 14. Knee. 2015 Oct;22(5):360-71. doi: 10.1016/j.knee.2015.05.003. Epub 2015 Jun 6. The clinical effectiveness of self-care interventions with an exercise component

to manage knee conditions: A systematic review. Button K(1), Roos PE(2), Spasić I(3), Adamson P(4), van Deursen RW(2). Author information: (1)School of Healthcare Sciences, Cardiff University, United Kingdom; Physiotherapy Department, Cardiff and Vale UHB, United Kingdom. Electronic address: buttonk@cardiff.ac.uk. (2)School of Healthcare Sciences, Cardiff University, United Kingdom. (3)School of Computer Science and Informatics, Cardiff University, United Kingdom. (4)School of Healthcare Sciences, Cardiff University, United Kingdom; Physiotherapy Department, Cardiff and Vale UHB, United Kingdom. OBJECTIVE: Treatment of knee conditions should include approaches to support self-care and exercise based interventions. The most effective way to combine self-care and exercise has however not been determined sufficiently. Therefore the aim was to evaluate the clinical effectiveness of self-care programmes with an exercise component for individuals with any type of knee conditions. METHODS: A keyword search of Medline, CINAHL, Amed, PsycInfo, Web of Science, and Cochrane databases was conducted up until January 2015. Two reviewers independently assessed manuscript eligibility against inclusion/exclusion criteria. Study quality was assessed using the Downs and Black quality assessment tool and the Cochrane Risk of Bias Tool. Data were extracted about self-care and exercise intervention type, control intervention, participants, length of follow-up, outcome measures, and main findings. RESULTS: From the 7392 studies identified through the keyword search the title and abstract of 5498 were screened. The full text manuscripts of 106 studies were retrieved to evaluate their eligibility. Twenty-one manuscripts met the inclusion/exclusion criteria. CONCLUSION: The treatment potential of combined self-care and exercise interventions has not been maximised because of limitations in study design and failure to adequately define intervention content. Potentially the most beneficial self-care treatment components are training self-management skills, information delivery, and goal setting. Exercise treatment components could be strengthened by better attention to dose and progression. Modern technology to streamline delivery and support self-care should be considered. More emphasis is required on using self-care and exercise programmes for chronic condition prevention in addition to chronic condition management. Copyright © 2015. Published by Elsevier B.V. PMCID: PMC4642743 PMID: 26056046 [PubMed - in process] 15. Eur J Phys Rehabil Med. 2015 Sep 10. [Epub ahead of print] Hyaluronic acid intra-articular Injection and exercise therapy: effects on pain and disability in subjects affected by lower limb joints osteoarthritis. The Italian Society of Physical and Rehabilitation Medicine (SIMFER) systematic review.

Monticone M(1), Frizziero A, Rovere G, Vittadini F, Uliano D, La Bruna S, Gatto R, Nava C, Leggero V, Masiero S. Author information: (1)Physical Medicine and Rehabilitation Unit, Scientific Institute of Lissone, Milan, Institute of Care and Research (IRCCS), Salvatore Maugeri Foundation IRCCS, Lissone, Italy - antonio.frizziero@unipd.it. BACKGROUND: It is debated whether intra-articular viscosupplementation with hyaluronic acid (HA) can lead to improvements in subjects with osteoarthritis (OA) undergoing physical and rehabilitative interventions. AIM: To assess the effects of intra-articular viscosupplementation on disability in subjects with OA undergoing physical and rehabilitative interventions. Information on pain and quality of life were also collected. METHODS: The databases of PubMed, Medline, EMbase and CINAHL were searched for English language full-text randomized controlled trials comparing intra-articular viscosupplementation alone or associated with physical and rehabilitative interventions to viscosupplementation alone, shame treatment, waiting lists, and any type of rehabilitative interventions. Methodological quality of each study was assessed by using the Physiotherapy Evidence Database scale (PEDro). RESULTS: A total of 115 references were retrieved, and 8 studies were selected. Three trials compared HA injection and physical therapy in knee OA, with disability and pain improvements in all studies, and between-group differences in favor of physical therapy in two studies; two trials compared HA injection and home exercises in knee OA, with improvements in pain, disability and quality of life in all studies, without between-group differences; two trials compared HA injection plus physical therapy agents and exercises to exercises plus physical therapy agents in knee OA, with improvements in disability and pain in both studies, and between-group differences in favor of the inclusion HA in one study; one trial compared HA injection and home exercises in ankle OA, with improvements in disability and pain in both arms without between-group differences. CONCLUSION: Physical therapy agents seemed have greater effects than intra-articular viscosupplementation on disability and pain. In the other cases both intra-articular viscosupplementation and physical and rehabilitative interventions seemed to be equally effective in improving disability, pain, and quality of life in subjects with knee and ankle OA. PMID: 26365146 [PubMed - as supplied by publisher] 16. J Arthroplasty. 2015 Sep;30(9):1657-63. doi: 10.1016/j.arth.2015.04.013. Epub 2015 Apr 11. Does Pre-Operative Physiotherapy Improve Outcomes in Primary Total Knee Arthroplasty? - A Systematic Review. Kwok IH(1), Paton B(1), Haddad FS(1). Author information: (1)University College London Hospital, London, UK.

We undertook a systematic review of 11 randomised controlled trials comparing patient outcomes in total knee arthroplasty in those who had undergone pre-operative physiotherapy-based interventions against control groups. Results show that there is little evidence that pre-operative physiotherapy brings about significant improvements in patient outcome scores, lower limb strength, pain, range of movement and hospital length of stay following total knee arthroplasty. The overall quality of the studies was moderate to poor, mostly due to the small sample sizes. Copyright © 2015 Elsevier Inc. All rights reserved. PMID: 25913232 [PubMed - indexed for MEDLINE] 17. Osteoarthritis Cartilage. 2015 Sep;23(9):1445-56. doi: 10.1016/j.joca.2015.05.002. Epub 2015 May 21. Is long-term physical activity safe for older adults with knee pain?: a systematic review. Quicke JG(1), Foster NE(2), Thomas MJ(3), Holden MA(4). Author information: (1)Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom. Electronic address: j.g.quicke@keele.ac.uk. (2)Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom. Electronic address: n.foster@keele.ac.uk. (3)Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom. Electronic address: m.thomas@keele.ac.uk. (4)Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, Staffordshire, ST5 5BG, United Kingdom. Electronic address: m.holden@keele.ac.uk. OBJECTIVE: To determine whether long-term physical activity is safe for older adults with knee pain. DESIGN: A comprehensive systematic review and narrative synthesis of existing literature was conducted using multiple electronic databases from inception until May 2013. Two reviewers independently screened, checked data extraction and carried out quality assessment. Inclusion criteria for study designs were randomised controlled trials (RCTs), prospective cohort studies or case control studies, which included adults of mean age over 45 years old with knee pain or osteoarthritis (OA), undertaking physical activity over at least 3 months and which measured a safety related outcome (adverse events, pain, physical functioning, structural OA imaging progression or progression to total knee replacement (TKR)). RESULTS: Of the 8614 unique references identified, 49 studies were included in the review, comprising 48 RCTs and one case control study. RCTs varied in quality and included an array of low impact therapeutic exercise interventions of varying

cardiovascular intensity. There was no evidence of serious adverse events, increases in pain, decreases in physical function, progression of structural OA on imaging or increased TKR at group level. The case control study concluded that increasing levels of regular physical activity was associated with lower risk of progression to TKR. CONCLUSIONS: Long-term therapeutic exercise lasting 3 to 30 months is safe for most older adults with knee pain. This evidence supports current clinical guideline recommendations. However, most studies investigated selected, consenting older adults carrying out low impact therapeutic exercise which may affect result generalizability. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2014:CRD42014006913. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved. PMID: 26003947 [PubMed - in process] 18. Z Rheumatol. 2015 Aug;74(6):543-52. doi: 10.1007/s00393-014-1559-9. Effectiveness of aquatic exercise for treatment of knee osteoarthritis: Systematic review and meta-analysis. Lu M(1), Su Y, Zhang Y, Zhang Z, Wang W, He Z, Liu F, Li Y, Liu C, Wang Y, Sheng L, Zhan Z, Wang X, Zheng N. Author information: (1)Fujian University of Traditional Chinese Medicine, No.1 Qiuyang St., Shangjie, Minhou, Fuzhou, Fujian, China. OBJECTIVE: This paper presents a systematic review and meta-analysis of the effectiveness of aquatic exercise for treatment of knee osteoarthritis (OA). METHODS: PubMed, the Cochrane Library, Embase, CAMbase, and the Web of Science were screened through to June 2014. Only randomized controlled trials (RCTs) comparing aquatic exercise with control conditions were included. Two authors independently selected trials for inclusion, assessed the included trials, and extracted data. Outcome measures included pain, physical function, joint stiffness, quality of life (QOL), and safety. Pooled outcomes were analyzed using standardized mean difference (SMD). RESULTS: There is a lack of high quality studies in this area. Six RCTs (398 participants) were included. There was moderate evidence for a moderate effect on physical function in favor of aquatic exercise immediately after the intervention, but no evidence for pain or QOL when comparing aquatic exercise with nonexercise. Only one trial reported 3 months of follow-up measurements, which demonstrated limited evidence for pain improvement with aquatic exercise and no evidence for QOL or physical function when comparing aquatic exercise with nonexercise. There was limited evidence for pain improvement with land-based exercise and no evidence for QOL or physical function, when comparing aquatic exercise with land-based exercise according to follow-up measurements. No evidence was found for pain, physical function, stiffness, QOL, or mental health with aquatic exercise immediately after the intervention when comparing aquatic exercise with land-based exercise. Two studies reported aquatic exercise was not

associated with serious adverse events. CONCLUSION: Aquatic exercise appears to have considerable short-term benefits compared with land-based exercise and nonexercise in patients with knee OA. Based on these results, aquatic exercise is effective and safe and can be considered as an adjuvant treatment for patients with knee OA. Studies in this area are still too scarce and too short-term to provide further recommendations on how to apply this therapy. PMID: 25691109 [PubMed - indexed for MEDLINE] 19. Clin Biomech (Bristol, Avon). 2015 Jul;30(6):521-7. doi: 10.1016/j.clinbiomech.2015.03.028. Epub 2015 Apr 11. The effect of exercise therapy on knee adduction moment in individuals with knee osteoarthritis: A systematic review. Ferreira GE(1), Robinson CC(2), Wiebusch M(3), Viero CC(4), da Rosa LH(5), Silva MF(6). Author information: (1)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: giovannieferreira@hotmail.com. (2)Doctoral Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: carollinerobinson@gmail.com. (3)Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: matheusw.fisio@hotmail.com. (4)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: carolinaviero@gmail.com. (5)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: luisr@ufcspa.edu.br. (6)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil; Doctoral Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: marcelofs@ufcspa.edu.br. BACKGROUND: Exercise therapy is an evidence-based intervention for the conservative management of knee osteoarthritis. It is hypothesized that exercise therapy could reduce the knee adduction moment. A systematic review was performed in order to verify the effects of exercise therapy on the knee adduction moment in individuals with knee osteoarthritis in studies that also assessed pain and physical function. METHODS: A comprehensive electronic search was performed on MEDLINE, Cochrane CENTRAL, EMBASE, Google scholar and OpenGrey. Inclusion criteria were randomized controlled trials with control or sham groups as comparator assessing pain, physical function, muscle strength and knee adduction moment during walking at self-selected speed in individuals with knee osteoarthritis that underwent a structured exercise therapy rehabilitation program. Two independent reviewers extracted the data and assessed risk of bias. For each study, knee adduction moment, pain and physical function outcomes were extracted. For each outcome,

mean differences and 95% confidence intervals were calculated. Due to clinical heterogeneity among exercise therapy protocols, a descriptive analysis was chosen. FINDINGS: Three studies, comprising 233 participants, were included. None of the studies showed significant differences between strengthening and control/sham groups in knee adduction moment. In regards to pain and physical function, the three studies demonstrated significant improvement in pain and two of them showed increased physical function following exercise therapy compared to controls. Muscle strength and torque significantly improved in all the three trials favoring the intervention group. INTERPRETATION: Clinical benefits from exercise therapy were not associated with changes in the knee adduction moment. The lack of knee adduction moment reduction indicates that exercise therapy may not be protective in knee osteoarthritis from a joint loading point of view. Alterations in neuromuscular control, not captured by the knee adduction moment measurement, may contribute to alter dynamic joint loading following exercise therapy. To conclude, mechanisms other than the reduction in knee adduction moment might explain the clinical benefits of exercise therapy on knee osteoarthritis. Copyright © 2015 Elsevier Ltd. All rights reserved. PMID: 25896448 [PubMed - indexed for MEDLINE] 20. J Phys Ther Sci. 2015 Jul;27(7):2387-90. doi: 10.1589/jpts.27.2387. Epub 2015 Jul 22. Effectiveness of therapeutic physical exercise in the treatment of patellofemoral pain syndrome: a systematic review. Alba-Martín P(1), Gallego-Izquierdo T(1), Plaza-Manzano G(2), Romero-Franco N(3), Núñez-Nagy S(1), Pecos-Martín D(1). Author information: (1)Physiotherapy and Nursery Department, University of Alcalá, Spain. (2)Rehabilitation and Physical Medicine Department, Medical Hydrology, Complutense University, Spain. (3)Physiotherapy Department, Catholic University of San Antonio, Spain. [Purpose] The aim of this study was to analyze the effectiveness of conservative treatment of patellofemoral pain syndrome with physical exercise. [Subjects and Methods] A computer-based review conducted of four databases (PubMed, the Cochrane Library, PEDro, and the University Library) was completed based on the inclusion criteria of patellofemoral pain syndrome patients treated with physical exercise methods and examination with self-reported pain and/or functional questionnaires. [Results] The findings of ten clinical trials of moderate to high quality were evaluated to determine the effectiveness of physical exercise as conservative management for patellofemoral pain syndrome. [Conclusion] The intervention programs that were most effective in relieving pain and improving function in patellofemoral pain syndrome included proprioceptive neuromuscular facilitation stretching and strengthening exercises for the hip external rotator

and abductor muscles and knee extensor muscles. PMCID: PMC4540887 PMID: 26311988 [PubMed] 21. BMC Musculoskelet Disord. 2015 Feb 7;16:15. doi: 10.1186/s12891-015-0469-6. Effectiveness of physiotherapy exercise following total knee replacement: systematic review and meta-analysis. Artz N(1), Elvers KT(2), Lowe CM(3), Sackley C(4), Jepson P(5), Beswick AD(6). Author information: (1)Peninsula Allied Health Centre, School of Health Professions, University of Plymouth, Plymouth, PL6 8BH, UK. Neil.Artz@plymouth.ac.uk. (2)Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB, UK. Karen.Elvers@bristol.ac.uk. (3)Physiotherapy Research Unit, Oxford United Hospitals NHS Trust, Oxford, UK. Catherine.MinnsLowe@ouh.nhs.uk. (4)King's College London, Capital House, Guy's Campus, London, SE1 3QD, UK. Catherine.sackley@kcl.ac.uk. (5)School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK. p.d.jepson@bham.ac.uk. (6)Musculoskeletal Research Unit, School of Clinical Sciences, University of Bristol, Bristol, BS10 5NB, UK. Andy.Beswick@bristol.ac.uk. BACKGROUND: Rehabilitation, with an emphasis on physiotherapy and exercise, is widely promoted after total knee replacement. However, provision of services varies in content and duration. The aim of this study is to update the review of Minns Lowe and colleagues 2007 using systematic review and meta-analysis to evaluate the effectiveness of post-discharge physiotherapy exercise in patients with primary total knee replacement. METHODS: We searched MEDLINE, Embase, PsycInfo, CINAHL and Cochrane CENTRAL to October 4(th) 2013 for randomised evaluations of physiotherapy exercise in adults with recent primary knee replacement. Outcomes were: patient-reported pain and function, knee range of motion, and functional performance. Authors were contacted for missing data and outcomes. Risk of bias and heterogeneity were assessed. Data was combined using random effects meta-analysis and reported as standardised mean differences (SMD) or mean differences (MD). RESULTS: Searches identified 18 randomised trials including 1,739 patients with total knee replacement. Interventions compared: physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling. Compared with controls receiving minimal physiotherapy, patients receiving physiotherapy exercise had improved physical function at 3-4 months, SMD -0.37 (95% CI -0.62, -0.12), and pain, SMD -0.45 (95% CI -0.85, -0.06). Benefit up to 6 months was apparent when considering only higher quality studies. There were no differences for outpatient physiotherapy exercise compared with home-based provision in physical function or pain outcomes. There was a short-term benefit favouring home-based physiotherapy exercise for range of motion flexion. There were no

differences in outcomes when the comparator was hydrotherapy, or when additional balancing or cycling components were included. In one study, a walking skills intervention was associated with a long-term improvement in walking performance. However, for all these evaluations studies were under-powered individually and in combination. CONCLUSION: After recent primary total knee replacement, interventions including physiotherapy and exercise show short-term improvements in physical function. However this conclusion is based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Future research should target improvements to long-term function, pain and performance outcomes in appropriately powered trials. PMCID: PMC4333167 PMID: 25886975 [PubMed - indexed for MEDLINE] 22. Clin Rehabil. 2015 Jan;29(1):14-29. doi: 10.1177/0269215514537093. Epub 2014 Jul 3. Progressive resistance training before and after total hip and knee arthroplasty: a systematic review. Skoffer B(1), Dalgas U(2), Mechlenburg I(3). Author information: (1)Institute of Clinical Medicine, Aarhus University, Denmark Department of Physical and Occupational Therapy, Aarhus University Hospital, Denmark bss@mph.au.dk. (2)Section of Sport Science, Department of Public Health, Aarhus University, Denmark. (3)Orthopaedic Research Centre, Aarhus University Hospital, Denmark. OBJECTIVE: To investigate the effect of progressive resistance training (PRT) on muscle strength and functional capacity before and/or after total hip arthroplasty (THA) and total knee arthroplasty (TKA). The effects of THA and TKA upon quality of life and the rate of adverse events were also investigated. DATA SOURCES: Literature from nine databases. REVIEW METHODS: Studies were included if 1) the effect of a PRT intervention was compared with no intervention or another type of intervention; 2) the outcomes included muscle strength and/or functional capacity; 3) all participants were scheduled for or had just undergone THA or TKA; 4) they were randomized, controlled trials (RCT); and 5) only full-length papers in English were studied. Data on patient characteristics, training regime, controls, and outcome measures were extracted. RESULTS: Four RCT studies on PRT and THA including 136 patients and three RCT studies on PRT and TKA including 284 patients were identified and rated according to the PEDro scale. The general methodological quality of the studies was low. No adverse events were reported in any of the studies. Weak evidence of a beneficial effect of PRT before and/or after THA on muscle strength and functional capacity was found. No effect of PRT before TKA on muscle strength and functional capacity was found. The results of postoperative PRT were too heterogeneous to allow conclusions.

CONCLUSION: PRT is safe and feasible before and/or after THA. PRT is safe, but the methodological quality of existing evidence permits no conclusion on the effectiveness of PRT before and/or after TKA. © The Author(s) 2014. PMID: 24994766 [PubMed - indexed for MEDLINE] 23. Physiotherapy. 2014 Dec;100(4):305-12. doi: 10.1016/j.physio.2014.03.003. Epub 2014 Mar 11. Enhanced education and physiotherapy before knee replacement; is it worth it? A systematic review. Jordan RW(1), Smith NA(2), Chahal GS(3), Casson C(4), Reed MR(5), Sprowson AP(6). Author information: (1)University Hospitals Coventry and Warwickshire, United Kingdom. Electronic address: Robert.jordan@doctors.org.uk. (2)University of Warwick, United Kingdom. Electronic address: Nicholas.smith@warwick.ac.uk. (3)University Hospitals Coventry and Warwickshire, United Kingdom. Electronic address: Gurdip.chahal@uhcw.nhs.uk. (4)Northumbria Healthcare NHS Foundation Trust, United Kingdom. Electronic address: Clare.casson@nhct.nhs.uk. (5)Northumbria Healthcare NHS Foundation Trust, United Kingdom. Electronic address: Mike.reed@nhs.net. (6)University of Warwick, United Kingdom. Electronic address: a.p.sprowson@warwick.ac.uk. Comment in Physiotherapy. 2015 Dec;101(4):394. BACKGROUND: Around 20% of knee replacement have an unsatisfactory outcome. Pre-operative physiotherapy and education have been proposed to improve post-operative outcomes. OBJECTIVES: This systematic review evaluated whether these factors improved length of stay and patient reported outcomes after knee replacement surgery. DATA SOURCES: Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO and PEDro were searched on the 1st January 2013. STUDY SELECTION OR ELIGIBILITY CRITERIA: Randomised or quasi-randomised studies assessing either pre-operative education or physiotherapy on patients undergoing a planned total or partial knee replacement were included in the review. Only studies with a control group receiving a defined standard of pre-operative care were included. RESULTS: Eleven studies met the inclusion criteria set. Two studies analysed the effect of pre-operative education, seven pre-operative treatment by a physiotherapist and two studies used both factors. No study found significant differences in validated joint specific patient reported outcome measures. The education studies found a decrease in pre-operative expectation and an improvement in knowledge, flexion and regularity of exercise. Two studies found an improvement in muscle strength in the group treated by a physiotherapist at three months. The combination of education and physiotherapy was shown to reduce

patient length of stay and cost in one study. CONCLUSION: The evidence reviewed is insufficient to support the implementation of either pre-operative education or physiotherapy programmes. The combination of pre-operative education and treatment by a physiotherapist may reduce the medical costs associated with surgery. Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 24882691 [PubMed - indexed for MEDLINE] 24. Br J Sports Med. 2014 Nov;48(21):1579. doi: 10.1136/bjsports-2014-5555rep. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. Uthman OA(1), van der Windt DA(2), Jordan JL(2), Dziedzic KS(2), Healey EL(2), Peat GM(2), Foster NE(2). Author information: (1)Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL UK. (2)Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK. Republished from BMJ. 2013;347:f5555. STUDY QUESTION: Which types of exercise intervention are most effective in relieving pain and improving function in people with lower limb osteoarthritis? SUMMARY ANSWER: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise. An approach combining exercises to increase strength, flexibility, and aerobic capacity is most likely to be effective for relieving pain and improving function. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Current international guidelines recommend therapeutic exercise (land or water based) as "core" and effective management of osteoarthritis. Evidence from this first network meta-analysis, largely based on studies in knee osteoarthritis, indicates that an intervention combining strengthening exercises with flexibility and aerobic exercise is most likely to improve outcomes of pain and function. Further trials of exercise versus no exercise are unlikely to overturn this positive result. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. PMID: 25313133 [PubMed]

25. J Phys Ther Sci. 2014 Jul;26(7):1133-7. doi: 10.1589/jpts.26.1133. Epub 2014 Jul 30. Effects of tai chi for patients with knee osteoarthritis: a systematic review. Ye J(1), Cai S(1), Zhong W(2), Cai S(2), Zheng Q(2). Author information: (1)Department of Rehabilitation Assessment, Rehabilitation Hospital, Fujian University of Traditional Chinese Medicine, China ; Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong, China. (2)Department of Rehabilitation Assessment, Rehabilitation Hospital, Fujian University of Traditional Chinese Medicine, China. [Purpose] The aim of the present study was to seek evidence for the effectiveness of Tai Chi for patients with knee osteoarthritis (KOA). [Subjects and Methods] Systematic searches were conducted of the China Journals Full-text Database, Pubmed, Medline, Science Direct-Online Journals and CINAHL for studies published between 2000 and 2012. Studies were evaluated based on following inclusion criteria: 1) design: randomized control, clinical trial; 2) subjects: patients with a knee osteoarthritis diagnosis; 3) intervention: exercise involving Tai Chi; 4) studies published in English or Chinese. [Results] Six randomized control studies involving Tai Chi and knee osteoarthritis were found. [Conclusion] Tai Chi was an effective way of relieving pain and improving physical function. Further randomized controlled trials with large sample sizes and long training period are needed to compare groups who perform Tai Chi training with other groups who undergo other forms of physical exercise in order to confirm the efficacy of Tai Chi. PMCID: PMC4135213 PMID: 25140112 [PubMed] 26. J Phys Ther Sci. 2014 Jul;26(7):969-75. doi: 10.1589/jpts.26.969. Epub 2014 Jul 30. Effect of the Frequency and Duration of Land-based Therapeutic Exercise on Pain Relief for People with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Tanaka R(1), Ozawa J(1), Kito N(1), Moriyama H(2). Author information: (1)Department of Rehabilitation, Hiroshima International University, Japan. (2)Department of Rehabilitation Science, Graduate School of Health Sciences, Kobe University, Japan. [Purpose] This study aimed to investigate the influence of land-based exercise frequency and duration on pain relief for people with knee osteoarthritis (OA). [Subjects and Methods] The systematic review included randomized controlled trials that investigated this influence, which were identified by searches of

PubMed, the Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature. The exercise groups in the identified trials were categorized according to their type, frequency, and duration of exercise, and subgroup analyses were performed. [Results] Data integration of 17 studies (23 exercise groups) revealed a significant effect and a medium effect size. In subgroups involving strengthening exercise programs of ≥9 weeks duration, heterogeneity was found between subjects who performed up to 3 sessions/week and those who performed ≥4 sessions/week. In subgroups involving strengthening exercise programs of up to 3 sessions/week, there was heterogeneity between subjects who exercised for up to 8 weeks and those who exercised for ≥9 weeks. Heterogeneity was not confirmed in aerobic exercise subgroups. [Conclusion] Differences in exercise frequency and duration influence pain relief in effects of strengthening exercises but do not influence the effect size of aerobic exercise for people with knee OA. PMCID: PMC4135217 PMID: 25140076 [PubMed] 27. Arthritis Rheumatol. 2014 Mar;66(3):622-36. doi: 10.1002/art.38290. Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Juhl C(1), Christensen R, Roos EM, Zhang W, Lund H. Author information: (1)University of Southern Denmark, Odense, Denmark, and Copenhagen University Hospital, Gentofte, Denmark. OBJECTIVE: To identify the optimal exercise program, characterized by type and intensity of exercise, length of program, duration of individual supervised sessions, and number of sessions per week, for reducing pain and patient-reported disability in knee osteoarthritis (OA). METHODS: A systematic review and meta-analysis of randomized controlled trials were performed. Standardized mean differences (SMDs) were combined using a random-effects model. Study-level covariates were applied in meta-regression analyses in order to reduce between-study heterogeneity. RESULTS: Forty-eight trials were included. Similar effects in reducing pain were found for aerobic, resistance, and performance exercise (SMD 0.67, 0.62, and 0.48, respectively; P = 0.733). These single-type exercise programs were more efficacious than programs that included different exercise types (SMD 0.61 versus 0.16; P < 0.001). The effect of aerobic exercise on pain relief increased with an increased number of supervised sessions (slope 0.022 [95% confidence interval 0.002, 0.043]). More pain reduction occurred with quadriceps-specific exercise than with lower limb exercise (SMD 0.85 versus 0.39; P = 0.005) and when supervised exercise was performed at least 3 times a week (SMD 0.68 versus 0.41; P = 0.017). No impact of intensity, duration of individual sessions, or patient characteristics was found. Similar results were found for the effect on patient-reported disability.

CONCLUSION: Optimal exercise programs for knee OA should have one aim and focus on improving aerobic capacity, quadriceps muscle strength, or lower extremity performance. For best results, the program should be supervised and carried out 3 times a week. Such programs have a similar effect regardless of patient characteristics, including radiographic severity and baseline pain. Copyright © 2014 by the American College of Rheumatology. PMID: 24574223 [PubMed - indexed for MEDLINE] 28. Open Rheumatol J. 2014 Nov 28;8:89-95. doi: 10.2174/1874312901408010089. eCollection 2014. Physical exercise and weight loss for hip and knee osteoarthritis in very old patients: a systematic review of the literature. Quintrec JL(1), Verlhac B(2), Cadet C(3), Bréville P(4), Vetel JM(5), Gauvain JB(6), Jeandel C(7), Maheu E(8). Author information: (1)Service de Médecine Gériatrique 3 [Department of Geriatric Medicine 3], Hôpital Sainte-Périne (A.P-H.P), Paris, France. (2)Pôle Vieillissement, réadaptation et Accompagnement [Centre for the Aged, Rehabilitation and Support], Hôpital Paul Brousse (A.P-H.P) Villejuif, France. (3)Medical Office, Paris, France. (4)Service de Rhumatologie [Department of Rheumatology], Groupe Hospitalier Paris Saint Joseph, Paris, France. (5)Centre Hospitalier, Le Mans, France. (6)Centre de Médecine Interne Gériatrique [Centre for Geriatric Internal Medicine], Centre Hospitalier régional, Orléans, France. (7)Service de Médecine interne et Gériatrie [Department of Internal and Geriatric Medicine], Montpellier, France. (8)Service de Rhumatologie, Rheumatology Department, Medical Office / Hôpital Saint Antoine -A.P-H.P, Paris, France. BACKGROUND: Rheumatologic and geriatric scholarly organisations recommendations for the management of hip and knee osteoarthritis, which emphasise the usefulness of non-pharmacological therapies, are not scaled according to patient's age and physical condition. We conducted a systematic review of clinical trials on exercise and weight loss in hip and knee osteoarthritis in very old patients. METHODS: Electronic search in MEDLINE, EMBASE, PASCAL database, systematic search of the Cochrane Reviews, manual search in guidelines, meta-analyses and identified relevant articles. RESULTS: We identified 83 trials, with only 2 on patients aged ≥ 75 years; we therefore lowered the mean age threshold to 70 years and found 15 trials, mainly performed in knee osteoarthritis and outpatients. PHYSICAL EXERCISE 8 TRIALS: was effective on pain and function (4 controlled trials), with a persistent effect only in case of self-rehabilitation. AQUATIC EXERCISE 5 TRIALS: was as effective as land-based exercise. WEIGHT LOSS 2 TRIALS: only patients under diet + exercise had significant improvement on symptoms. CONCLUSION: Our systematic review confirms that international recommendations on exercise for knee osteoarthritis also apply to subjects aged 70-80 years.

Long-term effectiveness requires a maintenance strategy. Specific trials on very old patients with various comorbidities are mandatory, given that these subjects are more exposed to drug-related iatrogenesis. PMCID: PMC4258698 PMID: 25489352 [PubMed] 29. Eur J Phys Rehabil Med. 2013 Dec;49(6):877-92. Epub 2013 Oct 30. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Pozzi F(1), Snyder-Mackler L, Zeni J. Author information: (1)Department of Physical Therapy University of Delaware, Newark, DE, USA - jzenijr@udel.edu. Total knee arthroplasty (TKA) is the gold standard treatment for end-stage knee osteoarthritis. Most patients report successful long-term outcomes and reduced pain after TKA, but recovery is variable and the majority of patients continue to demonstrate lower extremity muscle weakness and functional deficits compared to age-matched control subjects. Given the potential positive influence of postoperative rehabilitation and the lack of established standards for prescribing exercise paradigms after TKA, the purpose of this study was to systematically review randomized, controlled studies to determine the effectiveness of postoperative outpatient care on short- and long-term functional recovery. Nineteen studies were identified as highly relevant for the review and four categories of postoperative intervention were discussed: 1) strengthening exercises; 2) aquatic therapy; 3) balance training; and 4) clinical environment. Optimal outpatient physical therapy protocols should include: strengthening and intensive functional exercises given through land-based or aquatic programs, the intensity of which is increased based on patient progress. Due to the highly individualized characteristics of these types of exercises, outpatient physical therapy performed in a clinic under the supervision of a trained physical therapist may provide the best long-term outcomes after the surgery. Supervised or remotely supervised therapy may be effective at reducing some of the impairments following TKA, but several studies without direct oversight produced poor results. Most studies did not accurately describe the "usual care" or control groups and information about the dose, frequency, intensity and duration of the rehabilitation protocols were lacking from several studies. PMCID: PMC4131551 PMID: 24172642 [PubMed - indexed for MEDLINE] 30. Clin Rehabil. 2013 Dec;27(12):1059-71. doi: 10.1177/0269215513488898. Epub 2013 Jul 4. Efficacy of strengthening or aerobic exercise on pain relief in people with knee

osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Tanaka R(1), Ozawa J, Kito N, Moriyama H. Author information: (1)1Department of Integrated Rehabilitation, Hiroshima International University, Japan. OBJECTIVE: We performed a systematic review and meta-analysis of randomized controlled trials to investigate the differences in the efficacies between strengthening and aerobic exercises for pain relief in people with knee osteoarthritis. DATA SOURCES: This search was applied to Medline, Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature. All literature published from each source's earliest date to March 2013 was included. REVIEW METHODS: Trials comparing the effects of exercise intervention with those of either non-intervention or psycho-educational intervention were collected. Meta-analysis was performed for trials in which therapeutic exercise was carried out with more than three sessions per week up to eight weeks, for pain in people with knee osteoarthritis. All trials were categorised into three subgroups (non-weight-bearing strengthening exercise, weight-bearing strengthening exercise, and aerobic exercise). Subgroup analyses were also performed. RESULTS: Data from eight studies were integrated. Overall effect of exercise was significant with a large effect size (standardised mean difference (SMD): -0.94; 95% confidence interval -1.31 to -0.57). Subgroup analyses showed a larger SMD for non-weight-bearing strengthening exercise (-1.42 [-2.09 to -0.75]) compared with weight-bearing strengthening exercise (-0.70 [-1.05 to -0.35]), and aerobic exercise (-0.45 [-0.77 to -0.13]). CONCLUSION: Muscle strengthening exercises with or without weight-bearing and aerobic exercises are effective for pain relief in people with knee osteoarthritis. In particular, for pain relief by short-term exercise intervention, the most effective exercise among the three types is non-weight-bearing strengthening exercise. PMID: 23828186 [PubMed - indexed for MEDLINE] 31. Int J Sports Phys Ther. 2013 Oct;8(5):689-700. Proximal exercises are effective in treating patellofemoral pain syndrome: a systematic review. Peters JS(1), Tyson NL. Author information: (1)Medicort Sports & Orthopedic Care, Utrecht, The Netherlands. BACKGROUND: Patellofemoral pain syndrome is a common disorder of the knee with multifactorial aetiology. Multimodal treatment, including exercise therapy, has

been shown to be effective in the treatment of patellofemoral pain, although some patients continue to experience pain and dysfunction despite treatment. To address this, recent research has started to investigate the lumbo-pelvic and hip girdle in patellofemoral pain. PURPOSE: The aim of this systematic review was to investigate the effectiveness of proximal exercises, compared with knee exercises, for patients with patellofemoral pain, in improving pain and function. METHODS: A computer-based search (population: patients with patellofemoral pain, intervention: proximal [hip or lumbo-pelvic] exercises, comparator: knee exercises, outcome: self-reported pain and/or functional questionnaire) was undertaken. Medline, Embase, CINAHL, SportsDiscus, Cochrane Library and PEDro were searched for studies published between January 2011 and January 2013. The included studies were appraised independently using the McMaster Critical Review Form for Quantitative Studies. Data was extracted for the exercise prescription and applicable outcome measures, and a descriptive analysis undertaken. RESULTS: Eight studies (three randomized controlled trials, one clinical controlled trial, three cohort studies and one case series) of moderate to high methodological quality met the inclusion criteria. Proximal exercise programs showed a consistent reduction of pain and function in the treatment of patellofemoral pain. Knee exercise programs had variable outcomes. CONCLUSION: Proximal interventions provide relief of pain and improved function in the short and long term and therefore physical therapists should consider using proximal interventions for treatment of patellofemoral pain. LEVEL OF EVIDENCE: 3a. PMCID: PMC3811739 PMID: 24175148 [PubMed] 32. BMJ. 2013 Sep 20;347:f5555. doi: 10.1136/bmj.f5555. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. Uthman OA(1), van der Windt DA, Jordan JL, Dziedzic KS, Healey EL, Peat GM, Foster NE. Author information: (1)Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK. Comment in Evid Based Nurs. 2014 Oct;17(4):109. Ann Intern Med. 2013 Dec 17;159(12):JC7. Republished in Br J Sports Med. 2014 Nov;48(21):1579. OBJECTIVE: To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and

improving function in patients with lower limb osteoarthritis. DATA SOURCES: Nine electronic databases searched from inception to March 2012. STUDY SELECTION: Randomised controlled trials comparing exercise interventions with each other or with no exercise control for adults with knee or hip osteoarthritis. DATA EXTRACTION: Two reviewers evaluated eligibility and methodological quality. Main outcomes extracted were pain intensity and limitation of function. Trial sequential analysis was used to investigate reliability and conclusiveness of available evidence for exercise interventions. Bayesian network meta-analysis was used to combine both direct (within trial) and indirect (between trial) evidence on treatment effectiveness. RESULTS: 60 trials (44 knee, two hip, 14 mixed) covering 12 exercise interventions and with 8218 patients met inclusion criteria. Sequential analysis showed that as of 2002 sufficient evidence had been accrued to show significant benefit of exercise interventions over no exercise control. For pain relief, strengthening, flexibility plus strengthening, flexibility plus strengthening plus aerobic, aquatic strengthening, and aquatic strengthening plus flexibility, exercises were significantly more effective than no exercise control. A combined intervention of strengthening, flexibility, and aerobic exercise was also significantly more effective than no exercise control for improving limitation in function (standardised mean difference -0.63, 95% credible interval -1.16 to -0.10). CONCLUSIONS: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise in patients with osteoarthritis, and further trials are unlikely to overturn this result. An approach combining exercises to increase strength, flexibility, and aerobic capacity is likely to be most effective in the management of lower limb osteoarthritis. The evidence is largely from trials in patients with knee osteoarthritis. PROTOCOL REGISTRATION: PROSPERO (www.crd.york.ac.uk/prospero/) No CRD42012002267. PMCID: PMC3779121 PMID: 24055922 [PubMed - indexed for MEDLINE] 33. J Orthop Sports Phys Ther. 2013 Aug;43(8):560-76. doi: 10.2519/jospt.2013.4255. Epub 2013 Jun 11. The effectiveness of postoperative physical therapy treatment in patients who have undergone arthroscopic partial meniscectomy: systematic review with meta-analysis. Dias JM(1), Mazuquin BF, Mostagi FQ, Lima TB, Silva MA, Resende BN, Borges da Silva RM, Lavado EL, Cardoso JR. Author information: (1)Laboratory of Biomechanics and Clinical Epidemiology, Department of Physical Therapy, Universidade Estadual de Londrina, Londrina, Brazil. STUDY DESIGN: Systematic review with meta-analysis. OBJECTIVES: To evaluate the effectiveness of postoperative physical therapy treatment for patients who have undergone arthroscopic partial meniscectomy.

BACKGROUND: There is no consensus on which treatment is best for patients post meniscectomy. METHODS: A search for articles published from 1950 to March 2013 was conducted in the MEDLINE, Embase, CINAHL, LILACS, SciELO, IBECS, Scopus, Web of Science, PEDro, Academic Search Premier, and Cochrane Central Register of Controlled Trials databases. The key words were physiotherapy, physical therapy modalities, exercise therapy, rehabilitation, knee, placebo, groups, tibial meniscus, meniscus, arthroscopy, meniscectomy, partial meniscectomy, randomized controlled trial, controlled clinical trial, randomized, systematic review, and meta-analysis. RESULTS: Eighteen randomized controlled trials were included in the review, 6 of which were included in the meta-analysis. Outpatient physical therapy plus a home exercise program, compared to a home program alone, improved function compared to a home program alone (mean difference, 10.3; 95% confidence interval: 1.3, 19.3; P = .02) and knee flexion range of motion (mean difference, 9.1; 95% confidence interval: 3.7, 14.5; P = .0009). Inpatient physical therapy alone compared to inpatient plus outpatient physical therapy reduced the likelihood of effusion (odds ratio = 0.25; 95% confidence interval: 0.10, 0.61; P = .003). CONCLUSION: Physical therapy associated with home exercises seems to be effective in improving patient-reported knee function and range of motion in patients post-arthroscopic meniscectomy, although the included randomized controlled trials were classified from moderate to high risk of bias and should be interpreted with caution. LEVEL OF EVIDENCE: Therapy, level 1a-. PMID: 23756350 [PubMed - indexed for MEDLINE] 34. Arch Phys Med Rehabil. 2013 Jan;94(1):164-76. doi: 10.1016/j.apmr.2012.08.211. Epub 2012 Sep 4. Does exercise reduce pain and improve physical function before hip or knee replacement surgery? A systematic review and meta-analysis of randomized controlled trials. Gill SD(1), McBurney H. Author information: (1)Department of Physiotherapy, Barwon Health, Geelong, Australia. steveg@barwonhealth.org.au OBJECTIVE: To investigate the preoperative effects of exercise-based interventions on pain and physical function for people awaiting joint replacement surgery of the hip or knee. DATA SOURCES: Four computer databases (CINAHL, MEDLINE, Embase, and Cochrane Library) were searched until July 4, 2012. Search terms included knee, hip, joint replacement, arthroplasty, physiotherapy, physical therapy, exercise, hydrotherapy, rehabilitation, and preoperative. Reference lists of retrieved articles were also screened. STUDY SELECTION: Randomized or quasi-randomized studies comparing an exercise-based intervention with a no-intervention group for people awaiting hip

or knee joint replacement surgery were included. Outcomes were pain and physical function including self-reported function, walking speed, and muscle strength. One of 2 reviewers determined that 18 studies met the inclusion criteria. DATA EXTRACTION: The methodologic quality of each study was independently assessed by 2 reviewers using the PEDro scale, and a final PEDro score was determined by discussion and consensus between the reviewers. Participants' characteristics, content and design of the interventions, and data for quantitative synthesis were extracted by 1 reviewer. DATA SYNTHESIS: For participants awaiting knee replacement surgery, quantitative data synthesis found no significant differences between the exercise and no-intervention groups for pain, self-reported function, walking speed, or muscle strength. For participants awaiting hip replacement surgery, quantitative data synthesis found a significant difference between the groups, with standardized mean differences (SMDs) indicating a medium-sized effect in favor of intervention for both pain (SMD=.45; 95% confidence interval .15-.75) and self-reported function (SMD=.46; 95% confidence interval .20-.72). CONCLUSIONS: Exercise-based interventions can reduce pain and improve physical function for people awaiting hip replacement surgery but not knee replacement surgery. Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. PMID: 22960276 [PubMed - indexed for MEDLINE] 35. J Jpn Phys Ther Assoc. 2013;16(1):7-21. doi: 10.1298/jjpta.Vol16_003. Evidence of Improvement in Various Impairments by Exercise Interventions in Patients with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Clinical Trials. Tanaka R(1), Ozawa J(1), Kito N(1), Yamasaki T(1), Moriyama H(2). Author information: (1)Department of Integrated Rehabilitation, Hiroshima International University, Japan. (2)Department of Rehabilitation Science, Kobe University Graduate School of Health Sciences, Japan. PURPOSE: To investigate improvement in various impairments by exercise interventions in patients with knee osteoarthritis (OA). METHODS: We collected data on randomized controlled trials (RCTs) comparing the effects of exercise intervention with those of either nonintervention or psychoeducational intervention in patients with knee OA. Data on pain, stiffness, muscle strength, range of motion, flexibility, maximal oxygen uptake, and position sense were synthesized. The Grading of Recommendations Assessment, Development, and Evaluation system was used to determine the quality of the evidence. RESULTS: Thirty-three RCTs involving 3,192 participants were identified. Meta-analysis provided highquality evidence that exercise intervention improves maximal oxygen uptake, and moderate-quality evidence that exercise intervention

also improves pain, stiffness, knee extensor and flexor muscle strength, and position sense. The evidence that exercise intervention improves knee extension and flexion range of motion was deemed as undetermined-quality. CONCLUSION: In patients with knee OA, improvement in pain, stiffness, muscle strength, maximal oxygen uptake, and position sense with the use of exercise intervention can be expected. Although the quality of evidence of the effect of exercise intervention on range of motion was inconclusive, exercise intervention should be recommended for patients with knee OA to improve various impairments. PMCID: PMC4316543 PMID: 25792899 [PubMed] 36. Rheumatol Int. 2012 Nov;32(11):3339-51. doi: 10.1007/s00296-012-2480-7. Epub 2012 Jul 22. The effectiveness of proprioceptive-based exercise for osteoarthritis of the knee: a systematic review and meta-analysis. Smith TO(1), King JJ, Hing CB. Author information: (1)Faculty of Medicine and Health Sciences, Queen's Building, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK. toby.smith@uea.ac.uk Osteoarthritis (OA) is a leading cause of functional impairment and pain. Proprioceptive defects may be associated with the onset and progression of OA of the knee. The purpose of this study was to determine the effectiveness of proprioceptive exercises for knee OA using meta-analysis. A systematic review was conducted on 12th December 2011 using published (Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, PubMed, PEDro) and unpublished/trial registry (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled Trials and the UK National Research Register Archive) databases. Studies were included if they were full publications of randomized or non-randomised controlled trials (RCT) comparing a proprioceptive exercise regime, against a non-proprioceptive exercise programme or non-treatment control for adults with knee OA. Methodological appraisal was performed using the PEDro checklist. Seven RCTs including 560 participants (203 males and 357 females) with a mean age of 63 years were eligible. The methodological quality of the evidence base was moderate. Compared to a non-treatment control, proprioceptive exercises significantly improved functional outcomes in people with knee OA during the first 8 weeks following commencement of their exercises (p < 0.02). When compared against a general non-proprioceptive exercise programme, proprioceptive exercises demonstrated similar outcomes, only providing superior results with respect to joint position sense-related measurements such as timed walk over uneven ground (p = 0.03) and joint position angulation error (p < 0.01). Proprioceptive exercises are efficacious in the treatment of knee OA. There is some evidence to indicate the effectiveness of proprioceptive exercises compared to general strengthening exercises in functional outcomes. PMID: 22821333 [PubMed - indexed for MEDLINE]

37. Ann Intern Med. 2012 Nov 6;157(9):632-44. doi: 10.7326/0003-4819-157-9-201211060-00007. Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review. Wang SY(1), Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL. Author information: (1)Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, Room 432, New Haven, CT 06520, USA. BACKGROUND: Osteoarthritis is a leading cause of disability. Nonsurgical treatment is a key first step. PURPOSE: Systematic literature review of physical therapy (PT) interventions for community-dwelling adults with knee osteoarthritis. DATA SOURCES: MEDLINE, the Cochrane Library, the Physiotherapy Evidence Database, Scirus, Allied and Complementary Medicine, and the Health and Psychosocial Instruments bibliography database. STUDY SELECTION: 193 randomized, controlled trials (RCTs) published in English from 1970 to 29 February 2012. DATA EXTRACTION: Means of outcomes, PT interventions, and risk of bias were extracted to pool standardized mean differences. Disagreements between reviewers abstracting and checking data were resolved through discussion. DATA SYNTHESIS: Meta-analyses of 84 RCTs provided evidence for 13 PT interventions on pain (58 RCTs), physical function (36 RCTs), and disability (29 RCTs). Meta-analyses provided low-strength evidence that aerobic (11 RCTs) and aquatic (3 RCTs) exercise improved disability and that aerobic exercise (19 RCTs), strengthening exercise (17 RCTs), and ultrasonography (6 RCTs) reduced pain and improved function. Several individual RCTs demonstrated clinically important improvements in pain and disability with aerobic exercise. Other PT interventions demonstrated no sustained benefit. Individual RCTs showed similar benefits with aerobic, aquatic, and strengthening exercise. Adverse events were uncommon and did not deter participants from continuing treatment. LIMITATION: Variability in PT interventions and outcomes measures hampered synthesis of evidence. CONCLUSION: Low-strength evidence suggested that only a few PT interventions were effective. Future studies should compare combined PT interventions (which is how PT is generally administered for pain associated with knee osteoarthritis). PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. PMID: 23128863 [PubMed - indexed for MEDLINE] 38. Res Sports Med. 2012 Jul;20(3-4):223-38. doi: 10.1080/15438627.2012.680988. Preventing ACL injuries in team-sport athletes: a systematic review of training interventions.

Stojanovic MD(1), Ostojic SM. Author information: (1)Center for Health, Exercise and Sport Sciences, Belgrade, Serbia. The purpose of this systematic review was to assess the efficacy of training interventions aimed to prevent and to reduce anterior cruciate ligament injury (ACLI) rates in team sport players. We searched MEDLINE from January 1991 to July 2011 using the terms knee, ACL, anterior cruciate ligament, injury, prevention, training, exercise, and intervention. Nine out of 708 articles met the inclusion criteria and were independently rated by two reviewers using the McMaster Occupational Therapy Evidence-Based Practice Research Group scale. Consensus scores ranged from 3 to 8 out of 10. Seven out of nine studies demonstrated that training interventions have a preventive effect on ACLI. Collectively, the studies indicate there is moderate evidence to support the use of multifaceted training interventions, which consisted of stretching, proprioception, strength, plyometric and agility drills with additional verbal and/or visual feedback on proper landing technique to decrease the rate of ACLIs in team sport female athletes, while the paucity of data preclude any conclusions for male athletes. PMID: 22742077 [PubMed - indexed for MEDLINE] 39. Br J Sports Med. 2012 Jun;46(8):570-7. doi: 10.1136/bjsm.2010.080218. Epub 2011 Mar 14. The additional effect of orthotic devices on exercise therapy for patients with patellofemoral pain syndrome: a systematic review. Swart NM(1), van Linschoten R, Bierma-Zeinstra SM, van Middelkoop M. Author information: (1)Clinical Health Sciences, Department of Physical Therapy Science, Utrecht University, The Netherlands. The aim of the study is to determine "the additional effect of... function" for patellofemoral pain syndrome (PFPS). The additional effect of orthotic devices over exercise therapy on pain and function. A systematic literature search was conducted in MEDLINE, CINAHL, EMBASE, Cochrane and PEDro. Randomised controlled trials and controlled clinical trials of patients diagnosed with PFPS evaluating a clinically relevant outcome were included. Treatment had to include exercise therapy combined with orthotics, compared with an identical exercise programme with or without sham orthotics. Data were summarised using a best evidence synthesis. Eight trials fulfilled the inclusion criteria, of which three had a low risk of bias. There is moderate evidence for no additive effectiveness of knee braces to exercise therapy on pain (effect sizes (ES) varied from -0.14 to 0.04) and conflicting evidence on function (ES -0.33). There is moderate evidence for no difference between knee braces and exercise therapy versus placebo knee braces and exercise therapy on pain and function (ES -0.1-0.10). More studies of high methodological quality are needed to draw definitive conclusions.

PMID: 21402565 [PubMed - indexed for MEDLINE] 40. Rev Bras Fisioter. 2012 Jan-Feb;16(1):1-9. The effects of therapeutic exercise on the balance of women with knee osteoarthritis: a systematic review. [Article in English, Portuguese] Silva A(1), Serrão PR, Driusso P, Mattiello SM. Author information: (1)Physical Therapy Department, Universidade Federal de São Carlos, SP, Brazil. OBJECTIVE: The objective of this review was to examine evidence regarding the effects of therapeutic exercise on the balance of women with knee osteoarthritis (OA). METHODS: The search was conducted in Pubmed, Medline, Lilacs, SciELO, ISI web of knowledge, PEDro and the Cochrane Collaboration. We used the keywords: "knee", "balance", "women" and "rehabilitation" in combination with "osteoarthritis". We selected randomized controlled clinical trials published in English, Portuguese and Spanish over the last 10 years. To verify the methodological quality of selected clinical trials, the PEDro Scale was applied. RESULTS: A total of 20 studies were found in the electronic search. Of these, only 9 met the inclusion criteria and were analyzed in full. Eight of these 9 studies were classified as having high methodological quality on the PEDro Scale. Although the methods and interventions regarding balance varied widely in these studies, most found significant improvement in the balance of women with knee OA. CONCLUSION: Since the studies included in this systematic review were of high methodological quality, we can conclude that the therapeutic exercises they used improved the balance of women with knee OA. PMID: 22441221 [PubMed - indexed for MEDLINE] 41. Value Health. 2012 Jan;15(1):1-12. doi: 10.1016/j.jval.2011.09.003. Epub 2011 Nov 29. Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review. Pinto D(1), Robertson MC, Hansen P, Abbott JH. Author information: (1)Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand. daniel-pinto@northwestern.edu OBJECTIVE: To investigate the cost-effectiveness of nonpharmacological, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. METHODS: We identified economic evaluations or cost studies associated with

randomized or quasi-randomized controlled trials that assessed nonpharmacologic, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. Medline, Embase, PubMed, National Health Service Economic Evaluation Database, CENTRAL, EconLit, and OpenSIGLE were searched up to October 1, 2010. Study characteristics extracted include study population, health outcomes, and economic analysis elements. Economic analyses were assessed by using the Quality of Health Economic Studies instrument, and the methodological quality of the randomized controlled trials was graded by using an internal validity checklist. All costs were converted to 2008 US dollars. RESULTS: Ten economic evaluations and one randomized controlled trial reporting health-care costs met our inclusion criteria. Interventions included exercise programs, acupuncture, rehabilitation programs, and lifestyle interventions. Six of the 11 studies exhibited high risks of bias for the cost and/or effect components of their cost-effectiveness estimate. Six studies used comparators of unknown cost-effectiveness. Four studies reported cost-effectiveness estimates lower than $50,000 per quality-adjusted life-year. All studies evaluating exercise interventions found the programs to be cost saving. CONCLUSIONS: There is only limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. More high-quality economic evaluations of conservative interventions are needed to further inform practice. Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved. PMID: 22264966 [PubMed - indexed for MEDLINE] 42. Open Orthop J. 2012;6:553-7. doi: 10.2174/1874325001206010553. Epub 2012 Nov 30. Eccentric Exercise Protocols for Patella Tendinopathy: Should we Really be Withdrawing Athletes from Sport? A Systematic Review. Saithna A(1), Gogna R, Baraza N, Modi C, Spencer S. Author information: (1)Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK. The 2007 review by Visnes and Bahr concluded that athletes with patella tendinopathy should be withdrawn from sport whilst engaging in eccentric exercise (EE) rehabilitation programs. However, deprivation of sport is associated with a number of negative psychological and physiological effects. Withdrawal from sport is therefore a decision that warrants due consideration of the risk/benefit ratio. The aim of this study was to determine whether sufficient evidence exists to warrant withdrawal of athletes from sport during an eccentric exercise rehabilitation program. A systematic review of the literature was performed to identify relevant randomised trials. Data was extracted to determine whether athletes were withdrawn from sport, what evidence was presented to support the chosen strategy and whether this affected the clinical outcome. Seven studies were included. None of these reported high quality evidence to support

withdrawal. In addition, three studies were identified in which athletes were not withdrawn from sport and still benefited from EE. This review has demonstrated that there is no high quality evidence to support a strategy of withdrawal from sport in the management of patella tendinopathy. PMCID: PMC3522085 PMID: 23248727 [PubMed] 43. Sports Med. 2012 Jan 1;42(1):31-49. doi: 10.2165/11594460-000000000-00000. Efficacy of nonsurgical interventions for anterior knee pain: systematic review and meta-analysis of randomized trials. Collins NJ(1), Bisset LM, Crossley KM, Vicenzino B. Author information: (1)Melbourne School of Engineering, The University of Melbourne, Melbourne, VIC, Australia. Anterior knee pain is a chronic condition that presents frequently to sports medicine clinics, and can have a long-term impact on participation in physical activity. Conceivably, effective early management may prevent chronicity and facilitate physical activity. Although a variety of nonsurgical interventions have been advocated, previous systematic reviews have consistently been unable to reach conclusions to support their use. Considering a decade has lapsed since publication of the most recent data in these reviews, it is timely to provide an updated synthesis of the literature to assist sports medicine practitioners in making informed, evidence-based decisions. A systematic review and meta-analysis was conducted to evaluate the evidence for nonsurgical interventions for anterior knee pain. A comprehensive search strategy was used to search MEDLINE, EMBASE, CINAHL and Pre-CINAHL, PEDro, PubMed, SportDiscus, Web of Science, BIOSIS Previews, and the full Cochrane Library, while reference lists of included papers and previous systematic reviews were hand searched. Studies were eligible for inclusion if they were randomized clinical trials that used a measure of pain to evaluate at least one nonsurgical intervention over at least 2 weeks in participants with anterior knee pain. A modified version of the PEDro scale was used to rate methodological quality and risk of bias. Effect size calculation and meta-analyses were based on random effects models. Of 48 suitable studies, 27 studies with low-to-moderate risk of bias were included. There was minimal opportunity for meta-analysis because of heterogeneity of interventions, comparators and follow-up times. Meta-analysis of high-quality clinical trials supports the use of a 6-week multimodal physiotherapy programme (standardized mean difference [SMD] 1.08, 95% CI 0.73, 1.43), but does not support the addition of electromyography biofeedback to an exercise programme in the short-term (4 weeks: SMD -0.21, 95% CI -0.64, 0.21; 8-12 weeks: SMD -0.22, 95% CI -0.65, 0.20). Individual study data showed beneficial effects for foot orthoses with and without multimodal physiotherapy (vs flat inserts), exercise (vs control), closed chain exercises (vs open chain exercises), patella taping in conjunction with exercise (vs exercise alone) and acupuncture (vs control). Findings suggest that, in implementing evidence-based practice for the nonsurgical management of

anterior knee pain, sports medicine practitioners should prescribe local, proximal and distal components of multimodal physiotherapy in the first instance for suitable patients, and then consider foot orthoses or acupuncture as required. PMID: 22149696 [PubMed - indexed for MEDLINE] 44. Osteoarthritis Cartilage. 2011 Dec;19(12):1381-95. doi: 10.1016/j.joca.2011.09.001. Epub 2011 Sep 10. Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis. Wallis JA(1), Taylor NF. Author information: (1)Physiotherapy Department, Eastern Health, Melbourne, Victoria, Australia. Jason.wallis@easternhealth.org.au OBJECTIVE: To determine if pre-operative interventions for hip and knee osteoarthritis provide benefit before and after joint replacement. METHOD: Systematic review with meta-analysis of randomised controlled trials (RCTs) of pre-operative interventions for people with hip or knee osteoarthritis awaiting joint replacement surgery. Standardised mean differences (SMD) were calculated for pain, musculoskeletal impairment, activity limitation, quality of life, and health service utilisation (length of stay and discharge destination). The GRADE approach was used to determine the quality of the evidence. RESULTS: Twenty-three RCTs involving 1461 participants awaiting hip or knee replacement surgery were identified. Meta-analysis provided moderate quality evidence that pre-operative exercise interventions for knee osteoarthritis reduced pain prior to knee replacement surgery (SMD (95% CI)=0.43 [0.13, 0.73]). None of the other meta-analyses investigating pre-operative interventions for knee osteoarthritis demonstrated any effect. Meta-analyses provided low to moderate quality evidence that exercise interventions for hip osteoarthritis reduced pain (SMD (95% CI)=0.52 [0.04, 1.01]) and improved activity (SMD (95% CI)=0.47 [0.11, 0.83]) prior to hip replacement surgery. Meta-analyses provided low quality evidence that exercise with education programs improved activity after hip replacement with reduced time to reach functional milestones during hospital stay (e.g., SMD (95% CI)=0.50 [0.10, 0.90] for first day walking). CONCLUSION: Low to moderate evidence from mostly small RCTs demonstrated that pre-operative interventions, particularly exercise, reduce pain for patients with hip and knee osteoarthritis prior to joint replacement, and exercise with education programs may improve activity after hip replacement. Copyright © 2011 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved. PMID: 21959097 [PubMed - indexed for MEDLINE]

45. BMC Musculoskelet Disord. 2011 Jun 2;12:123. doi: 10.1186/1471-2474-12-123. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes. Batterham SI(1), Heywood S, Keating JL. Author information: (1)Department of Physiotherapy, Monash University Peninsula Campus, McMahons Rd, Frankston, Australia. BACKGROUND: Aquatic and land based exercise are frequently prescribed to maintain function for people with arthritis. The relative efficacy of these rehabilitation strategies for this population has not been established.This review investigated the effects of aquatic compared to land based exercise on function, mobility or participants' perception of programs for people with arthritis. METHODS: Medline, CINAHL, AMED and the Cochrane Central Register of Controlled Clinical Trials were searched up to July 2010. Ten randomised, controlled clinical trials that compared land to aquatic exercise for adults with arthritis were included. Study quality was assessed with the PEDro scale. Data relevant to the review question were systematically extracted by two independent reviewers. Standardised mean differences between groups for key outcomes were calculated. Meta-analyses were performed for function, mobility and indices that pooled health outcomes across multiple domains. RESULTS: No differences in outcomes were observed for the two rehabilitation strategies in meta-analysis. There was considerable variability between trials in key program characteristics including prescribed exercises and design quality. Components of exercise programs were poorly reported by the majority of trials. No research was found that examined participant preferences for aquatic compared to land based exercise, identifying this as an area for further research. CONCLUSION: Outcomes following aquatic exercise for adults with arthritis appear comparable to land based exercise. When people are unable to exercise on land, or find land based exercise difficult, aquatic programs provide an enabling alternative strategy. PMCID: PMC3141607 PMID: 21635746 [PubMed - indexed for MEDLINE] 46. J Multidiscip Healthc. 2011;4:383-92. doi: 10.2147/JMDH.S24595. Epub 2011 Oct 31. A systematic review of randomized controlled trials on exercise parameters in the treatment of patellofemoral pain: what works? Harvie D(1), O'Leary T, Kumar S. Author information: (1)International Centre for Allied Health Evidence (iCAHE), City East Campus, University of South Australia, Adelaide, Australia.

PURPOSE: There is research evidence which supports the effectiveness of exercise in reducing pain and increasing function in patients with patellofemoral pain syndrome. However, what is unclear are the parameters underpinning this intervention. This has led to uncertainty when operationalizing exercises for patients with patellofemoral pain syndrome in clinical practice. The aim of this review was to evaluate the parameters of exercise programs reported in primary research, to provide clinicians with evidence-based recommendations for exercise prescription for patellofemoral pain. METHODS: A systematic review of randomized controlled trials was undertaken. Only trials that identified exercise to be effective in treating patellofemoral pain were included. Appropriate databases and reference lists were searched using established keywords. Data relating to common exercise parameters such as the type of exercise, length, and frequency of intervention, intensity, repetitions, sets, and specific technique were extracted, along with details of co-interventions that may have been used. RESULTS: A total of ten randomized controlled trials were included in this review and from these trials 14 interventions arms were evaluated. All 14 interventions focused on active exercises, all but two of which also included a passive stretching component. The current body of evidence demonstrates positive results with exercise interventions such as knee extension, squats, stationary cycling, static quadriceps, active straight leg raise, leg press, and step-up and down exercises for patients with patellofemoral pain syndrome. A progressive regime of daily exercises of two to four sets of ten or more repetitions over an intervention period of 6 weeks or more, combined with exercises to address flexibility of the lower limb musculature was commonly used. CONCLUSION: Currently, the primary research on this topic supports the use of closed kinetic chain, strengthening exercises for musculature of the lower limb, combined with flexibility options. The current evidence base supports a prescription of daily exercises of two-four sets of ten or more repetitions over a period of 6 weeks or more. PMCID: PMC3215347 PMID: 22135495 [PubMed] 47. J Physiother. 2011;57(1):11-20. doi: 10.1016/S1836-9553(11)70002-9. Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee osteoarthritis: a systematic review. Jansen MJ(1), Viechtbauer W, Lenssen AF, Hendriks EJ, de Bie RA. Author information: (1)Department of Epidemiology, Maastricht University, Heerlen, The Netherlands. mj.jansen@maastrichtuniversity.nl QUESTION: What are the effects of strength training alone, exercise therapy alone, and exercise with additional passive manual mobilisation on pain and function in people with knee osteoarthritis compared to control? What are the

effects of these interventions relative to each other? DESIGN: A meta-analysis of randomised controlled trials. PARTICIPANTS: Adults with osteoarthritis of the knee. INTERVENTION TYPES: Strength training alone, exercise therapy alone (combination of strength training with active range of motion exercises and aerobic activity), or exercise with additional passive manual mobilisation, versus any non-exercise control. Comparisons between the three interventions were also sought. OUTCOME MEASURES: The primary outcome measures were pain and physical function. RESULTS: 12 trials compared one of the interventions against control. The effect size on pain was 0.38 (95% CI 0.23 to 0.54) for strength training, 0.34 (95% CI 0.19 to 0.49) for exercise, and 0.69 (95% CI 0.42 to 0.96) for exercise plus manual mobilisation. Each intervention also improved physical function significantly. No randomised comparisons of the three interventions were identified. However, meta-regression indicated that exercise plus manual mobilisations improved pain significantly more than exercise alone (p = 0.03). The remaining comparisons between the three interventions for pain and physical function were not significant. CONCLUSION: Exercise therapy plus manual mobilisation showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone. To achieve better pain relief in patients with knee osteoarthritis physiotherapists or manual therapists might consider adding manual mobilisation to optimise supervised active exercise programs. Copyright © 2011 Australian Physiotherapy Association. Published by .. All rights reserved. PMID: 21402325 [PubMed - indexed for MEDLINE] 48. BMC Fam Pract. 2010 Jan 18;11:4. doi: 10.1186/1471-2296-11-4. The attitudes, beliefs and behaviours of GPs regarding exercise for chronic knee pain: a systematic review. Cottrell E(1), Roddy E, Foster NE. Author information: (1)Arthritis Research Campaign National Primary Care Centre, Primary Care Sciences, Keele University, Keele, Newcastle-under-Lyme, UK. ecottrell@doctors.org.uk BACKGROUND: Joint pain, specifically chronic knee pain (CKP), is a frequent cause of chronic pain and limitation of function and mobility among older adults. Multiple evidence-based guidelines recommend exercise as a first-line treatment for all patients with CKP or knee osteoarthritis (KOA), yet healthcare practitioners' attitudes and beliefs may limit their implementation. This systematic review aims to identify the attitudes, beliefs and behaviours of General Practitioners (GPs) regarding the use of exercise for CKP/KOA. METHODS: We searched four electronic databases between inception and January 2008, using subject headings to identify studies examining the attitudes, beliefs or behaviours of GPs regarding the use of exercise for the treatment of CKP/KOA

in adults aged over 45 years in primary care. Studies referring to patellofemoral pain syndrome or CKP secondary to other causes or that occurring in a prosthetic joint were excluded. Once inclusion and exclusion criteria were applied, study data were extracted and summarised. Study quality was independently reviewed using two assessment tools. RESULTS: From 2135 potentially relevant articles, 20 were suitable for inclusion. A variety of study methodologies and approaches to measuring attitudes beliefs and behaviours were used among the studies. Quality assessment revealed good reporting of study objective, type, outcome factors and, generally, the sampling frame. However, criticisms included use of small sample sizes, low response rates and under-reporting of non-responder factors. Although 99% of GPs agreed that exercise should be used for CKP/KOA and reported ever providing advice or referring to a physiotherapist, up to 29% believed that rest was the optimum management approach. The frequency of actual provision of exercise advice or physiotherapy referral was lower. Estimates of provision of exercise advice and physiotherapy referral were generally higher for vignette-based studies (exercise advice 9%-89%; physiotherapy referral 44%-77%) than reviews of actual practice (exercise advice 5%-52%; physiotherapy referral 13-63%). Advice to exercise and exercise prescription were not clearly differentiated. CONCLUSIONS: Attitudes and beliefs of GPs towards exercise for CKP/KOA vary widely and exercise appears to be underused in the management of CKP/KOA. Limitations of the evidence base include the paucity of studies directly examining attitudes of GPs, poor methodological quality, limited generalisability of results and ambiguity concerning GPs' expected roles. Further investigation is required of the roles of GPs in using exercise as first-line management of CKP/KOA. PMCID: PMC2826301 PMID: 20082694 [PubMed - indexed for MEDLINE] 49. Knee. 2009 Jun;16(3):171-5. doi: 10.1016/j.knee.2008.09.001. Epub 2008 Oct 11. Is physical therapy more beneficial than unsupervised home exercise in treatment of post surgical knee disorders? A systematic review. Coppola SM(1), Collins SM. Author information: (1)Coppola Physical Therapy, 171 Pleasant Street, Suite 101 Concord, New Hampshire, USA. CoppolaPT@verizon.net Physical therapy is common following a knee surgery. With rising healthcare costs there is debate as to the appropriateness of outpatient physical therapy following such interventions. Many of the existing controlled trials have concluded that there is no benefit to subjects that receive supervised physical therapy when compared to subjects that perform their exercises at home. The purpose of this systematic review was to consider the existing evidence regarding benefit following knee surgery and evaluate the quality, internal and external validity of such evidence. Ten studies, all randomized control trials, were found to be applicable to our review. Using the PEDro scale all studies were considered

at least moderate in quality. Many of the studies had designs that biased the home exercise group, providing supervision similar to that provided by outpatient physical therapy. In select young and healthy population with few co morbidities supervised physical therapy is no more beneficial than a home exercise program following relatively simple knee surgical procedures (arthroscopic meniscetomy). However there is a lack of evidence regarding older populations with co morbidities or for more complicated knee surgical procedures (ACL reconstruction, Total Knee Arthroplasty) prohibiting a conclusion at this time for these populations and/or these procedures. PMID: 18851916 [PubMed - indexed for MEDLINE] 50. Arthritis Rheum. 2007 Oct 15;57(7):1245-53. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review. Pisters MF(1), Veenhof C, van Meeteren NL, Ostelo RW, de Bakker DH, Schellevis FG, Dekker J. Author information: (1)Netherlands Institute for Health Services Research, Utrecht, The Netherlands. m.pisters@nivel.nl OBJECTIVE: To determine the long-term effectiveness (>/=6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee. METHODS: We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long-term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings. RESULTS: Five high-quality and 6 low-quality randomized clinical trials were included. Strong evidence was found for no long-term effectiveness on pain and self-reported physical function, moderate evidence for long-term effectiveness on patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term effectiveness on pain, self-reported physical function, and observed physical function. CONCLUSION: The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long-term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term. PMID: 17907210 [PubMed - indexed for MEDLINE]

51. BMJ. 2007 Oct 20;335(7624):812. Epub 2007 Sep 20. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. Minns Lowe CJ(1), Barker KL, Dewey M, Sackley CM. Author information: (1)Department of Primary Care and General Practice, University of Birmingham. catherine.minnslowe@noc.anglox.nhs.uk Comment in J Bone Joint Surg Am. 2008 May;90(5):1172. Aust J Physiother. 2008;54(1):73. BMJ. 2007 Oct 20;335(7624):786. OBJECTIVE: To evaluate the effectiveness of physiotherapy exercise after elective primary total knee arthroplasty in patients with osteoarthritis. DESIGN: Systematic review. DATA SOURCES: Database searches: AMED, CINAHL, Embase, King's Fund, Medline, Cochrane library (Cochrane reviews, Cochrane central register of controlled trials, DARE), PEDro, Department of Health national research register. Hand searches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. Review methods Randomised controlled trials were reviewed if they included a physiotherapy exercise intervention compared with usual or standard physiotherapy care, or compared two types of exercise physiotherapy interventions meeting the review criteria, after discharge from hospital after elective primary total knee arthroplasty for osteoarthritis. OUTCOME MEASURES: Functional activities of daily living, walking, quality of life, muscle strength, and range of motion in the knee joint. Trial quality was extensively evaluated. Narrative synthesis plus meta-analyses with fixed effect models, weighted mean differences, standardised effect sizes, and tests for heterogeneity. RESULTS: Six trials were identified, five of which were suitable for inclusion in meta-analyses. There was a small to moderate standardised effect size (0.33, 95% confidence interval 0.07 to 0.58) in favour of functional exercise for function three to four months postoperatively. There were also small to moderate weighted mean differences of 2.9 (0.61 to 5.2) for range of joint motion and 1.66 (-1 to 4.3) for quality of life in favour of functional exercise three to four months postoperatively. Benefits of treatment were no longer evident at one year. CONCLUSIONS: Interventions including physiotherapy functional exercises after discharge result in short term benefit after elective primary total knee arthroplasty. Effect sizes are small to moderate, with no long term benefit. PMCID: PMC2034713 PMID: 17884861 [PubMed - indexed for MEDLINE]

52. Osteoarthritis Cartilage. 2007 Sep;15(9):981-1000. Epub 2007 Aug 27. OARSI recommendations for the management of hip and knee osteoarthritis, part I: critical appraisal of existing treatment guidelines and systematic review of current research evidence. Zhang W(1), Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. Author information: (1)University of Edinburgh, Osteoarticular Research Group, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom. PURPOSE: As a prelude to developing updated, evidence-based, international consensus recommendations for the management of hip and knee osteoarthritis (OA), the Osteoarthritis Research Society International (OARSI) Treatment Guidelines Committee undertook a critical appraisal of published guidelines and a systematic review (SR) of more recent evidence for relevant therapies. METHODS: Sixteen experts from four medical disciplines (primary care two, rheumatology 11, orthopaedics one and evidence-based medicine two), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. Three additional experts were invited to take part in the critical appraisal of existing guidelines in languages other than English. MEDLINE, EMBASE, Science Citation Index, CINAHL, AMED, Cochrane Library, seven Guidelines Websites and Google were searched systematically to identify guidelines for the management of hip and/or knee OA. Guidelines which met the inclusion/exclusion criteria were assigned to four groups of four appraisers. The quality of the guidelines was assessed using the AGREE (Appraisal of Guidelines for Research and Evaluation) instrument and standardised percent scores (0-100%) for scope, stakeholder involvement, rigour, clarity, applicability and editorial independence, as well as overall quality, were calculated. Treatment modalities addressed and recommended by the guidelines were summarised. Agreement (%) was estimated and the best level of evidence to support each recommendation was extracted. Evidence for each treatment modality was updated from the date of the last SR in January 2002 to January 2006. The quality of evidence was evaluated using the Oxman and Guyatt, and Jadad scales for SRs and randomised controlled trials (RCTs), respectively. Where possible, effect size (ES), number needed to treat, relative risk (RR) or odds ratio and cost per quality-adjusted life year gained (QALY) were estimated. RESULTS: Twenty-three of 1462 guidelines or consensus statements retrieved from the literature search met the inclusion/exclusion criteria. Six were predominantly based on expert opinion, five were primarily evidence based and 12 were based on both. Overall quality scores were 28%, 41% and 51% for opinion-based, evidence-based and hybrid guidelines, respectively (P=0.001). Scores for aspects of quality varied from 18% for applicability to 67% for scope. Thirteen guidelines had been developed for specific care settings including five for primary care (e.g., Prodigy Guidance), three for rheumatology (e.g., European League against Rheumatism recommendations), three for physiotherapy (e.g., Dutch clinical practice guidelines for physical therapy) and two for orthopaedics

(e.g., National Institutes of Health consensus guidelines), whereas 10 did not specify the target users (e.g., Ontario guidelines for optimal therapy). Whilst 14 guidelines did not separate hip and knee, eight were specific for knee but only one for hip. Fifty-one different treatment modalities were addressed by these guidelines, but only 20 were universally recommended. Evidence to support these modalities ranged from Ia (meta-analysis/SR of RCTs) to IV (expert opinion). The efficacy of some modalities of therapy was confirmed by the results of RCTs published between January 2002 and 2006. These included exercise (strengthening ES 0.32, 95% confidence interval (CI) 0.23, 0.42, aerobic ES 0.52, 95% CI 0.34, 0.70 and water-based ES 0.25, 95% CI 0.02, 0.47) and nonsteroidal anti-inflammatory drugs (NSAIDs) (ES 0.32, 95% CI 0.24, 0.39). Examples of other treatment modalities where recent trials failed to confirm efficacy included ultrasound (ES 0.06, 95% CI -0.39, 0.52), massage (ES 0.10, 95% CI -0.23, 0.43) and heat/ice therapy (ES 0.69, 95% CI -0.07, 1.45). The updated evidence on adverse effects also varied from treatment to treatment. For example, while the evidence for gastrointestinal (GI) toxicity of non-selective NSAIDs (RR=5.36, 95% CI 1.79, 16.10) and for increased risk of myocardial infarction associated with rofecoxib (RR=2.24, 95% CI 1.24, 4.02) were reinforced, evidence for other potential drug related adverse events such as GI toxicity with acetaminophen or myocardial infarction with celecoxib remained inconclusive. CONCLUSION: Twenty-three guidelines have been developed for the treatment of hip and/or knee OA, based on opinion alone, research evidence or both. Twenty of 51 modalities of therapy are universally recommended by these guidelines. Although this suggests that a core set of recommendations for treatment exists, critical appraisal shows that the overall quality of existing guidelines is sub-optimal, and consensus recommendations are not always supported by the best available evidence. Guidelines of optimal quality are most likely to be achieved by combining research evidence with expert consensus and by paying due attention to issues such as editorial independence, stakeholder involvement and applicability. This review of existing guidelines provides support for the development of new guidelines cognisant of the limitations in existing guidelines. Recommendations should be revised regularly following SR of new research evidence as this becomes available. PMID: 17719803 [PubMed - indexed for MEDLINE] 53. Res Sports Med. 2005 Apr-Jun;13(2):163-78. A systematic review of the effect of proprioceptive and balance exercises on people with an injured or reconstructed anterior cruciate ligament. Cooper RL(1), Taylor NF, Feller JA. Author information: (1)Musculoskeletal Research Centre, School of Physiotherapy, La Trobe University, Victoria, Australia. This systematic review investigated the effect of proprioceptive and balance exercise on outcomes following injury and surgical reconstruction of the anterior cruciate ligament (ACL). Five studies of high quality that offered empirical

evidence by comparing one rehabilitation program to another were included in this review. There is some evidence that proprioceptive and balance exercise improves outcomes in individuals with ACL-deficient knees. Improvements in joint position sense, muscle strength, perceived knee joint function, and hop testing were reported following proprioceptive and balance exercise. Only one included study investigated proprioceptive exercise following ACL reconstruction. Benefits were noted in the proprioceptive group for measures of strength and proprioception; however, no benefits were noted for any measures of activity. No detrimental effects--such as increased passive joint laxity or decrease in strength--were noted when compared with standard rehabilitation programs for both ACL-deficient and ACL-reconstructed individuals. Further research is required to determine if proprioceptive and balance exercise improves long-term outcomes such as return to sport. PMID: 16392446 [PubMed - indexed for MEDLINE] 54. J Rheumatol. 2002 Aug;29(8):1737-45. Therapeutic exercise for people with osteoarthritis of the hip or knee. A systematic review. Fransen M(1), McConnell S, Bell M. Author information: (1)Institute for International Health, University of Sydney, Australia. mfransen@iih.usyd.edu.au OBJECTIVE: To determine whether land based therapeutic exercise is beneficial for people with osteoarthritis (OA) of the hip or knee in terms of reduced joint pain, improved physical function, and/or the patient's global assessment of therapeutic effectiveness. METHODS: Five databases were searched for randomized clinical trials. Standardized mean differences (SMD) with their 95% confidence intervals (CI) were calculated for each study and then combined using a fixed effects model. RESULTS: Only 2 studies, totaling about 100 participants, could potentially provide data on people with hip OA. Fourteen studies provided data on 1633 participants with knee OA. Nine of these studies were considered of high methodological quality. For pain, combining the results revealed a mean moderate beneficial effect (SMD 0.46, 95% Cl 0.35, 0.57), while for self-reported physical function a mean small beneficial effect (SMD 0.33, 95% CI 0.23, 0.43) was found. These results appeared to be sensitive to blinding of outcome assessor and choice of control group. CONCLUSION: Land based therapeutic exercise was shown to reduce pain and improve physical function for people with OA of the knee. PMID: 12180738 [PubMed - indexed for MEDLINE] 55. Arthritis Res Ther. 2009;11(3):R98. doi: 10.1186/ar2743. Epub 2009 Jun 25.

Exercise therapy for the management of osteoarthritis of the hip joint: a systematic review. McNair PJ(1), Simmonds MA, Boocock MG, Larmer PJ. Author information: (1)Health and Rehabilitation Research Centre, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand. peter.mcnair@aut.ac.nz INTRODUCTION: Recent guidelines pertaining to exercise for individuals with osteoarthritis have been released. These guidelines have been based primarily on studies of knee-joint osteoarthritis. The current study was focused on the hip joint, which has different biomechanical features and risk factors for osteoarthritis and has received much less attention in the literature. The purpose was to conduct a systematic review of the literature to evaluate the exercise programs used in intervention studies focused solely on hip-joint osteoarthritis, to decide whether their exercise regimens met the new guidelines, and to determine the level of support for exercise-therapy interventions in the management of hip-joint osteoarthritis. METHODS: A systematic literature search of 14 electronic databases was undertaken to identify interventions that used exercise therapy as a treatment modality for hip osteoarthritis. The quality of each article was critically appraised and graded according to standardized methodologic approaches. A 'pattern-of-evidence' approach was used to determine the overall level of evidence in support of exercise-therapy interventions for treating hip osteoarthritis. RESULTS: More than 4,000 articles were identified, of which 338 were considered suitable for abstract review. Of these, only 6 intervention studies met the inclusion criteria. Few well-designed studies specifically investigated the use of exercise-therapy management on hip-joint osteoarthritis. Insufficient evidence was found to suggest that exercise therapy can be an effective short-term management approach for reducing pain levels, improving joint function and the quality of life. CONCLUSIONS: Limited information was available on which conclusions regarding the efficacy of exercise could be clearly based. No studies met the level of exercise recommended for individuals with osteoarthritis. High-quality trials are needed, and further consideration should be given to establishing the optimal exercises and exposure levels necessary for achieving long-term gains in the management of osteoarthritis of the hip. PMCID: PMC2714154 PMID: 19555502 [PubMed - indexed for MEDLINE] 56. Osteoarthritis Cartilage. 2008 Feb;16(2):137-62. doi: 10.1016/j.joca.2007.12.013. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Zhang W(1), Moskowitz RW, Nuki G, Abramson S, Altman RD, Arden N, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P.

Author information: (1)University of Edinburgh, Osteoarticular Research Group, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, United Kingdom. Comment in Osteoarthritis Cartilage. 2008 Dec;16(12):1585; author reply 1589. Osteoarthritis Cartilage. 2008 Dec;16(12):1586-7; author reply 1588. PURPOSE: To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world. METHODS: Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale. RESULTS: Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and

the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided. CONCLUSION: Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available. PMID: 18279766 [PubMed - indexed for MEDLINE] 57. Arthritis Rheum. 1999 Jul;42(7):1361-9. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. van Baar ME(1), Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW. Author information: (1)Netherlands Institute of Primary Health Care, Utrecht. OBJECTIVE: To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee. METHODS: A computerized literature search of Medline, Embase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power. RESULTS: Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect. CONCLUSION: There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions. PMID: 10403263 [PubMed - indexed for MEDLINE]

58. Ann Rheum Dis. 2005 Apr;64(4):544-8. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Roddy E(1), Zhang W, Doherty M. Author information: (1)Academic Rheumatology, Nottingham City Hospital, Nottingham NG5 1PB, UK. edward.roddy@nottingham.ac.uk Comment in ACP J Club. 2005 Nov-Dec;143(3):71. OBJECTIVE: To compare the efficacy of aerobic walking and home based quadriceps strengthening exercises in patients with knee osteoarthritis. METHODS: The Medline, Pubmed, EMBASE, CINAHL, and PEDro databases and the Cochrane controlled trials register were searched for randomised controlled trials (RCTs) of subjects with knee osteoarthritis comparing aerobic walking or home based quadriceps strengthening exercise with a non-exercise control group. Methodological quality of retrieved RCTs was assessed. Outcome data were abstracted for pain and self reported disability and the effect size calculated for each outcome. RCTs were grouped according to exercise mode and the data pooled using both fixed and random effects models. RESULTS: 35 RCTs were identified, 13 of which met inclusion criteria and provided data suitable for further analysis. Pooled effect sizes for pain were 0.52 for aerobic walking and 0.39 for quadriceps strengthening. For self reported disability, pooled effect sizes were 0.46 for aerobic walking and 0.32 for quadriceps strengthening. CONCLUSIONS: Both aerobic walking and home based quadriceps strengthening exercise reduce pain and disability from knee osteoarthritis but no difference between them was found on indirect comparison. PMCID: PMC1755453 PMID: 15769914 [PubMed - indexed for MEDLINE]

Exercise and Low back pain 1. Spine (Phila Pa 1976). 2016 Apr 26. [Epub ahead of print] Motor Control Exercise for Non-specific Low Back Pain: A Cochrane Review. Saragiotto BT(1), Maher CG, Yamato TP, Costa LO, Costa LC, Ostelo RW, Macedo LG. Author information: (1)*Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia †Masters and Doctoral Program in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil ‡Department of Health Sciences, EMGO+ Institute for Health and Care Research, VU University Amsterdam, Amsterdam, Netherlands §Department of Epidemiology and biostatistics, VU University Medical Centre Amsterdam, Netherlands ¶Glen Sather Sports Medicine Clinic, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Canada. STUDY DESIGN: Systematic review. OBJECTIVE: To evaluate the effectiveness of motor control exercise in patients with non-specific low back pain. SUMMARY OF BACKGROUND DATA: Motor control exercise (MCE) is a common form of exercise used for managing low back pain (LBP). MCE focuses on the activation of the deep trunk muscles and targets the restoration of control and coordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. METHODS: We conducted electronic searches of CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers from their inception up to April 2015. Two independent review authors screened the search results, assessed risk of bias and extracted the data. A third reviewer resolved any disagreement. We included randomised controlled trials comparing MCE with no treatment, another treatment or as a supplement to other interventions in patients with non-specific LBP. Primary outcomes were pain intensity and disability. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group 12-item criteria. We combined results in a meta-analysis expressed as mean difference and 95% confidence interval. We assessed the overall quality of the evidence using the GRADE approach. RESULTS: We included 32 trials (n = 2,628). Most included trials had low risk of bias. For acute LBP, low to moderate quality evidence indicates no clinically important differences between MCE and spinal manipulative therapy or other forms of exercise. There is very low quality evidence that the addition of MCE to medical management does not provide clinically important improvements. For recurrence at one year, there is very low quality evidence that MCE and medical management decrease the risk of recurrence. For chronic LBP, there is low to moderate quality evidence that MCE is effective for reducing pain compared with minimal intervention. There is low to high quality evidence that MCE is not clinically more effective than other exercises or manual therapy. There is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPA) or telerehabilitation for pain and disability. CONCLUSION: MCE is probably more effective than a minimal intervention for reducing pain, but probably does not have an important effect on disability, in

patients with chronic LBP. There was no clinically important difference between MCE and other forms of exercises or manual therapy for acute and chronic LBP. LEVEL OF EVIDENCE: 1. PMID: 27128390 [PubMed - as supplied by publisher] 2. Int J Occup Environ Med. 2016 Apr;7(2):61-74. Physical Activity and Exercise Interventions in the Workplace Impacting Work Outcomes: A Stakeholder-Centered Best Evidence Synthesis of Systematic Reviews. White MI(1), Dionne CE, Wärje O, Koehoorn M, Wagner SL, Schultz IZ, Koehn C, Williams-Whitt K, Harder HG, Pasca R, Hsu V, McGuire L, Schulz W, Kube D, Wright MD. Author information: (1)Canadian Institute for the Relief of Pain and Disability, Vancouver, Canada, and Department of Family Practice, University of British Columbia, Vancouver, Canada. marc.white@familymed.ubc.ca. BACKGROUND: The prevention of work disability is beneficial to employees and employers, and mitigates unnecessary societal costs associated with social welfare. Many service providers and employers have initiated workplace interventions designed to reduce unnecessary work disability. OBJECTIVE: To conduct a best-evidence synthesis of systematic reviews on workplace interventions that address physical activities or exercise and their impact on workplace absence, work productivity or financial outcomes. METHODS: Using a participatory research approach, academics and stakeholders identified inclusion and exclusion criteria, built an abstraction table, evaluated systematic review quality and relevance, and interpreted the combined findings. A minimum of two scientists participated in a methodological review of the literature followed by a consensus process. RESULTS: Stakeholders and researchers participated as a collaborative team. 3363 unique records were identified, 115 full text articles and 46 systematic reviews were included, 18 assessed the impact of physical fitness or exercise interventions. 11 focused on general workers rather than workers who were absent from work at baseline; 16 of the reviews assessed work absence, 4 assessed productivity and 6 assessed financial impacts. CONCLUSION: The strongest evidence supports the use of short, simple exercise or fitness programs for both workers at work and those absent from work at baseline. For workers at work, simple exercise programs (1-2 modal components) appear to provide similar benefits to those using more complex multimodal interventions. For workers off-work with subacute low back pain, there is evidence that some complex exercise programs may be more effective than simple exercise interventions, especially if they involve workplace stakeholder engagement, communication and coordination with employers and other stakeholders. The development and utilization of standardized definitions, methods and measures and blinded evaluation would improve research quality and strengthen stakeholder-centered guidance.

PMID: 27112715 [PubMed - in process] 3. Complement Ther Med. 2016 Apr;25:1-19. doi: 10.1016/j.ctim.2015.12.018. Epub 2016 Jan 4. Effectiveness of Pilates exercise: A quality evaluation and summary of systematic reviews based on randomized controlled trials. Kamioka H(1), Tsutani K(2), Katsumata Y(3), Yoshizaki T(4), Okuizumi H(5), Okada S(6), Park SJ(6), Kitayuguchi J(7), Abe T(7), Mutoh Y(8). Author information: (1)Faculty of Regional Environment Science, Tokyo University of Agriculture, Japan. Electronic address: h1kamiok@nodai.ac.jp. (2)Tokyo Ariake Medical and Health Science University, Japan. (3)Faculty of Applied Bio-Sciences, Tokyo University of Agriculture, Japan. (4)Faculty of Food and Nutritional Sciences, Toyo University, Japan. (5)Mimaki Onsen (Spa) Clinic, Tomi City, Japan. (6)Physical Education and Medicine Research Foundation, Japan. (7)Physical Education and Medicine Research Center Unnan, Japan. (8)The Research Institute of Nippon Sport Science University, Japan. OBJECTIVE: The objective of this review were to summarize evidence for the effectiveness of Pilates exercise (PE) and to assess the quality of systematic review (SRs) based on randomized controlled trials (RCTs). STUDY DESIGN: A systematic review of SRs based on RCTs. METHODS: Studies were eligible if they were RCTs. Studies included those with one treatment group in which PE was applied. We searched the following databases from 1995 up to August 20, 2014: MEDLINE via PubMed, CINAHL, Web of Science, Global Health Library, and Ichushi-Web. We also searched All Cochrane Database and Campbell Systematic Reviews up to August 20, 2014. Based on the International Classification of Diseases-10 (ICD-10), we identified a disease targeted for each article. RESULTS: Nine studies met all inclusion criteria. As a whole, the quality of the articles was good. Seven studies were about "Musculoskeletal system and connective tissue (M5456)". There were two studies in "Factors influencing health status and contact with health services (Z723)". The traits of participants were for females and the comparatively young- and middle-aged. Five SRs for chronic low back pain (CLBP) concluded that there was pain-relief and functional improvement of the intervention in the short term, but two SRs were inconclusive about the effectiveness of PE. There were no adverse events described in any of the studies. CONCLUSION: Although no SR reported any adverse effect or harm by PE, there was pain-relief and functional improvement attributed to PE in the short term in participants with CLBP. There was also evidence of improved flexibility and dynamic balance, and of enhanced muscular endurance in healthy people in the short term. In addition, there may have been an effect on body composition in the short term. Copyright © 2015 Elsevier Ltd. All rights reserved.

PMID: 27062942 [PubMed - in process] 4. J Pain. 2016 Feb 1. pii: S1526-5900(16)00504-6. doi: 10.1016/j.jpain.2016.01.473. [Epub ahead of print] Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis. O'Keeffe M(1), Purtill H(2), Kennedy N(3), Conneely M(3), Hurley J(3), O'Sullivan P(4), Dankaerts W(5), O'Sullivan K(3). Author information: (1)Department of Clinical Therapies, University of Limerick, Limerick, Ireland. Electronic address: Mary.OKeeffe@ul.ie. (2)Department of Mathematics and Statistics, University of Limerick, Limerick, Ireland. (3)Department of Clinical Therapies, University of Limerick, Limerick, Ireland. (4)School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia. (5)Musculoskeletal Unit, Department of Rehabilitation Sciences, University of Leuven, Leuven, Belgium. Nonspecific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation commonly includes physical and behavioral interventions, or a combination of these approaches. Physical interventions aim to enhance physical capacity by using methods such as exercise, manual therapy, and ergonomics. Behavioral/psychologically informed interventions aim to enhance behaviors, cognitions, or mood by using methods such as relaxation and cognitive behavioral therapy. Combined interventions aim to target physical and also behavioral/psychological factors contributing to patients' pain by using methods such as multidisciplinary pain management programs. Because it remains unclear whether any of these approaches are superior, this review aimed to assess the comparative effectiveness of physical, behavioral/psychologically informed, and combined interventions on pain and disability in patients with NSCSP. Nine electronic databases were searched for randomized controlled trials (RCTs) including participants reporting NSCSP. Studies were required to have an "active" conservative treatment control group for comparison. Studies were not eligible if the interventions were from the same domain (eg, if the study compared 2 physical interventions). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical, behavioral/psychologically informed, and combined interventions were assessed using meta-analyses. Twenty-four studies were included. No clinically significant differences were found for pain and disability between physical, behavioral/psychologically informed, and combined interventions. The simple categorization of interventions into physical, behavioral/psychologically informed, and combined could be considered a limitation of this review, because these interventions may not be easily differentiated to allow accurate comparisons to be made. Further work should consider investigating whether tailoring rehabilitation to individual patients and their perceived risk of chronicity, as seen in recent RCTs for low back pain, can enhance outcomes in NSCSP.PERSPECTIVE: In this systematic review of RCTs in NSCSP, only small

differences in pain or disability were observed between physical, behavioral/psychologically informed, and combined interventions. Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved. PMID: 26844416 [PubMed - as supplied by publisher] 5. JAMA Intern Med. 2016 Feb 1;176(2):199-208. doi: 10.1001/jamainternmed.2015.7431. Prevention of Low Back Pain: A Systematic Review and Meta-analysis. Steffens D(1), Maher CG(2), Pereira LS(3), Stevens ML(2), Oliveira VC(3), Chapple M(4), Teixeira-Salmela LF(3), Hancock MJ(4). Author information: (1)Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia2Department of Physiotherapy, Federal University of Minas Gerais, Belo Horizonte, Brazil. (2)Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia. (3)Department of Physiotherapy, Federal University of Minas Gerais, Belo Horizonte, Brazil. (4)Discipline of Physiotherapy, Medicine and Health Sciences, Macquarie University, Sydney, Australia. IMPORTANCE: Existing guidelines and systematic reviews lack clear recommendations for prevention of low back pain (LBP). OBJECTIVE: To investigate the effectiveness of interventions for prevention of LBP. DATA SOURCES: MEDLINE, EMBASE, Physiotherapy Evidence Database Scale, and Cochrane Central Register of Controlled Trials from inception to November 22, 2014. STUDY SELECTION: Randomized clinical trials of prevention strategies for nonspecific LBP. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers extracted data and assessed the risk of bias. The Physiotherapy Evidence Database Scale was used to evaluate the risk-of-bias. The Grading of Recommendations Assessment, Development, and Evaluation system was used to describe the quality of evidence. MAIN OUTCOMES AND MEASURES: The primary outcome measure was an episode of LBP, and the secondary outcome measure was an episode of sick leave associated with LBP. We calculated relative risks (RRs) and 95% CIs using random-effects models. RESULTS: The literature search identified 6133 potentially eligible studies; of these, 23 published reports (on 21 different randomized clinical trials including 30 850 unique participants) met the inclusion criteria. With results presented as RRs (95% CIs), there was moderate-quality evidence that exercise combined with education reduces the risk of an episode of LBP (0.55 [0.41-0.74]) and low-quality evidence of no effect on sick leave (0.74 [0.44-1.26]). Low- to very low-quality evidence suggested that exercise alone may reduce the risk of both an LBP episode (0.65 [0.50-0.86]) and use of sick leave (0.22 [0.06-0.76]). For education alone, there was moderate- to very low-quality evidence of no effect on

LBP (1.03 [0.83-1.27]) or sick leave (0.87 [0.47-1.60]). There was low- to very low-quality evidence that back belts do not reduce the risk of LBP episodes (1.01 [0.71-1.44]) or sick leave (0.87 [0.47-1.60]). There was low-quality evidence of no protective effect of shoe insoles on LBP (1.01 [0.74-1.40]). CONCLUSION AND RELEVANCE: The current evidence suggests that exercise alone or in combination with education is effective for preventing LBP. Other interventions, including education alone, back belts, and shoe insoles, do not appear to prevent LBP. Whether education, training, or ergonomic adjustments prevent sick leave is uncertain because the quality of evidence is low. PMID: 26752509 [PubMed - in process] 6. Cochrane Database Syst Rev. 2016 Jan 8;1:CD012004. doi: 10.1002/14651858.CD012004. Motor control exercise for chronic non-specific low-back pain. Saragiotto BT(1), Maher CG, Yamato TP, Costa LO, Menezes Costa LC, Ostelo RW, Macedo LG. Author information: (1)Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia. Comment in BMJ. 2016;352:i84. BACKGROUND: Non-specific low back pain (LBP) is a common condition. It is reported to be a major health and socioeconomic problem associated with work absenteeism, disability and high costs for patients and society. Exercise is a modestly effective treatment for chronic LBP. However, current evidence suggests that no single form of exercise is superior to another. Among the most commonly used exercise interventions is motor control exercise (MCE). MCE intervention focuses on the activation of the deep trunk muscles and targets the restoration of control and co-ordination of these muscles, progressing to more complex and functional tasks integrating the activation of deep and global trunk muscles. While there are previous systematic reviews of the effectiveness of MCE, recently published trials justify an updated systematic review. OBJECTIVES: To evaluate the effectiveness of MCE in patients with chronic non-specific LBP. SEARCH METHODS: We conducted electronic searches in CENTRAL, MEDLINE, EMBASE, five other databases and two trials registers from their inception up to April 2015. We also performed citation tracking and searched the reference lists of reviews and eligible trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that examined the effectiveness of MCE in patients with chronic non-specific LBP. We included trials comparing MCE with no treatment, another treatment or that added MCE as a supplement to other interventions. Primary outcomes were pain intensity and disability. We considered function, quality of life, return to work or recurrence as secondary outcomes. All outcomes must have been measured with a valid and

reliable instrument. DATA COLLECTION AND ANALYSIS: Two independent review authors screened the search results, assessed risk of bias and extracted the data. A third independent review author resolved any disagreement. We assessed risk of bias using the Cochrane Back and Neck (CBN) Review Group expanded 12-item criteria (Furlan 2009). We extracted mean scores, standard deviations and sample sizes from the included trials, and if this information was not provided we calculated or estimated them using methods recommended in the Cochrane Handbook. We also contacted the authors of the trials for any missing or unclear information. We considered the following time points: short-term (less than three months after randomisation); intermediate (at least three months but less than 12 months after randomisation); and long-term (12 months or more after randomisation) follow-up. We assessed heterogeneity by visual inspection of the forest plots, and by calculating the Chi(2) test and the I(2) statistic. We combined results in a meta-analysis expressed as mean difference (MD) and 95% confidence interval (CI). We assessed the overall quality of the evidence using the GRADE approach. MAIN RESULTS: We included 29 trials (n = 2431) in this review. The study sample sizes ranged from 20 to 323 participants. We considered a total of 76.6% of the included trials to have a low risk of bias, representing 86% of all participants. There is low to high quality evidence that MCE is not clinically more effective than other exercises for all follow-up periods and outcomes tested. When compared with minimal intervention, there is low to moderate quality evidence that MCE is effective for improving pain at short, intermediate and long-term follow-up with medium effect sizes (long-term, MD -12.97; 95% CI -18.51 to -7.42). There was also a clinically important difference for the outcomes function and global impression of recovery compared with minimal intervention. There is moderate to high quality evidence that there is no clinically important difference between MCE and manual therapy for all follow-up periods and outcomes tested. Finally, there is very low to low quality evidence that MCE is clinically more effective than exercise and electrophysical agents (EPA) for pain, disability, global impression of recovery and quality of life with medium to large effect sizes (pain at short term, MD -30.18; 95% CI -35.32 to -25.05). Minor or no adverse events were reported in the included trials. AUTHORS' CONCLUSIONS: There is very low to moderate quality evidence that MCE has a clinically important effect compared with a minimal intervention for chronic low back pain. There is very low to low quality evidence that MCE has a clinically important effect compared with exercise plus EPA. There is moderate to high quality evidence that MCE provides similar outcomes to manual therapies and low to moderate quality evidence that it provides similar outcomes to other forms of exercises. Given the evidence that MCE is not superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety. PMID: 26742533 [PubMed - indexed for MEDLINE] 7. Spine (Phila Pa 1976). 2015 Dec 14. [Epub ahead of print] Pilates for Low Back Pain: Complete Republication of a Cochrane Review. Yamato TP(1), Maher CG, Saragiotto BT, Hancock MJ, Ostelo RW, Cabral CM, Costa

LC, Costa LO. Author information: (1)*Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, Australia. †Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia ‡Department of Health Sciences, EMGO Institute for Health and Care Research, VU University, Amsterdam, Netherlands. §Department of Epidemiology and biostatistics, VU University medical centre, Amsterdam, Netherlands. ¶Masters and Doctoral Programs in Physical Therapy, Universidade Cidade de São Paulo, São Paulo, Brazil. STUDY DESIGN: Systematic review. OBJECTIVES: To determine the effects of the Pilates method for patients with non-specific acute, subacute or chronic low back pain. SUMMARY OF BACKGROUND DATA: The Pilates method is one of the most common forms of intervention based on exercise used for treating patients with low back pain. However, its effectiveness is not well established. METHODS: We conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, PEDro and SPORTDiscus up to March 2014. We included randomised controlled trials examining the effectiveness of Pilates in patients with acute, subacute or chronic non-specific low back pain. The outcomes evaluated were pain, disability, function, and global impression of recovery. Two independent reviewers screened for potentially eligible studies, assessed risk of bias, and extracted the data. We evaluated the overall quality of evidence using the GRADE approach and treatment effect sizes were described using mean differences and 95% confidence intervals. RESULTS: Searches retrieved 126 trials, of which 10 were included in the review (n = 510 participants). Seven studies were considered to have low risk of bias, and three were considered at high risk of bias. When compared to minimal intervention, Pilates reduces pain at short and intermediate term with low to moderate quality evidence and medium effect sizes. For disability, there is also a significant difference in favour to Pilates with low to moderate quality evidence and small effect size for short term and medium effect size for intermediate term compared with minimal intervention. It is unclear whether Pilates is better than other exercises for short-term pain, but there is low quality evidence that Pilates reduces pain at intermediate term. For disability, there is moderate quality evidence that there is no significant difference between Pilates and other exercise, either in the short term, or in the intermediate term. CONCLUSION: There is low to moderate quality evidence that Pilates is more effective than minimal intervention with most of the effect sizes being considered medium. However, there is no conclusive evidence that Pilates is superior to other forms of exercise. LEVEL OF EVIDENCE: 1. PMID: 26679894 [PubMed - as supplied by publisher] 8. Chin J Integr Med. 2015 Oct 26. [Epub ahead of print] Integrative treatment for low back pain: An exploratory systematic review and

meta-analysis of randomized controlled trials. Hu XY(1), Chen NN(2), Chai QY(2), Yang GY(2), Trevelyan E(3), Lorenc A(3), Liu JP(2), Robinson N(3). Author information: (1)School of Health and Social Care, London South Bank University, London, UK. hux2@lsbu.ac.uk. (2)Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100700, China. (3)School of Health and Social Care, London South Bank University, London, UK. OBJECTIVE: Low back pain (LBP) is a common musculoskeletal condition often treated using integrative medicine (IM). Most reviews have focused on a single complementary and alternative medicine (CAM) therapy for LBP rather than evaluating wider integrative approaches. This exploratory systematic review aimed to identify randomized controlled trials (RCTs) and provide evidence on the effectiveness, cost effectiveness and adverse effects of integrative treatment for LBP. METHODS: A literature search was conducted in 12 English and Chinese databases. RCTs evaluating an integrative treatment for musculoskeletal related LBP were included. Reporting, methodological quality and relevant clinical characteristics were assessed and appraised. Metaanalyses were performed for outcomes where trials were sufficiently homogenous. RESULTS: Fifty-six RCTs were identified evaluating integrative treatment for LBP. Although reporting and methodological qualities were poor, meta-analysis showed a favourable effect for integrative treatment over conventional and CAM treatment for back pain and function at 3 months or less follow-up. Two trials investigated costs, reporting £ 5332 per quality adjusted life years with 6 Alexander technique lessons plus exercise at 12 months follow-up; and an increased total costs of $244 when giving an additional up to 15 sessions of CAM package of care at 12 weeks. Sixteen trials mentioned safety; no severe adverse effects were reported. CONCLUSION: Integrative treatment that combines CAM with conventional therapies appeared to have beneficial effects on pain and function. However, evidence is limited due to heterogeneity, the relatively small numbers available for subgroup analyses and the low methodological quality of the included trials. Identification of studies of true IM was not possible due to lack of reporting of the intervention details (registration No. CRD42013003916). PMID: 26501693 [PubMed - as supplied by publisher] 9. Physiotherapy. 2015 Dec;101(4):310-8. doi: 10.1016/j.physio.2015.04.009. Epub 2015 Jun 17. Activating therapy modalities in older individuals with chronic non-specific low back pain: a systematic review. Kuss K(1), Becker A(2), Quint S(3), Leonhardt C(2). Author information:

(1)Department of General Practice/Family Medicine, Philipps University Marburg, Germany. Electronic address: kuss@staff.uni-marburg.de. (2)Department of General Practice/Family Medicine, Philipps University Marburg, Germany. (3)Department of Medical Psychology, Philipps University Marburg, Germany. BACKGROUND: Although there are many special exercise-based therapy approaches for the working population suffering chronic low back pain, similar programmes for older individuals are rare. OBJECTIVES: To summarise all evaluated physical therapy approaches, and assess the effects on older people with chronic low back pain. DATA SOURCES: Medline, CINAHL, Cochrane, Embase, PEDro, PsychINFO and Psyndex. STUDY SELECTION/ELIGIBILITY: Age≥65 years, subacute or chronic non-specific low back pain of ≥6weeks' duration, and a physical therapy approach. STUDY APPRAISAL AND SYNTHESIS METHODS: Study selection, data extraction, and assessment of methodological quality and clinical relevance were performed independently by two reviewers. As there were only a few controlled trials and wide heterogeneity in observation periods and outcome measures, pooling of data was not feasible. Therefore, the results are presented descriptively. RESULTS: In total, nine studies were included; six related to mixed physiotherapy modalities, one related to strength training, and two related to endurance training. Low-quality evidence suggests that physical therapy modalities are associated with a small-to-moderate reduction in pain and a small improvement in function. LIMITATIONS: The results must be interpreted with caution due to poor methodological quality. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: Few studies have been performed in this highly relevant and growing age group. It is not possible to recommend one particular modality or programme; as such, prescriptions should reflect patients' preferences and local conditions. Further research of higher methodological quality is needed urgently. Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 26414346 [PubMed - in process] 10. Pain Med. 2015 Aug 3. doi: 10.1111/pme.12882. [Epub ahead of print] A Systematic Review and Meta-Analysis on the Effectiveness of Graded Activity and Graded Exposure for Chronic Nonspecific Low Back Pain. López-de-Uralde-Villanueva I(1,)(2,)(3,)(4), Muñoz-García D(1,)(2), Gil-Martínez A(1,)(2,)(3,)(4), Pardo-Montero J(1,)(2,)(3,)(4), Muñoz-Plata R(1,)(2), Angulo-Díaz-Parreño S(2,)(3,)(5), Gómez-Martínez M(2,)(6), La Touche R(1,)(2,)(3,)(4). Author information: (1)Department of Physiotherapy, Faculty of Health Science, The Center for Advanced Studies University La Salle, Universidad Autónoma De Madrid, Aravaca, Madrid, Spain. (2)Motion in Brains Research Group, The Center for Advanced

Studies University La Salle, Universidad Autónoma De Madrid, Aravaca, Madrid, Spain. (3)Institute of Neuroscience and Craniofacial Pain (INDCRAN), Madrid, Spain. (4)Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain. (5)Faculty of Medicine, Universidad San Pablo CEU, Madrid, Spain. (6)Department of Occupational Therapy, Faculty of Health Science, The Center for Advanced Studies University La Salle, Universidad Autónoma De Madrid, Aravaca, Madrid, Spain. OBJECTIVE: Our aim was to systematically review and meta-analyze the effectiveness of graded activity (GA) or graded exposure (GEXP) for chronic nonspecific low back pain (CNSLBP). METHODS: A literature search of multiple databases (MEDLINE, EMBASE, PEDro, CINAHL, and PsychINFO) was conducted to identify randomized control trials (RCTs). Standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated for relevant outcome measures (pain intensity, disability, quality of life, and catastrophizing). RESULTS: Thirteen RCTs met the inclusion criteria. Only nine studies were included in the meta-analysis. GA was significantly more effective than the control group (CG) for improvements in disability in the short term (three studies: n = 254, SMD = -0.3, 95% CI -0.55 to -0.05, P = 0.02) and long term (two studies: n = 238, SMD = -0.53, 95% CI -0.79 to -0.27, P < 0.0001). GA was significantly less effective than GEXP for the improvement of disability in the short term (two studies: n = 105, SMD = 0.39, 95% CI 0.003-0.78, P = 0.048). GA was also significantly less effective than GEXP at improving catastrophizing in the short term (two studies: n = 105, SMD = 0.48, 95% CI 0.09-0.87, P = 0.02). CONCLUSION: Limited evidence has been found to show that GA significantly reduces disability in the short and long term when compared with the CG in CNSLBP. There is moderate evidence that GEXP more effectively decreases catastrophizing than GA in the short term. No difference was found between GA and other exercise for any variable. Wiley Periodicals, Inc. PMID: 26235368 [PubMed - as supplied by publisher] 11. Clin Rehabil. 2016 Jun;30(6):523-36. doi: 10.1177/0269215515590487. Epub 2015 Jun 18. Does walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review. Lawford BJ(1), Walters J(2), Ferrar K(3). Author information: (1)Division of Health Sciences, School of Health Sciences, University of South Australia, Adelaide, Australia lawbj004@mymail.unisa.edu.au. (2)Division of Health Sciences, School of Health Sciences, University of South Australia, Adelaide, Australia International Centre for Allied Health Evidence, Sansom Institute, University of South Australia, Adelaide, Australia. (3)Division of Health Sciences, School of Health Sciences, University of South Australia,

Adelaide, Australia Alliance for Research in Exercise, Nutrition and Activity, Sansom Institute, University of South Australia, Adelaide, Australia. OBJECTIVE: To establish the effectiveness of walking alone and walking compared to other non-pharmacological management methods to improve disability, quality of life, or function in adults with chronic low back pain. DATA SOURCES: A systematic search of the following databases was undertaken: Medline, Embase, CINAHL, Scopus, Pedro, SportDiscus, Cochrane Central Register of Controlled Trials. The following keywords were used: 'back pain' or 'low back pain' or 'chronic low back pain' and 'walk*' or 'ambulation' or 'treadmill*' or 'pedometer*' or 'acceleromet*' or 'recreational' and 'disability' or 'quality of life' or 'function*'. REVIEW METHODS: Primary research studies with an intervention focus that investigated walking as the primary intervention compared to no intervention or any other non-pharmacological method in adults with chronic low back pain (duration >3 months). RESULTS: Seven randomised controlled trials involving 869 participants were included in the review. There was no evidence that walking was more effective than other management methods such as usual care, specific strength exercises, medical exercise therapy, or supervised exercise classes. One study found over-ground walking to be superior to treadmill walking, and another found internet-mediated walking to be more beneficial than non-internet-mediated walking in the short term. CONCLUSION: There is low quality evidence to suggest that walking is as effective as other non-pharmacological management methods at improving disability, function, and quality of life in adults with chronic low back pain. © The Author(s) 2015. PMID: 26088673 [PubMed - in process] 12. Physiotherapy. 2016 Mar;102(1):78-85. doi: 10.1016/j.physio.2015.02.003. Epub 2015 Apr 19. Current management of pregnancy-related low back pain: a national cross-sectional survey of UK physiotherapists. Bishop A(1), Holden MA(2), Ogollah RO(2), Foster NE(2); EASE Back Study Team. Author information: (1)Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK. Electronic address: a.bishop@keele.ac.uk. (2)Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK. BACKGROUND: Pregnancy-related low back pain (LBP) is very common. Evidence from a systematic review supports the use of exercise and acupuncture, although little is known about the care received by women with pregnancy-related back pain in the UK. OBJECTIVE: To describe current acupuncture and standard care management of pregnancy-related LBP by UK physiotherapists.

DESIGN: Cross-sectional survey of physiotherapists with experience of treating women with pregnancy-related LBP from three professional networks of the Chartered Society of Physiotherapy. METHODS: In total, 1093 physiotherapists were mailed a questionnaire. The questionnaire captured respondents' demographic and practice setting information, and experience of managing women with pregnancy-related back pain, and investigated the reported management of pregnancy-related LBP using a patient case vignette of a specific, 'typical' case. RESULTS: The overall response rate was 58% (629/1093). Four hundred and ninety-nine physiotherapists had experience of treating women with pregnancy-related LBP and were included in the analysis. Most respondents worked wholly or partly in the UK National Health Service (78%). Most respondents reported that they treat patients with pregnancy-related LBP in three to four one-to-one treatment sessions over 3 to 6 weeks. The results show that a range of management strategies are employed for pregnancy-related LBP, and multimodal management is common. The most common reported treatment was home exercises (94%), and 24% of physiotherapists reported that they would use acupuncture with the patient described in the vignette. CONCLUSIONS: This study provides the first robust data on the management of pregnancy-related LBP by UK physiotherapists. Multimodal management is common, although exercise is the most frequently used treatment for pregnancy-related LBP. Acupuncture is used less often for this patient group. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved. PMID: 26050136 [PubMed - in process] 13. Acta Obstet Gynecol Scand. 2015 Nov;94(11):1156-67. doi: 10.1111/aogs.12681. Epub 2015 Jun 16. Treatments for pregnancy-related lumbopelvic pain: a systematic review of physiotherapy modalities. Gutke A(1,)(2), Betten C(3), Degerskär K(4), Pousette S(5), Olsén MF(1,)(6). Author information: (1)Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. (2)Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden. (3)Primary Health Care, Skurup, Region Skåne, Sweden. (4)Primary Health Care, Lund, Region Skåne, Sweden. (5)Private Clinic 'Friskispraktiken', Stockholm, Sweden. (6)Department of Physical and Occupational Therapy, Sahlgrenska University Hospital, Gothenburg, Sweden. OBJECTIVE: To explore the effect of physiotherapeutic interventions on pregnancy-related lumbopelvic pain. MATERIAL AND METHODS: Data sources: MEDLINE, Cochrane Central Register of Controlled Trials, PEDro, CINAHL, AMED, and SCOPUS databases were searched up to December 2014 for studies written in English, French, German or Scandinavian

languages that evaluated physiotherapeutic modalities for preventing and treating pregnancy-related lumbopelvic pain. RESULTS: For lumbopelvic pain during pregnancy, the evidence was strong for positive effects of acupuncture and pelvic belts. The evidence was low for exercise in general and for specific stabilizing exercises. The evidence was very limited for efficacy of water gymnastics, progressive muscle relaxation, a specific pelvic tilt exercise, osteopathic manual therapy, craniosacral therapy, electrotherapy and yoga. For postpartum lumbopelvic pain, the evidence was very limited for clinic-based treatment concepts, including specific stabilizing exercises, and for self-management interventions for women with severe disabilities. No specific adverse events were reported for any intervention. No meta-analysis could be performed because of study heterogeneity. CONCLUSIONS: The levels of evidence were strong for a positive effect of acupuncture and pelvic belts, but weak for an effect of specific exercises. Caution should prevail in choosing other interventions for pregnancy-related lumbopelvic pain. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 26018758 [PubMed - indexed for MEDLINE] 14. Clin Rehabil. 2015 Dec;29(12):1155-67. doi: 10.1177/0269215515570379. Epub 2015 Feb 13. Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials. Searle A(1), Spink M(2), Ho A(3), Chuter V(4). Author information: (1)Discipline of Podiatry, University of Newcastle, NSW, Australia Angela.Searle@newcastle.edu.au. (2)Discipline of Podiatry, University of Newcastle, NSW, Australia. (3)School of Psychology, Faculty of Science and Information Technology, University of Newcastle, NSW, Australia. (4)Discipline of Podiatry, University of Newcastle, NSW, Australia Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Australia. OBJECTIVE: To determine, for adults with chronic low back pain, which exercise interventions are the most effective at reducing pain compared to other treatments. DATA SOURCES: A search of MEDLINE, CINAHL, EMBASE, SPORTDiscus, PsycINFO and The Cochrane Library was conducted up to October 2014. REVIEW METHODS: Databases were searched for published reports of randomised trials that investigated the treatment of chronic low back pain of non-specific origin with an exercise intervention. Two authors independently reviewed and selected relevant trials. Methodological quality was evaluated using the Downs and Black tool. RESULTS: Forty-five trials met the inclusion criteria and thirty-nine were included in the meta-analysis. Combined meta-analysis revealed significantly lower chronic low back pain with intervention groups using exercise compared to a

control group or other treatment group (Standard Mean Deviation (SMD) =-0.32, CI 95% -0.44 to -0.19, P<0.01). Separate exploratory subgroup analysis showed a significant effect for strength/resistance and coordination/stabilisation programs. CONCLUSIONS: Our results found a beneficial effect for strength/resistance and coordination/stabilisation exercise programs over other interventions in the treatment of chronic low back pain and that cardiorespiratory and combined exercise programs are ineffective. © The Author(s) 2015. PMID: 25681408 [PubMed - in process] 15. Medicine (Baltimore). 2015 Jan;94(4):e383. doi: 10.1097/MD.0000000000000383. Effects of Pilates exercise programs in people with chronic low back pain: a systematic review. Patti A(1), Bianco A, Paoli A, Messina G, Montalto MA, Bellafiore M, Battaglia G, Iovane A, Palma A. Author information: (1)Sport and Exercise Sciences Research Unit (A Patti, AB, GM, MAM, MB, GB, AI, A Palma), University of Palermo; Posturalab (A Patti, GM), Italy; and Department of Biomedical Science (A Paoli), University of Padua, Padua, Italy. The Pilates method has recently become a fast-growing popular way of exercise recommended for healthy individuals and those engaged in rehabilitation. Several published studies have examined the effects of Pilates method in people with chronic low back pain (LBP). The objective of this study is to describe and provide an extensive overview of the scientific literature comparing the effectiveness of the Pilates method on pain and disability in patients with chronic nonspecific LBP. The study is based on the data from the following sources: MEDLINE-NLM, MEDLINE-EBSCO, Scopus Elsevier, Cochrane, DOAJ, SciELO, and PLOSONE. Original articles and systematic reviews of adults with chronic nonspecific LBP that evaluated pain and/or disability were included in this study; studies in which the primary treatment was based on Pilates method exercises compared with no treatment, minimal intervention, other types of intervention, or other types of exercises. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were adopted. The literature search included 7 electronic databases and the reference list of relevant systematic reviews and original articles to July 2014. Two independent investigators conducted the literature search and performed the synthesis as follows: Study Design; Sample (n); Disability measure; Intervention; and Main results. The searches identified a total of 128 articles. From these, 29 were considered eligible and were included in the analysis. The items were stratified as follows: Pilates method versus other kind of exercises (n = 6 trials) and Pilates method versus no treatment group or minimal intervention for short-term pain (n = 9 trials); the therapeutic effect of the Pilates method in randomized cohorts (n = 5); and analysis of reviews (n = 9). We found that there is a dearth of studies

that clearly demonstrates the efficacy of a specific Pilates exercise program over another in the treatment of chronic pain. However, the consensus in the field suggests that Pilates method is more effective than minimal physical exercise intervention in reducing pain. These conclusions need to be supported by other proper investigations. PMCID: PMC4602949 PMID: 25634166 [PubMed - indexed for MEDLINE] 16. BMC Musculoskelet Disord. 2014 Dec 9;15:416. doi: 10.1186/1471-2474-15-416. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. Smith BE(1), Littlewood C, May S. Author information: (1)Physiotherapy Outpatients, London Road Community Hospital, Derby Hospitals NHS Foundation Trust, London Road, Derby DE1 2QY, UK. benjamin.smith3@nhs.net. BACKGROUND: Non-specific low back pain (NSLBP) is a large and costly problem. It has a lifetime prevalence of 80% and results in high levels of healthcare cost. It is a major cause for long term sickness amongst the workforce and is associated with high levels of fear avoidance and kinesiophobia. Stabilisation (or 'core stability') exercises have been suggested to reduce symptoms of pain and disability and form an effective treatment. Despite it being the most commonly used form of physiotherapy treatment within the UK there is a lack of positive evidence to support its use. The aims of this systematic review update is to investigate the effectiveness of stabilisation exercises for the treatment of NSLBP, and compare any effectiveness to other forms of exercise. METHODS: A systematic review published in 2008 was updated with a search of PubMed, CINAHL, AMED, Pedro and The Cochrane Library, October 2006 to October 2013. Two authors independently selected studies, and two authors independently extracted the data. Methodological quality was evaluated using the PEDro scale. Meta-analysis was carried out when appropriate. RESULTS: 29 studies were included: 22 studies (n = 2,258) provided post treatment effect on pain and 24 studies (n = 2,359) provided post treatment effect on disability. Pain and disability scores were transformed to a 0 to 100 scale. Meta-analysis showed significant benefit for stabilisation exercises versus any alternative treatment or control for long term pain and disability with mean difference of -6.39 (95% CI -10.14 to -2.65) and -3.92 (95% CI -7.25 to -0.59) respectively. The difference between groups was clinically insignificant. When compared with alternative forms of exercise, there was no statistical or clinically significant difference. Mean difference for pain was -3.06 (95% CI -6.74 to 0.63) and disability -1.89 (95% CI -5.10 to 1.33). CONCLUSION: There is strong evidence stabilisation exercises are not more effective than any other form of active exercise in the long term. The low levels of heterogeneity and large number of high methodological quality of available studies, at long term follow-up, strengthen our current findings, and further research is unlikely to considerably alter this conclusion.

PMCID: PMC4295260 PMID: 25488399 [PubMed - indexed for MEDLINE] 17. BMC Musculoskelet Disord. 2014 Nov 19;15:382. doi: 10.1186/1471-2474-15-382. Effects of proprioceptive exercises on pain and function in chronic neck- and low back pain rehabilitation: a systematic literature review. McCaskey MA(1), Schuster-Amft C, Wirth B, Suica Z, de Bruin ED. Author information: (1)Research Department, Reha Rheinfelden, Salinenstrasse 98, 4310 Rheinfelden, Switzerland. m.mccaskey@reha-rhf.ch. BACKGROUND: Proprioceptive training (PrT) is popularly applied as preventive or rehabilitative exercise method in various sports and rehabilitation settings. Its effect on pain and function is only poorly evaluated. The aim of this systematic review was to summarise and analyse the existing data on the effects of PrT on pain alleviation and functional restoration in patients with chronic (≥ 3 months) neck- or back pain. METHODS: Relevant electronic databases were searched from their respective inception to February 2014. Randomised controlled trials comparing PrT with conventional therapies or inactive controls in patients with neck- or low back pain were included. Two review authors independently screened articles and assessed risk of bias (RoB). Data extraction was performed by the first author and crosschecked by a second author. Quality of findings was assessed and rated according to GRADE guidelines. Pain and functional status outcomes were extracted and synthesised qualitatively and quantitatively. RESULTS: In total, 18 studies involving 1380 subjects described interventions related to PrT (years 1994-2013). 6 studies focussed on neck-, 12 on low back pain. Three main directions of PrT were identified: Discriminatory perceptive exercises with somatosensory stimuli to the back (pPrT, n=2), multimodal exercises on labile surfaces (mPrT, n=13), or joint repositioning exercise with head-eye coordination (rPrT, n=3). Comparators entailed usual care, home based training, educational therapy, strengthening, stretching and endurance training, or inactive controls. Quality of studies was low and RoB was deemed moderate to high with a high prevalence of unclear sequence generation and group allocation (>60%). Low quality evidence suggests PrT may be more effective than not intervening at all. Low quality evidence suggests that PrT is no more effective than conventional physiotherapy. Low quality evidence suggests PrT is inferior to educational and behavioural approaches. CONCLUSIONS: There are few relevant good quality studies on proprioceptive exercises. A descriptive summary of the evidence suggests that there is no consistent benefit in adding PrT to neck- and low back pain rehabilitation and functional restoration. PMCID: PMC4247630 PMID: 25409985 [PubMed - indexed for MEDLINE]

18. Syst Rev. 2014 Sep 19;3:106. doi: 10.1186/2046-4053-3-106. A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain--protocol. Marley J, Tully MA, Porter-Armstrong A, Bunting B, O'Hanlon J, McDonough SM(1). Author information: (1)Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health, School of Health Sciences, University of Ulster, Shore Road, Newtownabbey, Co Antrim BT37 0QB, UK. s.mcdonough@ulster.ac.uk. BACKGROUND: Chronic musculoskeletal pain is highly prevalent, affecting around one in five people across Europe. Osteoarthritis, low back pain, neck pain and other musculoskeletal disorders are leading causes of disability worldwide and the most common source of chronic pain. Exercise and/or physical activity interventions have the potential to address not only the pain and disability associated with chronic pain but also the increased risk of morbidity and mortality seen in this population. Although exercise and/or physical activity is widely recommended, there is currently a paucity of research that offers an evidence base upon which the development or optimisation of interventions can be based. This systematic review will investigate the components of interventions associated with changes in physical activity levels in adults with chronic musculoskeletal pain. METHODS/DESIGN: This systematic review will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidance. Randomised and quasi-randomised controlled trials of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: CENTRAL in the Cochrane Library, the Cochrane Database of Systematic Reviews (CDSR), MEDLINE, Embase, CINAHL, PsycINFO and AMED. Two review authors will independently screen articles retrieved from the search for eligibility, extract relevant data on methodological issues and code interventions according to the behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques. As complex healthcare interventions can be modified by a wide variety of factors, data will be summarised statistically when the data are available, are sufficiently similar and are of sufficient quality. A narrative synthesis will be completed if there is insufficient data to permit a formal meta-analysis. DISCUSSION: This review will be of value to clinicians working in chronic pain services and to researchers involved in designing and evaluating interventions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO reference: CRD42014010640. PMCID: PMC4179220 PMID: 25239378 [PubMed - indexed for MEDLINE] 19. J Phys Ther Sci. 2014 Aug;26(8):1301-6. doi: 10.1589/jpts.26.1301. Epub 2014 Aug 30.

Effectiveness of sling exercise for chronic low back pain: a systematic review. Lee JS(1), Yang SH(2), Koog YH(1), Jun HJ(1), Kim SH(3), Kim KJ(4). Author information: (1)Department of Physical Therapy, Graduate School of Dongshin University, Republic of Korea. (2)Department of Physical Therapy, Vision University, Republic of Korea. (3)Department of Physical Therapy, Dongshin University Oriental Hospital, Republic of Korea. (4)Department of Physical Therapy, Cheongam College, Republic of Korea. [Purpose] This study investigated effects of sling exercise for patients with chronic low back pain. [Methods] We reviewed all relevant papers indexed in PubMed, SCOPUS, and the Cochrane Registered Trials. Eligible trials were randomized controlled trials that compared sling exercise with any type of treatment. We extracted data on muscle thickness, muscle activation, pain, and disability, and assessed the methodological quality of the data. Seven studies met our inclusion criteria. [Results] When sling exercise had an impact on activation of the trunk muscles, increasing the trunk muscle thickness, and the reduction in pain and disability had been assessed shortly after the final exercise session, it was more effective than general exercise at activating trunk muscles, but not more effective at increasing trunk muscle thickness and improving pain and disability than general exercise. [Conclusion] As sling therapy studies are based on a small number of trials, we cannot draw conclusions about the therapeutic effects of sling exercise. When segmental stabilizing exercise and individually designed programs are added to sling exercise, it increases the effectiveness of sling exercise at improving low back pain. This should be the focus of future studies. PMCID: PMC4155241 PMID: 25202202 [PubMed] 20. Br J Sports Med. 2015 Oct;49(20):1351. doi: 10.1136/bjsports-2014-093780. Epub 2014 Jul 31. Yoga for low back pain: PEDro systematic review update. Saragiotto BT(1), Yamato TP(1), Maher C(1). Author information: (1)Musculoskeletal Division, The George Institute for Global Heath, University of Sydney, Sydney, New South Wales, Australia. PMID: 25082615 [PubMed - in process] 21. Eur Spine J. 2014 Oct;23(10):2046-58. doi: 10.1007/s00586-014-3461-1. Epub 2014 Jul 29. Low back pain in children and adolescents: a systematic review and meta-analysis

evaluating the effectiveness of conservative interventions. Michaleff ZA(1), Kamper SJ, Maher CG, Evans R, Broderick C, Henschke N. Author information: (1)The George Institute for Global Health and Sydney Medical School, The University of Sydney, Kent Street, Sydney, 2000, Australia, zmichaleff@georgeinstitute.org.au. PURPOSE: To identify and evaluate the effectiveness of conservative treatment approaches used in children and adolescents to manage and prevent low back pain (LBP). METHODS: Five electronic databases and the reference lists of systematic reviews were searched for relevant studies. Randomised controlled trials (RCTs) were considered eligible for inclusion if they enrolled a sample of children or adolescents (<18 years old) and evaluated the effectiveness of any conservative intervention to treat or prevent LBP. Two authors independently screened search results, extracted data, assessed risk of bias using the PEDro scale, and rated the quality of evidence using the GRADE criteria. RESULTS: Four RCTs on intervention and eleven RCTs on prevention of LBP were included. All included studies had a high risk of bias scoring ≤7 on the PEDro scale. For the treatment of LBP, a supervised exercise program compared to no treatment improved the average pain intensity over the past month by 2.9 points (95 % CI 1.6-4.1) measured by a 0-10 scale (2 studies; n = 125). For the prevention of LBP, there was moderate quality evidence to suggest back education and promotion programs are not effective in reducing LBP prevalence in children and adolescents. CONCLUSIONS: While exercise interventions appear to be promising to treat LBP in children and adolescents, there is a dearth of research data relevant to paediatric populations. Future studies conducted in children and adolescents with LBP should incorporate what has been learnt from adult LBP research and be of rigorous methodological quality. PMID: 25070788 [PubMed - indexed for MEDLINE] 22. PLoS One. 2014 Jul 1;9(7):e100402. doi: 10.1371/journal.pone.0100402. eCollection 2014. The effectiveness of Pilates exercise in people with chronic low back pain: a systematic review. Wells C(1), Kolt GS(2), Marshall P(2), Hill B(3), Bialocerkowski A(4). Author information: (1)Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia; School of Science and Health, University of Western Sydney, Campbelltown, New South Wales, Australia. (2)School of Science and Health, University of Western Sydney, Campbelltown, New South Wales, Australia. (3)Epworth HealthCare, Richmond, Victoria, Australia. (4)Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia.

OBJECTIVE: To evaluate the effectiveness of Pilates exercise in people with chronic low back pain (CLBP) through a systematic review of randomised controlled trials (RCTs). DATA SOURCES: A search for RCTs was undertaken using Medical Search Terms and synonyms for "Pilates" and "low back pain" within the maximal date range of 10 databases. Databases included the Cumulative Index to Nursing and Allied Health Literature; Cochrane Library; Medline; Physiotherapy Evidence Database; ProQuest: Health and Medical Complete, Nursing and Allied Health Source, Dissertation and Theses; Scopus; Sport Discus; Web of Science. STUDY SELECTION: Two independent reviewers were involved in the selection of evidence. To be included, relevant RCTs needed to be published in the English language. From 152 studies, 14 RCTs were included. DATA EXTRACTION: Two independent reviewers appraised the methodological quality of RCTs using the McMaster Critical Review Form for Quantitative Studies. The author(s), year of publication, and details regarding participants, Pilates exercise, comparison treatments, and outcome measures, and findings, were then extracted. DATA SYNTHESIS: The methodological quality of RCTs ranged from "poor" to "excellent". A meta-analysis of RCTs was not undertaken due to the heterogeneity of RCTs. Pilates exercise provided statistically significant improvements in pain and functional ability compared to usual care and physical activity between 4 and 15 weeks, but not at 24 weeks. There were no consistent statistically significant differences in improvements in pain and functional ability with Pilates exercise, massage therapy, or other forms of exercise at any time period. CONCLUSIONS: Pilates exercise offers greater improvements in pain and functional ability compared to usual care and physical activity in the short term. Pilates exercise offers equivalent improvements to massage therapy and other forms of exercise. Future research should explore optimal Pilates exercise designs, and whether some people with CLBP may benefit from Pilates exercise more than others. PMCID: PMC4077575 PMID: 24984069 [PubMed - indexed for MEDLINE] 23. PLoS One. 2014 Jun 11;9(6):e99307. doi: 10.1371/journal.pone.0099307. eCollection 2014. Sling exercise for chronic low back pain: a systematic review and meta-analysis. Yue YS(1), Wang XD(2), Xie B(3), Li ZH(4), Chen BL(5), Wang XQ(5), Zhu Y(1). Author information: (1)Second School of Clinical Medical, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China. (2)Institute of Literature in Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China. (3)First School of Clinical Medical, Nanjing University of Chinese Medicine, Nanjing, Jiangsu, China. (4)Applied Health Science Department, University of Waterloo, Waterloo, Ontario, Canada. (5)Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China.

BACKGROUND: Trials on sling exercise (SE), commonly performed to manage chronic low back pain (LBP), yield conflicting results. This study aimed to review the effects of SE on chronic LBP. METHODS: The randomized controlled trials comparing SE with other treatments or no treatment, published up to August 2013, were identified by electronic searches. Primary outcomes were pain, function, and return to work. The weighted mean difference (WMD) and 95% confidence interval (CI) were calculated, using a random-effects model. RESULTS: Risk of bias was rated as high in 9 included trials, where some important quality components such as blinding were absent and sample sizes were generally small. We found no clinically relevant differences in pain or function between SE and other forms of exercise, traditional Chinese medical therapy, or in addition to acupuncture. Based on two trials, SE was more effective than thermomagnetic therapy at reducing pain (short-term: WMD -13.90, 95% CI -22.19 to -5.62; long-term: WMD -26.20, 95% CI -31.32 to -21.08) and improving function (short-term: WMD -10.54, 95% CI -14.32 to -6.75; long-term: WMD -25.75, 95% CI -30.79 to -20.71). In one trial we found statistically significant differences between SE and physical agents combined with drug therapy (meloxicam combined with eperisone hydrochloride) but of borderline clinical relevance for pain (short-term: WMD -15.00, 95% CI -19.64 to -10.36) and function (short-term: WMD -10.00; 95% CI -13.70 to -6.30). There was substantial heterogeneity among the two trials comparing SE and thermomagnetic therapy; both these trials and the trial comparing SE with physical agents combined with drug therapy had serious methodological limitations. INTERPRETATION: Based on limited evidence from 2 trials, SE was more effective for LBP than thermomagnetic therapy. Clinically relevant differences in effects between SE and other forms of exercise, physical agents combined with drug therapy, traditional Chinese medical therapy, or in addition to acupuncture could not be found. More high-quality randomized trials on the topic are warranted. PMCID: PMC4053356 PMID: 24919119 [PubMed - indexed for MEDLINE] 24. Sports Health. 2013 Nov;5(6):510-3. doi: 10.1177/1941738113502634. Core stabilization exercise prescription, part 2: a systematic review of motor control and general (global) exercise rehabilitation approaches for patients with low back pain. Brumitt J(1), Matheson JW(2), Meira EP(3). Author information: (1)School of Physical Therapy, Pacific University (Oregon), Hillsboro, Oregon. (2)Catalyst Sports Medicine, Hudson, Wisconsin. (3)Black Diamond Physical Therapy, Portland, Oregon. CONTEXT: Therapeutic exercises are frequently prescribed to patients with low back pain. Numerous exercise programs for patients with low back pain have been described. Many of these treatment programs are based on 1 of 2 popular rehabilitation strategies: a motor control exercise approach or a general

exercise approach. DATA SOURCES: PubMed clinical queries from 1966 to March 2013 for keyword combinations including motor control exercise, core stability exercise, therapeutic exercise, general exercise, global exercise, local exercise, transversus abdominis, segmental stabilization, and low back pain. STUDY SELECTION: Randomized controlled trials that assessed the effects of a motor control exercise approach, a general exercise approach, or both for patients with low back pain that were published in scientific peer-reviewed journals. DATA EXTRACTION: Included studies underwent appraisal for exercise intervention and outcomes. RESULTS: Fifteen studies were identified (8, motor control exercise approach without general exercise comparison; 7, general exercise approach with or without motor control exercise approach comparison). Current evidence suggests that exercise interventions may be effective at reducing pain or disability in patients with low back pain. CONCLUSION: Stabilization exercises for patients with low back pain may help to decrease pain and disability. It may not be necessary to prescribe exercises purported to restore motor control of specific muscles. PMCID: PMC3806182 PMID: 24427425 [PubMed] 25. Sports Health. 2013 May;5(3):225-32. doi: 10.1177/1941738113480936. Nonoperative treatment in lumbar spondylolysis and spondylolisthesis: a systematic review. Garet M(1), Reiman MP(1), Mathers J(1), Sylvain J(1). Author information: (1)Duke University Medical Center, Durham, North Carolina. CONTEXT: Both spondylolysis and spondylolisthesis can be diagnosed across the life span of sports-participating individuals. Determining which treatments are effective for these conditions is imperative to the rehabilitation professional. DATA SOURCES: A computer-assisted literature search was completed in MEDLINE, CINAHL, and EMBASE databases (1966-April 2012) utilizing keywords related to nonoperative treatment of spondylolysis and/or spondylolisthesis. Reference lists were also searched to find all relevant articles that fit our inclusion criteria: English language, human, lumbar pain with diagnosed spondylolysis and/or spondylolisthesis, inclusion of at least 1 nonoperative treatment method, and use of a comparative study design. DATA EXTRACTION: Data were independently extracted from the selected studies by 2 authors and cross-referenced. Any disagreement on relevant data was discussed and resolved by a third author. RESULTS: Ten studies meeting the criteria were rated for quality using the GRADE scale. Four studies found surgical intervention more successful than nonoperative treatment for treating pain and functional limitation. One study found no difference between surgery and nonoperative treatment with regard to future low

back pain. Improvement was found in bracing, bracing and exercises emphasizing lumbar extension, range of motion and strengthening exercises focusing on lumbar flexion, and strengthening specific abdominal and lumbar muscles. CONCLUSION: No consensus can be reached on the role of nonoperative versus surgical care because of limited investigation and heterogeneity of studies reported. Studies of nonoperative care options suffered from lack of blinding assessors and control groups and decreased patient compliance with exercise programs. PMCID: PMC3658408 PMID: 24427393 [PubMed] 26. Braz J Phys Ther. 2013 Nov-Dec;17(6):517-32. doi: 10.1590/S1413-35552012005000127. Efficacy of the Pilates method for pain and disability in patients with chronic nonspecific low back pain: a systematic review with meta-analysis. [Article in English, Portuguese] Miyamoto GC(1), Costa LO(1), Cabral CM(1). Author information: (1)Universidade Cidade de São Paulo, São PauloSP, Brazil. OBJECTIVE: To systematically review the available evidence on the efficacy of the Pilates method in patients with chronic nonspecific low back pain. METHOD: Searches were performed in MEDLINE, EMBASE, PEDro, SciELO, LILACS, CINAHL and CENTRAL in March 2013. Randomized controlled trials that tested the effectiveness of the Pilates method (against a nontreatment group, minimal intervention or other types of interventions) in adults with chronic low back pain were included regardless the language of publication. The outcome data were extracted from the eligible studies and were combined using a meta-analysis approach. RESULTS: The searches identified a total of 1,545 articles. From these, eight trials were considered eligible, and seven trials were combined in the meta-analysis. The comparison groups were as follows: Pilates versus other types of exercises (n=2 trials), and Pilates versus no treatment group or minimal intervention (n=4 trials) for short term pain; Pilates versus minimal intervention for short-term disability (n=4).We determined that Pilates was not better than other types of exercises for reducing pain intensity. However, Pilates was better than a minimal intervention for reducing short-term pain and disability (pain: pooled mean difference=1.6 points; 95% CI 1.4 to 1.8; disability: pooled mean difference=5.2 points; 95% CI 4.3 to 6.1). CONCLUSIONS: Pilates was better than a minimal intervention for reducing pain and disability in patients with chronic low back pain. Pilates was not better than other types of exercise for short-term pain reduction. PMCID: PMC4207151 PMID: 24346291 [PubMed - indexed for MEDLINE]

27. Spine J. 2013 Dec;13(12):1940-50. doi: 10.1016/j.spinee.2013.08.027. Epub 2013 Oct 26. Individual and intervention-related factors associated with adherence to home exercise in chronic low back pain: a systematic review. Beinart NA(1), Goodchild CE, Weinman JA, Ayis S, Godfrey EL. Author information: (1)Division of Health and Social Care Research, School of Medicine, King's College London, 7th Floor Capital House, 42 Weston St, London SE1 3QD, UK. Electronic address: naomi.beinart@kcl.ac.uk. BACKGROUND CONTEXT: Exercise has been shown to reduce pain and increase function in patients with chronic low back pain. However up to 70% of patients do not engage in prescribed home exercise. Physiotherapists need to understand more about the complex factors influencing patients' adherence to prescribed home exercise to tailor their exercise interventions more effectively and support patients to self-manage. PURPOSE: This review identifies factors associated with adherence to health care practitioner-prescribed home exercise in adults with chronic low back pain. STUDY DESIGN: Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used for the reporting of this review. PATIENT SAMPLE: We explored literature in which the authors studied adherence to home exercise in adults with CLBP. OUTCOME MEASURES: Adherence to home exercise was the primary outcome. Additional outcome measures were recorded in the data extraction table. METHODS: The following databases were searched: Embase, PsychINFO, MEDLINE, PEDro, and the Cochrane Central Register of Controlled Trials. Data were independently extracted and assessed for methodologic quality by two reviewers. RESULTS: Eleven randomized controlled trials, including 1,088 participants, met the inclusion criteria. Moderate evidence was found for one individual patient subfactor and three intervention-related subfactors associated with increased adherence to home exercise. These subfactors were greater health locus of control, supervision, participation in an exercise program, and participation in a general behavior change program incorporating motivational strategies. CONCLUSIONS: This is the first systematic review investigating adherence to prescribed home exercise in a chronic low back pain population. It is difficult to draw firm conclusions because the research lacks detailed descriptions of intervention content. The use of a taxonomy of behavior change techniques has been suggested to overcome this key problem. This review has highlighted the lack of standardized measures of adherence to prescribed home exercise. The development of a validated measure of adherence should be a priority because this will provide a better understanding of the multitude of factors that may influence adherence to home exercise. Copyright © 2013 Elsevier Inc. All rights reserved. PMID: 24169445 [PubMed - indexed for MEDLINE]

28. Clin J Pain. 2014 Nov;30(11):995-1005. doi: 10.1097/AJP.0000000000000044. What are patient beliefs and perceptions about exercise for nonspecific chronic low back pain? A systematic review of qualitative studies. Slade SC(1), Patel S, Underwood M, Keating JL. Author information: (1)*Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia †Warwick Medical School, Clinical Trials Unit, Coventry, UK. OBJECTIVES: The global burden of low back pain is the highest ranked condition contributing to years of living with disability. Exercise is moderately effective, and adherence to exercise may improve if participants are engaged. Identification of elements that enhance engagement would enable clinicians to prescribe appropriate interventions. The review objective was to identify and synthesize qualitative empirical studies that have explored beliefs about exercise therapy of people with nonspecific chronic low back pain. METHODS: Two independent reviewers conducted a structured review and metasynthesis informed by Cochrane and Campbell Collaboration guidelines and the PRISMA statement. Fifteen papers were included for data extraction, method quality assessment, and thematic analysis. RESULTS: Four key themes emerged: (1) perceptions and classification of exercise; (2) role and impact of the health professional; (3) exercise and activity enablers/facilitators; (4) exercise and activity barriers. Participants believed that there were distinctions between general activity, real/fitness exercise, and medical exercise. Levels of acquired skills and capability and participant experience with exercise culture require consideration in program design. People participating in exercise classes and group work may be more comfortable when matched for abilities and experience. When an intervention interferes with everyday life and appears to be ineffective or too difficult to implement, people make a reasoned decision to discontinue. DISCUSSION: People are likely to prefer and participate in exercise or training programs and activities that are designed with consideration of their preferences, circumstances, fitness levels, and exercise experiences. PMID: 24300225 [PubMed - indexed for MEDLINE] 29. BMC Med Res Methodol. 2013 Jan 19;13:7. doi: 10.1186/1471-2288-13-7. Effectiveness of Pilates exercise in treating people with chronic low back pain: a systematic review of systematic reviews. Wells C(1), Kolt GS, Marshall P, Hill B, Bialocerkowski A. Author information: (1)School of Science and Health, University of Western Sydney, Locked Bag 1797, Penrith, NSW, 2751, Australia. c.wells@uws.edu.au

BACKGROUND: Systematic reviews provide clinical practice recommendations that are based on evaluation of primary evidence. When systematic reviews with the same aims have different conclusions, it is difficult to ascertain which review reported the most credible and robust findings. METHODS: This study examined five systematic reviews that have investigated the effectiveness of Pilates exercise in people with chronic low back pain. A four-stage process was used to interpret findings of the reviews. This process included comparison of research questions, included primary studies, and the level and quality of evidence of systematic reviews. Two independent reviewers assessed the level of evidence and the methodological quality of systematic reviews, using the National Health and Medical Research Council hierarchy of evidence, and the Revised Assessment of Multiple Systematic Reviews respectively. Any disagreements were resolved by a third researcher. RESULTS: A high level of consensus was achieved between the reviewers. Conflicting findings were reported by the five systematic reviews regarding the effectiveness of Pilates in reducing pain and disability in people with chronic low back pain. Authors of the systematic reviews included primary studies that did not match their questions in relation to treatment or population characteristics. A total of ten primary studies were identified across five systematic reviews. Only two of the primary studies were included in all of the reviews due to different inclusion criteria relating to publication date and status, definition of Pilates, and methodological quality. The level of evidence of reviews was low due to the methodological design of the primary studies. The methodological quality of reviews varied. Those which conducted a meta-analysis obtained higher scores. CONCLUSION: There is inconclusive evidence that Pilates is effective in reducing pain and disability in people with chronic low back pain. This is due to the small number and poor methodological quality of primary studies. The Revised Assessment of Multiple Systematic Reviews provides a useful method of appraising the methodological quality of systematic reviews. Individual item scores, however, should be examined in addition to total scores, so that significant methodological flaws of systematic reviews are not missed, and results are interpreted appropriately. (348 words). PMCID: PMC3563510 PMID: 23331384 [PubMed - indexed for MEDLINE] 30. PLoS One. 2012;7(12):e52082. doi: 10.1371/journal.pone.0052082. Epub 2012 Dec 17. A meta-analysis of core stability exercise versus general exercise for chronic low back pain. Wang XQ(1), Zheng JJ, Yu ZW, Bi X, Lou SJ, Liu J, Cai B, Hua YH, Wu M, Wei ML, Shen HM, Chen Y, Pan YJ, Xu GH, Chen PJ. Author information: (1)Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China.

OBJECTIVE: To review the effects of core stability exercise or general exercise for patients with chronic low back pain (LBP). SUMMARY OF BACKGROUND DATA: Exercise therapy appears to be effective at decreasing pain and improving function for patients with chronic LBP in practice guidelines. Core stability exercise is becoming increasingly popular for LBP. However, it is currently unknown whether core stability exercise produces more beneficial effects than general exercise in patients with chronic LBP. METHODS: Published articles from 1970 to October 2011 were identified using electronic searches. For this meta-analysis, two reviewers independently selected relevant randomized controlled trials (RCTs) investigating core stability exercise versus general exercise for the treatment of patients with chronic LBP. Data were extracted independently by the same two individuals who selected the studies. RESULTS: From the 28 potentially relevant trials, a total of 5 trials involving 414 participants were included in the current analysis. The pooling revealed that core stability exercise was better than general exercise for reducing pain [mean difference (-1.29); 95% confidence interval (-2.47, -0.11); P = 0.003] and disability [mean difference (-7.14); 95% confidence interval (-11.64, -2.65); P = 0.002] at the time of the short-term follow-up. However, no significant differences were observed between core stability exercise and general exercise in reducing pain at 6 months [mean difference (-0.50); 95% confidence interval (-1.36, 0.36); P = 0.26] and 12 months [mean difference (-0.32); 95% confidence interval (-0.87, 0.23); P = 0.25]. CONCLUSIONS: Compared to general exercise, core stability exercise is more effective in decreasing pain and may improve physical function in patients with chronic LBP in the short term. However, no significant long-term differences in pain severity were observed between patients who engaged in core stability exercise versus those who engaged in general exercise. SYSTEMATIC REVIEW REGISTRATION: http://www.crd.york.ac.uk/PROSPERO PROSPERO registration number: CRD42011001717. PMCID: PMC3524111 PMID: 23284879 [PubMed - indexed for MEDLINE] 31. Physiother Theory Pract. 2013 Aug;29(6):419-31. doi: 10.3109/09593985.2012.748114. Epub 2012 Dec 17. Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: a systematic review. Ferreira CW(1), Alburquerque-Sendı N F. Author information: (1)Physiotherapy Department , Universidade Federal de Pernambuco , Recife, PE , Brazil. caroline.wanderley@ufpe.br The aim of this work was to investigate the effectiveness of physical therapy for the treatment of low back pain (LBP) and pelvic girdle pain (PGP) related to pregnancy after delivery. A systematic review of studies published since 1985 in the databases Medline, PEDro, SciELO, SCOPUS, LILACS, and the Cochrane Library

was made. Studies that focused on postpartum LBP or PGP, without being related to pregnancy or in other non-pregnant patients, were excluded, as were papers addressing LBP or PGP indicating radiculopathy, rheumatism, or any other serious disease or pathologic condition. In accordance with the exclusion criteria and duplicate articles, of the 105 articles retrieved only six were considered for quality assessment with the PEDro Scale. Among these six papers, two were follow-ups, such that only four trials were included in this review. All trials used exercise for motor control and stability of the lumbopelvic region, but with different intervention approaches. The study affording the best evidence used individual guidance and adjustments given by the physiotherapists. Nevertheless, this systematic review was inconclusive and showed that more randomized clinical trials, with good quality, are needed. PMID: 23244038 [PubMed - indexed for MEDLINE] 32. Eur J Phys Rehabil Med. 2012 Sep;48(3):361-70. Epub 2012 Jul 23. A systematic review on the effectiveness of medical training therapy for subacute and chronic low back pain. Scharrer M(1), Ebenbichler G, Pieber K, Crevenna R, Gruther W, Zorn C, Grimm-Stieger M, Herceg M, Keilani M, Ammer K. Author information: (1)St Anna's Children Hospital, Vienna, Austria. Medical training therapy (MTT) to improve muscular strength and endurance follows evidence based guidelines and is increasingly recommended to patients suffering from subacute and chronic back pain (LBP). This study investigated whether MTT was effective in reducing pain and improving function in patients with subacute or chronic LBP. Data sources were MEDLINE, EMBASE, CINAHL, Pedro, Cochrane Central Register of Controlled Trials. We included RCTs that examined exercise or MTT in adult patients with LBP compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: pain intensity; functional status, absenteeism. Two independent reviewers performed quality assessment. Visual analogue scale ratings ranging from 0-10 MTT quantified the MTT aspects of the intervention. Studies with rating scores >7.5 were included. We identified only 2 studies that examined the effectiveness of MTT. Both trials, one was of high quality, found MTT to decrease pain and improve function significantly better than therapy of uncertain effectiveness. There is moderate evidence that would support the effectiveness of MTT in the treatment chronic LBP. Future high quality RCT will have to clarify whether MTT is effective and would be superior to other forms of therapeutic exercise. PMID: 22820818 [PubMed - indexed for MEDLINE] 33. Acta Obstet Gynecol Scand. 2012 Sep;91(9):1038-45. doi: 10.1111/j.1600-0412.2012.01462.x. Epub 2012 Jul 2.

Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review. Richards E(1), van Kessel G, Virgara R, Harris P. Author information: (1)School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia. OBJECTIVE: A systematic review was undertaken to update the understanding of the available evidence for antenatal physical therapy interventions for low back or pelvic pain in pregnant women to improve functional outcomes when compared with other treatments or no treatment. DATA SOURCES: Seven electronic databases were systematically searched and supplemented by hand searching through reference lists. METHODS OF STUDY SELECTION: Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials using the Clinical Appraisal Skills Program tool. RESULTS: Four trials with 566 participants were identified that met the inclusion criteria. The validity of the trials was moderate. Exercise, pelvic support garments and acupuncture were found to improve functional outcomes in pregnant women with low back or pelvic pain. No meta-analysis was performed because of the heterogeneity of functional outcome measures. CONCLUSIONS: While there is some evidence that physical therapy using exercise, acupuncture and pelvic supports may be useful, further research needs to consider other treatment modalities used by physical therapists and establish an appropriate, reliable and valid functional outcome measure to assess low back and pelvic pain in pregnancy. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 22583125 [PubMed - indexed for MEDLINE] 34. Disabil Rehabil. 2012;34(13):1070-6. doi: 10.3109/09638288.2011.631682. Epub 2011 Dec 10. The effectiveness of graded activity in patients with non-specific low-back pain: a systematic review. van der Giessen RN(1), Speksnijder CM, Helders PJ. Author information: (1)Department of Physiotherapy Science, Clinical Health Sciences, Utrecht University, Utrecht, The Netherlands. BACKGROUND: Non-specific low-back pain (LBP) is considered a major health and economic problem in Western society. Nowadays a common used intervention on non-specific LBP is graded activity (GA). Graded Activity developed by Lindström et al., consisted of four parts: (i) measurements of functional capacity; (ii) a

work-place visit; (iii) back school education and (iv) an individual, sub-maximal, gradually increased exercise program with an operant-conditioning behavioural approach as described by Fordyce et al. OBJECTIVE: To evaluate the effectiveness of GA in adults with non-specific LBP on pain, disabilities and return to work. DATA SOURCES: An extensive literature search of PubMed, Embase, CINAHL and The Cochrane Library was conducted in July 2011. REVIEW METHODS: Randomized controlled trials (RCTs) evaluating the effect of GA in patients with non-specific LBP were eligible. Methodological quality of the studies was assessed according to the PEDro scale. A best-evidence synthesis was conducted according to van Peppen et al. to interpret the outcomes of the included studies. RESULTS: Ten articles were included in this systematic review; these articles described five RCTs (680 patients). The best-evidence synthesis revealed that there was no or insufficient evidence for a positive effect of GA on pain, disabilities and return to work in patients with non-specific LBP. CONCLUSION: Currently there is no or insufficient evidence that GA results in better outcomes of patients with non-specific LBP. © 2012 Informa UK, Ltd. PMID: 22148906 [PubMed - indexed for MEDLINE] 35. Eur Spine J. 2012 Apr;21(4):575-98. doi: 10.1007/s00586-011-2045-6. Epub 2011 Nov 10. Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review. Steiger F(1), Wirth B, de Bruin ED, Mannion AF. Author information: (1)Institute of Human Movement Sciences and Sport, ETH Zürich, Zurich, Switzerland. Comment in Eur Spine J. 2012 Sep;21(9):1887; author reply 1888-9. INTRODUCTION: The effect size for exercise therapy in the treatment of chronic non-specific low back pain (cLBP) is only modest. This review aims to analyse the specificity of the effect by examining the relationship between the changes in clinical outcome (pain, disability) and the changes in the targeted aspects of physical function (muscle strength, mobility, muscular endurance) after exercise therapy. METHODS: We searched for exercise therapy trials for cLBP published up to 15 April 2010 in Medline, Embase, Cochrane Library, Cinahl, and PEDro. Two independent reviewers selected studies according to the inclusion criteria. DATA EXTRACTION: one author extracted the data of the articles. RESULTS:

DATA SYNTHESIS: 16 studies with a total of 1,476 participants met the inclusion criteria. There was little evidence supporting a relationship between the changes in pain or physical function and the changes in performance for the following measures: mobility (no correlation in 9 studies, weak correlation in 1 study), trunk extension strength (7 and 2, respectively), trunk flexion strength (4 and 1, respectively) and back muscle endurance (7 and 0, respectively). Changes in disability showed no correlation with changes in mobility in three studies and a weak correlation in two; for strength, the numbers were four (no correlation) and two (weak correlation), respectively. CONCLUSIONS: The findings do not support the notion that the treatment effects of exercise therapy in cLBP are directly attributable to changes in the musculoskeletal system. Future research aimed at increasing the effectiveness of exercise therapy in cLBP should explore the coincidental factors influencing symptom improvement. PMCID: PMC3326132 PMID: 22072093 [PubMed - indexed for MEDLINE] 36. Ger Med Sci. 2011;9:Doc19. doi: 10.3205/000142. Epub 2011 Aug 9. Climbing for preventing and treating health problems: a systematic review of randomized controlled trials. Buechter RB(1), Fechtelpeter D. Author information: (1)Institute for Quality and Efficiency in Health Care (IQWiG), Köln, Germany. roland.buechter@iqwig.de OBJECTIVE: To summarize the best available evidence on effectiveness of therapeutic or sport climbing in preventing or treating health problems. METHODS: We searched Medline, Embase, CENTRAL, PsycINFO, PEDro, OTseeker and SportDiscus for randomized controlled trials published up to December 26, 2010. We included all trials assessing patient-relevant outcomes. Two reviewers independently selected relevant studies, assessed their methodological quality and extracted data. Quality of evidence was rated using the GRADE system. Data were entered into RevMan 5 to calculate effect sizes and 95% confidence intervals where appropriate. RESULTS: Eligible for inclusion were four RCTs studying the effectiveness of climbing in (a) geriatric patients, (b) adults with multiple sclerosis, (c) adults with chronic low-back pain and (d) children with disabilities and poor motor function. The sample sizes ranged between 20 and 95. All trials had major methodological limitations. We found very low quality evidence that therapeutic climbing may improve activities of daily living in geriatric patients compared to physiotherapy as measured by the Barthel index (difference in mean change score: 2.32 [95%-CI: 0.45 to 4.19]). We found very low quality evidence that therapeutic climbing compared to standard exercise therapy may improve physical functioning (difference in mean change score: 16.15 [95%-CI: 4.45 to 27.85]) and general physical health (13.14 [95%-CI: 3.61 to 22.67]) as measured by the SF-36 in adults with chronic low back-pain.

CONCLUSIONS: Evidence for the effectiveness of therapeutic climbing is limited to small trials at high risk of bias. The effects of therapeutic climbing are therefore unclear. PMCID: PMC3158649 PMID: 21863133 [PubMed - indexed for MEDLINE] 37. Clin Rehabil. 2012 Jan;26(1):10-20. doi: 10.1177/0269215511411113. Epub 2011 Aug 19. Comparing the Pilates method with no exercise or lumbar stabilization for pain and functionality in patients with chronic low back pain: systematic review and meta-analysis. Pereira LM(1), Obara K, Dias JM, Menacho MO, Guariglia DA, Schiavoni D, Pereira HM, Cardoso JR. Author information: (1)MSc Programme in Physical Education, Universidade Estadual de Londrina-UEM, Londrina, Brazil. OBJECTIVE: To perform a systematic review with meta-analyses that evaluates the effectiveness of the Pilates method on the pain and functionality outcome in adults with non-specific chronic low back pain. DATA SOURCES: The search was performed in the following databases: Medline, Embase, AMED, Cinahl, Lilacs, Scielo, SportDiscus, ProQuest, Web of Science, PEDro, Academic Search Premier and the Cochrane Central Register of Controlled Trials from 1950 to 2011; the following keywords were used: 'Pilates', 'Pilates-based', 'back exercises', 'exercise therapy', 'low back pain', 'back pain' and 'backache'. REVIEW METHODS: The inclusion criteria were studies that assessed the effects of the Pilates method on patients with chronic low back pain. RESULTS: Five studies met the inclusion criteria. The total number of patients was 71 in the Pilates group and 68 in the control group. Pilates exercise did not improve functionality (standardized mean difference (SMD = -1.34; 95% confidence interval (CI) -2.80, 0.11; P = 0.07) or pain between Pilates and control groups (SMD = -1.99; 95% CI -4.35, 0.37; P = 0.10). Pilates and lumbar stabilization exercises presented no significant difference in functionality (mean difference (MD) = -0.31; 95% CI -1.02, 0.40; P = 0.39) or pain (MD = -0.31; 95% CI -1.02, 0.40; P = 0.39). CONCLUSION: The Pilates method did not improve functionality and pain in patients who have low back pain when compared with control and lumbar stabilization exercise groups. PMID: 21856719 [PubMed - indexed for MEDLINE] 38. Eur Spine J. 2011 Jun;20(6):826-45. doi: 10.1007/s00586-010-1680-7. Epub 2011 Jan 9.

Physical activity and low back pain: a systematic review of recent literature. Heneweer H(1), Staes F, Aufdemkampe G, van Rijn M, Vanhees L. Author information: (1)Research Department Lifestyle and Health, University of Applied Sciences, PO Box 85182, 3508 AD Utrecht, The Netherlands. Hans.Heneweer@hu.nl The objective of the study is to systematically evaluate the available evidence on the association between physical activity (i.e. occupational load and non-occupational physical activities) and low back pain (LBP). A systematic approach was used to explore the literature between 1999 and 2009. Studies were selected for inclusion following a comprehensive search of Medline, Embase and CINAHL. The methodological quality of each study was assessed. Studies were considered to be of 'high quality' if they met the cut-off criterion of 60% of the maximum available quality score. Thirty-six cohort or case-control studies were retrieved. Heavy workload and the accumulation of loads or frequency of lifts were moderate to strong risk factors for LBP. Strong associations were found for flexed, rotated and the awkward positions of the lumbar spine. Inconsistent results were found for leisure time physical activities, sports and physical exercise. Studies focusing on daily habitual physical activities (e.g. domestic activities and commuting) in association with LBP are lacking. In conclusion, the occurrence of LBP is related to the nature and intensity of the physical activities undertaken. However, physical activities can be subdivided into separate types and intensities and the ultimate physical load is the sum of all these activities. This makes it difficult to designate one particular activity as the cause of LBP. PMCID: PMC3099170 PMID: 21221663 [PubMed - indexed for MEDLINE] 39. Eur Spine J. 2011 Mar;20(3):464-74. doi: 10.1007/s00586-010-1616-2. Epub 2010 Nov 4. The relationship between physical activity and low back pain outcomes: a systematic review of observational studies. Hendrick P(1), Milosavljevic S, Hale L, Hurley DA, McDonough S, Ryan B, Baxter GD. Author information: (1)Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, PO Box 56, Dunedin, New Zealand. paul.hendrick@otago.ac.nz Although clinical guidelines advocate exercise and activity in the management of non-specific low back pain (NSLBP), the link between levels of physical activity and outcomes is unclear. This systematic review investigated the relationships between free living activity levels after onset of low back pain (LBP) and measures of pain, and disability in patients with NSLBP. Cohort and cross-sectional studies were located using OVID, CINAHL, Medline, AMED, Embase,

Biomed, PubMed-National Library of Medicine, Proquest and Cochrane Databases, and hand searches of reference lists. Studies were included if a statistical relationship was investigated between measures of free living physical activity (PA) in subjects with LBP and LBP outcome measures. Twelve studies (seven cohort and five cross-sectional) were included. One prospective study reported a statistically significant relationship between increased leisure time activity and improved LBP outcomes, and one cross-sectional study found that lower levels of sporting activity were associated with higher levels of pain and disability. All other studies (n = 10) found no relationship between measures of activity levels and either pain or disability. Heterogeneity of study designs, particularly in terms of activity measurement, made comparisons between studies difficult. These data suggest that the activity levels of patients with NSLBP are neither associated with, nor predictive of, disability or pain levels. Validated activity measurement in prospective research is required to better evaluate the relationships between PA and LBP. PMCID: PMC3048226 PMID: 21053026 [PubMed - indexed for MEDLINE] 40. J Orthop Sports Phys Ther. 2011 Feb;41(2):70-80. doi: 10.2519/jospt.2011.3393. Epub 2010 Oct 22. Effects of Pilates-based exercises on pain and disability in individuals with persistent nonspecific low back pain: a systematic review with meta-analysis. Lim EC(1), Poh RL, Low AY, Wong WP. Author information: (1)Department of Physiotherapy, Singapore General Hospital, Singapore. edwin.lim.c.w@sgh.com.sg STUDY DESIGN: A systematic review with meta-analysis. OBJECTIVES: To compare pain and disability in individuals with persistent nonspecific low back pain who were treated with Pilates exercises compared to minimal or other interventions. METHODS: Searches of Medline, CINAHL, Embase, Cochrane library, PEDro, and ProQuest Dissertations and Thesis databases were conducted. Randomized controlled trials (RCTs) were selected and reviewed if they compared pain and disability in individuals with persistent nonspecific low back pain who were treated with Pilates exercises compared to other treatment approaches. Quality of the trials was evaluated. Data for pain and disability scores were extracted. Narrative synthesis plus meta-analyses were performed, with either a fixed-effects or random-effects model, standardized mean differences (SMDs), and tests for heterogeneity. RESULTS: Seven RCTs were identified and included in the meta-analyses. Data pooling was performed using RevMan 5. When compared to minimal intervention, Pilates-based exercise provided superior pain relief (pooled SMD, -2.72; 95% CI: -5.33, -0.11; P = .04) but the pooled disability scores were not significantly different (pooled SMD, -0.74; 95% CI: -1.81, 0.33;P = .17). No significant differences were found when comparing Pilates-based exercise to other forms of

exercise for pain (pooled SMD, 0.03; 95% CI: -0.52, 0.58; P = .92) or disability scores (pooled SMD, -0.41; 95% CI: -0.96, 0.14; P = .14). CONCLUSION: Pilates-based exercises are superior to minimal intervention for pain relief. Existing evidence does not establish superiority of Pilates-based exercise to other forms of exercise to reduce pain and disability for patients with persistent nonspecific low back pain. However, the relatively low quality of existing studies and the heterogeneity of pooled studies in this systematic review combine to suggest that these results should be interpreted with caution. LEVEL OF EVIDENCE: Therapy, level 1a. PMID: 20972339 [PubMed - indexed for MEDLINE] 41. Eur Spine J. 2011 Jan;20(1):19-39. doi: 10.1007/s00586-010-1518-3. Epub 2010 Jul 18. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. van Middelkoop M(1), Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW, van Tulder MW. Author information: (1)Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, The Netherlands. m.vanmiddelkoop@erasmusmc.nl Low back pain (LBP) is a common and disabling disorder in western society. The management of LBP comprises a range of different intervention strategies including surgery, drug therapy, and non-medical interventions. The objective of the present study is to determine the effectiveness of physical and rehabilitation interventions (i.e. exercise therapy, back school, transcutaneous electrical nerve stimulation (TENS), low level laser therapy, education, massage, behavioural treatment, traction, multidisciplinary treatment, lumbar supports, and heat/cold therapy) for chronic LBP. The primary search was conducted in MEDLINE, EMBASE, CINAHL, CENTRAL, and PEDro up to 22 December 2008. Existing Cochrane reviews for the individual interventions were screened for studies fulfilling the inclusion criteria. The search strategy outlined by the Cochrane Back Review Groups (CBRG) was followed. The following were included for selection criteria: (1) randomized controlled trials, (2) adult (≥ 18 years) population with chronic (≥ 12 weeks) non-specific LBP, and (3) evaluation of at least one of the main clinically relevant outcome measures (pain, functional status, perceived recovery, or return to work). Two reviewers independently selected studies and extracted data on study characteristics, risk of bias, and outcomes at short, intermediate, and long-term follow-up. The GRADE approach was used to determine the quality of evidence. In total 83 randomized controlled trials met the inclusion criteria: exercise therapy (n = 37), back school (n = 5), TENS (n = 6), low level laser therapy (n = 3), behavioural treatment (n = 21), patient education (n = 1), traction (n = 1), and multidisciplinary treatment (n = 6). Compared to usual care, exercise therapy improved post-treatment pain intensity and disability, and long-term function. Behavioural treatment was found to be effective in reducing pain intensity at short-term follow-up compared to no

treatment/waiting list controls. Finally, multidisciplinary treatment was found to reduce pain intensity and disability at short-term follow-up compared to no treatment/waiting list controls. Overall, the level of evidence was low. Evidence from randomized controlled trials demonstrates that there is low quality evidence for the effectiveness of exercise therapy compared to usual care, there is low evidence for the effectiveness of behavioural therapy compared to no treatment and there is moderate evidence for the effectiveness of a multidisciplinary treatment compared to no treatment and other active treatments at reducing pain at short-term in the treatment of chronic low back pain. Based on the heterogeneity of the populations, interventions, and comparison groups, we conclude that there are insufficient data to draw firm conclusion on the clinical effect of back schools, low-level laser therapy, patient education, massage, traction, superficial heat/cold, and lumbar supports for chronic LBP. PMCID: PMC3036018 PMID: 20640863 [PubMed - indexed for MEDLINE] 42. J Rehabil Med. 2010 Mar;42(3):193-205. doi: 10.2340/16501977-0524. Effectiveness of exercise on work disability in patients with non-acute non-specific low back pain: Systematic review and meta-analysis of randomised controlled trials. Oesch P(1), Kool J, Hagen KB, Bachmann S. Author information: (1)Research Department, Rehabilitation Centre Valens, Valens, Switzerland. p.oesch@klinik-valens.ch OBJECTIVES: To determine whether exercise is more effective than usual care to reduce work disability in patients with non-acute non-specific low back pain, and if so, to explore which type of exercise is most effective. METHODS: Systematic review and meta-analysis of randomized controlled trials investigating the effectiveness of exercise in non-acute non-specific low back pain, and reporting on work disability. DATA SOURCES: MEDLINE, EMBASE, PEDro, Cochrane Library databases, NIOSHTIC-2, and PsycINFO until August 2008. Work disability data were converted to odds ratios. Random effects meta-analyses were conducted. RESULTS: A total of 23 trials met the inclusion criteria, 20 of which were suitable for inclusion in meta-analysis allowing 17 comparisons of exercise interventions with usual care and 11 comparisons of 2 different exercise interventions. A statistically significant effect in favour of exercise on work disability was found in the long term (odds ratio (OR) = 0.66, 95% confidence interval (CI) 0.48-0.92) but not in the short (OR = 0.80, 95% CI 0.51-1.25) and intermediate term (OR = 0.78, 95% CI 0.45-1.34). Meta-regression indicated no significant effect of specific exercise characteristics. CONCLUSION: Exercise interventions have a significant effect on work disability in patients with non-acute non-specific low back pain in the long term. No conclusions can be made regarding exercise types.

PMID: 20411212 [PubMed - indexed for MEDLINE] 43. Phys Ther. 2010 Jun;90(6):860-79. doi: 10.2522/ptj.20090303. Epub 2010 Apr 15. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Macedo LG(1), Smeets RJ, Maher CG, Latimer J, McAuley JH. Author information: (1)University of Sydney, PO Box M201, Missenden Rd, Camperdown, New South Wales 2050, Australia. lmacedo@george.org.au BACKGROUND: Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood. PURPOSE: The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain. DATA SOURCES: Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10). STUDY SELECTION: Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study. DATA EXTRACTION: Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews. RESULTS: are presented as weighted mean differences with 95% confidence intervals. DATA SYNTHESIS: Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3-9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were -6.2 (-9.4 to -3.0), -5.5 (-9.9 to -1.0), -6.5 (-10.1 to -3.0), and -3.9 (-7.4 to -0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant. LIMITATIONS: Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies. CONCLUSIONS: The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain. PMID: 20395306 [PubMed - indexed for MEDLINE]

44. BMC Med. 2010 Apr 8;8:22. doi: 10.1186/1741-7015-8-22. Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review. Kent P(1), Mjøsund HL, Petersen DH. Author information: (1)Spine Centre of Southern Denmark, Ringe, Denmark. peter.kent@slb.regionsyddanmark.dk BACKGROUND: A central element in the current debate about best practice management of non-specific low back pain (NSLBP) is the efficacy of targeted versus generic (non-targeted) treatment. Many clinicians and researchers believe that tailoring treatment to NSLBP subgroups positively impacts on patient outcomes. Despite this, there are no systematic reviews comparing the efficacy of targeted versus non-targeted manual therapy and/or exercise. This systematic review was undertaken in order to determine the efficacy of such targeted treatment in adults with NSLBP. METHOD: MEDLINE, EMBASE, Current Contents, AMED and the Cochrane Central Register of Controlled Trials were electronically searched, reference lists were examined and citation tracking performed. Inclusion criteria were randomized controlled trials of targeted manual therapy and/or exercise for NSLPB that used trial designs capable of providing robust information on targeted treatment (treatment effect modification) for the outcomes of activity limitation and pain. Included trials needed to be hypothesis-testing studies published in English, Danish or Norwegian. Method quality was assessed using the criteria recommended by the Cochrane Back Review Group. RESULTS: Four high-quality randomized controlled trials of targeted manual therapy and/or exercise for NSLBP met the inclusion criteria. One study showed statistically significant effects for short-term outcomes using McKenzie directional preference-based exercise. Research into subgroups requires much larger sample sizes than traditional two-group trials and other included studies showed effects that might be clinically important in size but were not statistically significant with their samples sizes. CONCLUSIONS: The clinical implications of these results are that they provide very cautious evidence supporting the notion that treatment targeted to subgroups of patients with NSLBP may improve patient outcomes. The results of the studies included in this review are too patchy, inconsistent and the samples investigated are too small for any recommendation of any treatment in routine clinical practice to be based on these findings. The research shows that adequately powered controlled trials using designs capable of providing robust information on treatment effect modification are uncommon. Considering how central the notion of targeted treatment is to manual therapy principles, further studies using this research method should be a priority for the clinical and research communities. PMCID: PMC2873245 PMID: 20377854 [PubMed - indexed for MEDLINE]

45. Br J Sports Med. 2010 Nov;44(14):1054-62. doi: 10.1136/bjsm.2009.063289. Epub 2009 Dec 8. Integration of subclassification strategies in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for non-specific chronic low back pain: a systematic review. Fersum KV(1), Dankaerts W, O'Sullivan PB, Maes J, Skouen JS, Bjordal JM, Kvåle A. Author information: (1)Section for Physiotherapy Science, Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway. kjartan.fersum@isf.uib.no BACKGROUND: There is lack of evidence for specific treatment interventions for patients with non-specific chronic low back pain (NSCLBP) despite the substantial amount of randomised controlled clinical trials evaluating treatment outcome for this disorder. HYPOTHESIS: It has been hypothesised that this vacuum of evidence is caused by the lack of subclassification of the heterogeneous population of patients with chronic low back pain for outcome research. STUDY DESIGN: A systematic review. METHODS: A systematic review with a meta-analysis was undertaken to determine the integration of subclassification strategies with matched interventions in randomised controlled clinical trials evaluating manual therapy treatment and exercise therapy for NSCLBP. A structured search for relevant studies in Embase, Cinahl, Medline, PEDro and the Cochrane Trials Register database, followed by hand searching all relevant studies in English up to December 2008. RESULTS: Only 5 of 68 studies (7.4%) subclassified patients beyond applying general inclusion and exclusion criteria. In the few studies where classification and matched interventions have been used, our meta-analysis showed a statistical difference in favour of the classification-based intervention for reductions in pain (p=0.004) and disability (p=0.0005), both for short-term and long-term reduction in pain (p=0.001). Effect sizes ranged from moderate (0.43) for short term to minimal (0.14) for long term. CONCLUSION: A better integration of subclassification strategies in NSCLBP outcome research is needed. We propose the development of explicit recommendations for the use of subclassification strategies and evaluation of targeted interventions in future research evaluating NSCLBP. PMID: 19996331 [PubMed - indexed for MEDLINE] 46. Clin Rehabil. 2009 Jan;23(1):3-14. doi: 10.1177/0269215508097856. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Waller B(1), Lambeck J, Daly D.

Author information: (1)University of Jyväskylä, Finland. OBJECTIVE: To examine the effectiveness of therapeutic aquatic exercise in the treatment of low back pain. DESIGN: A systematic review. METHODS: A search was performed of PEDro, CINAHL (ovid), PUBMED, Cochrane Controlled Trials Register and SPORTDiscus databases to identify relevant studies published between 1990 and 2007. POPULATION: Adults suffering from low back pain. INTERVENTION: All types of therapeutic aquatic exercise. COMPARISON: All clinical trials using a control group. OUTCOMES: Oswestry Disability Index, McGill Pain Questionnaire, subjective assessment scale for pain (e.g. visual analogue scale) and number of work days lost as a direct result of low back pain. Methodological quality was assessed using the PEDro scale and the SIGN 50 assessment forms. RESULTS: Thirty-seven trials were found and seven were accepted into the review. Therapeutic aquatic exercise appeared to have a beneficial effect, however, no better than other interventions. Methodological quality was considered low in all included studies. The heterogeneity among studies, in numbers of subjects, symptoms durations, interventions and reporting of outcomes, precluded any extensive meta-analysis of the results. CONCLUSION: There was sufficient evidence to suggest that therapeutic aquatic exercise is potentially beneficial to patients suffering from chronic low back pain and pregnancy-related low back pain. There is further need for high-quality trials to substantiate the use of therapeutic aquatic exercise in a clinical setting. PMID: 19114433 [PubMed - indexed for MEDLINE] 47. Phys Ther. 2009 Jan;89(1):9-25. doi: 10.2522/ptj.20080103. Epub 2008 Dec 4. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Macedo LG(1), Maher CG, Latimer J, McAuley JH. Author information: (1)The George Institute for International Health, The University of Sydney, PO Box M201, Missenden Rd, Camperdown, Sydney, New South Wales, 2050 Australia. lmacedo@george.org.au BACKGROUND: Previous systematic reviews have concluded that the effectiveness of motor control exercise for persistent low back pain has not been clearly established. OBJECTIVE: The objective of this study was to systematically review randomized controlled trials evaluating the effectiveness of motor control exercises for persistent low back pain. METHODS: Electronic databases were searched to June 2008. Pain, disability, and quality-of-life outcomes were extracted and converted to a common 0 to 100 scale.

Where possible, trials were pooled using Revman 4.2. RESULTS: Fourteen trials were included. Seven trials compared motor control exercise with minimal intervention or evaluated it as a supplement to another treatment. Four trials compared motor control exercise with manual therapy. Five trials compared motor control exercise with another form of exercise. One trial compared motor control exercise with lumbar fusion surgery. The pooling revealed that motor control exercise was better than minimal intervention in reducing pain at short-term follow-up (weighted mean difference=-14.3 points, 95% confidence interval [CI]=-20.4 to -8.1), at intermediate follow-up (weighted mean difference=-13.6 points, 95% CI=-22.4 to -4.1), and at long-term follow-up (weighted mean difference=-14.4 points, 95% CI=-23.1 to -5.7) and in reducing disability at long-term follow-up (weighted mean difference=-10.8 points, 95% CI=-18.7 to -2.8). Motor control exercise was better than manual therapy for pain (weighted mean difference=-5.7 points, 95% CI=-10.7 to -0.8), disability (weighted mean difference=-4.0 points, 95% CI=-7.6 to -0.4), and quality-of-life outcomes (weighted mean difference=-6.0 points, 95% CI=-11.2 to -0.8) at intermediate follow-up and better than other forms of exercise in reducing disability at short-term follow-up (weighted mean difference=-5.1 points, 95% CI=-8.7 to -1.4). CONCLUSIONS: Motor control exercise is superior to minimal intervention and confers benefit when added to another therapy for pain at all time points and for disability at long-term follow-up. Motor control exercise is not more effective than manual therapy or other forms of exercise. PMID: 19056854 [PubMed - indexed for MEDLINE] 48. Ann Readapt Med Phys. 2007 Jul;50(6):425-9, 419-24. Epub 2007 Apr 25. Functional restoration programs for low back pain: a systematic review. [Article in English, French] Poiraudeau S(1), Rannou F, Revel M. Author information: (1)Service de rééducation et de réadaptation fonctionnelle de l'appareil locomoteur et des pathologies du rachis, groupe hospitalier Cochin, Saint-Vincent-de-Paul, 75679 Paris cedex, France. serge.poiraudeau@cch.ap-hop-paris.fr BACKGROUND: In developed countries, chronic low back pain (LBP) is one the most common reasons for disability and work-time loss. Conventional treatments have not slowed the increasing prevalence of chronic LBP. Therefore, in a search for new solutions to the problem, functional restoration programs were developed. OBJECTIVE: To synthesize the literature on the efficacy of functional restoration programs for LBP. METHODS: We performed a systematic literature search of the MedLINE database using the keywords LBP, functional restoration, work-hardening program, exercise therapy, rehabilitation, aerobic, and cognitive behavioral therapy. SYNTHESIS: The term "functional restoration" has been associated with a full-day

multidisciplinary program lasting from 3 to 6 weeks. Results of most published controlled studies on the efficacy of functional restoration programs are positive regarding the return-to-work rate. Maintaining job status with the pre-injury employer is often best accomplished by the provision of suitable modified duties. Finally, results of functional restoration programs in terms of return-to-work rate probably depend strongly on the social security system of the country where the program was developed. PMID: 17512079 [PubMed - indexed for MEDLINE] 49. J Manipulative Physiol Ther. 2007 May;30(4):301-11. Unloaded movement facilitation exercise compared to no exercise or alternative therapy on outcomes for people with nonspecific chronic low back pain: a systematic review. Slade SC(1), Keating JL. Author information: (1)School of Primary Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia. elgarphysio@bigpond.com <elgarphysio@bigpond.com> OBJECTIVE: The purpose of this study was to determine the effect of unloaded movement facilitation exercises on outcomes for people with nonspecific chronic low back pain (NSCLBP). METHODS: This systematic review was conducted according to Cochrane Back Review Group and Quality of Reporting of Meta-analyses (QUORUM) guidelines. Exercise effects were reported as standardized mean difference (SMD) with 95% confidence intervals (95% CI). RESULTS: Six high-quality randomized controlled trials were included. For NSCLBP effects favored McKenzie therapy over intensive trunk strengthening for pain: SMD: short-term: 0.35 (0.10, 0.59); long-term 0.36 (0.12, 0.61) and short-term function: SMD: 0.45 (0.20, 0.70) and were comparable for medium-term function: SMD: 0.15 (-0.90, 0.40). Effects of favored McKenzie therapy were comparable to specific spinal stabilization exercises for short-term pain: SMD: 0.63 (-0.11, 1.38) and function: SMD: 0.47 (-0.27, 1.20). Pooled effects favored McKenzie therapy over other exercises for short-term pain (pooled SMD: 0.38 (0.14, 0.61)) and were comparable for short-term function: SMD: 0.10 (-0.20, 0.40). Yoga compared to trunk strengthening produced comparable effects for pain: (SMD: short-term: 0.13 (-0.46, 0.71); medium-term 0.51 (-0.08, 1.11)) and function SMD: short-term: 0.51 (-0.08, 1.10); medium-term 0.38 (-0.22, 0.97)). Compared to education, effects of yoga were large for medium-term pain and function (pooled SMDs: 0.92 (0.47, 1.37); 0.95 (0.50, 1.40)). Effects favored unloaded movement facilitation exercises of McKenzie compared to other or no exercise and were comparable for yoga. CONCLUSIONS: For NSCLBP, there is strong evidence that unloaded movement facilitation exercise, compared to no exercise, improves pain and function. Compared to other types of exercise, including effort-intensive strengthening and time-intensive stabilization exercise, the effects are comparable. This

challenges the role of strengthening for NSCLBP. PMID: 17509439 [PubMed - indexed for MEDLINE] 50. Eur Spine J. 2006 Nov;15(11):1633-44. Epub 2006 Mar 31. What predicts outcome in non-operative treatments of chronic low back pain? A systematic review. Wessels T(1), van Tulder M, Sigl T, Ewert T, Limm H, Stucki G. Author information: (1)Department of Physical Medicine and Rehabilitation, Ludwig-Maximilans University, Marchioninistr. 15, 81377, Munich, Germany. Systematic reviews have shown that as non-operative treatments exercise, behavioural and multimodal treatment programs are effective for chronic low back pain. There is, however, a lack of knowledge concerning the association between changes in treatment process variables and changes in outcome for the three treatment forms. The objective of this systematic review was to evaluate which changes in treatment process variables predict outcome of exercise, behavioural and multimodal treatment of chronic low back pain. Medline, Embase and PsychInfo were systematically searched. A descriptive analysis was used to summarize the results regarding the outcomes pain, disability and return to work (RTW). 13 studies were identified. The results showed that functional coping mechanisms and pain reduction were associated with a decrease in disability and increase in RTW, and physical performance factors were not. Related to pain reduction decreases in disability, functional coping mechanisms as well as physical performance factors were associated. Strong conclusions cannot be drawn from this review, because of the heterogeneity and the limited number of studies. The results of this review raise the question if changes in behavioural variables and reductions of disability which facilitate an improvement in function, may be more important than physical performance factors for successful treatment of chronic low back pain. This is relevant for the refinement of future treatment programs. PMID: 16575598 [PubMed - indexed for MEDLINE] 51. Ann Intern Med. 2005 May 3;142(9):776-85. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Hayden JA(1), van Tulder MW, Tomlinson G. Author information: (1)Institute for Work & Health and University of Toronto, Toronto, Ontario, Canada. jhayden@iwh.on.ca Comment in

ACP J Club. 2006 Jan-Feb;144(1):12-3. Summary for patients in Ann Intern Med. 2005 May 3;142(9):I72. BACKGROUND: Exercise therapy encompasses a heterogeneous group of interventions. There continues to be uncertainty about the most effective exercise approach in chronic low back pain. PURPOSE: To identify particular exercise intervention characteristics that decrease pain and improve function in adults with nonspecific chronic low back pain. DATA SOURCES: MEDLINE, EMBASE, PsychInfo, CINAHL, and Cochrane Library databases to October 2004 and citation searches and bibliographic reviews of previous systematic reviews. STUDY SELECTION: Randomized, controlled trials evaluating exercise therapy in populations with chronic (>12 weeks duration) low back pain. DATA EXTRACTION: Two reviewers independently extracted data on exercise intervention characteristics: program design (individually designed or standard program), delivery type (independent home exercises, group, or individual supervision), dose or intensity (hours of intervention time), and inclusion of additional conservative interventions. DATA SYNTHESIS: 43 trials of 72 exercise treatment and 31 comparison groups were included. Bayesian multivariable random-effects meta-regression found improved pain scores for individually designed programs (5.4 points [95% credible interval (CrI), 1.3 to 9.5 points]), supervised home exercise (6.1 points [CrI, -0.2 to 12.4 points]), group (4.8 points [CrI, 0.2 to 9.4 points]), and individually supervised programs (5.9 points [CrI, 2.1 to 9.8 points]) compared with home exercises only. High-dose exercise programs fared better than low-dose exercise programs (1.8 points [CrI, -2.1 to 5.5 points]). Interventions that included additional conservative care were better (5.1 points [CrI, 1.8 to 8.4 points]). A model including these most effective intervention characteristics would be expected to demonstrate important improvement in pain (18.1 points [CrI, 11.1 to 25.0 points] compared with no treatment and 13.0 points [CrI, 6.0 to 19.9 points] compared with other conservative treatment) and small improvement in function (5.5 points [CrI, 0.5 to 10.5 points] compared with no treatment and 2.7 points [CrI, -1.7 to 7.1 points] compared with other conservative treatment). Stretching and strengthening demonstrated the largest improvement over comparisons. LIMITATIONS: Limitations of the literature, including low-quality studies with heterogeneous outcome measures and inconsistent and poor reporting; publication bias. CONCLUSIONS: Exercise therapy that consists of individually designed programs, including stretching or strengthening, and is delivered with supervision may improve pain and function in chronic nonspecific low back pain. Strategies should be used to encourage adherence. Future studies should test this multivariable model and further assess specific patient-level characteristics and exercise types. PMID: 15867410 [PubMed - indexed for MEDLINE] 52. J Manipulative Physiol Ther. 2006 Feb;29(2):163-73.

Trunk-strengthening exercises for chronic low back pain: a systematic review. Slade SC(1), Keating JL. Author information: (1)School of Physiotherapy, Faculty of Health Sciences, La Trobe University, Melbourne, Australia. elgarphysio@bigpond.com.au OBJECTIVE: The objective of this systematic review was to determine the effect of lumbar spine-strengthening exercises on outcomes for people with chronic low back pain. METHODS: Two independent reviewers followed Cochrane Back Review Group and QUORUM Statement guidelines to complete this systematic review. Exercise effects were reported as standardized mean difference (SMD) with 95% confidence intervals. RESULTS: Thirteen high-quality randomized controlled trials were included. For chronic low back pain, trunk strengthening is more effective than no exercise on long-term pain (SMD 0.95 [0.35-1.55]; intensive trunk strengthening is more effective than less intensive on function (pooled SMD: short-term, 0.58 [0.22-0.94]; long-term, 0.77 [0.33-1.20]). Compared with physiotherapy or aerobics, effects are comparable on pain and function. Motivation strategies increase effectiveness. After disk surgery, effects are significant for function (pooled SMD: short-term, 1.08 (0.76-1.41); long-term, 0.53 (0.03-1.04). For severe degeneration, trunk strengthening is less favorable than fusion on long-term pain (SMD, -0.50 [-0.99 to -0.01]) or function (SMD, -0.76 [-1.25 to -0.26]). Intensive trunk strengthening is less effective than McKenzie exercises for pain reduction (SMD: short-term, -0.29 [-0.54 to -0.05]; long-term, -0.31 [-0.55 to -0.06]). We estimated that moderate effect sizes (0.5) indicate that approximately 50% of participants and large effect sizes (0.8) indicate that approximately 80% of participants would achieve important improvement. CONCLUSIONS: Trunk strengthening appears effective compared with no exercise. Increasing exercise intensity and adding motivation increase treatment effects. Trunk strengthening, compared with aerobics or McKenzie exercises, showed no clear benefit of strengthening. It is unclear whether observed benefits are due to tissue loading or movement repetition. PMID: 16461178 [PubMed - indexed for MEDLINE] 53. Spine J. 2004 May-Jun;4(3):335-56. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Bronfort G(1), Haas M, Evans RL, Bouter LM. Author information: (1)Department of Research, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W, 84th Street Bloomington, MN 55431, USA. gbronfort@nwhealth.edu

BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. CONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of

patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care. PMID: 15125860 [PubMed - indexed for MEDLINE] 54. Arch Phys Med Rehabil. 2002 Dec;83(12):1745-52. Impact of quality scales on levels of evidence inferred from a systematic review of exercise therapy and low back pain. Colle F(1), Rannou F, Revel M, Fermanian J, Poiraudeau S. Author information: (1)Service de médecine physique et de réadaptation de l'appareil locomoteur et des pathologies du rachis, Hôpital Cochin AP-HP, Université René Descartes, Paris, France. OBJECTIVE: To assess whether the scale used affects levels of evidence inferred from a systematic review of studies on exercise therapy and chronic low back pain (LBP). DESIGN: Twenty trials previously analyzed in a systematic review were assessed by 2 readers using 16 different scales. SETTING: Tertiary care teaching hospital in France. PARTICIPANTS: Chronic LBP patients. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: For the scales allowing classification into high- and low-quality trials, a rating system with 4 levels of evidence was used to summarize conclusions drawn. The Spearman rank correlation coefficient was used to assess correlations between the scores obtained with the different scales. Interrater reliability of the scales was assessed with the intraclass correlation coefficient and the Bland and Altman method, and the degree of agreement between the readers was calculated using the kappa coefficient. RESULTS: Two of the 3 main results of the systematic review (conflicting evidence on the effectiveness of exercise therapy compared with inactive treatments; strong evidence that exercise therapy is more effective than usual care by a general practitioner) were influenced by the scale used. The range of the Spearman rank correlation coefficients between the different scales was wide (range,.49-.94), the interreader reliability of the scales was heterogeneous, and the interreader agreement was often low (kappa<or=.60 for 7/10 tests). CONCLUSIONS: The use of summary scores to identify physical therapy trials of high quality is questionable. Different quality assessment scales should probably be used to assess pharmacologic interventions and physical therapies. Development and validation of quality scales specific to physical treatments are needed. Copyright 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation PMID: 12474181 [PubMed - indexed for MEDLINE]

55. Spine (Phila Pa 1976). 2000 Nov 1;25(21):2784-96. Exercise therapy for low back pain: a systematic review within the framework of the cochrane collaboration back review group. van Tulder M(1), Malmivaara A, Esmail R, Koes B. Author information: (1)Institute for Research in Extramural Medicine, Free University, Amsterdam, The Netherlands. mw.van_tulder.emgo@med.vu.nl Comment in Spine (Phila Pa 1976). 2001 Aug 15;26(16):1827-9. Spine (Phila Pa 1976). 2001 Aug 15;26(16):1829. Spine (Phila Pa 1976). 2001 Aug 15;26(16):1829-31. STUDY DESIGN: A systematic review of randomized controlled trials was performed. SUMMARY OF BACKGROUND DATA: Exercise therapy is a widely used treatment for low back pain. OBJECTIVES: To evaluate the effectiveness of exercise therapy for low back pain with regard to pain intensity, functional status, overall improvement, and return to work. METHODS: The Cochrane Controlled Trials Register, Medline, Embase, PsycLIT, and reference lists of articles were searched. Randomized trials testing all types of exercise therapy for subjects with nonspecific low back pain with or without radiation into the legs were included. Two reviewers independently extracted data and assessed trial quality. Because trials were considered heterogeneous with regard to study populations, interventions, and outcomes, it was decided not to perform a meta-analysis, but to summarize the results using a rating system of four levels of evidence: strong, moderate, limited, or none. RESULTS: In this review, 39 trials were identified. There is strong evidence that exercise therapy is not more effective for acute low back pain than inactive or other active treatments with which it has been compared. There is conflicting evidence on the effectiveness of exercise therapy compared with inactive treatments for chronic low back pain. Exercise therapy was more effective than usual care by the general practitioner and just as effective as conventional physiotherapy for chronic low back pain. CONCLUSIONS: The evidence summarized in this systematic review does not indicate that specific exercises are effective for the treatment of acute low back pain. Exercises may be helpful for patients with chronic low back pain to increase return to normal daily activities and work. PMID: 11064524 [PubMed - indexed for MEDLINE] 56. Spine (Phila Pa 1976). 1997 Sep 15;22(18):2128-56. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions.

van Tulder MW(1), Koes BW, Bouter LM. Author information: (1)Institute for Research in Extramural Medicine, Vrije Universiteit, Amsterdam, The Netherlands. Comment in ACP J Club. 1998 May-Jun;128(3):65. Spine (Phila Pa 1976). 1998 Jun 1;23(11):1288-91. STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain. SUMMARY OF BACKGROUND DATA: Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy. METHODS: A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results. RESULTS: The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti-inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term effects. CONCLUSIONS: The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain. PMID: 9322325 [PubMed - indexed for MEDLINE]

Exercise and Neck pain 1. Eur Spine J. 2016 Feb 6. [Epub ahead of print] Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Varatharajan S(1,)(2,)(3), Ferguson B(4), Chrobak K(4), Shergill Y(5), Côté P(6,)(7,)(8), Wong JJ(1,)(2), Yu H(1,)(2), Shearer HM(1,)(2), Southerst D(1,)(9), Sutton D(1,)(2), Randhawa K(1,)(2,)(3), Jacobs C(1,)(10), Abdulla S(4), Woitzik E(4), Marchand AA(11), van der Velde G(12,)(13,)(14), Carroll LJ(15), Nordin M(16), Ammendolia C(17,)(14,)(18), Mior S(2,)(17), Ameis A(19), Stupar M(1), Taylor-Vaisey A(1). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (2)Division of Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (3)Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (4)Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (5)University of Ottawa Centre for Interdisciplinary Pain Research, Ottawa Hospital Research Institute, The Ottawa Hospital General Campus, 501 Smyth Rd, Box 249-B, Ottawa, ON, K1H 8L6, Canada. (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. pierre.cote@uoit.ca. (7)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada. pierre.cote@uoit.ca. (8)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada. pierre.cote@uoit.ca. (9)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, ON, M5T 3L9, Canada. (10)Division of Clinical Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (11)Département d'anatomie, Université du Québec à Trois-Rivières, 3351 Boul. des Forges, C.P. 500, Trois-Rivières, QUÉBEC, G9A 5H7, Canada. (12)Toronto Health Economics and Technology Assessment (THETA) Collaborative, 6th Floor, Room 658, 144 College Street, Toronto, ON, M5S 3M2, Canada. (13)Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada. (14)Institute for Work and Health, 481 University Avenue, Toronto, ON, M5G 2E9, Canada. (15)Injury Prevention Centre and School of Public Health, University of Alberta, 3-300 ECHA, 11405-87 Ave, Edmonton, AB, T6G 1C9, Canada. (16)Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue,

New York, NY, 10016, USA. (17)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada. (18)Institute for Health Policy, Management and Evaluation, University of Toronto, 4th Flodior, 155 College St, Toronto, ON, M5T 3M6, Canada. (19)Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada. PURPOSE: To update findings of the 2000-2010 Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders and evaluate the effectiveness of non-invasive and non-pharmacological interventions for the management of patients with headaches associated with neck pain (i.e., tension-type, cervicogenic, or whiplash-related headaches). METHODS: We searched five databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort studies, and case-control studies comparing non-invasive interventions with other interventions, placebo/sham, or no interventions. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria to determine scientific admissibility. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 17,236 citations, 15 studies were relevant, and 10 had a low risk of bias. The evidence suggests that episodic tension-type headaches should be managed with low load endurance craniocervical and cervicoscapular exercises. Patients with chronic tension-type headaches may also benefit from low load endurance craniocervical and cervicoscapular exercises; relaxation training with stress coping therapy; or multimodal care that includes spinal mobilization, craniocervical exercises, and postural correction. For cervicogenic headaches, low load endurance craniocervical and cervicoscapular exercises; or manual therapy (manipulation with or without mobilization) to the cervical and thoracic spine may also be helpful. CONCLUSIONS: The management of headaches associated with neck pain should include exercise. Patients who suffer from chronic tension-type headaches may also benefit from relaxation training with stress coping therapy or multimodal care. Patients with cervicogenic headache may also benefit from a course of manual therapy. PMID: 26851953 [PubMed - as supplied by publisher] 2. Spine J. 2015 Nov 26. pii: S1529-9430(15)01235-8. doi: 10.1016/j.spinee.2015.08.025. [Epub ahead of print] Which interventions are cost-effective for the management of whiplash-associated and neck pain-associated disorders? A systematic review of the health economic literature by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. van der Velde G(1), Yu H(2), Paulden M(3), Côté P(4), Varatharajan S(2), Shearer HM(2), Wong JJ(2), Randhawa K(5), Southerst D(6), Mior S(7), Sutton D(2), Jacobs C(8), Taylor-Vaisey A(9).

Author information: (1)Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College Street, Toronto, Ontario, M5S 3M2, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada; Institute for Work and Health, 481 University Avenue, Toronto, Ontario, M5G 2E9, Canada. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada. (3)Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 Walter C Mackenzie Health, Sciences Centre, 8440 112 St. NW, Edmonton, Alberta, T6G 2R7, Canada. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada. Electronic address: Pierre.Cote@uoit.ca. (5)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada. (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada. (7)Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario, L1H 7K4, Canada. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada; Division of Clinical Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada. (9)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, M2H 3J1, Canada. BACKGROUND CONTEXT: Whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) are prevalent conditions that impact society and impose a significant economic burden on health-care systems. Health economic evidence on WAD and NAD interventions has been sparse: only three economic evaluations of interventions for NAD were identified by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (NPTF). An updated

overview is needed to inform health-care policy and guidelines. PURPOSE: This study aimed to determine the cost-effectiveness of interventions for grades I-III WAD and NAD in children and adults. STUDY DESIGN: Systematic review of health economic literature, best-evidence synthesis. METHODS: We systematically searched CINAHL, the Cochrane economic databases (Health Technology Assessment, NHS Economic Evaluation Database), EconLit, EMBASE, MEDLINE, PsycINFO, and Tufts CEA Registry from 2000 to 2015 for economic evaluations of WAD and NAD interventions. We appraised relevant evaluations using the Scottish Intercollegiate Guidelines Network Methodology Criteria for Economic Evaluations. We extracted data, including mean costs (standardized to 2013 Canadian dollars [CAD]) and quality-adjusted life years (QALYs), from studies with adequate methodological quality. We recalculated cost-effectiveness statistics based on the standardized currency using a willingness-to-pay of CAD $50,000 per additional QALY. Funding was provided by the Ministry of Finance. RESULTS: Our search identified 1,616 citations. Six studies fulfilled our selection criteria, including three studies previously reviewed by the NPTF. Structured education appears cost-effective for adults with WAD. For adults with NAD, acupuncture added to routine medical care; manual therapy; multimodal care that includes manual therapy; advice and exercise; and psychological care using cognitive-behavioral therapy appear cost-effective. In contrast, adding manual therapy or diathermy to advice and exercise; multimodal care by a physiotherapist or physician; and behavioral-graded activity do not appear cost-effective for adults with NAD. CONCLUSIONS: Our review adds to the findings of the NPTF. Recent evidence suggests that structured education is cost-effective for WAD, whereas advice and exercise and multimodal care that include manual therapy are cost-effective for NAD. Obtaining more robust health economic evidence for non-invasive interventions for WAD and NAD in children and adults remains an essential research priority. Copyright © 2015 Elsevier Inc. All rights reserved. PMID: 26631759 [PubMed - as supplied by publisher] 3. Syst Rev. 2014 Sep 19;3:106. doi: 10.1186/2046-4053-3-106. A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain--protocol. Marley J, Tully MA, Porter-Armstrong A, Bunting B, O'Hanlon J, McDonough SM(1). Author information: (1)Centre for Health and Rehabilitation Technologies, Institute of Nursing and Health, School of Health Sciences, University of Ulster, Shore Road, Newtownabbey, Co Antrim BT37 0QB, UK. s.mcdonough@ulster.ac.uk. BACKGROUND: Chronic musculoskeletal pain is highly prevalent, affecting around one in five people across Europe. Osteoarthritis, low back pain, neck pain and other musculoskeletal disorders are leading causes of disability worldwide and

the most common source of chronic pain. Exercise and/or physical activity interventions have the potential to address not only the pain and disability associated with chronic pain but also the increased risk of morbidity and mortality seen in this population. Although exercise and/or physical activity is widely recommended, there is currently a paucity of research that offers an evidence base upon which the development or optimisation of interventions can be based. This systematic review will investigate the components of interventions associated with changes in physical activity levels in adults with chronic musculoskeletal pain. METHODS/DESIGN: This systematic review will be reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidance. Randomised and quasi-randomised controlled trials of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain will be included. Articles will be identified through a comprehensive search of the following databases: CENTRAL in the Cochrane Library, the Cochrane Database of Systematic Reviews (CDSR), MEDLINE, Embase, CINAHL, PsycINFO and AMED. Two review authors will independently screen articles retrieved from the search for eligibility, extract relevant data on methodological issues and code interventions according to the behaviour change technique taxonomy (v1) of 93 hierarchically clustered techniques. As complex healthcare interventions can be modified by a wide variety of factors, data will be summarised statistically when the data are available, are sufficiently similar and are of sufficient quality. A narrative synthesis will be completed if there is insufficient data to permit a formal meta-analysis. DISCUSSION: This review will be of value to clinicians working in chronic pain services and to researchers involved in designing and evaluating interventions. SYSTEMATIC REVIEW REGISTRATION: PROSPERO reference: CRD42014010640. PMCID: PMC4179220 PMID: 25239378 [PubMed - indexed for MEDLINE] 4. Br J Sports Med. 2015 Oct;49(20):1350. doi: 10.1136/bjsports-2014-093874. Epub 2014 Aug 18. Therapeutic exercise for chronic non-specific neck pain: PEDro systematic review update. Yamato TP(1), Saragiotto BT(1), Maher C(1). Author information: (1)The George Institute for Global Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia. PMID: 25136081 [PubMed - in process] 5. Spine J. 2014 Jul 8. pii: S1529-9430(14)00650-0. doi: 10.1016/j.spinee.2014.06.019. [Epub ahead of print] Is multimodal care effective for the management of patients with

whiplash-associated disorders or neck pain and associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Sutton DA(1), Côté P(2), Wong JJ(3), Varatharajan S(3), Randhawa KA(3), Yu H(3), Southerst D(3), Shearer HM(3), van der Velde GM(4), Nordin MC(5), Carroll LJ(6), Mior SA(7), Taylor-Vaisey AL(8), Stupar M(3). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1. Electronic address: deborah.sutton@uoit.ca. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science Building, Room 3000, Oshawa, Ontario, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College St, Toronto, Ontario, Canada, M5S 3M2. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1. (4)Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College St, Toronto, Ontario, Canada, M5S 3M2; Faculty of Pharmacy, Leslie Dan Pharmacy Building, University of Toronto, 2nd Floor, 144 College St, Toronto, Ontario, Canada, M5S 3M2; Institute for Work and Health, 481 University Ave, Suite 800, Toronto, Ontario, Canada, M5G 2E9. (5)Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street, New York, NY, USA, 10014; Department of Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street, New York, NY, USA, 10014. (6)Department of Public Health Sciences and Alberta Centre for Injury Prevention and Research, School of Public Health, University of Alberta, 4075 RTG, 8308-114 Street, Edmonton, Alberta, Canada, T6G 2E1. (7)Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science Building, Room 3000, Oshawa, Ontario, Canada. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada M2H 3J1. BACKGROUND CONTEXT: Little is known about the effectiveness of multimodal care for individuals with whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD). PURPOSE: To update findings of the Bone and Joint Decade 2000-2010 Task Force on

Neck Pain and Its Associated Disorders and evaluate the effectiveness of multimodal care for the management of patients with WAD or NAD. STUDY DESIGN/SETTING: Systematic review and best-evidence synthesis. PATIENT SAMPLE: We included randomized controlled trials (RCTs), cohort studies, and case-control studies. OUTCOME MEASURES: Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes (eg, depression, fear), or adverse events. METHODS: We systematically searched five electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials) from 2000 to 2013. RCTs, cohort, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized using evidence tables and synthesized following best-evidence synthesis principles. RESULTS: We retrieved 2,187 articles, and 23 articles were eligible for critical appraisal. Of those, 18 articles from 14 different RCTs were scientifically admissible. There were a total of 31 treatment arms, including 27 unique multimodal programs of care. Overall, the evidence suggests that multimodal care that includes manual therapy, education, and exercise may benefit patients with grades I and II WAD and NAD. General practitioner care that includes reassurance, advice to stay active, and resumption of regular activities may be an option for the early management of WAD grades I and II. Our synthesis suggests that patients receiving high-intensity health care tend to experience poorer outcomes than those who receive fewer treatments for WAD and NAD. CONCLUSIONS: Multimodal care can benefit patients with WAD and NAD with early or persistent symptoms. The evidence does not indicate that one multimodal care package is superior to another. Clinicians should avoid high utilization of care for patients with WAD and NAD. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 25014556 [PubMed - as supplied by publisher] 6. J Manipulative Physiol Ther. 2014 Jul-Aug;37(6):343-62. doi: 10.1016/j.jmpt.2014.05.001. Epub 2014 Jun 27. Cost-effectiveness of manual therapy for the management of musculoskeletal conditions: a systematic review and narrative synthesis of evidence from randomized controlled trials. Tsertsvadze A(1), Clar C(1), Court R(2), Clarke A(3), Mistry H(4), Sutcliffe P(5). Author information: (1)Senior Research Fellow, Warwick Medical School, University of Warwick, Coventry, UK. (2)Information Specialist, Warwick Medical School, University of Warwick, Coventry, UK. (3)Professor, Warwick Medical School, University of Warwick, Coventry, UK. (4)Assistant Professor, Warwick Medical School, University

of Warwick, Coventry, UK. (5)Associate Professor, Warwick Medical School, University of Warwick, Coventry, UK. Electronic address: p.a.sutcliffe@warwick.ac.uk. OBJECTIVES: The purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions. METHODS: A comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases. RESULTS: Twenty-five publications were included (11 trial-based economic evaluations). The studies compared cost-effectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (e.g., osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain. CONCLUSIONS: Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients. Copyright © 2014 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 24986566 [PubMed - indexed for MEDLINE] 7. J Physiother. 2014 Jun;60(2):78-84. doi: 10.1016/j.jphys.2014.05.006. Epub 2014 Jun 10. Mechanical diagnosis and therapy has similar effects on pain and disability as 'wait and see' and other approaches in people with neck pain: a systematic review. Takasaki H(1), May S(2). Author information: (1)Division of Physical Therapy, Saitama Prefectural University, Japan. (2)Faculty of Health and Wellbeing, Sheffield Hallam University, UK.

QUESTIONS: In people with neck pain, does Mechanical Diagnosis and Therapy (MDT) reduce pain and disability more than 'wait and see'? Does MDT reduce pain and disability more than other interventions? Are any differences in effect clinically important? DESIGN: Systematic review of randomised trials with meta-analysis. PARTICIPANTS: People with neck pain. INTERVENTION: MDT. OUTCOME MEASURES: Pain intensity and disability due to neck pain in the short (< 3 months), intermediate (< 1 year) and long term (≥ 1 year). RESULTS: Five trials were included. Most comparisons demonstrated mean differences in effect that favoured MDT over wait-and-see controls or other interventions, although most were statistically non-significant. For pain, all comparisons had a 95% confidence interval (CI) with lower limits that were less than 20 on a scale of 0 to 100, which suggests that the difference may not be clinically important. For disability, even the upper limits of the 95% CI were below this threshold, confirming that the differences are not clinically important. In all of the trials, some or all of the treating therapists did not have the highest level of MDT training. CONCLUSION: The additional benefit of MDT compared with the wait-and-see approach or other therapeutic approaches may not be clinically important in terms of pain intensity and is not clinically important in terms of disability. However, these estimates of the effect of MDT may reflect suboptimal training of the treating therapists. Further research could improve the precision of the estimates and assess whether the extent of training in MDT influences its effect. Copyright © 2014 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. PMID: 24952834 [PubMed - indexed for MEDLINE] 8. Spine J. 2014 Apr 4. pii: S1529-9430(14)00347-7. doi: 10.1016/j.spinee.2014.03.039. [Epub ahead of print] Does structured patient education improve the recovery and clinical outcomes of patients with neck pain? A systematic review from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Yu H(1), Côté P(2), Southerst D(3), Wong JJ(3), Varatharajan S(4), Shearer HM(4), Gross DP(5), van der Velde GM(6), Carroll LJ(7), Mior SA(8), Ameis A(9), L Jacobs C(10), L Taylor-Vaisey A(11). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada; Division of Graduate Education and Research, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada. Electronic address: hainan.yu@uoit.ca. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1,

Canada; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario L1H 7K4, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario L1H 7K4, Canada. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada; Division of Graduate Education and Research, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada. (5)Department of Physical Therapy, University of Alberta, 2-50 Corbett Hall, University of Alberta, Edmonton, Alberta T6G 2G4, Canada. (6)Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College St, Toronto, Ontario M5S 3M2, Canada; Faculty of Pharmacy, Leslie Dan Pharmacy Building, University of Toronto, 2nd Floor, 144 College St, Toronto, Ontario M5S 3M2, Canada; Institute for Work and Health, 481 University Ave, Suite 800, Toronto, Ontario M5G 2E9, Canada. (7)School of Public Health, University of Alberta, 4075 Research Transition Facility, 8308 - 114 St, Edmonton, Alberta T6G 2E1, Canada. (8)Division of Graduate Education and Research, Canadian Memorial Chiropractic College, 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario L1H 7K4, Canada. (9)Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-Montpetit, Montreal, Quebec H3T 1J4, Canada. (10)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada; Division of Clinical Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada. (11)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario M2H 3J1, Canada. BACK GROUND CONTEXT: In 2008, the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders recommended patient education for the management of neck pain. However, the effectiveness of education interventions has recently been challenged. PURPOSE: To update the findings of the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders and evaluate the effectiveness of structured patient education for the management of patients with whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). STUDY DESIGN/SETTING: Systematic review of the literature and best-evidence synthesis. PATIENT SAMPLE: Randomized controlled trials that compared structured patient education with other conservative interventions.

OUTCOME MEASURES: Self-rated recovery, functional recovery (eg, disability, return to activities, work, or school), pain intensity, health-related quality of life, psychological outcomes such as depression or fear, or adverse effects. METHODS: We systematically searched eight electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials, DARE, PubMed, and ICL) from 2000 to 2012. Randomized controlled trials, cohort studies, and case-control studies meeting our selection criteria were eligible for critical appraisal. Random pairs of independent reviewers critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network criteria. Scientifically admissible studies were summarized in evidence tables and synthesized following best-evidence synthesis principles. RESULTS: We retrieved 4,477 articles. Of those, nine were eligible for critical appraisal and six were scientifically admissible. Four admissible articles investigated patients with WAD and two targeted patients with NAD. All structured patient education interventions included advice on activation or exercises delivered orally combined with written information or as written information alone. Overall, as a therapeutic intervention, structured patient education was equal or less effective than other conservative treatments including massage, supervised exercise, and physiotherapy. However, structured patient education may provide small benefits when combined with physiotherapy. Either mode of delivery (ie, oral or written education) provides similar results in patients with recent WAD. CONCLUSIONS: This review adds to the Bone and Joint Decade 2000 to 2010 Task Force on Neck Pain and Its Associated Disorders by defining more specifically the role of structured patient education in the management of WAD and NAD. Results suggest that structured patient education alone cannot be expected to yield large benefits in clinical effectiveness compared with other conservative interventions for patients with WAD or NAD. Moreover, structured patient education may be of benefit during the recovery of patients with WAD when used as an adjunct therapy to physiotherapy or emergency room care. These benefits are small and short lived. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 24704678 [PubMed - as supplied by publisher] 9. Spine J. 2014 Feb 15. pii: S1529-9430(14)00210-1. doi: 10.1016/j.spinee.2014.02.014. [Epub ahead of print] Is exercise effective for the management of neck pain and associated disorders or whiplash-associated disorders? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Southerst D(1), Nordin MC(2), Côté P(3), Shearer HM(4), Varatharajan S(4), Yu H(4), Wong JJ(4), Sutton DA(4), Randhawa KA(4), van der Velde GM(5), Mior SA(6), Carroll LJ(7), Jacobs CL(8), Taylor-Vaisey AL(4). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial

Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1. Electronic address: danielle.southerst@uoit.ca. (2)Department of Orthopedic Surgery, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 63 Downing Street, New York, New York, USA, 10014. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College Street, Toronto, Ontario, Canada, M5S 3M2. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1. (5)Toronto Health Economics and Technology Assessment (THETA) Collaborative, Leslie Dan Pharmacy Building, University of Toronto, 6th Floor, Room 658, 144 College Street, Toronto, Ontario, Canada, M5S 3M2; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario, Canada, M5S 3M2; Institute for Work and Health, 481 University Ave, Toronto, Ontario, Canada, M5G 2E9. (6)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Science building, Room 3000, Oshawa, Ontario, Canada, L1H 7K4; (g)Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1. (7)Department of Public Health Sciences and Alberta Centre for Injury Prevention and Research, School of Public Health, University of Alberta, 4075 RTF, 8308-114 Street, Edmonton, Alberta, Canada, T6G 2E1. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1; Division of Clinical Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario, Canada, M2H 3J1. BACKGROUND CONTEXT: In 2008, the Neck Pain Task Force (NPTF) recommended exercise for the management of neck pain and whiplash-associated disorders (WAD). However, no evidence was available on the effectiveness of exercise for Grade III neck pain or WAD. Moreover, limited evidence was available to contrast the effectiveness of various types of exercises. PURPOSE: To update the findings of the NPTF on the effectiveness of exercise for the management of neck pain and WAD grades I to III. STUDY DESIGN/SETTING: Systematic review and best evidence synthesis. SAMPLE: Studies comparing the effectiveness of exercise to other conservative interventions or no intervention. OUTCOME MEASURES: Outcomes of interest included self-rated recovery, functional recovery, pain intensity, health-related quality of life, psychological outcomes, and/or adverse events. METHODS: We searched eight electronic databases from 2000 to 2013. Eligible studies were critically appraised using the Scottish Intercollegiate Guidelines Network criteria. The results of scientifically admissible studies were synthesized following best-evidence synthesis principles. RESULTS: We retrieved 4,761 articles, and 21 randomized controlled trials (RCTs) were critically appraised. Ten RCTs were scientifically admissible: nine investigated neck pain and one addressed WAD. For the management of recent neck pain Grade I/II, unsupervised range-of-motion exercises, nonsteroidal

anti-inflammatory drugs and acetaminophen, or manual therapy lead to similar outcomes. For recent neck pain Grade III, supervised graded strengthening is more effective than advice but leads to similar short-term outcomes as a cervical collar. For persistent neck pain and WAD Grade I/II, supervised qigong and combined strengthening, range-of-motion, and flexibility exercises are more effective than wait list. Additionally, supervised Iyengar yoga is more effective than home exercise. Finally, supervised high-dose strengthening is not superior to home exercises or advice. CONCLUSIONS: We found evidence that supervised qigong, Iyengar yoga, and combined programs including strengthening, range of motion, and flexibility are effective for the management of persistent neck pain. We did not find evidence that one supervised exercise program is superior to another. Overall, most studies reported small effect sizes suggesting that a small clinical effect can be expected with the use of exercise alone. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 24534390 [PubMed - as supplied by publisher] 10. Evid Based Spine Care J. 2013 Apr;4(1):30-41. doi: 10.1055/s-0033-1341605. The outcomes of manipulation or mobilization therapy compared with physical therapy or exercise for neck pain: a systematic review. Schroeder J(1), Kaplan L(2), Fischer DJ(3), Skelly AC(3). Author information: (1)Department of Spine Surgery, The Hospital for Special Surgery, New York, New York, United States. (2)Department of Orthopedic Surgery, Spine Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel. (3)Spectrum Research, Inc., Tacoma, Washington, United States. Study Design Systematic review. Study Rationale Neck pain is a prevalent condition. Spinal manipulation and mobilization procedures are becoming an accepted treatment for neck pain. However, data on the effectiveness of these treatments have not been summarized. Objective To compare manipulation or mobilization of the cervical spine to physical therapy or exercise for symptom improvement in patients with neck pain. Methods A systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Database, and bibliographies of key articles, which compared spinal manipulation or mobilization therapy with physical therapy or exercise in patients with neck pain. Articles were included based on predetermined criteria and were appraised using a predefined quality rating scheme. Results From 197 citations, 7 articles met all inclusion and exclusion criteria. There were no differences in pain improvement when comparing spinal manipulation to exercise, and there were inconsistent reports of pain improvement in subjects who underwent mobilization therapy versus physical therapy. No disability improvement was reported between treatment groups in studies of acute or chronic neck pain patients. No functional improvement was found with manipulation therapy compared with exercise treatment or mobilization therapy compared with physical therapy groups in patients with

acute pain. In chronic neck pain subjects who underwent spinal manipulation therapy compared to exercise treatment, results for short-term functional improvement were inconsistent. Conclusion The data available suggest that there are minimal short- and long-term treatment differences in pain, disability, patient-rated treatment improvement, treatment satisfaction, health status, or functional improvement when comparing manipulation or mobilization therapy to physical therapy or exercise in patients with neck pain. This systematic review is limited by the variability of treatment interventions and lack of standardized outcomes to assess treatment benefit. PMCID: PMC3699243 PMID: 24436697 [PubMed] 11. Phys Ther. 2013 Aug;93(8):1026-36. doi: 10.2522/ptj.20120412. Epub 2013 Apr 4. Effect of therapeutic exercise on pain and disability in the management of chronic nonspecific neck pain: systematic review and meta-analysis of randomized trials. Bertozzi L(1), Gardenghi I, Turoni F, Villafañe JH, Capra F, Guccione AA, Pillastrini P. Author information: (1)School of Physical Therapy, Alma Mater Studiorum, University of Bologna, Bologna, Italy. BACKGROUND: Given the prevalence of chronic nonspecific neck pain (CNSNP) internationally, attention has increasingly been paid in recent years to evaluating the efficacy of therapeutic exercise (TE) in the management of this condition. PURPOSE: The purpose of this study was to conduct a current review of randomized controlled trials concerning the effect of TE on pain and disability among people with CNSNP, perform a meta-analysis, and summarize current understanding. DATA SOURCES: Data were obtained from MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Physiotherapy Evidence Database (PEDro), and Cochrane Central Register of Controlled Trials (CENTRAL) databases from their inception to August 2012. Reference lists of relevant literature reviews also were tracked. STUDY SELECTION: All published randomized trials without any restriction regarding time of publication or language were considered for inclusion. Study participants had to be symptomatic adults with only CNSNP. DATA EXTRACTION: Two reviewers independently selected the studies, conducted the quality assessment, and extracted the results. Data were pooled in a meta-analysis using a random-effects model. DATA SYNTHESIS: Seven studies met the inclusion criteria. Therapeutic exercise proved to have medium and significant short-term and intermediate-term effects on pain (g=-0.53, 95% confidence interval [CI]=-0.86 to -0.20, and g=-0.45, 95% CI=-0.82 to -0.07, respectively) and medium but not significant short-term and intermediate-term effects on disability (g=-0.39, 95% CI=-0.86 to 0.07, and g=-0.46, 95% CI=-1.00 to -0.08, respectively).

LIMITATIONS: Only one study investigated the effect of TE on pain and disability at follow-up longer than 6 months after intervention. CONCLUSIONS: Consistent with other reviews, the results support the use of TE in the management of CNSNP. In particular, a significant overall effect size was found supporting TE for its effect on pain in both the short and intermediate terms. PMID: 23559524 [PubMed - indexed for MEDLINE] 12. Eur Spine J. 2012 Aug;21(8):1441-50. doi: 10.1007/s00586-012-2272-5. Epub 2012 Mar 25. Cost-effectiveness of conservative treatments for neck pain: a systematic review on economic evaluations. Driessen MT(1), Lin CW, van Tulder MW. Author information: (1)Department of Health Sciences, The EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands. m.t.driessen@gmail.com PURPOSE: Various conservative interventions have been used for the treatment of non-specific neck pain. The aim of this systematic review was to investigate the cost-effectiveness of conservative treatments for non-specific neck pain. METHODS: Clinical and economic electronic databases, reference lists and authors' databases were searched up to 13 January 2011. Two reviewers independently selected studies for inclusion, performed the risk of bias assessment and data extraction. RESULTS: A total of five economic evaluations met the inclusion criteria. All studies were conducted alongside randomised controlled trials and included a cost-utility analysis, and four studies also conducted a cost-effectiveness analysis. Most often, the economic evaluation was conducted from a societal or a health-care perspective. One study found that manual therapy was dominant over physiotherapy and general practitioner care, whilst behavioural graded activity was not cost-effective compared to manual therapy. The combination of advice and exercise with manual therapy was not cost-effective compared to advice and exercise only. One study found that acupuncture was cost-effective compared to a delayed acupuncture intervention, and another study found no differences on cost-effectiveness between a brief physiotherapy intervention compared to usual physiotherapy. Pooling of the data was not possible as heterogeneity existed between the studies on participants, interventions, controls, outcomes, follow-up duration and context related socio-political differences. CONCLUSION: At present, the limited number of studies and the heterogeneity between studies warrant no definite conclusions on the cost-effectiveness of conservative treatments for non-specific neck pain. PMCID: PMC3535241 PMID: 22447407 [PubMed - indexed for MEDLINE]

13. Phys Ther Sport. 2011 Nov;12(4):199-209. doi: 10.1016/j.ptsp.2010.12.002. Epub 2011 Feb 26. Muscle onset can be improved by therapeutic exercise: a systematic review. Crow J(1), Pizzari T, Buttifant D. Author information: (1)School of Physiotherapy, La Trobe university, Bundoora, VIC 3086, Australia. justin.crow@students.latrobe.edu.au OBJECTIVES: To determine whether therapeutic exercise can improve the timing of muscle onset following musculoskeletal pathology, and examine what exercise prescription parameters are being used to achieve these effects. PARTICIPANTS: People with a musculoskeletal pathology. MAIN OUTCOME MEASURE: Muscle onset timing as measured by electromyography. RESULTS: Sixteen investigations were identified containing 19 therapeutic exercise groups. Three exercise modes were identified including: isolated muscle training, instability training, and general strength training. Isolated muscle training is consistently shown to have a positive effect on the muscle onset timing of transversus abdominus in people with low back pain. There is some evidence from cohort studies that instability training may change muscle onset timing in people with functional ankle instability, however controlled trials suggest that no effect is present. General strength training shows no effect on muscle onset timing in people with low back or neck pain, although one cohort study suggests that a positive effect on gluteus maximus may be present in people with low back pain. CONCLUSION: Therapeutic exercise training is likely to improve muscle onset timing. Additionally, isolated muscle training appears to be the best exercise mode to use to achieve these effects. Copyright © 2011 Elsevier Ltd. All rights reserved. PMID: 22085715 [PubMed - indexed for MEDLINE] 14. J Manipulative Physiol Ther. 2011 Jan;34(1):62-71. doi: 10.1016/j.jmpt.2010.11.005. Exercise therapy for office workers with nonspecific neck pain: a systematic review. Sihawong R(1), Janwantanakul P, Sitthipornvorakul E, Pensri P. Author information: (1)Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand. OBJECTIVE: The purpose of this study was to evaluate the effectiveness of various types of exercise for prevention and cure of nonspecific neck pain in office

workers. METHODS: Publications between 1980 and April 2010 were systematically searched in various databases (PubMed, CINAHL Plus with full text, The Cochrane Library, Science Direct, PEDro, ProQuest, PsycNet, and Scopus). The following key words were used: neck pain, cervical pain, exercise, strengthening, stretching, endurance, office workers, visual display unit, visual display terminal, and computer users. A hand search of relevant journals was also carried out. Relevant randomized controlled trials were retrieved and assessed for methodological quality by 2 independent reviewers. The strength of the evidence was based on methodological quality and consistency of the results. RESULTS: Nine randomized controlled trials were included in this review, of which 6 were rated as high-quality studies. No exercise type was identified as being effective in the prevention of nonspecific neck pain in office workers. Strong evidence was found for the effectiveness of muscle strengthening and endurance exercises in treating neck pain. Moderate evidence supported the use of muscle endurance exercise in reducing disability attributed to neck pain. CONCLUSION: Literature investigating the efficacy of exercise in office workers with nonspecific neck pain was heterogeneous. Within the limitations, for treatment of neck pain, either muscle strengthening or endurance exercise is recommended, whereas for reduction of pain-related disability, muscle endurance exercise is suggested. Further research is needed before any firm conclusions regarding the most effective exercise programs for office workers can be reached. Copyright © 2011 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 21237409 [PubMed - indexed for MEDLINE] 15. Man Ther. 2010 Aug;15(4):334-54. Manual therapy and exercise for neck pain: a systematic review. Miller J(1), Gross A, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Author information: (1)School of Rehabilitation Science, McMaster University, Hamilton, Canada. Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI: -1.69, -0.06)), function/disability, and global perceived effect when manual therapy and exercise

are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI: -0.76, -0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made. PMID: 20593537 [PubMed - indexed for MEDLINE] 16. Man Ther. 2010 Oct;15(5):415-33. doi: 10.1016/j.math.2010.04.003. Epub 2010 Jun 9. Manual therapy with or without physical medicine modalities for neck pain: a systematic review. D'Sylva J(1), Miller J, Gross A, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL; Cervical Overview Group. Author information: (1)School of Rehabilitation Science, McMaster University, 1400 Main Street West, Hamilton, Ontario L8S 1C7, Canada. Manual therapy interventions are often used with or without physical medicine modalities to treat neck pain. This review assessed the effect of 1) manipulation and mobilisation, 2) manipulation, mobilisation and soft tissue work, and 3) manual therapy with physical medicine modalities on pain, function, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults with neck pain. A computerised search for randomised trials was performed up to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (RR) and standardised mean differences (SMD) were calculated when possible. We included 19 trials, 37% of which had a low risk of bias. Moderate quality evidence (1 trial, 221 participants) suggested mobilisation, manipulation and soft tissue techniques decrease pain and improved satisfaction when compared to short wave diathermy, and that this treatment combination paired with advice and exercise produces greater improvements in GPE and satisfaction than advice and exercise alone for acute neck pain. Low quality evidence suggests a clinically important benefit favouring mobilisation and manipulation in pain relief [1 meta-analysis, 112 participants: SMD -0.34(95% CI: -0.71, 0.03), improved function and GPE (1 trial, 94 participants) for participants with chronic cervicogenic headache when compared to a control at intermediate and long term follow-up; but no difference when used with various physical medicine modalities. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 20538501 [PubMed - indexed for MEDLINE]

17. J Physiother. 2010;56(2):73-85. Conservative interventions provide short-term relief for non-specific neck pain: a systematic review. Leaver AM(1), Refshauge KM, Maher CG, McAuley JH. Author information: (1)Faculty of Health Sciences, The University of Sydney, Sydney, NSW, Australia. andrew.leaver@sydney.edu.au Comment in J Physiother. 2010;56(4):282; author reply 283. QUESTION: Which interventions for non-specific neck pain are effective in reducing pain or disability? DESIGN: Systematic review with meta-analysis of randomised controlled trials. PARTICIPANTS: Adults with non-specific neck pain. INTERVENTION: All interventions for neck pain that were evaluated in trials with a placebo, minimal- or no-intervention control. OUTCOME MEASURES: Pain and disability outcomes (0-100 scale) at the conclusion of a course of treatment (short term), and in the medium (3 to 9 months) and long (> 9 months) term. RESULTS: 33 trials were identified. The interventions with significant short-term effects on pain were manipulation (MD -22, 95% CI -32 to -11), multimodal intervention (MD -21, 95% CI -34 to -7), specific exercise (MD -12, 95% CI -22 to -2), combination orphenadrine/paracetamol (MD -17, 95% CI -32 to -2), and manual therapy (MD -12, 95% CI -16 to -7). There was a significant short-term effect on disability for acupuncture (MD -8, 95% CI -13 to -2) and manual therapy (MD -6, 95% CI -11 to -2). Treatment with laser therapy resulted in better pain outcomes at medium-term follow-up but not at short-term follow-up. No other intervention demonstrated medium- or long-term effects. CONCLUSION: Some conservative interventions for neck pain are effective in the short term. Few interventions that have been investigated have shown longer term effects that are better than placebo or minimal intervention. PMID: 20482474 [PubMed - indexed for MEDLINE] 18. Spine J. 2009 Oct;9(10):859-71. doi: 10.1016/j.spinee.2009.04.019. Epub 2009 Jul 12. A Cochrane review of patient education for neck pain. Haines T(1), Gross AR, Burnie S, Goldsmith CH, Perry L, Graham N; Cervical Overview Group (COG). Author information: (1)Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada.

BACKGROUND CONTEXT: Neck pain is common, disabling, and costly. The effectiveness of patient education strategies is unclear. PURPOSE: To assess whether patient education strategies are of benefit for pain, function/disability, global perceived effect, quality of life, or patient satisfaction, in adults with neck pain with or without radiculopathy. STUDY DESIGN: Cochrane systematic review. METHODS: Computerized bibliographic databases were searched from their start to May 31, 2008. Eligible studies were randomized trials investigating the effectiveness of patient education strategies for neck pain. Paired independent reviewers carried out study selection, data abstraction, and methodological quality assessment. Relative risk and standardized mean differences were calculated. Because of differences in intervention type or disorder, no studies were considered appropriate to pool. RESULTS: Of the 10 selected trials, two (20%) were rated as of high quality. Patient education was assessed as follows: 1) eight trials of advice focusing on activation compared with no treatment, or to various active treatments, including therapeutic exercise, manual therapy, and cognitive behavioral therapy, showed either inferiority or no difference for pain, spanning a full range of follow-up periods, acuity and disorder types. When compared with rest, two trials that assessed acute whiplash-associated disorder showed moderate evidence of no difference for advice focusing on activation; 2) two trials studying advice focusing on pain and stress coping skills found moderate evidence of no benefit for chronic neck pain at intermediate- to long-term follow-up; and 3) one trial compared the effects of neck school to no treatment, yielding limited evidence of no benefit for pain, at intermediate-term follow-up in mixed acute/subacute/chronic neck pain. CONCLUSIONS: This review has not shown effectiveness for educational interventions for neck pain of various acuity stages and disorder types and at various follow-up periods, including advice to activate, advice on stress coping skills, and neck school. In future research, further attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of specific educational components. PMID: 19596214 [PubMed - indexed for MEDLINE] 19. J Manipulative Physiol Ther. 2005 Jul-Aug;28(6):443-8. A systematic review of conservative treatments for acute neck pain not due to whiplash. Vernon HT(1), Humphreys BK, Hagino CA. Author information: (1)Center for Studies of the Cervical Spine, Graduate Education and Research, Canadian Memorial Chiropractic College, Graduate Education and Research, Toronto, Ontario, Canada M2H 3J1. hvernon@cmcc.ca OBJECTIVE: To identify the evidence base of clinical trials of conservative treatments for acute neck pain not due to whiplash injury.

DESIGN AND SETTING: A comprehensive literature search was performed in MEDLINE, CINHAHL, AMED, MANTIS, Index to Chiropractic Literature, Alt HealthWatch, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Registry, and several EBSCO Information Services databases. Systematic retrieval and evaluation procedures were used. RESULTS: The search generated 1980 citations. Four trials (5 publications) were accepted according to the inclusion/exclusion criteria. Three trials used a form of spinal manual therapy. One of these trials used only one manipulation and reported immediate effects on pain, with real manipulation producing significantly greater pain reduction than control procedure. The other 2 of these trials reported on outcomes over 1 to 3 weeks. In 1 trial, the group receiving manipulation showed significantly greater pain reduction at 1 week than did the group receiving only medication. In the other trial, the group receiving transcutaneous electrical nerve stimulation had a significantly greater level of pain reduction at 3 weeks. In the fourth trial, exercise was compared to passive physiotherapy; however, outcomes were not reported until 6 and 12 months, so the results cannot be compared to the natural history of acute neck pain not due to whiplash. CONCLUSION: There is limited evidence of the benefit of spinal manipulation and transcutaneous electrical nerve stimulation in the treatment of acute neck pain not due to whiplash injury. There is a dearth of high-quality clinical trials of conservative treatments for this condition. PMID: 16096044 [PubMed - indexed for MEDLINE] 20. Spine J. 2004 May-Jun;4(3):335-56. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Bronfort G(1), Haas M, Evans RL, Bouter LM. Author information: (1)Department of Research, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W, 84th Street Bloomington, MN 55431, USA. gbronfort@nwhealth.edu BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and

bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. CONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care. PMID: 15125860 [PubMed - indexed for MEDLINE] 21. Spine (Phila Pa 1976). 2003 Oct 1;28(19):E391-5. Physical conditioning programs for workers with back and neck pain: a cochrane systematic review. Schonstein E(1), Kenny D, Keating J, Koes B, Herbert RD.

Author information: (1)School of Physiotherapy, Faculty of Health Sciences, The University of Sydney, New South Wales, Australia. e.schonstein@fhs.usyd.edu.au OBJECTIVE: To determine the effect on time lost from work of physical conditioning programs for workers with back and neck pain. DATA SOURCES Randomized trials were located by searching MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Controlled Trial Register, and PEDro. REVIEW METHODS: Two reviewers independently extracted data and assessed trial quality. Where data could be pooled, meta-analysis was performed. Based on cost considerations, we nominated a mean saving of 10 sick days per year or a number needed to treat to return 1 person to work of 10 as the smallest treatment effects that would be clinically worthwhile. RESULTS: Nineteen trials in 21 publications yielded 23 contrasts relevant to this review. These trials provide evidence that physical conditioning programs that included a cognitive-behavioral approach could produce a clinically worthwhile reduction in the number of sick days taken at 12 months (average of 45 days; 95% confidence interval 3-88) when compared to general practitioner care or advice for workers with chronic back pain. There was little evidence of an effect on time lost from work of specific exercise programs that did not include a cognitive-behavioral component. CONCLUSION: Physical conditioning programs that incorporate a cognitive-behavioral approach reduce the number of sick days for workers with chronic back pain when compared to usual care. PMID: 14520051 [PubMed - indexed for MEDLINE]

Exercise and Osteoarthritis 1. J Orthop Sports Phys Ther. 2016 Jun;46(6):431-42. doi: 10.2519/jospt.2016.6449. Epub 2016 Apr 26. Does Physical Activity Increase After Total Hip or Knee Arthroplasty for Osteoarthritis? A Systematic Review. Arnold JB, Walters JL, Ferrar KE. Study Design Systematic review. Background Despite improvements in self-reported symptoms and perceived functional ability after total hip arthroplasty (THA) and total knee arthroplasty (TKA), it is unclear whether changes in objectively measured physical activity (PA) occur after surgery. Objective To determine if objectively measured PA increases after THA and TKA in adults with osteoarthritis. Methods Five electronic databases were searched from inception to March 3, 2015. All study designs objectively measuring PA before and after THA or TKA were eligible, including randomized controlled trials, cohort studies, and case-control studies. Two reviewers independently screened abstracts and full texts and extracted study demographic, PA, and clinical outcome data. Standardized mean differences (SMDs) and 95% confidence intervals were calculated for accelerometer- and pedometer-derived estimates of PA. Risk of methodological bias was assessed with Critical Appraisal Skills Programme checklists. Results Eight studies with a total of 373 participants (238 TKA, 135 THA) were included. Findings were mixed regarding improvement in objectively measured PA at 6 months after THA (SMDs, -0.20 to 1.80) and TKA (SMDs, -0.36 to 0.63). Larger improvements from 2 studies at 1 year postsurgery were generally observed after THA (SMDs, 0.39 to 0.79) and TKA (SMDs, 0.10 to 0.85). However, at 1 year, PA levels were still considerably lower than those of healthy controls (THA SMDs, -0.25 to -0.77; TKA SMDs, -1.46 to -1.80). Risk-of-bias scores ranged from 3 to 9 out of 11 (27%-82%) for cohort studies, and from 3 to 8 out of 10 (30%-80%) for case-control studies. Conclusion The best available evidence indicates negligible changes in PA at 6 months after THA or TKA, with limited evidence for larger changes at 1 year after surgery. In the 4 studies that reported control-group data, postoperative PA levels were still considerably less than those of healthy controls. Improved perioperative strategies to instill behavioral change are required to narrow the gap between patient-perceived functional improvement and the actual amount of PA undertaken after THA and TKA. Registered with PROSPERO (registration number CRD42014010155). Level of Evidence Therapy, level 2a. J Orthop Sports Phys Ther 2016;46(6):431-442. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6449. PMID: 27117726 [PubMed - in process]

2. Br J Sports Med. 2016 Apr;50(8):458-63. doi: 10.1136/bjsports-2015-095255. Epub 2015 Nov 26. Effects of exercise and manual therapy on pain associated with hip osteoarthritis: a systematic review and meta-analysis. Beumer L(1), Wong J(1), Warden SJ(2), Kemp JL(3), Foster P(1), Crossley KM(4). Author information: (1)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia. (2)School of Health and Rehabilitation Sciences, Indiana University, Indianapolis, Indiana, USA. (3)Australian Centre for Research into Injury and Sport and its Prevention (ACRISP), Federation University Australia, Ballarat, Victoria, Australia. (4)School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia. AIM: To explore the effects of exercise (water-based or land-based) and/or manual therapies on pain in adults with clinically and/or radiographically diagnosed hip osteoarthritis (OA). METHODS: A systematic review and meta-analysis was performed, with patient reported pain assessed using a visual analogue scale (VAS) or the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. Data were grouped by follow-up time (0-3 months=short term; 4-12 months=medium term and; >12 months=long term), and standardised mean differences (SMD) with 95% CIs were used to establish intervention effect sizes. Study quality was assessed using modified PEDro scores. RESULTS: 19 trials were included. Four studies showed short-term benefits favouring water-based exercise over minimal control using the WOMAC pain subscale (SMD -0.53, 95% CI -0.96 to -0.10). Six studies supported a short-term benefit of land-based exercise compared to minimal control on VAS assessed pain (SMD -0.49, 95% CI -0.70 to -0.29). There were no medium (SMD -0.23, 95% CI -0.48 to 0.03) or long (SMD -0.22, 95% CI -0.51 to 0.06) term benefits of exercise therapy, or benefit of combining exercise therapy with manual therapy (SMD -0.38, 95% CI -0.88 to 0.13) when compared to minimal control. CONCLUSIONS: Best available evidence indicates that exercise therapy (whether land-based or water-based) is more effective than minimal control in managing pain associated with hip OA in the short term. Larger high-quality RCTs are needed to establish the effectiveness of exercise and manual therapies in the medium and long term. Published by the BMJ Publishing Group Limited. For permission to use (where not

already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26612846 [PubMed - in process] 3. Br J Sports Med. 2016 Apr;50(7):397-407. doi: 10.1136/bjsports-2014-094388. Epub 2015 Sep 17. The effect of Tai Chi on four chronic conditions-cancer, osteoarthritis, heart failure and chronic obstructive pulmonary disease: a systematic review and meta-analyses. Chen YW(1), Hunt MA(1), Campbell KL(1), Peill K(2), Reid WD(3). Author information: (1)Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada. (2)Department of Biology, University of British Columbia, Vancouver, British Columbia, Canada. (3)Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada. BACKGROUND: Many middle-aged and older persons have more than one chronic condition. Thus, it is important to synthesise the effectiveness of interventions across several comorbidities. The aim of this systematic review was to summarise current evidence regarding the effectiveness of Tai Chi in individuals with four common chronic conditions-cancer, osteoarthritis (OA), heart failure (HF) and chronic obstructive pulmonary disease (COPD). METHODS: 4 databases (MEDLINE, EMBASE, CINAHL and SPORTDiscus) were searched for original articles. Two reviewers independently screened the titles and abstracts and then conducted full-text reviews, quality assessment and finally data abstraction. 33 studies met the inclusion criteria. Meta-analyses were performed on disease-specific symptoms, physiological outcomes and physical performance of each chronic condition. Subgroup analyses on disease-specific symptoms were conducted by categorising studies into subsets based on the type of comparison groups. RESULTS: Meta-analyses showed that Tai Chi improved or showed a tendency to improve physical performance outcomes, including 6-min walking distance (6MWD) and knee extensor strength, in most or all four chronic conditions. Tai Chi also improved disease-specific symptoms of pain and stiffness in OA. CONCLUSIONS: The results demonstrated a favourable effect or tendency of Tai Chi to improve physical performance and showed that this type of exercise could be performed by individuals with different chronic conditions, including COPD, HF and OA. Published by the BMJ Publishing Group Limited. For permission to use (where not

already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMID: 26383108 [PubMed - in process] 4. Ann Phys Rehabil Med. 2016 Apr 11. pii: S1877-0657(16)00040-3. doi: 10.1016/j.rehab.2016.01.013. [Epub ahead of print] Isokinetic muscle strengthening for knee osteoarthritis: A systematic review of randomized controlled trials with meta-analysis. Coudeyre E(1), Jegu AG(2), Giustanini M(3), Marrel JP(3), Edouard P(4), Pereira B(5). Author information: (1)Service de médecine physique et de réadaptation, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France; Université Clermont Auvergne, 63000 Clermont-Ferrand, France; INRA, unité de nutrition humaine (UNH, UMR 1019), CRNH Auvergne, 63000 Clermont-Ferrand, France. Electronic address: ecoudeyre@chu-clermontferrand.fr. (2)Service de médecine physique et de réadaptation, site du Tampon, CHU Sud Réunion, CHU Réunion, 97448 Saint-Pierre, France. (3)Service de médecine physique et de réadaptation, CHU Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand, France. (4)Laboratoire de physiologie de l'exercice (LPE EA 4338), hôpital de Bellevue, faculté de médecine Jacques-Lisfranc, université Jean-Monnet, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France. (5)CHU Clermont-Ferrand, Biostatistics Unit, délégation recherche clinique & innovation (DRCI), Villa annexe IFSI, 63003 Clermont-Ferrand, France. OBJECTIVE: To assess the level of scientific evidence and the place in the rehabilitation framework of isokinetic muscle strengthening (IMS) for knee osteoarthritis (OA). METHODS: A systematic review of the English literature in MEDLINE via PubMed, the Cochrane Library, and PEDro databases for only randomized comparative trials. Data that were sufficiently homogeneous underwent comprehensive meta-analysis. Methodological assessment was done by using the CLEAR scale for non-pharmacologic trials. RESULTS: We identified articles for 9 trials (696 patients). All trials were of low to moderate quality. Tolerance of IMS was considered good. Improvement in muscle strength was better with an IMS program than no treatment or an isometric exercise but did not differ with an aerobic program. We found an important effect for pain (standardized mean difference 1.218 [95% CI 0.899-1.54], P<0.001) and functional Lequesne index (1.61 [0.40-2.81], P=0.009) and a moderate effect for the Western Ontario and McMaster Universities Osteoarthritis Index subscore C for

disability (0.58 [0.04-1.11], P=0.03). CONCLUSIONS: IMS is an effective way to propose dynamic muscle strengthening for knee OA rehabilitation and has a significant effect on pain and disability. Because of the weak methodology and the great heterogeneity of studies, particularly in IMS protocol and outcome measures, insufficient data are available to provide guidelines about efficacy and strategy. Future clinical trials are needed, but more attention should be paid to the methods of such studies to clarify the role of IMS in the therapeutic armamentarium of knee OA. Copyright © 2016 Elsevier Masson SAS. All rights reserved. PMID: 27079585 [PubMed - as supplied by publisher] 5. Ann Phys Rehabil Med. 2016 Apr 1. pii: S1877-0657(16)00043-9. doi: 10.1016/j.rehab.2016.02.005. [Epub ahead of print] Educating patients about the benefits of physical activity and exercise for their hip and knee osteoarthritis. Systematic literature review. Gay C(1), Chabaud A(2), Guilley E(3), Coudeyre E(4). Author information: (1)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France; Université Clermont Auvergne, 63003 Clermont-Ferrand, France; Unité de Nutrition Humaine, INRA, UMR 1019, CRNH Auvergne, 63000 Clermont-Ferrand, France. (2)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France; Université Clermont Auvergne, 63003 Clermont-Ferrand, France. (3)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France. (4)Service de Médecine Physique et de Réadaptation, CHU de Clermont-Ferrand, Hôpital Nord, route de Chateaugay, BP 30056, 63118 Cébazat, France; Université Clermont Auvergne, 63003 Clermont-Ferrand, France; Unité de Nutrition Humaine, INRA, UMR 1019, CRNH Auvergne, 63000 Clermont-Ferrand, France. Electronic address: ecoudeyre@chu-clermontferrand.fr. OBJECTIVES: Highlight the role of patient education about physical activity and exercise in the treatment of hip and knee osteoarthritis (OA). METHODS: Systematic literature review from the Cochrane Library, PubMed and Wiley Online Library databases. A total of 125 items were identified, including 11 recommendations from learned societies interested in OA and 45 randomized controlled trials addressing treatment education and activity/exercise for the treatment of hip and knee osteoarthritis. RESULTS: In the end, 13 randomized controlled trials and 8 recommendations were

reviewed (1b level of evidence). Based on the analysis, it was clear that education, exercise and weight loss are the pillars of non-pharmacological treatments. These treatments have proven to be effective but require changes in patient behaviour that are difficult to obtain. Exercise and weight loss improve function and reduce pain. Education potentiates compliance to exercise and weight loss programs, thereby improving their long-term benefits. Cost efficiency studies have found a reduction in medical visits and healthcare costs after 12 months because of self-management programs. CONCLUSION: Among non-surgical treatment options for hip and knee osteoarthritis, the most recent guidelines focus on non-pharmacological treatment. Self-management for general physical activity and exercise has a critical role. Programs must be personalized and adjusted to the patient's phenotype. This development should help every healthcare professional adapt the care they propose to each patient. Registration number for the systematic review: CRD42015032346. Copyright © 2016 Elsevier Masson SAS. All rights reserved. PMID: 27053003 [PubMed - as supplied by publisher] 6. J Rehabil Med. 2016 Mar 1;48(3):245-52. doi: 10.2340/16501977-2057. Course and predictors of pain and physical functioning in patients with hip osteoarthritis: Systematic review and meta-analysis. de Rooij M(1), van der Leeden M, Heymans MW, Holla JF, Häkkinen A, Lems WF, Roorda LD, Veenhof C, Sanchez-Ramirez DC, de Vet HC, Dekker J. Author information: (1)Amsterdam Rehabilitation Research Centre Reade, PO Box 58271 , NL-1040 HG Amsterdam, The Netherlands. m.d.rooij@reade.nl. OBJECTIVE: To systematically summarize the literature on: (i) the course of pain and physical functioning; and (ii) predictors of deterioration of pain and physical functioning in patients with osteoarthritis of the hip. METHODS: A literature search was conducted in PubMed, CINAHL, Embase, PsychINFO and SPORTDiscus up to July 2015. Meta-analyses and qualitative data syntheses were performed. RESULTS: Eleven of the 15 included studies were of high quality. With regard to the course of pain and physical functioning, high heterogeneity was found across studies (I2 > 71%) and within study populations (reflected by large standard deviations (SDs) of change scores). Therefore, the course of pain and physical functioning was interpreted to be indistinct. Clinical characteristics (higher comorbidity count and presence of knee osteoarthritis), health behaviour factors (no supervised exercise and physical inactivity) and socio-demographics (lower

education) were found to predict deterioration of pain (weak evidence). Higher comorbidity count and lower vitality were found to predict deterioration of physical functioning (strong evidence). For several other predictive factors weak evidence was found (e.g. bilateral hip pain, increase in hip pain (change), bilateral knee pain, presence of knee osteoarthritis). CONCLUSION: Because of high heterogeneity across studies and within study populations, no conclusions can be drawn with regard to the course of pain and physical functioning. Several clinical characteristics, health behaviours and psychosocial factors prognosticate deterioration of pain and physical functioning. These findings may guide future research aimed at the identification of subgroups of patients with hip osteoarthritis. PMID: 26871564 [PubMed - in process] 7. Clin Rehabil. 2016 Jan;30(1):36-52. doi: 10.1177/0269215515570098. Epub 2015 Feb 17. Effects of exercise therapy on walking ability in individuals with knee osteoarthritis: a systematic review and meta-analysis of randomised controlled trials. Tanaka R(1), Ozawa J(2), Kito N(2), Moriyama H(3). Author information: (1)Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Japan r-tanaka@hs.hirokoku-u.ac.jp. (2)Department of Rehabilitation, Faculty of Rehabilitation, Hiroshima International University, Japan. (3)Department of Rehabilitation Science, Graduate School of Health Sciences, Kobe University, Japan. OBJECTIVE: To examine the effect of exercise therapy on the walking ability of individuals with knee osteoarthritis. DATA SOURCES: Randomised clinical trials (RCTs) were identified by searching through PubMed, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature. All literature published to October 2014 were included in the search. REVIEW METHODS: Data were collected from RCTs that compared the effects of exercise therapy on walking ability with the effects of no intervention or psychoeducational intervention in participants with knee osteoarthritis. The outcome data on the total distance walked (6-minute walk test); the amount of time spent walking (the time to walk arbitrary distances); and gait velocity were obtained and analysed. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated. RESULTS: Twenty-eight RCTs were identified. Meta-analysis provided

very-low-quality evidence that exercise therapy increased the total distance walked in the 6-minute walk test, in comparison with the effects of the control interventions (SMD = 0.44, 95% CI 0.27 to 0.60). Meta-analysis also provided low- or moderate-quality evidence that the amount of time spent walking and gait velocity were improved more by exercise therapy than by the control interventions (the amount of time spent walking: SMD = -0.50, 95% CI -0.70 to -0.30; gait velocity: SMD = 1.78, 95% CI 0.98 to 2.58). CONCLUSION: In individuals with knee osteoarthritis, exercise therapy can improve the amount of time spent walking, gait velocity, and maybe the total distance walked. © The Author(s) 2015. PMID: 25691583 [PubMed - in process] 8. J Geriatr Phys Ther. 2016 Jan-Mar;39(1):38-48. doi: 10.1519/JPT.0000000000000045. Effect of Home Exercise Program in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis. Anwer S(1), Alghadir A, Brismée JM. Author information: (1)1Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Kingdom of Saudi Arabia. 2Padmashree Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India. 3Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock. BACKGROUND: The Osteoarthritis Research Society International recommended that nonpharmacological methods include patient education programs, weight reduction, coping strategies, and exercise programs for the management of knee osteoarthritis (OA). However, neither a systematic review nor a meta-analysis has been published regarding the effectiveness of home exercise programs for the management of knee OA. PURPOSE: The purpose of this systematic review was to examine the evidence regarding the effect of home exercise programs with and without supervised clinic-based exercises in the management of knee OA. METHODS: We searched PubMed, CINAHL, Embase, Scopus, and PEDro for research articles published prior to September 2014 using key words such as pain, exercise, home exercise program, rehabilitation, supervised exercise program, and physiotherapy in combination with Medical Subject Headings "Osteoarthritis knee." We selected randomized and case-controlled trials published in English language. To verify the quality of the selected studies, we applied the PEDro Scale. Two

evaluators individually selected the studies based on titles, excluding those articles that were not related to the objectives of this review. One evaluator extracted data from the included studies. A second evaluator independently verified extracted data for accuracy. RESULTS: A total of 31 studies were found in the search. Of these, 19 studies met the inclusion criteria and were further analyzed. Seventeen of these 19 studies reached high methodological quality on the PEDro scale. Although the methods and home exercise program interventions varied widely in these studies, most found significant improvements in pain and function in individuals with knee OA. DISCUSSIONS: The analysis indicated that both home exercise programs with and without supervised clinic-based exercises were beneficial in the management of knee OA. CONCLUSIONS: The large evidence of high-quality trials supports the effectiveness of home exercise programs with and without supervised clinic-based exercises in the rehabilitation of knee OA. In addition, small but growing evidence supports the effectiveness of other types of exercise such as tai chi, balance, and proprioceptive training for individuals with knee OA. PMID: 25695471 [PubMed - in process] 9. Clin Rehabil. 2015 Dec 22. pii: 0269215515622670. [Epub ahead of print] The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: A systematic review and meta-analysis. Sampath KK(1), Mani R(2), Miyamori T(2), Tumilty S(2). Author information: (1)Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand kesava.kovanur-sampath@otago.ac.nz. (2)Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand. OBJECTIVE: To determine whether manual therapy or exercise therapy or both is beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life. METHODS: Databases such as Medline, AMED, EMBASE, CINAHL, SPORTSDiscus, PubMed, Cochrane Library, Web of Science, Physiotherapy Evidence Database, and SCOPUS were searched from their inception till September 2015. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures (pain, physical function and quality of life) were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for assessing the quality of

the body of evidence for each outcome of interest. RESULTS: Seven trials (886 participants) that met the inclusion criteria were included in the meta-analysis. There was high quality evidence that exercise therapy was beneficial at post-treatment (pain-SMD-0.27,95%CI-0.5to-0.04;physical function-SMD-0.29,95%CI-0.47to-0.11) and follow-up (pain-SMD-0.24,95%CI- 0.41to-0.06; physical function-SMD-0.33,95%CI-0.5to-0.15). There was low quality evidence that manual therapy was beneficial at post-treatment (pain-SMD-0.71,95%CI-1.08to-0.33; physical function-SMD-0.71,95%CI-1.08to-0.33) and follow-up (pain-SMD-0.43,95%CI-0.8to-0.06; physical function-SMD-0.47,95%CI-0.84to-0.1). Low quality evidence indicated that combined treatment was beneficial at post-treatment (pain-SMD-0.43,95%CI-0.78to-0.08; physical function-SMD-0.38,95%CI-0.73to-0.04) but not at follow-up (pain-SMD0.25,95%CI-0.35to0.84; physical function-SMD0.09,95%CI-0.5to0.68). There was no effect of any interventions on quality of life. CONCLUSION: An Exercise therapy intervention provides short-term as well as long-term benefits in terms of reduction in pain, and improvement in physical function among people with hip osteoarthritis. The observed magnitude of the treatment effect would be considered small to moderate. © The Author(s) 2015. PMID: 26701903 [PubMed - as supplied by publisher] 10. J Phys Ther Sci. 2015 Oct;27(10):3309-14. doi: 10.1589/jpts.27.3309. Epub 2015 Oct 30. Does exercise therapy improve the health-related quality of life of people with knee osteoarthritis? A systematic review and meta-analysis of randomized controlled trials. Tanaka R(1), Ozawa J(1), Kito N(1), Moriyama H(2). Author information: (1)Department of Rehabilitation, Hiroshima International University, Japan. (2)Department of Rehabilitation Science, Graduate School of Health Sciences, Kobe University, Japan. [Purpose] The aim of this study was to examine the effects of exercise therapy on the health-related QOL of people with knee osteoarthritis. [Subjects] Four databases (PubMed, Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature) were searched for randomized controlled trials that evaluated the effects of exercise therapy on health-related QOL assessed by the SF-36 for inclusion in our systematic review. The methodological qualities of the trials

were assessed independently by two reviewers using the PEDro scale. Pooled analyses with a random-effects model or a fixed-effects model were used in the meta-analyses to calculate the standardized mean differences and 95% confidence intervals. [Results] Twelve studies met the inclusion criteria. Our meta-analysis provides high-quality evidence that exercise therapy increases the summary score, physical functioning score, and role-physical score of knee osteoarthritis sufferers. Our meta-analysis also provides moderate-quality evidence that the physical component summary and mental component summary scores were improved to a greater extent by exercise therapy than by control interventions. [Conclusion] Exercise therapy can improve health-related QOL, as assessed by the SF-36, of knee osteoarthritis sufferers. PMCID: PMC4668190 PMID: 26644699 [PubMed] 11. Clin Rehabil. 2015 Oct 15. pii: 0269215515610039. [Epub ahead of print] The effects of resistance exercise in patients with knee osteoarthritis: A systematic review and meta-analysis. Li Y(1), Su Y(2), Chen S(1), Zhang Y(1), Zhang Z(1), Liu C(1), Lu M(1), Liu F(1), Li S(1), He Z(1), Wang Y(1), Sheng L(1), Wang W(1), Zhan Z(1), Wang X(1), Zheng N(1). Author information: (1)Department of Rehabilitation Medicine College, Fujian University of Traditional Chinese Medicine, Fujian, China. (2)Department of Rehabilitation Medicine College, Fujian University of Traditional Chinese Medicine, Fujian, China suyouxin777@hotmail.com. OBJECTIVE: To analyze the effectiveness of resistance exercise in the treatment of knee osteoarthritis on pain, stiffness, and physical function. DESIGN: Systematic review and meta-analysis of randomized controlled trials. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, the Web of Science, and Chinese Biomedical Literature Database were searched from the date of inception to August 2015. METHODS: Trials comparing effects of resistance exercise intervention with either non-intervention or psycho-educational intervention were selected by two reviewers independently. The risk of bias was assessed and studies with similar outcomes were pooled using a fixed or random effects model. RESULTS: Data from 17 randomized clinical trials including 1705 patients were integrated. The main source of methodological bias in the selected studies was lack of double blinding. The meta-analysis results suggested that resistance exercise training relieved pain (standard mean difference [SMD]: -0.43; 95%

confidence interval [CI]: -0.57 to -0.29; P < 0.001), alleviated stiffness (SMD: -0.31; 95%: CI -0.56 to -0.05; P = 0.02), and improved physical function (SMD -0.53; 95% CI: -0.70 to -0.37; P < 0.001). CONCLUSION: Resistance exercise is beneficial in terms of reducing pain, alleviating stiffness, and improving physical function in patients with knee osteoarthritis. © The Author(s) 2015. PMID: 26471972 [PubMed - as supplied by publisher] 12. Physiotherapy. 2015 Sep;101(3):252-65. doi: 10.1016/j.physio.2014.12.003. Epub 2015 Jan 16. Effectiveness of land-based physiotherapy exercise following hospital discharge following hip arthroplasty for osteoarthritis: an updated systematic review. Lowe CJ(1), Davies L(2), Sackley CM(3), Barker KL(4). Author information: (1)Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Hospital, Windmill Road, Headington, Oxford, UK. Electronic address: catherine.minnslowe@ouh.nhs.uk. (2)Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Hospital, Windmill Road, Headington, Oxford, UK. (3)School of Rehabilitation Sciences, University of East Anglia, Norwich Research Park, Norwich, UK. (4)Physiotherapy Research Unit, Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Hospital, Windmill Road, Headington, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford University Hospitals NHS Trust, Oxford, UK. BACKGROUND: Existing review required updating. OBJECTIVE: To evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for patients following elective primary total hip arthroplasty for osteoarthritis. DESIGN: Systematic review from January 2007 to November 2013. DATA SOURCES: AMED, CINAHL, EMBASE, MEDLINE, Kingsfund Database, and PEDro. Cochrane CENTRAL, BioMed Central (BMC), The Department of Health National Research Register and Clinical Trials.gov register. Searches were overseen by a librarian. Authors were contacted for missing information. No language restrictions were applied. ELIGIBILITY CRITERIA: Trials comparing physiotherapy exercise vs usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for

osteoarthritis were reviewed. OUTCOMES: Functional activities of daily living, walking, quality of life, muscle strength and joint range of motion. STUDY APPRAISAL: Quality and risk of bias for studies were evaluated. Data were extracted and meta-analyses considered. RESULTS: 11 trials are included in the review. Trial quality was mixed. Newly included studies were assessed as having lower risk of bias than previous studies. Narrative review indicates that physiotherapy exercise after discharge following total hip replacement may potentially benefit patients in terms of function, walking and muscle strengthening. LIMITATIONS: The overall quality and quantity of trials, and their diversity, prevented meta-analyses. CONCLUSIONS: Disappointingly, insufficient evidence still prevents the effectiveness of physiotherapy exercise following discharge to be determined for this patient group. High quality, adequately powered, trials with long term follow up are required. Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 25724323 [PubMed - indexed for MEDLINE] 13. Clin Rehabil. 2015 Sep 23. pii: 0269215515606198. [Epub ahead of print] Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercise in the management of hip osteoarthritis. Brosseau L(1), Wells GA(2), Pugh AG(3), Smith CA(2), Rahman P(4), Àlvarez Gallardo IC(5), Toupin-April K(6), Loew L(7), De Angelis G(2), Cavallo S(8), Taki J(9), Marcotte R(10), Fransen M(11), Hernandez-Molina G(12), Kenny GP(10), Regnaux JP(13), Lefevre-Colau MM(14), Brooks S(15), Laferriere L(16), McLean L(7), Longchamp G(17). Author information: (1)School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada Lucie.Brosseau@uottawa.ca. (2)School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada. (3)Department of Public Health Sciences, Queens University, Canada. (4)Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada. (5)Department of Physical Education and Sport, University of Granada, Granada, Spain. (6)Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada. (7)School of Rehabilitation Sciences, University of Ottawa, Ottawa, Ontario, Canada. (8)School of Public Health, Option Epidemiology, University of Montreal, Montreal, Quebec, Canada. (9)Interdisciplinary School of

Health Sciences, University of Ottawa, Ottawa, Ontario, Canada. (10)School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada. (11)Faculty of Health Sciences, University of Sydney, Sydney, Australia. (12)Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico, Canada. (13)Centre de recherche Epidémiologie et Biostatistique, Hôpital Hôtel-Dieu, Paris, France. (14)Department of Medicine and Rehabilitation, Institute of Rheumatology, Cochin Hospital, Paris, France. (15)The Arthritis Society, Ontario Division, Ontario, Canada. (16)Canadian Forces Health Services Group Headquarters, National Defense, Ottawa, Ontario, Canada. (17)Consumer expert. OBJECTIVES: The primary objective is to identify effective land-based therapeutic exercise interventions and provide evidence-based recommendations for managing hip osteoarthritis. A secondary objective is to develop an Ottawa Panel evidence-based clinical practice guideline for hip osteoarthritis. METHODS: The search strategy and modified selection criteria from a Cochrane review were used. Studies included hip osteoarthritis patients in comparative controlled trials with therapeutic exercise interventions. An Expert Panel arrived at a Delphi survey consensus to endorse the recommendations. The Ottawa Panel hierarchical alphabetical grading system (A, B, C+, C, D, D+, or D-) considered the study design (level I: randomized controlled trial and level II: controlled clinical trial), statistical significance (p < 0.5), and clinical importance (⩾15% improvement). RESULTS: Four high-quality studies were included, which demonstrated that variations of strength training, stretching, and flexibility exercises are generally effective for improving the management of hip osteoarthritis. Strength training exercises displayed the greatest improvements for pain (Grade A), disability (Grades A and C+), physical function (Grade A), stiffness (Grade A), and range of motion (Grade A) within a short time period (8-24 weeks). Stretching also greatly improved physical function (Grade A), and flexibility exercises improved pain (Grade A), range of motion (Grade A), physical function (Grade A), and stiffness (Grade C+). CONCLUSION: The Ottawa Panel recommends land-based therapeutic exercise, notably strength training, for management of hip osteoarthritis in reducing pain, stiffness and self-reported disability, and improving physical function and range of motion. © The Author(s) 2015. PMID: 26400851 [PubMed - as supplied by publisher] 14. Z Rheumatol. 2015 Aug;74(6):543-52. doi: 10.1007/s00393-014-1559-9. Effectiveness of aquatic exercise for treatment of knee osteoarthritis:

Systematic review and meta-analysis. Lu M(1), Su Y, Zhang Y, Zhang Z, Wang W, He Z, Liu F, Li Y, Liu C, Wang Y, Sheng L, Zhan Z, Wang X, Zheng N. Author information: (1)Fujian University of Traditional Chinese Medicine, No.1 Qiuyang St., Shangjie, Minhou, Fuzhou, Fujian, China. OBJECTIVE: This paper presents a systematic review and meta-analysis of the effectiveness of aquatic exercise for treatment of knee osteoarthritis (OA). METHODS: PubMed, the Cochrane Library, Embase, CAMbase, and the Web of Science were screened through to June 2014. Only randomized controlled trials (RCTs) comparing aquatic exercise with control conditions were included. Two authors independently selected trials for inclusion, assessed the included trials, and extracted data. Outcome measures included pain, physical function, joint stiffness, quality of life (QOL), and safety. Pooled outcomes were analyzed using standardized mean difference (SMD). RESULTS: There is a lack of high quality studies in this area. Six RCTs (398 participants) were included. There was moderate evidence for a moderate effect on physical function in favor of aquatic exercise immediately after the intervention, but no evidence for pain or QOL when comparing aquatic exercise with nonexercise. Only one trial reported 3 months of follow-up measurements, which demonstrated limited evidence for pain improvement with aquatic exercise and no evidence for QOL or physical function when comparing aquatic exercise with nonexercise. There was limited evidence for pain improvement with land-based exercise and no evidence for QOL or physical function, when comparing aquatic exercise with land-based exercise according to follow-up measurements. No evidence was found for pain, physical function, stiffness, QOL, or mental health with aquatic exercise immediately after the intervention when comparing aquatic exercise with land-based exercise. Two studies reported aquatic exercise was not associated with serious adverse events. CONCLUSION: Aquatic exercise appears to have considerable short-term benefits compared with land-based exercise and nonexercise in patients with knee OA. Based on these results, aquatic exercise is effective and safe and can be considered as an adjuvant treatment for patients with knee OA. Studies in this area are still too scarce and too short-term to provide further recommendations on how to apply this therapy. PMID: 25691109 [PubMed - indexed for MEDLINE] 15. Clin Biomech (Bristol, Avon). 2015 Jul;30(6):521-7. doi: 10.1016/j.clinbiomech.2015.03.028. Epub 2015 Apr 11.

The effect of exercise therapy on knee adduction moment in individuals with knee osteoarthritis: A systematic review. Ferreira GE(1), Robinson CC(2), Wiebusch M(3), Viero CC(4), da Rosa LH(5), Silva MF(6). Author information: (1)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: giovannieferreira@hotmail.com. (2)Doctoral Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: carollinerobinson@gmail.com. (3)Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: matheusw.fisio@hotmail.com. (4)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: carolinaviero@gmail.com. (5)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: luisr@ufcspa.edu.br. (6)Masters Program in Rehabilitation Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil; Doctoral Program in Health Sciences, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil. Electronic address: marcelofs@ufcspa.edu.br. BACKGROUND: Exercise therapy is an evidence-based intervention for the conservative management of knee osteoarthritis. It is hypothesized that exercise therapy could reduce the knee adduction moment. A systematic review was performed in order to verify the effects of exercise therapy on the knee adduction moment in individuals with knee osteoarthritis in studies that also assessed pain and physical function. METHODS: A comprehensive electronic search was performed on MEDLINE, Cochrane CENTRAL, EMBASE, Google scholar and OpenGrey. Inclusion criteria were randomized controlled trials with control or sham groups as comparator assessing pain, physical function, muscle strength and knee adduction moment during walking at self-selected speed in individuals with knee osteoarthritis that underwent a structured exercise therapy rehabilitation program. Two independent reviewers extracted the data and assessed risk of bias. For each study, knee adduction moment, pain and physical function outcomes were extracted. For each outcome, mean differences and 95% confidence intervals were calculated. Due to clinical heterogeneity among exercise therapy protocols, a descriptive analysis was chosen. FINDINGS: Three studies, comprising 233 participants, were included. None of the studies showed significant differences between strengthening and control/sham groups in knee adduction moment. In regards to pain and physical function, the three studies demonstrated significant improvement in pain and two of them showed increased physical function following exercise therapy compared to controls.

Muscle strength and torque significantly improved in all the three trials favoring the intervention group. INTERPRETATION: Clinical benefits from exercise therapy were not associated with changes in the knee adduction moment. The lack of knee adduction moment reduction indicates that exercise therapy may not be protective in knee osteoarthritis from a joint loading point of view. Alterations in neuromuscular control, not captured by the knee adduction moment measurement, may contribute to alter dynamic joint loading following exercise therapy. To conclude, mechanisms other than the reduction in knee adduction moment might explain the clinical benefits of exercise therapy on knee osteoarthritis. Copyright © 2015 Elsevier Ltd. All rights reserved. PMID: 25896448 [PubMed - indexed for MEDLINE] 16. Osteoarthritis Cartilage. 2015 Jul;23(7):1071-82. doi: 10.1016/j.joca.2014.12.027. Epub 2015 Apr 9. Identifying potential working mechanisms behind the positive effects of exercise therapy on pain and function in osteoarthritis; a systematic review. Runhaar J(1), Luijsterburg P(2), Dekker J(3), Bierma-Zeinstra SM(4). Author information: (1)Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: j.runhaar@erasmusmc.nl. (2)Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: p.luijsterburg@erasmusmc.nl. (3)Department of Rehabilitation Medicine and Department of Psychiatry, VU University Medical Center, Amsterdam, The Netherlands. Electronic address: j.dekker@vumc.nl. (4)Department of General Practice, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands; Department of Orthopedics, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. Electronic address: s.bierma-zeinstra@erasmusmc.nl. OBJECTIVE: Although physical exercise is the commonly recommended for osteoarthritis (OA) patients, the working mechanism behind the positive effects of physical exercise on pain and function is a black box phenomenon. In the present study we aimed to identify possible mediators in the relation between physical exercise and improvements of pain and function in OA patients. DESIGN: A systematic search for all studies evaluating the effects of physical exercise in OA patients and select those that additionally reported the change in any physiological factor from pre-to post-exercise.

RESULTS: In total, 94 studies evaluating 112 intervention groups were included. Most included studies evaluated subjects with solely knee OA (96 out of 112 groups). Based on the measured physiological factors within the included studies, 12 categories of possible mediators were formed. Muscle strength and ROM/flexibility were the most measured categories of possible mediators with 61 and 21 intervention groups measuring one or more physiological factors within these categories, respectively. 60% (31 out of 52) of the studies showed a significant increase in knee extensor muscle strength and 71% (22 out of 31) in knee flexor muscle strength over the intervention period. All 5 studies evaluating extension impairments and 10 out of 12 studies (83%) measuring proprioception found a significant change from pre-to post-intervention. CONCLUSION: An increase of upper leg strength, a decrease of extension impairments and improvement in proprioception were identified as possible mediators in the positive association between physical exercise and OA symptoms. Copyright © 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved. PMID: 25865391 [PubMed - indexed for MEDLINE] 17. Ann Rheum Dis. 2015 Jun;74(6):1145-9. doi: 10.1136/annrheumdis-2014-206176. Epub 2014 Nov 21. Development of patient-centred standards of care for osteoarthritis in Europe: the eumusc.net-project. Stoffer MA(1), Smolen JS(1), Woolf A(2), Ambrozic A(3), Berghea F(4), Boonen A(5), Bosworth A(6), Carmona L(7), Dougados M(8), de Wit M(9), Erwin J(2), Fialka-Moser V(10), Ionescu R(4), Keenan AM(11), Loza E(7), Moe RH(12), Greiff R(13), Olejnik P(14), Petersson IF(15), Rat AC(16), Rozman B(3), Strömbeck B(15), Tanner L(6), Uhlig T(12), Vlieland TP(17), Stamm TA(1); eumusc.net WP 5 Expert Panel. Collaborators: Ambrozic A, Berghea F, Boonen A, Bosworth A, Carmona L, Dougados M, de Wit M, Erwin J, Fialka-Moser V, Ionescu R, Keenan AM, Loza E, Moe RH, Greiff R, Olejnik P, Petersson IF, Rat AC, Rozman B, Smolen J, Stamm TA, Stoffer MA, Strömbeck B, Tanner L, Uhlig T, Vliet TP, Woolf A. Author information: (1)Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria. (2)Royal Cornwall Hospital, Truro Cornwall, UK. (3)University Medical Centre Ljubljana, Ljubljana, Slovenia. (4)Universitatea de Medicina si Farmacie Carol Davila, Bucharest, Romania. (5)Maastricht University Medical Center, Maastricht, The Netherlands. (6)National Rheumatoid Arthritis

Society, Berkshire, UK. (7)Instituto de Salud Musculoesqueletica, Madrid, Spain. (8)Paris Descartes University, Paris, France Department of Rheumatology-Hôpital Cochin. Assistance Publique-Hôpitaux de Paris, Paris, France INSERM (U1153): Clinical Epidemiology and biostatistics, PRES Sorbonne Paris-Cité, Paris, France. (9)Reumapatientenbond, Amersfoort, The Netherlands. (10)Department of Physical Medicine and Rehabilitation, Medical University of Vienna, Vienna, Austria. (11)University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK. (12)National Advisory Unit on Rehabilitation in Rheumatology (NKRR), Oslo, Norway. (13)Rheumatikerförbundet, Swedish Rheumatism Association, Stockholm, Sweden. (14)Instytut Reumatologii, Warsaw, Poland. (15)Orthopedics and Rheumatology, Clinical Sciences, Lund University, Lund, Sweden. (16)Université de Lorraine, Université Paris Descartes, Apemac, EA 4360, Nancy, France. (17)Leiden University Medical Center, Leiden, The Netherlands. OBJECTIVE: The eumusc.net project is an initiative founded by the European Community and the European League Against Rheumatism. One aim of the project was to facilitate equal standards for musculoskeletal health across Europe. The aim of this work-package was to develop patient-centred and consensus based standards of care (SOC) for osteoarthritis (OA), which should be available in a professional and a patient version. METHODS: A systematic review concerning guidelines dealing with OA was conducted. Furthermore, experts in musculoskeletal diseases were contacted to ensure that 'grey' literature was not excluded. Documents that fulfilled predefined inclusion/exclusion criteria were included and all interventions for OA were extracted and categorised. Based on this list of interventions, a three round Delphi exercise with an international and multidisciplinary expert panel, including patient research partners, was performed to achieve expert consensus. RESULTS: Six documents were included and used for further analysis. Out of them, 46 interventions have been extracted and 10 consensus based SOC were formulated. In addition, a patient version, written in a lay-understandable wording and in the format of checklist questions was developed. An example is SOC 5: "People with OA should achieve optimal pain control using pharmacological and non-pharmacological means." The matching patient-centred checklist question reads: "Do I know how to control pain associated with OA?" CONCLUSIONS: The SOC for OA will be available in the 23 languages of the European Union to enhance unified information to patients and professionals and to further harmonise the treatment/care of OA within Europe. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. PMCID: PMC4431331 PMID: 25416720 [PubMed - indexed for MEDLINE]

18. Musculoskeletal Care. 2015 Mar;13(1):1-18. doi: 10.1002/msc.1084. Epub 2014 Nov 5. The effects of interventions to increase exercise adherence in people with arthritis: a systematic review. Ezzat AM(1), MacPherson K, Leese J, Li LC. Author information: (1)Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, BC, Canada; Child and Family Research Institute, Vancouver, BC, Canada. PMID: 25752931 [PubMed - indexed for MEDLINE] 19. Arthritis Res Ther. 2015 Feb 3;17:21. doi: 10.1186/s13075-015-0533-5. Effects of exercise on depression in adults with arthritis: a systematic review with meta-analysis of randomized controlled trials. Kelley GA(1), Kelley KS(2), Hootman JM(3). Author information: (1)Department of Biostatistics, Robert C. Byrd Health Sciences Center, School of Public Health, West Virginia University, Morgantown, WV, 26506-9190, USA. gkelley@hsc.wvu.edu. (2)Department of Biostatistics, Robert C. Byrd Health Sciences Center, School of Public Health, West Virginia University, Morgantown, WV, 26506-9190, USA. kskelley@hsc.wvu.edu. (3)Division of Population Health MS F-78, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention Atlanta, Atlanta, GA, 30341, USA. jhootman@cdc.gov. INTRODUCTION: Previous randomized controlled trials have led to conflicting findings regarding the effects of exercise on depressive symptoms in adults with arthritis and other rheumatic conditions (AORC). The purpose of this study was to use the meta-analytic approach to resolve these discrepancies. METHODS: The inclusion criteria were: (1) randomized controlled trials, (2) exercise (aerobic, strength training, or both) ≥4 weeks, (3) comparative control group, (4) adults with osteoarthritis, rheumatoid arthritis, fibromyalgia or systemic lupus erythematosus, (5) published studies in any language since January 1, 1981 and (6) depressive symptoms assessed. Studies were located by searching 10 electronic databases, cross-referencing, hand searching and expert review. Dual-selection of studies and data abstraction was performed. Hedge's

standardized mean difference effect size (g) was calculated for each result and pooled using random-effects models, an approach that accounts for heterogeneity. Non-overlapping 95% confidence intervals (CI) were considered statistically significant. Heterogeneity based on fixed-effect models was estimated using Q and I (2) with alpha values ≤0.10 for Q considered statistically significant. RESULTS: Of the 500 citations reviewed, 2,449 participants (1,470 exercise, 979 control) nested within 29 studies were included. Length of training, reported as mean ± standard deviation (±SD) was 19 ± 16 weeks, frequency 4 ± 2 times per week and duration 34 ± 17 minutes per session. Overall, statistically significant exercise minus control group reductions were found for depressive symptoms (g = -0.42, 95% CI, -0.58, -0.26, Q = 126.9, P <0.0001, I(2) = 73.2%). The number needed-to-treat was 7 (95% CI, 6 to 11) with an estimated 3.1 million (95% CI, 2.0 to 3.7) United States adults not currently meeting physical activity guidelines improving their depressive symptoms if they began and maintained a regular exercise program. Using Cohen's U3 Index, the percentile reduction was 16.4% (95% CI, 10.4% to 21.9%). All studies were considered to be at high risk of bias with respect to blinding of participants and personnel to group assignment. CONCLUSIONS: Exercise is associated with reductions in depressive symptoms among selected adults with AORC. A need exists for additional, well-designed and reported studies on this topic. PMCID: PMC4467075 PMID: 25645739 [PubMed - indexed for MEDLINE] 20. Br J Sports Med. 2014 Nov;48(21):1579. doi: 10.1136/bjsports-2014-5555rep. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. Uthman OA(1), van der Windt DA(2), Jordan JL(2), Dziedzic KS(2), Healey EL(2), Peat GM(2), Foster NE(2). Author information: (1)Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL UK. (2)Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK. Republished from BMJ. 2013;347:f5555. STUDY QUESTION: Which types of exercise intervention are most effective in relieving pain and improving function in people with lower limb osteoarthritis?

SUMMARY ANSWER: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise. An approach combining exercises to increase strength, flexibility, and aerobic capacity is most likely to be effective for relieving pain and improving function. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Current international guidelines recommend therapeutic exercise (land or water based) as "core" and effective management of osteoarthritis. Evidence from this first network meta-analysis, largely based on studies in knee osteoarthritis, indicates that an intervention combining strengthening exercises with flexibility and aerobic exercise is most likely to improve outcomes of pain and function. Further trials of exercise versus no exercise are unlikely to overturn this positive result. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. PMID: 25313133 [PubMed] 21. Osteoarthritis Cartilage. 2014 Nov;22(11):1752-73. doi: 10.1016/j.joca.2014.07.005. Epub 2014 Jul 24. Efficacy of rehabilitation programs for improving muscle strength in people with hip or knee osteoarthritis: a systematic review with meta-analysis. Zacharias A(1), Green RA(2), Semciw AI(3), Kingsley MI(4), Pizzari T(5). Author information: (1)La Trobe Rural Health School, La Trobe University, Victoria, Australia; Sport, Exercise and Rehabilitation Research Focus Area, Australia. Electronic address: a.zacharias@latrobe.edu.au. (2)La Trobe Rural Health School, La Trobe University, Victoria, Australia; Sport, Exercise and Rehabilitation Research Focus Area, Australia. Electronic address: Rod.Green@latrobe.edu.au. (3)School of Allied Health, La Trobe University, Victoria, Australia; Sport, Exercise and Rehabilitation Research Focus Area, Australia. Electronic address: A.Semciw@latrobe.edu.au. (4)La Trobe Rural Health School, La Trobe University, Victoria, Australia; Sport, Exercise and Rehabilitation Research Focus Area, Australia. Electronic address: M.Kingsley@latrobe.edu.au. (5)School of Allied Health, La Trobe University, Victoria, Australia; Sport, Exercise and Rehabilitation Research Focus Area, Australia. Electronic address: T.Pizzari@latrobe.edu.au. To analyse the effect of exercise-based rehabilitation programs for improving lower limb muscle strength in individuals with hip or knee osteoarthritis (OA). A systematic search utilizing seven databases identified randomized controlled

trials (RCTs) evaluating lower limb strength outcomes of exercise-based interventions for participants with hip or knee OA. All studies were screened for eligibility and methodological quality. Quality of evidence was assessed using Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach. Data were pooled and meta-analyses performed where appropriate. Forty RCTs were included and the majority (77%) involved resistance based exercise programs. For knee OA populations, there was high quality evidence for improved knee extension (standardized mean difference (SMD) = 0.47, 95% confidence intervals (CI) 0.29, 0.66) and flexion strength (SMD = 0.74, 95% CI 0.56, 0.92) with low-intensity resistance program when compared to a control at short term (ST) follow-up. There was moderate quality evidence for a large effect favouring high-intensity resistance programs (SMD = 0.76, 95% CI 0.47, 1.06) when compared to a control. This effect was sustained at intermediate term (IT) follow-up (SMD = 0.80, 95% CI 0.44, 1.17). Few studies reported on outcomes at long term (LT) follow-up. Only one study reported on a population with hip OA. When compared to a control group, high-intensity resistance exercise demonstrated moderate quality of evidence for large and sustained improvements for knee muscle strength in knee OA patients. Further work is needed to compare different modes of exercise at a LT follow-up for knee OA patients and to address the dearth of literature evaluating exercise interventions in people with hip OA. Copyright © 2014 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved. PMID: 25065642 [PubMed - indexed for MEDLINE] 22. Phys Ther. 2014 Oct;94(10):1383-95. doi: 10.2522/ptj.20130417. Epub 2014 Jun 5. Effect of therapeutic aquatic exercise on symptoms and function associated with lower limb osteoarthritis: systematic review with meta-analysis. Waller B(1), Ogonowska-Slodownik A(2), Vitor M(3), Lambeck J(4), Daly D(5), Kujala UM(6), Heinonen A(7). Author information: (1)B. Waller, PT, MSc, Department of Health Sciences, University of Jyvaskyla, PO Box 35, FI-40014, Jyvaskyla, Finland. ben.waller@jyu.fi. (2)A. Ogonowska-Slodownik, MSc, Faculty of Rehabilitation, Jozef Pilsudski University of Physical Education, Warsaw, Poland. (3)M. Vitor, MSc, Faculty of Sport, University of Porto, Porto, Portugal. (4)J. Lambeck, PT, BHS, KU Leuven, Faculty of Kinesiology and Rehabilitation Sciences, Leuven, Belgium. (5)D. Daly, PhD, KU Leuven, Faculty of Kinesiology and Rehabilitation Sciences. (6)U.M. Kujala, MD, PhD, Department of Health Sciences, University of Jyvaskyla. (7)A. Heinonen, PhD, Department of Health Sciences, University of Jyvaskyla.

BACKGROUND: Current management of osteoarthritis (OA) focuses on pain control and maintaining physical function through pharmacological, nonpharmacological, and surgical treatments. Exercise, including therapeutic aquatic exercise (TAE), is considered one of the most important management options. Nevertheless, there is no up-to-date systematic review describing the effect of TAE on symptoms and function associated with lower limb OA. PURPOSE: The purpose of this study was to conduct a systematic review with meta-analysis to determine the effect of TAE on symptoms and function associated with lower limb OA. DATA SOURCES: The data sources used in this study were: MEDLINE, PubMed, EMBASE, CINAHL, PEDro, and SPORTDiscus. STUDY SELECTION: All studies selected for review were randomized controlled trials with an aquatic exercise group and a nontreatment control group. In total, 11 studies fulfilled the inclusion criteria and were included in the synthesis and meta-analysis. DATA EXTRACTION: Data were extracted and checked for accuracy by 3 independent reviewers. DATA SYNTHESIS: Standardized mean difference (SMD) with 95% confidence interval (95% CI) was calculated for all outcomes. The meta-analysis showed a significant TAE effect on pain (SMD=0.26 [95% CI=0.11, 0.41]), self-reported function (SMD=0.30 [95% CI=0.18, 0.43]), and physical functioning (SMD=0.22 [95% CI=0.07, 0.38]). Additionally, a significant effect was seen on stiffness (SMD=0.20 [95% CI=0.03, 0.36]) and quality of life (SMD=0.24 [95% CI=0.04, 0.45]). LIMITATIONS: Heterogeneity of outcome measures and small sample sizes for many of the included trials imply that conclusions based on these results should be made with caution. CONCLUSIONS: The results indicate that TAE is effective in managing symptoms associated with lower limb OA. © 2014 American Physical Therapy Association. PMID: 24903110 [PubMed - indexed for MEDLINE] 23. J Phys Ther Sci. 2014 Jul;26(7):1133-7. doi: 10.1589/jpts.26.1133. Epub 2014 Jul 30. Effects of tai chi for patients with knee osteoarthritis: a systematic review. Ye J(1), Cai S(1), Zhong W(2), Cai S(2), Zheng Q(2). Author information: (1)Department of Rehabilitation Assessment, Rehabilitation Hospital, Fujian University of Traditional Chinese Medicine, China ; Department of Rehabilitation

Sciences, The Hong Kong Polytechnic University, Hong Kong, China. (2)Department of Rehabilitation Assessment, Rehabilitation Hospital, Fujian University of Traditional Chinese Medicine, China. [Purpose] The aim of the present study was to seek evidence for the effectiveness of Tai Chi for patients with knee osteoarthritis (KOA). [Subjects and Methods] Systematic searches were conducted of the China Journals Full-text Database, Pubmed, Medline, Science Direct-Online Journals and CINAHL for studies published between 2000 and 2012. Studies were evaluated based on following inclusion criteria: 1) design: randomized control, clinical trial; 2) subjects: patients with a knee osteoarthritis diagnosis; 3) intervention: exercise involving Tai Chi; 4) studies published in English or Chinese. [Results] Six randomized control studies involving Tai Chi and knee osteoarthritis were found. [Conclusion] Tai Chi was an effective way of relieving pain and improving physical function. Further randomized controlled trials with large sample sizes and long training period are needed to compare groups who perform Tai Chi training with other groups who undergo other forms of physical exercise in order to confirm the efficacy of Tai Chi. PMCID: PMC4135213 PMID: 25140112 [PubMed] 24. J Phys Ther Sci. 2014 Jul;26(7):969-75. doi: 10.1589/jpts.26.969. Epub 2014 Jul 30. Effect of the Frequency and Duration of Land-based Therapeutic Exercise on Pain Relief for People with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Tanaka R(1), Ozawa J(1), Kito N(1), Moriyama H(2). Author information: (1)Department of Rehabilitation, Hiroshima International University, Japan. (2)Department of Rehabilitation Science, Graduate School of Health Sciences, Kobe University, Japan. [Purpose] This study aimed to investigate the influence of land-based exercise frequency and duration on pain relief for people with knee osteoarthritis (OA). [Subjects and Methods] The systematic review included randomized controlled trials that investigated this influence, which were identified by searches of PubMed, the Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature. The exercise groups in the identified trials were categorized according to their type, frequency, and duration of exercise, and subgroup

analyses were performed. [Results] Data integration of 17 studies (23 exercise groups) revealed a significant effect and a medium effect size. In subgroups involving strengthening exercise programs of ≥9 weeks duration, heterogeneity was found between subjects who performed up to 3 sessions/week and those who performed ≥4 sessions/week. In subgroups involving strengthening exercise programs of up to 3 sessions/week, there was heterogeneity between subjects who exercised for up to 8 weeks and those who exercised for ≥9 weeks. Heterogeneity was not confirmed in aerobic exercise subgroups. [Conclusion] Differences in exercise frequency and duration influence pain relief in effects of strengthening exercises but do not influence the effect size of aerobic exercise for people with knee OA. PMCID: PMC4135217 PMID: 25140076 [PubMed] 25. Semin Arthritis Rheum. 2014 Jun;43(6):701-12. doi: 10.1016/j.semarthrit.2013.11.012. Epub 2013 Dec 4. A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Nelson AE(1), Allen KD(2), Golightly YM(3), Goode AP(4), Jordan JM(5). Author information: (1)Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC. Electronic address: aenelson@med.unc.edu. (2)Department of Medicine, Duke University Medical Center & Health Services Research & Development, VA Medical Center, Durham, NC. (3)Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Injury Prevention Research Center, University of North Carolina, Chapel Hill, NC. (4)Department of Community and Family Medicine, Duke University Medical Center, Durham, NC. (5)Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC; Department of Medicine, University of North Carolina, Chapel Hill, NC; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC; Department of Orthopaedics, University of North Carolina, Chapel Hill, NC. PURPOSE: Although a number of osteoarthritis (OA) management guidelines exist, uptake has been suboptimal. Our aim was to review and critically evaluate existing OA management guidelines to better understand potential issues and barriers.

METHODS: A systematic review of the literature in MEDLINE published from January 1, 2000 to April 1, 2013 was performed and supplemented by bibliographic reviews, following PRISMA guidelines and a written protocol. Following initial title and abstract screening, 2 authors independently reviewed full-text articles; a third settled disagreements. Two independent reviewers extracted data into a standardized form. Two authors independently assessed guideline quality using the AGREE II instrument; three generated summary recommendations based on the extracted guideline data. RESULTS: Overall, 16 articles were included in the final review. There was broad agreement on recommendations by the various organizations. For non-pharmacologic modalities, education/self-management, exercise, weight loss if overweight, walking aids as indicated, and thermal modalities were widely recommended. For appropriate patients, joint replacement was recommended; arthroscopy with debridement was not recommended for symptomatic knee OA. Pharmacologic modalities most recommended included acetaminophen/paracetamol (first line) and NSAIDs (topical or oral, second line). Intra-articular corticosteroids were generally recommended for hip and knee OA. Controversy remains about the use of acupuncture, knee braces, heel wedges, intra-articular hyaluronans, and glucosamine/chondroitin. CONCLUSIONS: The relative agreement on many OA management recommendations across organizations indicates a problem with dissemination and implementation rather than a lack of quality guidelines. Future efforts should focus on optimizing implementation in primary care settings, where the majority of OA care occurs. Copyright © 2014 Elsevier Inc. All rights reserved. PMID: 24387819 [PubMed - indexed for MEDLINE] 26. BMC Musculoskelet Disord. 2014 Apr 7;15:121. doi: 10.1186/1471-2474-15-121. Effects of exercise on depressive symptoms in adults with arthritis and other rheumatic disease: a systematic review of meta-analyses. Kelley GA(1), Kelley KS. Author information: (1)Department of Biostatistics, Robert C, Byrd Health Sciences Center, West Virginia University, PO Box 9190, 26506-9190 Morgantown, WV, USA. gkelley@hsc.wvu.edu. BACKGROUND: Depression is a major public health problem among adults with arthritis and other rheumatic disease. The purpose of this study was to conduct a systematic review of previous meta-analyses addressing the effects of exercise (aerobic, strength or both) on depressive symptoms in adults with osteoarthritis,

rheumatoid arthritis, fibromyalgia and systemic lupus erythematous. METHODS: Previous meta-analyses of randomized controlled trials were included by searching nine electronic databases and cross-referencing. Methodological quality was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) Instrument. Random-effects models that included the standardized mean difference (SMD) and 95% confidence intervals (CIs) were reported. The alpha value for statistical significance was set at p ≤ 0.05. The U3 index, number needed to treat (NNT) and number of US people who could benefit were also calculated. RESULTS: Of the 95 citations initially identified, two aggregate data meta-analyses representing 6 and 19 effect sizes in as many as 870 fibromyalgia participants were included. Methodological quality was 91% and 82%, respectively. Exercise minus control group reductions in depressive symptoms were found for both meta-analyses (SMD, -0.61, 95% CI, -0.99 to -0.23, p = 0.002; SMD, -0.32, 95% CI, -0.53 to -0.12, p = 0.002). Percentile improvements (U3) were equivalent to 22.9 and 12.6. The number needed to treat was 6 and 9 with an estimated 0.83 and 0.56 million US people with fibromyalgia potentially benefitting. CONCLUSIONS: Exercise improves depressive symptoms in adults with fibromyalgia. However, a need exists for additional meta-analytic work on this topic. PMCID: PMC4107718 PMID: 24708605 [PubMed - indexed for MEDLINE] 27. Arthritis Rheumatol. 2014 Mar;66(3):622-36. doi: 10.1002/art.38290. Impact of exercise type and dose on pain and disability in knee osteoarthritis: a systematic review and meta-regression analysis of randomized controlled trials. Juhl C(1), Christensen R, Roos EM, Zhang W, Lund H. Author information: (1)University of Southern Denmark, Odense, Denmark, and Copenhagen University Hospital, Gentofte, Denmark. OBJECTIVE: To identify the optimal exercise program, characterized by type and intensity of exercise, length of program, duration of individual supervised sessions, and number of sessions per week, for reducing pain and patient-reported disability in knee osteoarthritis (OA). METHODS: A systematic review and meta-analysis of randomized controlled trials were performed. Standardized mean differences (SMDs) were combined using a random-effects model. Study-level covariates were applied in meta-regression analyses in order to reduce between-study heterogeneity. RESULTS: Forty-eight trials were included. Similar effects in reducing pain were found for aerobic, resistance, and performance exercise (SMD 0.67, 0.62, and 0.48, respectively; P = 0.733). These single-type exercise programs were more

efficacious than programs that included different exercise types (SMD 0.61 versus 0.16; P < 0.001). The effect of aerobic exercise on pain relief increased with an increased number of supervised sessions (slope 0.022 [95% confidence interval 0.002, 0.043]). More pain reduction occurred with quadriceps-specific exercise than with lower limb exercise (SMD 0.85 versus 0.39; P = 0.005) and when supervised exercise was performed at least 3 times a week (SMD 0.68 versus 0.41; P = 0.017). No impact of intensity, duration of individual sessions, or patient characteristics was found. Similar results were found for the effect on patient-reported disability. CONCLUSION: Optimal exercise programs for knee OA should have one aim and focus on improving aerobic capacity, quadriceps muscle strength, or lower extremity performance. For best results, the program should be supervised and carried out 3 times a week. Such programs have a similar effect regardless of patient characteristics, including radiographic severity and baseline pain. Copyright © 2014 by the American College of Rheumatology. PMID: 24574223 [PubMed - indexed for MEDLINE] 28. Arch Phys Med Rehabil. 2014 Feb;95(2):375-89. doi: 10.1016/j.apmr.2013.10.011. Epub 2013 Nov 1. Systematic review of guidelines for the physical management of osteoarthritis. Larmer PJ(1), Reay ND(2), Aubert ER(2), Kersten P(3). Author information: (1)Faculty of Health and Environmental Sciences, School of Rehabilitation and Occupation Studies, AUT University, Auckland. Electronic address: peter.larmer@aut.ac.nz. (2)Faculty of Health and Environmental Sciences, Department of Physiotherapy, AUT University, Auckland. (3)Faculty of Health and Environmental Sciences, Person Centred Research Centre, School of Rehabilitation and Occupation Studies, AUT University, Auckland, New Zealand. OBJECTIVE: To undertake a systematic critical appraisal of guidelines to provide a summary of recommendations for the physical management of osteoarthritis (OA). DATA SOURCES: The Cochrane Library, MEDLINE, CINAHL, SPORTDiscus with Full Text, Scopus, ScienceDirect, PEDro, and Google Scholar databases were searched (2000-2013) to identify all guidelines, protocols, and recommendations for the management or treatment of OA. In addition, Internet searches of all relevant arthritis organizations were undertaken. All searches were performed between July 2012 and end of April 2013. Guidelines that included only pharmacological, injection therapy, or surgical interventions were excluded. Guidelines published only in English were retrieved.

STUDY SELECTION: OA guidelines developed from evidence-based research, consensus, and/or expert opinion were retrieved. There were no restrictions on severity or site of OA, sex, or age. Nineteen guidelines were identified for evaluation. DATA EXTRACTION: The quality of all guidelines was critically appraised using the Appraisal of Guidelines for REsearch and Evaluation II instrument. Each guideline was independently reviewed. All relevant recommendations for the physical management of OA were synthesized, graded, and ranked according to available evidence. DATA SYNTHESIS: Seventeen guidelines with recommendations on the physical management of OA met the inclusion criteria and underwent a full critical appraisal. There were variations in the interventions, levels of evidence, and strength of recommendations across the guidelines. Forty different interventions were identified. Recommendations were graded from "strongly recommended" to "unsupported." Exercise and education were found to be strongly recommended by most guidelines. CONCLUSIONS: Exercise and education were key recommendations supporting the importance of rehabilitation in the physical management of OA. This critical appraisal can assist health care providers who are involved in the management of people with OA. Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved. PMID: 24184307 [PubMed - indexed for MEDLINE] 29. Open Rheumatol J. 2014 Nov 28;8:89-95. doi: 10.2174/1874312901408010089. eCollection 2014. Physical exercise and weight loss for hip and knee osteoarthritis in very old patients: a systematic review of the literature. Quintrec JL(1), Verlhac B(2), Cadet C(3), Bréville P(4), Vetel JM(5), Gauvain JB(6), Jeandel C(7), Maheu E(8). Author information: (1)Service de Médecine Gériatrique 3 [Department of Geriatric Medicine 3], Hôpital Sainte-Périne (A.P-H.P), Paris, France. (2)Pôle Vieillissement, réadaptation et Accompagnement [Centre for the Aged, Rehabilitation and Support], Hôpital Paul Brousse (A.P-H.P) Villejuif, France. (3)Medical Office, Paris, France. (4)Service de Rhumatologie [Department of Rheumatology], Groupe Hospitalier Paris Saint Joseph, Paris, France. (5)Centre Hospitalier, Le Mans, France. (6)Centre de Médecine Interne Gériatrique [Centre for Geriatric Internal Medicine], Centre Hospitalier régional, Orléans, France. (7)Service de Médecine interne et Gériatrie [Department of Internal and Geriatric Medicine],

Montpellier, France. (8)Service de Rhumatologie, Rheumatology Department, Medical Office / Hôpital Saint Antoine -A.P-H.P, Paris, France. BACKGROUND: Rheumatologic and geriatric scholarly organisations recommendations for the management of hip and knee osteoarthritis, which emphasise the usefulness of non-pharmacological therapies, are not scaled according to patient's age and physical condition. We conducted a systematic review of clinical trials on exercise and weight loss in hip and knee osteoarthritis in very old patients. METHODS: Electronic search in MEDLINE, EMBASE, PASCAL database, systematic search of the Cochrane Reviews, manual search in guidelines, meta-analyses and identified relevant articles. RESULTS: We identified 83 trials, with only 2 on patients aged ≥ 75 years; we therefore lowered the mean age threshold to 70 years and found 15 trials, mainly performed in knee osteoarthritis and outpatients. PHYSICAL EXERCISE 8 TRIALS: was effective on pain and function (4 controlled trials), with a persistent effect only in case of self-rehabilitation. AQUATIC EXERCISE 5 TRIALS: was as effective as land-based exercise. WEIGHT LOSS 2 TRIALS: only patients under diet + exercise had significant improvement on symptoms. CONCLUSION: Our systematic review confirms that international recommendations on exercise for knee osteoarthritis also apply to subjects aged 70-80 years. Long-term effectiveness requires a maintenance strategy. Specific trials on very old patients with various comorbidities are mandatory, given that these subjects are more exposed to drug-related iatrogenesis. PMCID: PMC4258698 PMID: 25489352 [PubMed] 30. Clin Rehabil. 2013 Dec;27(12):1059-71. doi: 10.1177/0269215513488898. Epub 2013 Jul 4. Efficacy of strengthening or aerobic exercise on pain relief in people with knee osteoarthritis: a systematic review and meta-analysis of randomized controlled trials. Tanaka R(1), Ozawa J, Kito N, Moriyama H. Author information: (1)1Department of Integrated Rehabilitation, Hiroshima International University, Japan. OBJECTIVE: We performed a systematic review and meta-analysis of randomized controlled trials to investigate the differences in the efficacies between strengthening and aerobic exercises for pain relief in people with knee

osteoarthritis. DATA SOURCES: This search was applied to Medline, Cochrane Central Register of Controlled Trials, the Physiotherapy Evidence Database, and the Cumulative Index to Nursing and Allied Health Literature. All literature published from each source's earliest date to March 2013 was included. REVIEW METHODS: Trials comparing the effects of exercise intervention with those of either non-intervention or psycho-educational intervention were collected. Meta-analysis was performed for trials in which therapeutic exercise was carried out with more than three sessions per week up to eight weeks, for pain in people with knee osteoarthritis. All trials were categorised into three subgroups (non-weight-bearing strengthening exercise, weight-bearing strengthening exercise, and aerobic exercise). Subgroup analyses were also performed. RESULTS: Data from eight studies were integrated. Overall effect of exercise was significant with a large effect size (standardised mean difference (SMD): -0.94; 95% confidence interval -1.31 to -0.57). Subgroup analyses showed a larger SMD for non-weight-bearing strengthening exercise (-1.42 [-2.09 to -0.75]) compared with weight-bearing strengthening exercise (-0.70 [-1.05 to -0.35]), and aerobic exercise (-0.45 [-0.77 to -0.13]). CONCLUSION: Muscle strengthening exercises with or without weight-bearing and aerobic exercises are effective for pain relief in people with knee osteoarthritis. In particular, for pain relief by short-term exercise intervention, the most effective exercise among the three types is non-weight-bearing strengthening exercise. PMID: 23828186 [PubMed - indexed for MEDLINE] 31. BMJ. 2013 Sep 20;347:f5555. doi: 10.1136/bmj.f5555. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. Uthman OA(1), van der Windt DA, Jordan JL, Dziedzic KS, Healey EL, Peat GM, Foster NE. Author information: (1)Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire ST5 5BG, UK. Comment in Evid Based Nurs. 2014 Oct;17(4):109. Ann Intern Med. 2013 Dec 17;159(12):JC7. Republished in Br J Sports Med. 2014 Nov;48(21):1579.

OBJECTIVE: To determine whether there is sufficient evidence to conclude that exercise interventions are more effective than no exercise control and to compare the effectiveness of different exercise interventions in relieving pain and improving function in patients with lower limb osteoarthritis. DATA SOURCES: Nine electronic databases searched from inception to March 2012. STUDY SELECTION: Randomised controlled trials comparing exercise interventions with each other or with no exercise control for adults with knee or hip osteoarthritis. DATA EXTRACTION: Two reviewers evaluated eligibility and methodological quality. Main outcomes extracted were pain intensity and limitation of function. Trial sequential analysis was used to investigate reliability and conclusiveness of available evidence for exercise interventions. Bayesian network meta-analysis was used to combine both direct (within trial) and indirect (between trial) evidence on treatment effectiveness. RESULTS: 60 trials (44 knee, two hip, 14 mixed) covering 12 exercise interventions and with 8218 patients met inclusion criteria. Sequential analysis showed that as of 2002 sufficient evidence had been accrued to show significant benefit of exercise interventions over no exercise control. For pain relief, strengthening, flexibility plus strengthening, flexibility plus strengthening plus aerobic, aquatic strengthening, and aquatic strengthening plus flexibility, exercises were significantly more effective than no exercise control. A combined intervention of strengthening, flexibility, and aerobic exercise was also significantly more effective than no exercise control for improving limitation in function (standardised mean difference -0.63, 95% credible interval -1.16 to -0.10). CONCLUSIONS: As of 2002 sufficient evidence had accumulated to show significant benefit of exercise over no exercise in patients with osteoarthritis, and further trials are unlikely to overturn this result. An approach combining exercises to increase strength, flexibility, and aerobic capacity is likely to be most effective in the management of lower limb osteoarthritis. The evidence is largely from trials in patients with knee osteoarthritis. PROTOCOL REGISTRATION: PROSPERO (www.crd.york.ac.uk/prospero/) No CRD42012002267. PMCID: PMC3779121 PMID: 24055922 [PubMed - indexed for MEDLINE] 32. Osteoarthritis Cartilage. 2013 Sep;21(9):1290-8. doi: 10.1016/j.joca.2013.05.007. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Corbett MS(1), Rice SJ, Madurasinghe V, Slack R, Fayter DA, Harden M, Sutton AJ, Macpherson H, Woolacott NF.

Author information: (1)University of York, UK. mark.corbett@york.ac.uk Comment in Osteoarthritis Cartilage. 2014 May;22(5):712-3. Osteoarthritis Cartilage. 2014 May;22(5):710-1. OBJECTIVE: To compare the effectiveness of acupuncture with other relevant physical treatments for alleviating pain due to knee osteoarthritis. DESIGN: Systematic review with network meta-analysis, to allow comparison of treatments within a coherent framework. Comprehensive searches were undertaken up to January 2013 to identify randomised controlled trials in patients with osteoarthritis of the knee, which reported pain. RESULTS: Of 156 eligible studies, 114 trials (covering 22 treatments and 9,709 patients) provided data suitable for analysis. Most trials studied short-term effects and many were classed as being of poor quality with high risk of bias, commonly associated with lack of blinding (which was sometimes impossible to achieve). End of treatment results showed that eight interventions: interferential therapy, acupuncture, TENS, pulsed electrical stimulation, balneotherapy, aerobic exercise, sham acupuncture, and muscle-strengthening exercise produced a statistically significant reduction in pain when compared with standard care. In a sensitivity analysis of satisfactory and good quality studies, most studies were of acupuncture (11 trials) or muscle-strengthening exercise (9 trials); both interventions were statistically significantly better than standard care, with acupuncture being statistically significantly better than muscle-strengthening exercise (standardised mean difference: 0.49, 95% credible interval 0.00-0.98). CONCLUSIONS: As a summary of the current available research, the network meta-analysis results indicate that acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term. However, much of the evidence in this area of research is of poor quality, meaning there is uncertainty about the efficacy of many physical treatments. Copyright © 2013 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved. PMCID: PMC3769860 PMID: 23973143 [PubMed - indexed for MEDLINE] 33. Reumatismo. 2013 May 27;65(2):63-74. doi: 10.4081/reumatismo.2013.63. Manual therapy and therapeutic exercise in the treatment of osteoarthritis of the

hip: a systematic review. Romeo A(1), Parazza S, Boschi M, Nava T, Vanti C. Author information: (1)Manual Therapy, University of Padova, Italy. This systematic review aimed at investigating the role of therapeutic exercise and/or manual therapy in the treatment of hip osteoarthritis (OA). Two independent reviewers (AR, CV) searched PubMed, Cinahl, Cochrane Library, PEDro and Scopus databases and a third one (SP) was consulted in case of disagreement. The research criteria were publication period (from May 2007 to April 2012) and publication language (English or Italian). Ten randomized controlled trials matched inclusion criteria, eight of which concerning therapeutic exercise and two manual therapy. Few good quality studies were found. At mid- and long-term follow-up land-based exercises showed insufficient evidence of effectiveness with respect to pain and quality of life, but positive results were found for physical function. Water exercises significantly reduced fall risk when combined with functional exercises. Programs containing progressive and gradual exposure of difficult activities, education and exercises promoted better outcomes, higher adherence to home program and increased amount of physical activity, especially walking. Manual therapy seemed to reduce pain and decrease disability at short-term. Less use of nonsteroidal anti-inflammatory drugs was statistically significant at long-term follow-up in patients treated with manual therapy. The relationship between clinical results and radiological grade of OA was not investigated. Encouraging results were found in recent literature for manual therapy and functional training. Further research is needed to elucidate this issue through high-quality trials, especially addressing the aspects that have not been thoroughly explored yet, for instance type, amount and scheduling of conservative treatment. PMID: 23877410 [PubMed - indexed for MEDLINE] 34. J Jpn Phys Ther Assoc. 2013;16(1):7-21. doi: 10.1298/jjpta.Vol16_003. Evidence of Improvement in Various Impairments by Exercise Interventions in Patients with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Clinical Trials. Tanaka R(1), Ozawa J(1), Kito N(1), Yamasaki T(1), Moriyama H(2). Author information: (1)Department of Integrated Rehabilitation, Hiroshima International University, Japan. (2)Department of Rehabilitation Science, Kobe University Graduate School

of Health Sciences, Japan. PURPOSE: To investigate improvement in various impairments by exercise interventions in patients with knee osteoarthritis (OA). METHODS: We collected data on randomized controlled trials (RCTs) comparing the effects of exercise intervention with those of either nonintervention or psychoeducational intervention in patients with knee OA. Data on pain, stiffness, muscle strength, range of motion, flexibility, maximal oxygen uptake, and position sense were synthesized. The Grading of Recommendations Assessment, Development, and Evaluation system was used to determine the quality of the evidence. RESULTS: Thirty-three RCTs involving 3,192 participants were identified. Meta-analysis provided highquality evidence that exercise intervention improves maximal oxygen uptake, and moderate-quality evidence that exercise intervention also improves pain, stiffness, knee extensor and flexor muscle strength, and position sense. The evidence that exercise intervention improves knee extension and flexion range of motion was deemed as undetermined-quality. CONCLUSION: In patients with knee OA, improvement in pain, stiffness, muscle strength, maximal oxygen uptake, and position sense with the use of exercise intervention can be expected. Although the quality of evidence of the effect of exercise intervention on range of motion was inconclusive, exercise intervention should be recommended for patients with knee OA to improve various impairments. PMCID: PMC4316543 PMID: 25792899 [PubMed] 35. Ann Intern Med. 2012 Nov 6;157(9):632-44. doi: 10.7326/0003-4819-157-9-201211060-00007. Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review. Wang SY(1), Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL. Author information: (1)Department of Chronic Disease Epidemiology, Yale School of Public Health, 60 College Street, Room 432, New Haven, CT 06520, USA. BACKGROUND: Osteoarthritis is a leading cause of disability. Nonsurgical treatment is a key first step. PURPOSE: Systematic literature review of physical therapy (PT) interventions for community-dwelling adults with knee osteoarthritis. DATA SOURCES: MEDLINE, the Cochrane Library, the Physiotherapy Evidence Database, Scirus, Allied and Complementary Medicine, and the Health and Psychosocial

Instruments bibliography database. STUDY SELECTION: 193 randomized, controlled trials (RCTs) published in English from 1970 to 29 February 2012. DATA EXTRACTION: Means of outcomes, PT interventions, and risk of bias were extracted to pool standardized mean differences. Disagreements between reviewers abstracting and checking data were resolved through discussion. DATA SYNTHESIS: Meta-analyses of 84 RCTs provided evidence for 13 PT interventions on pain (58 RCTs), physical function (36 RCTs), and disability (29 RCTs). Meta-analyses provided low-strength evidence that aerobic (11 RCTs) and aquatic (3 RCTs) exercise improved disability and that aerobic exercise (19 RCTs), strengthening exercise (17 RCTs), and ultrasonography (6 RCTs) reduced pain and improved function. Several individual RCTs demonstrated clinically important improvements in pain and disability with aerobic exercise. Other PT interventions demonstrated no sustained benefit. Individual RCTs showed similar benefits with aerobic, aquatic, and strengthening exercise. Adverse events were uncommon and did not deter participants from continuing treatment. LIMITATION: Variability in PT interventions and outcomes measures hampered synthesis of evidence. CONCLUSION: Low-strength evidence suggested that only a few PT interventions were effective. Future studies should compare combined PT interventions (which is how PT is generally administered for pain associated with knee osteoarthritis). PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. PMID: 23128863 [PubMed - indexed for MEDLINE] 36. Rheumatol Int. 2012 Nov;32(11):3339-51. doi: 10.1007/s00296-012-2480-7. Epub 2012 Jul 22. The effectiveness of proprioceptive-based exercise for osteoarthritis of the knee: a systematic review and meta-analysis. Smith TO(1), King JJ, Hing CB. Author information: (1)Faculty of Medicine and Health Sciences, Queen's Building, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK. toby.smith@uea.ac.uk Osteoarthritis (OA) is a leading cause of functional impairment and pain. Proprioceptive defects may be associated with the onset and progression of OA of the knee. The purpose of this study was to determine the effectiveness of proprioceptive exercises for knee OA using meta-analysis. A systematic review was conducted on 12th December 2011 using published (Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, PubMed, PEDro) and unpublished/trial registry (OpenGrey, the WHO International Clinical Trials Registry Platform, Current Controlled

Trials and the UK National Research Register Archive) databases. Studies were included if they were full publications of randomized or non-randomised controlled trials (RCT) comparing a proprioceptive exercise regime, against a non-proprioceptive exercise programme or non-treatment control for adults with knee OA. Methodological appraisal was performed using the PEDro checklist. Seven RCTs including 560 participants (203 males and 357 females) with a mean age of 63 years were eligible. The methodological quality of the evidence base was moderate. Compared to a non-treatment control, proprioceptive exercises significantly improved functional outcomes in people with knee OA during the first 8 weeks following commencement of their exercises (p < 0.02). When compared against a general non-proprioceptive exercise programme, proprioceptive exercises demonstrated similar outcomes, only providing superior results with respect to joint position sense-related measurements such as timed walk over uneven ground (p = 0.03) and joint position angulation error (p < 0.01). Proprioceptive exercises are efficacious in the treatment of knee OA. There is some evidence to indicate the effectiveness of proprioceptive exercises compared to general strengthening exercises in functional outcomes. PMID: 22821333 [PubMed - indexed for MEDLINE] 37. Rev Bras Fisioter. 2012 Jan-Feb;16(1):1-9. The effects of therapeutic exercise on the balance of women with knee osteoarthritis: a systematic review. [Article in English, Portuguese] Silva A(1), Serrão PR, Driusso P, Mattiello SM. Author information: (1)Physical Therapy Department, Universidade Federal de São Carlos, SP, Brazil. OBJECTIVE: The objective of this review was to examine evidence regarding the effects of therapeutic exercise on the balance of women with knee osteoarthritis (OA). METHODS: The search was conducted in Pubmed, Medline, Lilacs, SciELO, ISI web of knowledge, PEDro and the Cochrane Collaboration. We used the keywords: "knee", "balance", "women" and "rehabilitation" in combination with "osteoarthritis". We selected randomized controlled clinical trials published in English, Portuguese and Spanish over the last 10 years. To verify the methodological quality of selected clinical trials, the PEDro Scale was applied. RESULTS: A total of 20 studies were found in the electronic search. Of these, only 9 met the inclusion criteria and were analyzed in full. Eight of these 9 studies were classified as having high methodological quality on the PEDro Scale.

Although the methods and interventions regarding balance varied widely in these studies, most found significant improvement in the balance of women with knee OA. CONCLUSION: Since the studies included in this systematic review were of high methodological quality, we can conclude that the therapeutic exercises they used improved the balance of women with knee OA. PMID: 22441221 [PubMed - indexed for MEDLINE] 38. Value Health. 2012 Jan;15(1):1-12. doi: 10.1016/j.jval.2011.09.003. Epub 2011 Nov 29. Cost-effectiveness of nonpharmacologic, nonsurgical interventions for hip and/or knee osteoarthritis: systematic review. Pinto D(1), Robertson MC, Hansen P, Abbott JH. Author information: (1)Centre for Physiotherapy Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand. daniel-pinto@northwestern.edu OBJECTIVE: To investigate the cost-effectiveness of nonpharmacological, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. METHODS: We identified economic evaluations or cost studies associated with randomized or quasi-randomized controlled trials that assessed nonpharmacologic, nonsurgical interventions for the treatment of hip and/or knee osteoarthritis. Medline, Embase, PubMed, National Health Service Economic Evaluation Database, CENTRAL, EconLit, and OpenSIGLE were searched up to October 1, 2010. Study characteristics extracted include study population, health outcomes, and economic analysis elements. Economic analyses were assessed by using the Quality of Health Economic Studies instrument, and the methodological quality of the randomized controlled trials was graded by using an internal validity checklist. All costs were converted to 2008 US dollars. RESULTS: Ten economic evaluations and one randomized controlled trial reporting health-care costs met our inclusion criteria. Interventions included exercise programs, acupuncture, rehabilitation programs, and lifestyle interventions. Six of the 11 studies exhibited high risks of bias for the cost and/or effect components of their cost-effectiveness estimate. Six studies used comparators of unknown cost-effectiveness. Four studies reported cost-effectiveness estimates lower than $50,000 per quality-adjusted life-year. All studies evaluating exercise interventions found the programs to be cost saving. CONCLUSIONS: There is only limited evidence for the cost-effectiveness of conservative treatments for the management of hip and/or knee osteoarthritis. More high-quality economic evaluations of conservative interventions are needed to further inform practice.

Copyright © 2012 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved. PMID: 22264966 [PubMed - indexed for MEDLINE] 39. Arthritis Care Res (Hoboken). 2011 Jun;63(6):834-48. doi: 10.1002/acr.20427. Systematic review of design and effects of splints and exercise programs in hand osteoarthritis. Kjeken I(1), Smedslund G, Moe RH, Slatkowsky-Christensen B, Uhlig T, Hagen KB. Author information: (1)Diakonhjemmet Hospital, Oslo, Norway. ingvild.kjeken@diakonsyk.no OBJECTIVE: To describe and evaluate the design and effects of splints and exercise programs in hand osteoarthritis. METHODS: Controlled trials identified through systematic literature reviews were included. Design of splints and exercise programs were evaluated according to existing recommendations and classification systems. The risk of bias was assessed by 2 independent reviewers and effects were summarized descriptively or by meta-analyses. RESULTS: Twelve trials were included in the review: 7 assessed the effect of splints, 3 the effect of exercises, and 2 a combination of splints and exercises. The results revealed a great variety in the design of splint and exercise programs. A meta-analysis of the 2 randomized trials with low risk of bias demonstrated that splints significantly reduced hand pain at short-term (<3 months) and long-term (≥3 months) followup, with a standardized mean difference of 0.37 (95% confidence interval [95% CI] 0.03, 0.71) and 0.80 (95% CI 0.45, 1.15), respectively. Further, results from single trials indicated that hand exercises may reduce pain and increase range of motion and strength, while a combination of splints and daily exercises may reduce pain and stiffness and improve function. CONCLUSION: There is consistent evidence that splints reduce hand pain, but limited evidence for the effects of hand exercises and a combination of hand exercises and splints in hand osteoarthritis. Copyright © 2011 by the American College of Rheumatology. PMID: 21630479 [PubMed - indexed for MEDLINE] 40. Int J Gen Med. 2011 Mar 25;4:239-60. doi: 10.2147/IJGM.S17384.

A systematic review of nonrandomized controlled trials on the curative effects of aquatic exercise. Kamioka H(1), Tsutani K, Mutoh Y, Okuizum H, Ohta M, Handa S, Okada S, Kitayuguchi J, Kamada M, Shiozawa N, Park SJ, Honda T, Moriyama S. Author information: (1)Faculty of Regional Environment Science, Tokyo University of Agriculture, Tokyo, Japan; BACKGROUND: The objectives of this review were to integrate the evidence of curative effects through aquatic exercise and assess the quality of studies based on a review of nonrandomized controlled trials (nRCTs). METHODS: Study design was a systematic review of nonrandomized controlled trials. Trials were eligible if they were nonrandomized clinical trials. Studies included one treatment group in which aquatic exercise was applied. We searched the following databases from 2000 up to July 20, 2009: MEDLINE via PubMed, CINAHL, and Ichushi-Web. RESULTS: Twenty-one trials met all inclusion criteria. Languages included were English (N = 9), Japanese (N = 11), and Korean (N = 1). Target diseases were knee and/or hip osteoarthritis, poliomyelitis, chronic kidney disease, discomforts of pregnancy, cardiovascular diseases, and rotator cuff tears. Many studies on nonspecific disease (healthy participants) were included. All studies reported significant effectiveness in at least one or more outcomes. However results of evaluations with the TREND and CLEAR-NPT checklists generally showed a remarkable lack of description in the studies. Furthermore, there was the problem of heterogeneity, and we were therefore not able to perform a meta-analysis. CONCLUSION: Because there was insufficient evidence on aquatic exercise due to poor methodological and reporting quality and heterogeneity of nRCTs, we were unable to offer any conclusions about the effects of this intervention. However, we were able to identify problems with current nRCTs of aquatic exercise, and propose a strategy of strengthening study quality, stressing the importance of study feasibility as a future research agenda objective. PMCID: PMC3085234 PMID: 21556311 [PubMed] 41. Arthritis Res Ther. 2011 Feb 18;13(1):R28. doi: 10.1186/ar3254. Effects of rehabilitative interventions on pain, function and physical impairments in people with hand osteoarthritis: a systematic review. Ye L(1), Kalichman L, Spittle A, Dobson F, Bennell K.

Author information: (1)Rehabilitative Services Department, Changi General Hospital, 2 Simei Street 3, 529889 Singapore. INTRODUCTION: Hand osteoarthritis (OA) is associated with pain, reduced grip strength, loss of range of motion and joint stiffness leading to impaired hand function and difficulty with daily activities. The effectiveness of different rehabilitation interventions on specific treatment goals has not yet been fully explored. The objective of this systematic review is to provide evidence based knowledge on the treatment effects of different rehabilitation interventions for specific treatment goals for hand OA. METHODS: A computerized literature search of Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ISI Web of Science, the Physiotherapy Evidence Database (PEDro) and SCOPUS was performed. Studies that had an evidence level of 2b or higher and that compared a rehabilitation intervention with a control group and assessed at least one of the following outcome measures - pain, physical hand function or other measures of hand impairment - were included. The eligibility and methodological quality of trials were systematically assessed by two independent reviewers using the PEDro scale. Treatment effects were calculated using standardized mean difference and 95% confidence intervals. RESULTS: Ten studies, of which six were of higher quality (PEDro score >6), were included. The rehabilitation techniques reviewed included three studies on exercise, two studies each on laser and heat, and one study each on splints, massage and acupuncture. One higher quality trial showed a large positive effect of 12-month use of a night splint on hand pain, function, strength and range of motion. Exercise had no effect on hand pain or function although it may be able to improve hand strength. Low level laser therapy may be useful for improving range of motion. No rehabilitation interventions were found to improve stiffness. CONCLUSIONS: There is emerging high quality evidence to support that rehabilitation interventions can offer significant benefits to individuals with hand OA. A summary of the higher quality evidence is provided to assist with clinical decision making based on current evidence. Further high-quality research is needed concerning the effects of rehabilitation interventions on specific treatment goals for hand OA. PMCID: PMC3241372 PMID: 21332991 [PubMed - indexed for MEDLINE] 42. J Physiother. 2011;57(1):11-20. doi: 10.1016/S1836-9553(11)70002-9. Strength training alone, exercise therapy alone, and exercise therapy with passive manual mobilisation each reduce pain and disability in people with knee

osteoarthritis: a systematic review. Jansen MJ(1), Viechtbauer W, Lenssen AF, Hendriks EJ, de Bie RA. Author information: (1)Department of Epidemiology, Maastricht University, Heerlen, The Netherlands. mj.jansen@maastrichtuniversity.nl QUESTION: What are the effects of strength training alone, exercise therapy alone, and exercise with additional passive manual mobilisation on pain and function in people with knee osteoarthritis compared to control? What are the effects of these interventions relative to each other? DESIGN: A meta-analysis of randomised controlled trials. PARTICIPANTS: Adults with osteoarthritis of the knee. INTERVENTION TYPES: Strength training alone, exercise therapy alone (combination of strength training with active range of motion exercises and aerobic activity), or exercise with additional passive manual mobilisation, versus any non-exercise control. Comparisons between the three interventions were also sought. OUTCOME MEASURES: The primary outcome measures were pain and physical function. RESULTS: 12 trials compared one of the interventions against control. The effect size on pain was 0.38 (95% CI 0.23 to 0.54) for strength training, 0.34 (95% CI 0.19 to 0.49) for exercise, and 0.69 (95% CI 0.42 to 0.96) for exercise plus manual mobilisation. Each intervention also improved physical function significantly. No randomised comparisons of the three interventions were identified. However, meta-regression indicated that exercise plus manual mobilisations improved pain significantly more than exercise alone (p = 0.03). The remaining comparisons between the three interventions for pain and physical function were not significant. CONCLUSION: Exercise therapy plus manual mobilisation showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone. To achieve better pain relief in patients with knee osteoarthritis physiotherapists or manual therapists might consider adding manual mobilisation to optimise supervised active exercise programs. Copyright © 2011 Australian Physiotherapy Association. Published by .. All rights reserved. PMID: 21402325 [PubMed - indexed for MEDLINE] 43. J Back Musculoskelet Rehabil. 2010;23(4):175-86. doi: 10.3233/BMR-2010-0267. Physical exercise and reduction of pain in adults with lower limb osteoarthritis: a systematic review.

Escalante Y(1), Saavedra JM, García-Hermoso A, Silva AJ, Barbosa TM. Author information: (1)Facultad de Ciencias del Deporte, AFIDES Research Group, Universidad de Extremadura, Cáceres, Spain. yescgon@unex.es Osteoarthritis is a degenerative joint disease. The knee and hip joints are the most frequently affected. Treatments fall into three main categories: pharmacological, non-pharmacological, and surgical. Treatments can be applied alone or in combination. In the last few years, within the non-pharmacological category have been a growing importance of physical exercise programs aimed to reduce pain in knee and hip joints. The purpose of this review was to summarize evidence for the effectiveness and structure of exercise programs on pain in patients with hip and knee osteoarthritis. To that end, several databases were searched, retrieving 33 studies that evaluated the influence of different exercise programs on pain. These studies were grouped according to the characteristics of the exercise program: land-based intervention (strength program, Tai Chi, aerobic program), aquatic intervention (hydrotherapy), and mixed exercise programs. The main conclusions drawn were: (i) despite recommendations for the use of exercise programs as pain therapy in patients with hip and knee osteoarthritis, very few randomized clinical studies were conducted; (ii) the structure of the exercise programs (content, duration, frequency and duration of the session) is very heterogeneous; (iii) on overall, exercise programs based on Tai Chi have better results than mixed exercise programs, but without clear differences. PMID: 21079296 [PubMed - indexed for MEDLINE] 44. BMC Musculoskelet Disord. 2009 Aug 4;10:98. doi: 10.1186/1471-2474-10-98. Effectiveness of physiotherapy exercise following hip arthroplasty for osteoarthritis: a systematic review of clinical trials. Minns Lowe CJ(1), Barker KL, Dewey ME, Sackley CM. Author information: (1)Department of Primary Care Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, UK. catherine.minnslowe@noc.anglox.nhs.uk BACKGROUND: Physiotherapy has long been a routine component of patient rehabilitation following hip joint replacement. The purpose of this systematic review was to evaluate the effectiveness of physiotherapy exercise after discharge from hospital on function, walking, range of motion, quality of life and muscle strength, for osteoarthritic patients following elective primary total

hip arthroplasty. METHODS: DESIGN: Systematic review, using the Cochrane Collaboration Handbook for Systematic Reviews of Interventions and the Quorom Statement. Database searches: AMED, CINAHL, EMBASE, KingsFund, MEDLINE, Cochrane library (Cochrane reviews, Cochrane Central Register of Controlled Trials, DARE), PEDro, The Department of Health National Research Register. Handsearches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. No language restrictions were applied. SELECTION: Trials comparing physiotherapy exercise versus usual/standard care, or comparing two types of relevant exercise physiotherapy, following discharge from hospital after elective primary total hip replacement for osteoarthritis were reviewed. OUTCOMES: Functional activities of daily living, walking, quality of life, muscle strength and range of hip joint motion. Trial quality was extensively evaluated. Narrative synthesis plus meta-analytic summaries were performed to summarise the data. RESULTS: 8 trials were identified. Trial quality was mixed. Generally poor trial quality, quantity and diversity prevented explanatory meta-analyses. The results were synthesised and meta-analytic summaries were used where possible to provide a formal summary of results. Results indicate that physiotherapy exercise after discharge following total hip replacement has the potential to benefit patients. CONCLUSION: Insufficient evidence exists to establish the effectiveness of physiotherapy exercise following primary hip replacement for osteoarthritis. Further well designed trials are required to determine the value of post discharge exercise following this increasingly common surgical procedure. PMCID: PMC2734755 PMID: 19653883 [PubMed - indexed for MEDLINE] 45. Arthritis Res Ther. 2009;11(3):R98. doi: 10.1186/ar2743. Epub 2009 Jun 25. Exercise therapy for the management of osteoarthritis of the hip joint: a systematic review. McNair PJ(1), Simmonds MA, Boocock MG, Larmer PJ. Author information: (1)Health and Rehabilitation Research Centre, Auckland University of Technology, Private Bag 92006, Auckland 1020, New Zealand. peter.mcnair@aut.ac.nz INTRODUCTION: Recent guidelines pertaining to exercise for individuals with osteoarthritis have been released. These guidelines have been based primarily on studies of knee-joint osteoarthritis. The current study was focused on the hip

joint, which has different biomechanical features and risk factors for osteoarthritis and has received much less attention in the literature. The purpose was to conduct a systematic review of the literature to evaluate the exercise programs used in intervention studies focused solely on hip-joint osteoarthritis, to decide whether their exercise regimens met the new guidelines, and to determine the level of support for exercise-therapy interventions in the management of hip-joint osteoarthritis. METHODS: A systematic literature search of 14 electronic databases was undertaken to identify interventions that used exercise therapy as a treatment modality for hip osteoarthritis. The quality of each article was critically appraised and graded according to standardized methodologic approaches. A 'pattern-of-evidence' approach was used to determine the overall level of evidence in support of exercise-therapy interventions for treating hip osteoarthritis. RESULTS: More than 4,000 articles were identified, of which 338 were considered suitable for abstract review. Of these, only 6 intervention studies met the inclusion criteria. Few well-designed studies specifically investigated the use of exercise-therapy management on hip-joint osteoarthritis. Insufficient evidence was found to suggest that exercise therapy can be an effective short-term management approach for reducing pain levels, improving joint function and the quality of life. CONCLUSIONS: Limited information was available on which conclusions regarding the efficacy of exercise could be clearly based. No studies met the level of exercise recommended for individuals with osteoarthritis. High-quality trials are needed, and further consideration should be given to establishing the optimal exercises and exposure levels necessary for achieving long-term gains in the management of osteoarthritis of the hip. PMCID: PMC2714154 PMID: 19555502 [PubMed - indexed for MEDLINE] 46. Arthritis Rheum. 1999 Jul;42(7):1361-9. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review of randomized clinical trials. van Baar ME(1), Assendelft WJ, Dekker J, Oostendorp RA, Bijlsma JW. Author information: (1)Netherlands Institute of Primary Health Care, Utrecht. OBJECTIVE: To review the effectiveness of exercise therapy in patients with osteoarthritis (OA) of the hip or knee. METHODS: A computerized literature search of Medline, Embase, and Cinahl was carried out. Randomized clinical trials on exercise therapy for OA of the hip or

knee were selected if treatment had been randomly allocated and if pain, self-reported disability, observed disability, or patient's global assessment of effect had been used as outcome measures. The validity of trials was systematically assessed by independent reviewers. Effect sizes and power estimates were calculated. A best evidence synthesis was conducted, weighting the studies with respect to their validity and power. RESULTS: Six of the 11 assessed trials satisfied at least 50% of the validity criteria. Two trials had sufficient power to detect medium-sized effects. Effect sizes indicated small-to-moderate beneficial effects of exercise therapy on pain, small beneficial effects on both disability outcome measures, and moderate-to-great beneficial effects according to patient's global assessment of effect. CONCLUSION: There is evidence of beneficial effects of exercise therapy in patients with OA of the hip or knee. However, the small number of good studies restricts drawing firm conclusions. PMID: 10403263 [PubMed - indexed for MEDLINE] 47. Arthritis Rheum. 2007 Oct 15;57(7):1245-53. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review. Pisters MF(1), Veenhof C, van Meeteren NL, Ostelo RW, de Bakker DH, Schellevis FG, Dekker J. Author information: (1)Netherlands Institute for Health Services Research, Utrecht, The Netherlands. m.pisters@nivel.nl OBJECTIVE: To determine the long-term effectiveness (>/=6 months after treatment) of exercise therapy on pain, physical function, and patient global assessment of effectiveness in patients with osteoarthritis (OA) of the hip and/or knee. METHODS: We conducted an extensive literature search in PubMed, EMBase, CINAHL, SciSearch, PEDro, and the Cochrane Central Register of Controlled Trials. Both randomized clinical trials and controlled clinical trials on the long-term effectiveness of exercise therapy were included. The followup assessments were at least 6 months after treatment ended. Methodologic quality was independently assessed by 2 reviewers. Effect estimates were calculated and a best evidence synthesis was performed based on design, methodologic quality, and statistical significance of findings. RESULTS: Five high-quality and 6 low-quality randomized clinical trials were included. Strong evidence was found for no long-term effectiveness on pain and self-reported physical function, moderate evidence for long-term effectiveness on

patient global assessment of effectiveness, and conflicting evidence for observed physical function. For exercise programs with additional booster sessions, moderate evidence was found for long-term effectiveness on pain, self-reported physical function, and observed physical function. CONCLUSION: The positive posttreatment effects of exercise therapy on pain and physical function in patients with OA of the hip and/or knee are not sustained in the long term. Long-term effectiveness was only found for patient global assessment of effectiveness. However, additional booster sessions after the treatment period positively influenced maintenance of beneficial posttreatment effects on pain and physical function in the long term. PMID: 17907210 [PubMed - indexed for MEDLINE] 48. BMJ. 2007 Oct 20;335(7624):812. Epub 2007 Sep 20. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. Minns Lowe CJ(1), Barker KL, Dewey M, Sackley CM. Author information: (1)Department of Primary Care and General Practice, University of Birmingham. catherine.minnslowe@noc.anglox.nhs.uk Comment in J Bone Joint Surg Am. 2008 May;90(5):1172. Aust J Physiother. 2008;54(1):73. BMJ. 2007 Oct 20;335(7624):786. OBJECTIVE: To evaluate the effectiveness of physiotherapy exercise after elective primary total knee arthroplasty in patients with osteoarthritis. DESIGN: Systematic review. DATA SOURCES: Database searches: AMED, CINAHL, Embase, King's Fund, Medline, Cochrane library (Cochrane reviews, Cochrane central register of controlled trials, DARE), PEDro, Department of Health national research register. Hand searches: Physiotherapy, Physical Therapy, Journal of Bone and Joint Surgery (Britain) Conference Proceedings. Review methods Randomised controlled trials were reviewed if they included a physiotherapy exercise intervention compared with usual or standard physiotherapy care, or compared two types of exercise physiotherapy interventions meeting the review criteria, after discharge from hospital after elective primary total knee arthroplasty for osteoarthritis. OUTCOME MEASURES: Functional activities of daily living, walking, quality of life, muscle strength, and range of motion in the knee joint. Trial quality was

extensively evaluated. Narrative synthesis plus meta-analyses with fixed effect models, weighted mean differences, standardised effect sizes, and tests for heterogeneity. RESULTS: Six trials were identified, five of which were suitable for inclusion in meta-analyses. There was a small to moderate standardised effect size (0.33, 95% confidence interval 0.07 to 0.58) in favour of functional exercise for function three to four months postoperatively. There were also small to moderate weighted mean differences of 2.9 (0.61 to 5.2) for range of joint motion and 1.66 (-1 to 4.3) for quality of life in favour of functional exercise three to four months postoperatively. Benefits of treatment were no longer evident at one year. CONCLUSIONS: Interventions including physiotherapy functional exercises after discharge result in short term benefit after elective primary total knee arthroplasty. Effect sizes are small to moderate, with no long term benefit. PMCID: PMC2034713 PMID: 17884861 [PubMed - indexed for MEDLINE] 49. J Rheumatol. 2002 Aug;29(8):1737-45. Therapeutic exercise for people with osteoarthritis of the hip or knee. A systematic review. Fransen M(1), McConnell S, Bell M. Author information: (1)Institute for International Health, University of Sydney, Australia. mfransen@iih.usyd.edu.au OBJECTIVE: To determine whether land based therapeutic exercise is beneficial for people with osteoarthritis (OA) of the hip or knee in terms of reduced joint pain, improved physical function, and/or the patient's global assessment of therapeutic effectiveness. METHODS: Five databases were searched for randomized clinical trials. Standardized mean differences (SMD) with their 95% confidence intervals (CI) were calculated for each study and then combined using a fixed effects model. RESULTS: Only 2 studies, totaling about 100 participants, could potentially provide data on people with hip OA. Fourteen studies provided data on 1633 participants with knee OA. Nine of these studies were considered of high methodological quality. For pain, combining the results revealed a mean moderate beneficial effect (SMD 0.46, 95% Cl 0.35, 0.57), while for self-reported physical function a mean small beneficial effect (SMD 0.33, 95% CI 0.23, 0.43) was found. These results appeared to be sensitive to blinding of outcome assessor and choice of control group. CONCLUSION: Land based therapeutic exercise was shown to reduce pain and improve

physical function for people with OA of the knee. PMID: 12180738 [PubMed - indexed for MEDLINE]

Exercise and Pelvic pain 1. BMC Pregnancy Childbirth. 2015 Nov 26;15:316. doi: 10.1186/s12884-015-0736-4. A systematic review of randomised controlled trials on the effectiveness of exercise programs on Lumbo Pelvic Pain among postnatal women. Tseng PC(1), Puthussery S(2), Pappas Y(3), Gau ML(4). Author information: (1)Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. pei-ching.tseng@study.beds.ac.uk. (2)Department of Clinical Education and Leadership & Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. shuby.puthussery@beds.ac.uk. (3)Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. yannis.pappas@beds.ac.uk. (4)Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, 365, Ming-Te Road, Peitou, Taipei, Taiwan. meeiling@ntunhs.edu.tw. BACKGROUND: A substantial number of women tend to be affected by Lumbo Pelvic Pain (LPP) following child birth. Physical exercise is indicated as a beneficial method to relieve LPP, but individual studies appear to suggest mixed findings about its effectiveness. This systematic review aimed to synthesise evidence from randomised controlled trials on the effectiveness of exercise on LPP among postnatal women to inform policy, practice and future research. METHODS: A systematic review was conducted of all randomised controlled trials published between January 1990 and July 2014, identified through a comprehensive search of following databases: PubMed, PEDro, Embase, Cinahl, Medline, SPORTDiscus, Cochrane Pregnancy and Childbirth Group's Trials Register, and electronic libraries of authors'institutions. Randomised controlled trials were eligible for inclusion if the intervention comprised of postnatal exercise for women with LPP onset during pregnancy or within 3 months after delivery and the outcome measures included changes in LPP. Selected articles were assessed using the PEDro Scale for methodological quality and findings were synthesised narratively as meta-analysis was found to be inappropriate due to heterogeneity among included studies. RESULTS: Four randomised controlled trials were included, involving 251 postnatal women. Three trials were rated as of 'good' methodological quality. All trials, except one, were at low risk of bias. The trials included physical exercise programs with varying components, differing modes of delivery, follow up times and outcome measures. Intervention in one trial, involving physical therapy with specific stabilising exercises, proved to be effective in reducing LPP intensity. An improvement in gluteal pain on the right side was reported in another trial and a significant difference in pain frequency in another. CONCLUSION: Our review indicates that only few randomised controlled trials have evaluated the effectiveness of exercise on LPP among postnatal women. There is also a great amount of variability across existing trials in the components of exercise programs, modes of delivery, follow up times and outcome measures. While there is some evidence to indicate the effectiveness of exercise for relieving LPP, further good quality trials are needed to ascertain the most effective

elements of postnatal exercise programs suited for LPP treatment. PMCID: PMC4661954 PMID: 26612732 [PubMed - in process] 2. Physiother Theory Pract. 2013 Aug;29(6):419-31. doi: 10.3109/09593985.2012.748114. Epub 2012 Dec 17. Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: a systematic review. Ferreira CW(1), Alburquerque-Sendı N F. Author information: (1)Physiotherapy Department , Universidade Federal de Pernambuco , Recife, PE , Brazil. caroline.wanderley@ufpe.br The aim of this work was to investigate the effectiveness of physical therapy for the treatment of low back pain (LBP) and pelvic girdle pain (PGP) related to pregnancy after delivery. A systematic review of studies published since 1985 in the databases Medline, PEDro, SciELO, SCOPUS, LILACS, and the Cochrane Library was made. Studies that focused on postpartum LBP or PGP, without being related to pregnancy or in other non-pregnant patients, were excluded, as were papers addressing LBP or PGP indicating radiculopathy, rheumatism, or any other serious disease or pathologic condition. In accordance with the exclusion criteria and duplicate articles, of the 105 articles retrieved only six were considered for quality assessment with the PEDro Scale. Among these six papers, two were follow-ups, such that only four trials were included in this review. All trials used exercise for motor control and stability of the lumbopelvic region, but with different intervention approaches. The study affording the best evidence used individual guidance and adjustments given by the physiotherapists. Nevertheless, this systematic review was inconclusive and showed that more randomized clinical trials, with good quality, are needed. PMID: 23244038 [PubMed - indexed for MEDLINE] 3. PLoS One. 2012;7(8):e41941. doi: 10.1371/journal.pone.0041941. Epub 2012 Aug 1. Therapeutic intervention for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a systematic review and meta-analysis. Cohen JM(1), Fagin AP, Hariton E, Niska JR, Pierce MW, Kuriyama A, Whelan JS, Jackson JL, Dimitrakoff JD. Author information: (1)Harvard Medical School, Boston, Massachusetts, United States of America. BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has been treated with several different interventions with limited success. This

meta-analysis aims to review all trials reporting on therapeutic intervention for CP/CPPS using the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI). METHODS: We searched Medline, PubMed, the Cochrane Pain, Palliative & Supportive Care Trials, the Cochrane Register of Controlled Trials, CINAHL, ClinicalTrials.gov, and the NIDDK website between 1947 and December 31, 2011 without language or study type restrictions. All RCTs for CP/CPPS lasting at least 6 weeks, with a minimum of 10 participants per arm, and using the NIH-CPSI score, the criterion standard for CP/CPPS, as an outcome measure were included. Data was extracted from each study by two independent reviewers. Gillbraith and I-squared plots were used for heterogeneity testing and Eggers and Peters methods for publication bias. Quality was assessed using a component approach and meta-regression was used to analyze sources of heterogeneity. RESULTS: Mepartricin, percutaneous tibial nerve stimulation (PTNS), and triple therapy comprised of doxazosin + ibuprofen + thiocolchicoside (DIT) resulted in clinically and statistically significant reduction in NIH-CPSI total score. The same agents and aerobic exercise resulted in clinically and statistically significant NIH-CPSI pain domain score reduction. Acupuncture, DIT, and PTNS were found to produce statistically and clinically significant reductions in the NIH-CPSI voiding domain. A statistically significant placebo effect was found for all outcomes and time analysis showed that efficacy of all treatments increased over time. Alpha-blockers, antibiotics, and combinations of the two failed to show statistically or clinically significant NIH-CPSI reductions. CONCLUSION: Results from this meta-analysis reflect our current inability to effectively manage CP/CPPS. Clinicians and researchers must consider placebo effect and treatment efficacy over time and design studies creatively so we can more fully elucidate the etiology and role of therapeutic intervention in CP/CPPS. PMCID: PMC3411608 PMID: 22870266 [PubMed - indexed for MEDLINE] 4. Acta Obstet Gynecol Scand. 2012 Sep;91(9):1038-45. doi: 10.1111/j.1600-0412.2012.01462.x. Epub 2012 Jul 2. Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review. Richards E(1), van Kessel G, Virgara R, Harris P. Author information: (1)School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia. OBJECTIVE: A systematic review was undertaken to update the understanding of the available evidence for antenatal physical therapy interventions for low back or pelvic pain in pregnant women to improve functional outcomes when compared with other treatments or no treatment. DATA SOURCES: Seven electronic databases were systematically searched and supplemented by hand searching through reference lists.

METHODS OF STUDY SELECTION: Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials using the Clinical Appraisal Skills Program tool. RESULTS: Four trials with 566 participants were identified that met the inclusion criteria. The validity of the trials was moderate. Exercise, pelvic support garments and acupuncture were found to improve functional outcomes in pregnant women with low back or pelvic pain. No meta-analysis was performed because of the heterogeneity of functional outcome measures. CONCLUSIONS: While there is some evidence that physical therapy using exercise, acupuncture and pelvic supports may be useful, further research needs to consider other treatment modalities used by physical therapists and establish an appropriate, reliable and valid functional outcome measure to assess low back and pelvic pain in pregnancy. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 22583125 [PubMed - indexed for MEDLINE] 5. Aust J Physiother. 2006;52(2):79-88. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Ferreira PH(1), Ferreira ML, Maher CG, Herbert RD, Refshauge K. Author information: (1)School of Physiotherapy, University of Sydney, NSW, Australia. The aim of this study was to conduct a systematic review of the efficacy of specific stabilisation exercise for spinal and pelvic pain. Randomised clinical trials evaluating specific stabilisation exercise were identified and retrieved. Outcomes were disability, pain, return to work, number of episodes, global perceived effect, or health-related quality of life. A single trial reported that specific stabilisation exercise was more effective than no treatment but not more effective than spinal manipulative therapy for the management of cervicogenic headache and associated neck pain. Single trials reported that specific stabilisation exercise was effective for pelvic pain and for prevention of recurrence after an acute episode of low back pain but not to reduce pain or disability associated with acute low back pain. Pooled analyses revealed that, for chronic low back pain, specific stabilisation exercise was superior to usual medical care and education but not to manipulative therapy, and no additional effect was found when specific stabilisation exercise was added to a conventional physiotherapy program. A single trial reported that specific stabilisation exercise and a surgical procedure to reduce pain and disability in chronic low back pain were equally effective. The available evidence suggests that specific stabilisation exercise is effective in reducing pain and disability in chronic but not acute low back pain. Single trials indicate that specific stabilisation exercise can be helpful in the treatment of cervicogenic headache and associated neck pain, pelvic pain, and in reducing recurrence after acute low back pain.

PMID: 16764545 [PubMed - indexed for MEDLINE] 6. Acta Obstet Gynecol Scand. 2003 Nov;82(11):983-90. Physical therapy for pregnancy-related low back and pelvic pain: a systematic review. Stuge B(1), Hilde G, Vøllestad N. Author information: (1)University of Oslo, Section for Health Science, Oslo, Norway. B.K.Stuge@helsefag.uio.no BACKGROUND: A systematic review of prospective controlled clinical trials was performed to assess the effectiveness of physical therapy interventions for the prevention and treatment of pregnancy-related back and pelvic pain. Pregnancy-related low back and pelvic pain has an impact on daily life for many women. Prevention and treatment of back and pelvic pain is therefore an important issue for all those concerned with women's health. METHODS: All prospective controlled clinical trials retrieved by systematic searching of electronic databases, checking of reference lists and contacting of authors were examined. Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials. Authors were contacted to obtain missing information. RESULTS: Nine trials with a total of 1350 patients were reviewed. Except for three high-quality studies, the validity of the trials was moderate to low. Two high-quality studies showed no difference in pain intensity and functional status between the exercise groups and the control groups. In the third high-quality study significant reduction in sick leave was found in favor of water gymnastics compared with no intervention. Because the included trials were considered heterogeneous with regard to study design, population intervention and outcome, no meta-analysis was performed. CONCLUSIONS: Because of heterogeneity and the varying quality of the studies no strong evidence exists concerning the effect of physical therapy interventions on the prevention and treatment of back and pelvic pain related to pregnancy. Future studies should meet current methodological standards, and interventions to be evaluated should be based on established theoretical framework. PMID: 14616270 [PubMed - indexed for MEDLINE] 1. BMC Pregnancy Childbirth. 2015 Nov 26;15:316. doi: 10.1186/s12884-015-0736-4. A systematic review of randomised controlled trials on the effectiveness of exercise programs on Lumbo Pelvic Pain among postnatal women. Tseng PC(1), Puthussery S(2), Pappas Y(3), Gau ML(4). Author information: (1)Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. pei-ching.tseng@study.beds.ac.uk.

(2)Department of Clinical Education and Leadership & Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. shuby.puthussery@beds.ac.uk. (3)Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. yannis.pappas@beds.ac.uk. (4)Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, 365, Ming-Te Road, Peitou, Taipei, Taiwan. meeiling@ntunhs.edu.tw. BACKGROUND: A substantial number of women tend to be affected by Lumbo Pelvic Pain (LPP) following child birth. Physical exercise is indicated as a beneficial method to relieve LPP, but individual studies appear to suggest mixed findings about its effectiveness. This systematic review aimed to synthesise evidence from randomised controlled trials on the effectiveness of exercise on LPP among postnatal women to inform policy, practice and future research. METHODS: A systematic review was conducted of all randomised controlled trials published between January 1990 and July 2014, identified through a comprehensive search of following databases: PubMed, PEDro, Embase, Cinahl, Medline, SPORTDiscus, Cochrane Pregnancy and Childbirth Group's Trials Register, and electronic libraries of authors'institutions. Randomised controlled trials were eligible for inclusion if the intervention comprised of postnatal exercise for women with LPP onset during pregnancy or within 3 months after delivery and the outcome measures included changes in LPP. Selected articles were assessed using the PEDro Scale for methodological quality and findings were synthesised narratively as meta-analysis was found to be inappropriate due to heterogeneity among included studies. RESULTS: Four randomised controlled trials were included, involving 251 postnatal women. Three trials were rated as of 'good' methodological quality. All trials, except one, were at low risk of bias. The trials included physical exercise programs with varying components, differing modes of delivery, follow up times and outcome measures. Intervention in one trial, involving physical therapy with specific stabilising exercises, proved to be effective in reducing LPP intensity. An improvement in gluteal pain on the right side was reported in another trial and a significant difference in pain frequency in another. CONCLUSION: Our review indicates that only few randomised controlled trials have evaluated the effectiveness of exercise on LPP among postnatal women. There is also a great amount of variability across existing trials in the components of exercise programs, modes of delivery, follow up times and outcome measures. While there is some evidence to indicate the effectiveness of exercise for relieving LPP, further good quality trials are needed to ascertain the most effective elements of postnatal exercise programs suited for LPP treatment. PMCID: PMC4661954 PMID: 26612732 [PubMed - in process] 2. Physiother Theory Pract. 2013 Aug;29(6):419-31. doi: 10.3109/09593985.2012.748114. Epub 2012 Dec 17. Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: a systematic review.

Ferreira CW(1), Alburquerque-Sendı N F. Author information: (1)Physiotherapy Department , Universidade Federal de Pernambuco , Recife, PE , Brazil. caroline.wanderley@ufpe.br The aim of this work was to investigate the effectiveness of physical therapy for the treatment of low back pain (LBP) and pelvic girdle pain (PGP) related to pregnancy after delivery. A systematic review of studies published since 1985 in the databases Medline, PEDro, SciELO, SCOPUS, LILACS, and the Cochrane Library was made. Studies that focused on postpartum LBP or PGP, without being related to pregnancy or in other non-pregnant patients, were excluded, as were papers addressing LBP or PGP indicating radiculopathy, rheumatism, or any other serious disease or pathologic condition. In accordance with the exclusion criteria and duplicate articles, of the 105 articles retrieved only six were considered for quality assessment with the PEDro Scale. Among these six papers, two were follow-ups, such that only four trials were included in this review. All trials used exercise for motor control and stability of the lumbopelvic region, but with different intervention approaches. The study affording the best evidence used individual guidance and adjustments given by the physiotherapists. Nevertheless, this systematic review was inconclusive and showed that more randomized clinical trials, with good quality, are needed. PMID: 23244038 [PubMed - indexed for MEDLINE] 3. PLoS One. 2012;7(8):e41941. doi: 10.1371/journal.pone.0041941. Epub 2012 Aug 1. Therapeutic intervention for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS): a systematic review and meta-analysis. Cohen JM(1), Fagin AP, Hariton E, Niska JR, Pierce MW, Kuriyama A, Whelan JS, Jackson JL, Dimitrakoff JD. Author information: (1)Harvard Medical School, Boston, Massachusetts, United States of America. BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) has been treated with several different interventions with limited success. This meta-analysis aims to review all trials reporting on therapeutic intervention for CP/CPPS using the National Institutes of Health-Chronic Prostatitis Symptom Index (NIH-CPSI). METHODS: We searched Medline, PubMed, the Cochrane Pain, Palliative & Supportive Care Trials, the Cochrane Register of Controlled Trials, CINAHL, ClinicalTrials.gov, and the NIDDK website between 1947 and December 31, 2011 without language or study type restrictions. All RCTs for CP/CPPS lasting at least 6 weeks, with a minimum of 10 participants per arm, and using the NIH-CPSI score, the criterion standard for CP/CPPS, as an outcome measure were included. Data was extracted from each study by two independent reviewers. Gillbraith and I-squared plots were used for heterogeneity testing and Eggers and Peters methods for publication bias. Quality was assessed using a component approach and

meta-regression was used to analyze sources of heterogeneity. RESULTS: Mepartricin, percutaneous tibial nerve stimulation (PTNS), and triple therapy comprised of doxazosin + ibuprofen + thiocolchicoside (DIT) resulted in clinically and statistically significant reduction in NIH-CPSI total score. The same agents and aerobic exercise resulted in clinically and statistically significant NIH-CPSI pain domain score reduction. Acupuncture, DIT, and PTNS were found to produce statistically and clinically significant reductions in the NIH-CPSI voiding domain. A statistically significant placebo effect was found for all outcomes and time analysis showed that efficacy of all treatments increased over time. Alpha-blockers, antibiotics, and combinations of the two failed to show statistically or clinically significant NIH-CPSI reductions. CONCLUSION: Results from this meta-analysis reflect our current inability to effectively manage CP/CPPS. Clinicians and researchers must consider placebo effect and treatment efficacy over time and design studies creatively so we can more fully elucidate the etiology and role of therapeutic intervention in CP/CPPS. PMCID: PMC3411608 PMID: 22870266 [PubMed - indexed for MEDLINE] 4. Acta Obstet Gynecol Scand. 2012 Sep;91(9):1038-45. doi: 10.1111/j.1600-0412.2012.01462.x. Epub 2012 Jul 2. Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review. Richards E(1), van Kessel G, Virgara R, Harris P. Author information: (1)School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia. OBJECTIVE: A systematic review was undertaken to update the understanding of the available evidence for antenatal physical therapy interventions for low back or pelvic pain in pregnant women to improve functional outcomes when compared with other treatments or no treatment. DATA SOURCES: Seven electronic databases were systematically searched and supplemented by hand searching through reference lists. METHODS OF STUDY SELECTION: Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials using the Clinical Appraisal Skills Program tool. RESULTS: Four trials with 566 participants were identified that met the inclusion criteria. The validity of the trials was moderate. Exercise, pelvic support garments and acupuncture were found to improve functional outcomes in pregnant women with low back or pelvic pain. No meta-analysis was performed because of the heterogeneity of functional outcome measures. CONCLUSIONS: While there is some evidence that physical therapy using exercise, acupuncture and pelvic supports may be useful, further research needs to consider other treatment modalities used by physical therapists and establish an appropriate, reliable and valid functional outcome measure to assess low back and

pelvic pain in pregnancy. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 22583125 [PubMed - indexed for MEDLINE] 5. Aust J Physiother. 2006;52(2):79-88. Specific stabilisation exercise for spinal and pelvic pain: a systematic review. Ferreira PH(1), Ferreira ML, Maher CG, Herbert RD, Refshauge K. Author information: (1)School of Physiotherapy, University of Sydney, NSW, Australia. The aim of this study was to conduct a systematic review of the efficacy of specific stabilisation exercise for spinal and pelvic pain. Randomised clinical trials evaluating specific stabilisation exercise were identified and retrieved. Outcomes were disability, pain, return to work, number of episodes, global perceived effect, or health-related quality of life. A single trial reported that specific stabilisation exercise was more effective than no treatment but not more effective than spinal manipulative therapy for the management of cervicogenic headache and associated neck pain. Single trials reported that specific stabilisation exercise was effective for pelvic pain and for prevention of recurrence after an acute episode of low back pain but not to reduce pain or disability associated with acute low back pain. Pooled analyses revealed that, for chronic low back pain, specific stabilisation exercise was superior to usual medical care and education but not to manipulative therapy, and no additional effect was found when specific stabilisation exercise was added to a conventional physiotherapy program. A single trial reported that specific stabilisation exercise and a surgical procedure to reduce pain and disability in chronic low back pain were equally effective. The available evidence suggests that specific stabilisation exercise is effective in reducing pain and disability in chronic but not acute low back pain. Single trials indicate that specific stabilisation exercise can be helpful in the treatment of cervicogenic headache and associated neck pain, pelvic pain, and in reducing recurrence after acute low back pain. PMID: 16764545 [PubMed - indexed for MEDLINE] 6. Acta Obstet Gynecol Scand. 2003 Nov;82(11):983-90. Physical therapy for pregnancy-related low back and pelvic pain: a systematic review. Stuge B(1), Hilde G, Vøllestad N. Author information: (1)University of Oslo, Section for Health Science, Oslo, Norway.

B.K.Stuge@helsefag.uio.no BACKGROUND: A systematic review of prospective controlled clinical trials was performed to assess the effectiveness of physical therapy interventions for the prevention and treatment of pregnancy-related back and pelvic pain. Pregnancy-related low back and pelvic pain has an impact on daily life for many women. Prevention and treatment of back and pelvic pain is therefore an important issue for all those concerned with women's health. METHODS: All prospective controlled clinical trials retrieved by systematic searching of electronic databases, checking of reference lists and contacting of authors were examined. Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials. Authors were contacted to obtain missing information. RESULTS: Nine trials with a total of 1350 patients were reviewed. Except for three high-quality studies, the validity of the trials was moderate to low. Two high-quality studies showed no difference in pain intensity and functional status between the exercise groups and the control groups. In the third high-quality study significant reduction in sick leave was found in favor of water gymnastics compared with no intervention. Because the included trials were considered heterogeneous with regard to study design, population intervention and outcome, no meta-analysis was performed. CONCLUSIONS: Because of heterogeneity and the varying quality of the studies no strong evidence exists concerning the effect of physical therapy interventions on the prevention and treatment of back and pelvic pain related to pregnancy. Future studies should meet current methodological standards, and interventions to be evaluated should be based on established theoretical framework. PMID: 14616270 [PubMed - indexed for MEDLINE]

Exercise and Peptic Ulcer 1. PLoS One. 2014 Aug 11;9(8):e104722. doi: 10.1371/journal.pone.0104722. eCollection 2014. Treatment efficacy for non-cardiovascular chest pain: a systematic review and meta-analysis. Burgstaller JM(1), Jenni BF(1), Steurer J(1), Held U(1), Wertli MM(2). Author information: (1)Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland. (2)Horten Center for Patient Oriented Research and Knowledge Transfer, Department of Internal Medicine, University of Zurich, Zurich, Switzerland; Cantonal Hospital Winterthur, Winterthur, Switzerland. BACKGROUND: Non-cardiovascular chest pain (NCCP) leads to impaired quality of life and is associated with a high disease burden. Upon ruling out cardiovascular disease, only vague recommendations exist for further treatment. OBJECTIVES: To summarize treatment efficacy for patients presenting with NCCP. METHODS: Systematic review and meta-analysis. In July 2013, Medline, Web of Knowledge, Embase, EBSCOhost, Cochrane Reviews and Trials, and Scopus were searched. Hand and bibliography searches were also conducted. Randomized controlled trials (RCTs) evaluating non-surgical treatments in patients with NCCP were included. Exclusion criteria were poor study quality and small sample size (<10 patients per group). RESULTS: Thirty eligible RCT's were included. Most studies assessed PPI efficacy for gastroesophageal reflux disorders (GERD, n = 10). Two RCTs included musculoskeletal chest pain, seven psychotropic drugs, and eleven various psychological interventions. Study quality was high in five RCTs and acceptable in 25. PPI treatment in patients with GERD (5 RCTs, 192 patients) was more effective than placebo [pooled OR 11.7 (95% CI 5.5 to 25.0, heterogeneity I2 = 6.1%)]. The pooled OR in GERD negative patients (4 RCTs, 156 patients) was 0.8 (95% CI 0.2 to 2.8, heterogeneity I2 = 50.4%). In musculoskeletal NCCP (2 RCTs, 229 patients) manual therapy was more effective than usual care but not than home exercise [pooled mean difference 0.5 (95% CI -0.3 to 1.3, heterogeneity I2 = 46.2%)]. The findings for cognitive behavioral treatment, serotonin reuptake inhibitors, tricyclic antidepressants were mixed. Most evidence was available for cognitive behavioral treatment interventions. LIMITATIONS: Only a small number of studies were available. CONCLUSIONS: Timely diagnostic evaluation and treatment of the disease underlying NCCP is important. For patients with suspected GERD, high-dose treatment with PPI is effective. Only limited evidence was available for most prevalent diseases

manifesting with chest pain. In patients with idiopathic NCCP, treatments based on cognitive behavioral principles might be considered. PMCID: PMC4128723 PMID: 25111147 [PubMed - indexed for MEDLINE]

Exercise and Pregnancy 1. Early Hum Dev. 2016 Mar;94:43-8. doi: 10.1016/j.earlhumdev.2016.01.004. Epub 2016 Feb 3. Benefits of aerobic or resistance training during pregnancy on maternal health and perinatal outcomes: A systematic review. Perales M(1), Santos-Lozano A(2), Ruiz JR(3), Lucia A(4), Barakat R(5). Author information: (1)Research Institute of Hospital 12 de Octubre ('i+12'), Avda. de Córdoba s/n, 28041 Madrid, Spain. Electronic address: m.perales.santaella@gmail.com. (2)Research Institute of Hospital 12 de Octubre ('i+12'), Avda. de Córdoba s/n, 28041 Madrid, Spain; GIDFYS, Department of Health Sciences, European University Miguel de Cervantes, Valladolid, Spain. Electronic address: asantos@uemc.es. (3)PROFITH "Promoting Fitness and Health through physical activity" research group, Faculty of Sport Sciences, Department of Physical Education and Sports, University of Granada, Granada, Spain. Electronic address: ruizj@ugr.es. (4)Research Institute of Hospital 12 de Octubre ('i+12'), Avda. de Córdoba s/n, 28041 Madrid, Spain; European University, Madrid, Spain. Electronic address: alejandro.lucia@universidadeuropea.es. (5)AFIPE Research Group, Technical University of Madrid, Spain. Electronic address: barakatruben@gmail.com. OBJECTIVE: To understand what evidence exists with regard to maternal and offspring benefits of aerobic and/or resistance training during pregnancy. METHODS: Systematic review of RCTs (published until May 2015) with healthy pregnant women and focusing on the benefits of exercise interventions on maternal health or perinatal outcomes. Studies were ranked as high/low quality, and a level of evidence was established according to the number of high-quality studies and consistency of the results. RESULTS: 61 RCTs were analyzed. The evidence for a benefit of combined exercise [aerobic+resistance (muscle strength)] interventions on maternal cardiorespiratory fitness and prevention of urinary incontinence was strong. A weak or insufficient level of evidence was found for the rest of interventions and outcomes CONCLUSION: The exercise modality that seems to induce a more favorable effect on maternal health is the combination of aerobic and resistance exercises during pregnancy. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved. PMID: 26850782 [PubMed - in process]

2. J Exerc Rehabil. 2016 Feb 1;12(1):15-20. doi: 10.12965/jer.160277. eCollection 2016. The effect of group training on pregnancy-induced lumbopelvic pain: systematic review and meta-analysis of randomized control trials. Fisseha B(1), Mishra PK(1). Author information: (1)Department of Physiotherapy, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia. Since there is lack of up to date consensus exists as to whether group training is effective in improving lumbopelvic pain (LPP) after pregnancy, a review of the recent evidences is needed. To determine the effect of group exercise training for the management of LPP among pregnant women compared with usual antenatal care. An electronic database search for relevant randomized control trials published in English from 2006 to 2015 was conducted. Articles with outcome measures of self-reported LPP, visual analogue scale and sick leave due to LPP after pregnancy were included. Quality of the included articles was rated using Physiotherapy Evidence Database (PEDro) scale and the pooled effect of self-reported LPP was obtained by Review Manager (RevMan 5) software. Significant effect of group training was detected over usual antenatal care or no treatment with P=0.0035 (95% confidence interval, -0.2348 to -0.0044). The results of this systematic review proposed that group training reduces LPP significantly better than routine antenatal care for pregnant women suffered from LPP. PMCID: PMC4771147 PMID: 26933655 [PubMed] 3. Acta Obstet Gynecol Scand. 2015 Nov;94(11):1156-67. doi: 10.1111/aogs.12681. Epub 2015 Jun 16. Treatments for pregnancy-related lumbopelvic pain: a systematic review of physiotherapy modalities. Gutke A(1,)(2), Betten C(3), Degerskär K(4), Pousette S(5), Olsén MF(1,)(6). Author information: (1)Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. (2)Division of Physiotherapy, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden. (3)Primary Health Care, Skurup, Region Skåne, Sweden. (4)Primary Health Care, Lund, Region Skåne, Sweden.

(5)Private Clinic 'Friskispraktiken', Stockholm, Sweden. (6)Department of Physical and Occupational Therapy, Sahlgrenska University Hospital, Gothenburg, Sweden. OBJECTIVE: To explore the effect of physiotherapeutic interventions on pregnancy-related lumbopelvic pain. MATERIAL AND METHODS: Data sources: MEDLINE, Cochrane Central Register of Controlled Trials, PEDro, CINAHL, AMED, and SCOPUS databases were searched up to December 2014 for studies written in English, French, German or Scandinavian languages that evaluated physiotherapeutic modalities for preventing and treating pregnancy-related lumbopelvic pain. RESULTS: For lumbopelvic pain during pregnancy, the evidence was strong for positive effects of acupuncture and pelvic belts. The evidence was low for exercise in general and for specific stabilizing exercises. The evidence was very limited for efficacy of water gymnastics, progressive muscle relaxation, a specific pelvic tilt exercise, osteopathic manual therapy, craniosacral therapy, electrotherapy and yoga. For postpartum lumbopelvic pain, the evidence was very limited for clinic-based treatment concepts, including specific stabilizing exercises, and for self-management interventions for women with severe disabilities. No specific adverse events were reported for any intervention. No meta-analysis could be performed because of study heterogeneity. CONCLUSIONS: The levels of evidence were strong for a positive effect of acupuncture and pelvic belts, but weak for an effect of specific exercises. Caution should prevail in choosing other interventions for pregnancy-related lumbopelvic pain. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 26018758 [PubMed - indexed for MEDLINE] 4. BMC Pregnancy Childbirth. 2015 Nov 26;15:316. doi: 10.1186/s12884-015-0736-4. A systematic review of randomised controlled trials on the effectiveness of exercise programs on Lumbo Pelvic Pain among postnatal women. Tseng PC(1), Puthussery S(2), Pappas Y(3), Gau ML(4). Author information: (1)Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. pei-ching.tseng@study.beds.ac.uk. (2)Department of Clinical Education and Leadership & Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2 8LE, Bedfordshire, UK. shuby.puthussery@beds.ac.uk. (3)Institute for Health Research, University of Bedfordshire, Putteridge Bury, Hitchin Road, Luton LU2

8LE, Bedfordshire, UK. yannis.pappas@beds.ac.uk. (4)Graduate Institute of Nurse-Midwifery, National Taipei University of Nursing and Health Sciences, 365, Ming-Te Road, Peitou, Taipei, Taiwan. meeiling@ntunhs.edu.tw. BACKGROUND: A substantial number of women tend to be affected by Lumbo Pelvic Pain (LPP) following child birth. Physical exercise is indicated as a beneficial method to relieve LPP, but individual studies appear to suggest mixed findings about its effectiveness. This systematic review aimed to synthesise evidence from randomised controlled trials on the effectiveness of exercise on LPP among postnatal women to inform policy, practice and future research. METHODS: A systematic review was conducted of all randomised controlled trials published between January 1990 and July 2014, identified through a comprehensive search of following databases: PubMed, PEDro, Embase, Cinahl, Medline, SPORTDiscus, Cochrane Pregnancy and Childbirth Group's Trials Register, and electronic libraries of authors'institutions. Randomised controlled trials were eligible for inclusion if the intervention comprised of postnatal exercise for women with LPP onset during pregnancy or within 3 months after delivery and the outcome measures included changes in LPP. Selected articles were assessed using the PEDro Scale for methodological quality and findings were synthesised narratively as meta-analysis was found to be inappropriate due to heterogeneity among included studies. RESULTS: Four randomised controlled trials were included, involving 251 postnatal women. Three trials were rated as of 'good' methodological quality. All trials, except one, were at low risk of bias. The trials included physical exercise programs with varying components, differing modes of delivery, follow up times and outcome measures. Intervention in one trial, involving physical therapy with specific stabilising exercises, proved to be effective in reducing LPP intensity. An improvement in gluteal pain on the right side was reported in another trial and a significant difference in pain frequency in another. CONCLUSION: Our review indicates that only few randomised controlled trials have evaluated the effectiveness of exercise on LPP among postnatal women. There is also a great amount of variability across existing trials in the components of exercise programs, modes of delivery, follow up times and outcome measures. While there is some evidence to indicate the effectiveness of exercise for relieving LPP, further good quality trials are needed to ascertain the most effective elements of postnatal exercise programs suited for LPP treatment. PMCID: PMC4661954 PMID: 26612732 [PubMed - in process] 5. Acta Obstet Gynecol Scand. 2015 Oct;94(10):1039-47. doi: 10.1111/aogs.12675. Epub 2015 May 30. Effects of exercise during pregnancy on mode of delivery: a meta-analysis.

Poyatos-León R(1), García-Hermoso A(2), Sanabria-Martínez G(1), Álvarez-Bueno C(3), Sánchez-López M(3,)(4), Martínez-Vizcaíno V(3). Author information: (1)Virgen de la Luz Hospital, Cuenca, Spain. (2)Physical Activity, Sport and Health Sciences Laboratory, University of Santiago de Chile, USACH, Santiago de Chile, Chile. (3)School of Education, University of Castilla-La Mancha, Ciudad Real, Spain. (4)Health and Social Research Center, University of Castilla-La Mancha, Cuenca, Spain. INTRODUCTION: We conducted a systematic review and meta-analysis to examine the influence of physical exercise interventions on the mode of delivery of healthy pregnant women with low to moderate levels of physical activity. MATERIAL AND METHODS: Key words were used to conduct a computerized search for articles on the topic in six databases: Cochrane Library Plus, Science Direct, EMBASE, PubMed, Web of Science and ClinicalTrials.gov. Ten randomized controlled trials were identified and included in the meta-analysis. Main outcome measures were mode of delivery (normal, instrumental vaginal, or cesarean delivery) and physical activity. RESULTS: Relative risk reductions and their 95% confidence interval were calculated for each study, and the heterogeneity of the studies was estimated using Cochran's Q statistic. The evidence suggests that physical exercise during pregnancy may increase the likelihood of normal delivery (relative risk = 1.12, 95% confidence interval 1.01-1.24; p = 0.041), in particular when exercise takes place during the second and third trimesters (relative risk = 1.14, 95% confidence interval 1.01-1.32; p = 0.048), even reducing the risk of cesarean delivery (relative risk = 0.66, 95% confidence interval 0.46-0.96; p = 0.028). CONCLUSIONS: Regular exercise during pregnancy appears to modestly increase the chance for normal delivery among healthy pregnant women. This applies to women with low to moderate levels of physical activity, but studies are needed to understand better the effect of physical exercise of moderate to vigorous intensity in the different trimesters. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 25965378 [PubMed - indexed for MEDLINE] 6. Br J Sports Med. 2015 Oct;49(20):1336-42. doi: 10.1136/bjsports-2014-093875. Epub 2014 Nov 18. Exercise interventions for weight management during pregnancy and up to 1 year postpartum among normal weight, overweight and obese women: a systematic review and meta-analysis.

Elliott-Sale KJ(1), Barnett CT(1), Sale C(1). Author information: (1)Sport, Health and Performance Enhancement (SHAPE) Research Group, School of Science and Technology, Nottingham Trent University, Nottingham, UK. BACKGROUND: The prevalence of excessive gestation weight gain, extended postpartum weight retention and pregravid obese women is increasing and is associated with numerous adverse health outcomes. OBJECTIVE: To review the evidence from studies employing exercise-only interventions for weight management among pregnant and postpartum women. SEARCH STRATEGY: Ten databases were searched for randomised controlled trials conducted during pregnancy or within the 12 months following childbirth and published between 1990 and 2013. SELECTION CRITERIA: There were no restrictions to the type, frequency, duration or intensity of exercise intervention. Interventions not specifically designed to target weight were excluded. The outcomes were a change in body weight (kg) or body mass index (BMI; kg/m(2)). DATA COLLECTION AND ANALYSIS: All data were continuous and were reported as weighted mean differences (WMD), with 95% CIs. Data were analysed with a fixed-effect model and heterogeneity was determined using the I(2) statistic. RESULTS: Five studies were included in this review. Exercise significantly reduced gestational weight gain (WMD=-2.22 kg, CI -3.14 to -1.3, p≤0.00001) and had no significant effect on postpartum weight loss (WMD=-1.74 kg, CI -3.59 to 0.10, p=0.06) or BMI during pregnancy (WMD=-2.8 kg/m(2), CI -5.60 to 0.00, p=0.05) or postpartum (WMD=-0.54 kg/m(2), CI -1.17 to 0.08, p=0.09). CONCLUSIONS: There is currently limited evidence to suggest that exercise can be used to limit maternal gestational weight gain. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. PMID: 25406335 [PubMed - in process] 7. Am J Health Promot. 2015 May 14. [Epub ahead of print] Effects of Exercise-Based Interventions on Neonatal Outcomes: A Meta-Analysis of Randomized Controlled Trials. Sanabria-Martínez G, García-Hermoso A, Poyatos-León R, González-García A, Sánchez-López M, Martínez-Vizcaíno V.

Objective . The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled clinical trials (RCTs) assessing the influence of physical exercise interventions during pregnancy on some neonatal outcomes. Data Source . Key words were used to conduct a computerized search in six databases: Cochrane Library Plus, Science Direct, EMBASE, PubMed, Web of Science, and ClinicalTrials.gov. Study Inclusion and Exclusion Criteria . RCTs that included an exercise program for healthy pregnant women who were sedentary or had low levels of physical activity were selected. Data Extraction . Two independent reviewers extracted data and assessed the quality of the studies included. Of 4296 articles retrieved, 14 RCTs (3044 pregnant women) met the inclusion criteria. Data Synthesis . Pooled effect sizes (ESs) were calculated using a fixed model. Results . Overall, physical exercise programs during pregnancy produced a small reduction in neonatal birth weight (ES = -.10; p = .04). The Apgar score at 1 minute was also weakly increased with combined exercise (aerobic, strength, and flexibility) (ES = .09; p = .048) and no differences between groups were observed in gestational age at delivery and Apgar score at 5 minutes. Conclusion . Structured physical exercise programs during pregnancy appear to be safe for the neonate, mainly favoring a lower birth weight within normal range. However, more studies are needed to establish recommendations. PMID: 25973965 [PubMed - as supplied by publisher] 8. BJOG. 2015 Mar;122(4):590-1. doi: 10.1111/1471-0528.13133. Re: The effectiveness of exercise for the prevention and treatment of antenatal depression: systematic review with meta-analysis; Association and prediction of amniotic fluid measurements for adverse pregnancy outcome: systematic review and meta-analysis; Does induction of labour increase the risk of caesarean section? A systematic review and meta analysis of trials in women with intact membranes. Griffin C(1). Author information: (1)School of Women's and Infants' Health, the University of Western Australia, King Edward Memorial Hospital, Bagot Road, Subiaco, WA, Australia. Comment in BJOG. 2015 Mar;122(4):592. BJOG. 2015 Mar;122(4):591. BJOG. 2015 Mar;122(4):591. BJOG. 2015 Mar;122(4):591-2. Comment on

BJOG. 2014 May;121(6):686-99. BJOG. 2014 May;121(6):674-85; discussion 685. BJOG. 2015 Jan;122(1):57-62. PMID: 25702552 [PubMed - indexed for MEDLINE] 9. BJOG. 2015 Jan;122(1):57-62. doi: 10.1111/1471-0528.12909. Epub 2014 Jun 17. The effectiveness of exercise for the prevention and treatment of antenatal depression: systematic review with meta-analysis. Daley AJ(1), Foster L, Long G, Palmer C, Robinson O, Walmsley H, Ward R. Author information: (1)Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK. Comment in BJOG. 2015 Mar;122(4):592. BJOG. 2015 Mar;122(4):591. BJOG. 2015 Jan;122(1):63. BJOG. 2015 Mar;122(4):590-1. BACKGROUND: Antenatal depression can have harmful consequences for the mother and fetus. Exercise may be a useful intervention to prevent and treat antenatal depression. OBJECTIVES: This systematic review aims to establish whether there is sufficient evidence to conclude that exercise is an effective intervention for preventing and treating antenatal depression. SEARCH STRATEGY: Searches using electronic databases from MEDLINE, Cochrane Library, CINAHL, EMBASE, AMED and PsycINFO were performed. SELECTION CRITERIA: Randomised controlled trials (RCT) that compared any type of exercise intervention with any comparator in pregnant women were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Meta-analysis was performed calculating standardised mean differences (SMD). MAIN RESULTS: Six trials (seven comparisons) were eligible for inclusion. Meta-analysis showed a significant reduction in depression scores (SMD -0.46, 95% CI -0.87 to -0.05, P = 0.03, I(2) = 68%) for exercise interventions relative to comparator groups. The test for subgroup differences in women who were non-depressed (one trial) (SMD -0.74, 95%CI -1.22 to -0.27, P = 0.002) and depressed (five trials) (SMD -0.41, 95% CI -0.88 to 0.07, P = 0.09) at baseline was not significant (P = 0.32). The test for subgroup differences between aerobic (one trial) and non-aerobic exercise (five trials) was also nonsignificant (P = 0.32).

AUTHORS' CONCLUSIONS: We found some evidence that exercise may be effective in treating depression during pregnancy but this conclusion is based on a small number of low-moderate quality trials with significant heterogeneity and wide confidence intervals. © 2014 Royal College of Obstetricians and Gynaecologists. PMID: 24935560 [PubMed - indexed for MEDLINE] 10. Nutr Hosp. 2014 Oct 1;30(4):719-26. doi: 10.3305/nh.2014.30.4.7679. [Physical activity by pregnant women and its influence on maternal and foetal parameters; a systematic review]. [Article in Spanish; Abstract available in Spanish from the publisher] Aguilar Cordero MJ(1), Sánchez López AM(2), Rodríguez Blanque R(3), Noack Segovia JP(4), Pozo Cano MD(5), López-Contreras G(6), Mur Villar N(7). Author information: (1)PhD. Departamento de Enfermería. Facultad de Ciencias de la Salud. Universidad de Granada. Hospital Clínico San Cecilio de Granada (España).. mariajaguilar@telefonica.net. (2)BsC. Grupo de Investigación CTS 367. Plan Andaluz de Investigación. Junta de Andalucía (España). Departamento de Enfermería. Facultad de Ciencias de la Salud. Universidad de Granada (España).. antoniosl@ugr.es. (3)BsC. Matrona Distrito Sanitario Granada-Metropolitano. Departamento de Enfermería. Universidad de Granada (España).. rarobla@gmail.com. (4)BsC. Universidad de Santo Tomás. Talca (Chile).. noackjessica1966@gmail.com. (5)PhD. Departamento de Enfermería. Facultad de Ciencias de la Salud. Universidad de Granada (España).. pozocano@ugr.es. (6)PhD. Facultad de Ciencias del Deporte. Universidad de Granada (España). Grupo de investigación: Actividad Física y deportiva en Medio Acuático (CTS-527).. gracia@ugr.es. (7)PhD. Grupo de Investigación CTS 367. Plan Andaluz de Investigación. Junta de Andalucía (España). Facultad de Ciencias Médicas de Cienfuegos (Cuba).. normamur@jagua.cfg.sld.cu. INTRODUCTION: Regular physical activity is known to be very beneficial to health. While it is important at all stages of life, during pregnancy doubts may arise about the suitability of physical exercise, as well as the type of activity, its frequency, intensity and duration. AIMS: To analyse major studies on the influence of physical activity on maternal and foetal parameters. METHOD: Systematic review of physical activity programmes for pregnant women and the results achieved, during pregnancy, childbirth and postpartum. 45 items were

identified through an automated database search in PubMed, Scopus and Google Scholar, carried out from October 2013 to March 2014. In selecting the items, the criteria applied included the usefulness and relevance of the subject matter and the credibility or experience of the research study authors. The internal and external validity of each of the articles reviewed was taken into account. CONCLUSIONS: The results of the review highlight the importance of physical activity during pregnancy, and show that the information currently available can serve as an initial benchmark for further investigation into the impact of regular physical exercise, in an aquatic environment, on maternal-foetal health. Publisher: Abstract available from the publisher. Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved. PMID: 25335654 [PubMed - in process] 11. J Orthop Sports Phys Ther. 2014 Jul;44(7):464-73, A1-15. doi: 10.2519/jospt.2014.5098. Epub 2014 May 10. Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review. van Benten E(1), Pool J, Mens J, Pool-Goudzwaard A. Author information: (1)University of Applied Sciences Utrecht, Utrecht, the Netherlands. Summary for patients in J Orthop Sports Phys Ther. 2014 Jul;44(7):474. STUDY DESIGN: Systematic review of the literature. OBJECTIVES: To review and assess the peer-reviewed literature on the effectiveness of physical therapy interventions in treating lumbopelvic pain during pregnancy. BACKGROUND: Current guidelines on interventions for lumbopelvic pain during pregnancy differ in their recommendations for assessment and intervention. Recent publications may allow revising current recommendations for the treatment of this complex problem. METHODS: An electronic search strategy was conducted in PubMed, PEDro, Scopus, and CINAHL of literature published from January 1992 to November 2013. Two authors independently assessed all abstracts for eligibility. Articles were independently rated for quality by 2 authors, using the Cochrane Back Review Group criteria for methodological quality. Where possible, effect sizes were calculated for the different interventions.

RESULTS: A total of 22 articles (all randomized controlled trials) reporting on 22 independent studies were included. Overall, the methodological quality of the studies was moderate. Data for 4 types of interventions were considered: a combination of interventions (7 studies, n = 1202), exercise therapy (9 studies, n = 2149), manual therapy (5 studies, n = 360), and material support (1 study, n = 115). CONCLUSION: All included studies on exercise therapy, and most of the studies on interventions combined with patient education, reported a positive effect on pain, disability, and/or sick leave. Evidence-based recommendations can be made for the use of exercise therapy for the treatment of lumbopelvic pain during pregnancy. LEVEL OF EVIDENCE: Therapy, level 1a-. J Orthop Sports Phys Ther 2014;44(7):464-473. Epub 10 May 2014. doi:10.2519/jospt.2014.5098. PMID: 24816503 [PubMed - indexed for MEDLINE] 12. Physiotherapy. 2014 Mar;100(1):1-8. doi: 10.1016/j.physio.2013.08.005. Epub 2013 Oct 5. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Benjamin DR(1), van de Water AT(2), Peiris CL(3). Author information: (1)Physiotherapy Department, Angliss Hospital, Eastern Health, Australia. Electronic address: Deenika.Benjamin@easternhealth.org.au. (2)Department of Physiotherapy, School of Allied Health, La Trobe University, Victoria, Australia. (3)Physiotherapy Department, Angliss Hospital, Eastern Health, Australia; Department of Physiotherapy, School of Allied Health, La Trobe University, Victoria, Australia. BACKGROUND: Diastasis of the rectus abdominis muscle (DRAM) is common during and after pregnancy, and has been related to lumbopelvic instability and pelvic floor weakness. Women with DRAM are commonly referred to physiotherapists for conservative management, but little is known about the effectiveness of such strategies. OBJECTIVES: To determine if non-surgical interventions (such as exercise) prevent or reduce DRAM. DATA SOURCES: EMBASE, Medline, CINAHL, PUBMED, AMED and PEDro were searched. STUDY SELECTION/ELIGIBILITY: Studies of all designs that included any non-surgical interventions to manage DRAM during the ante- and postnatal periods were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Methodological quality was assessed using

a modified Downs and Black checklist. Meta-analysis was performed using a fixed effects model to calculate risk ratios (RR) and 95% confidence intervals (CI) where appropriate. RESULTS: Eight studies totalling 336 women during the ante- and/or postnatal period were included. The study design ranged from case study to randomised controlled trial. All interventions included some form of exercise, mainly targeted abdominal/core strengthening. The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods. LIMITATIONS: The papers reviewed were of poor quality as there is very little high-quality literature on the subject. CONCLUSION AND IMPLICATIONS: Based on the available evidence and quality of this evidence, non-specific exercise may or may not help to prevent or reduce DRAM during the ante- and postnatal periods. Copyright © 2013 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 24268942 [PubMed - indexed for MEDLINE] 13. Br J Sports Med. 2014 Feb;48(4):299-310. doi: 10.1136/bjsports-2012-091758. Epub 2013 Jan 30. Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Mørkved S(1), Bø K. Author information: (1)Department of Clinical Service, St. Olavs Hospital, Trondheim University Hospital, , Trondheim, Norway. BACKGROUND: Urinary incontinence (UI) is a common condition in women causing reduced quality of life and withdrawal from fitness and exercise activities. Pregnancy and childbirth are established risk factors. Current guidelines for exercise during pregnancy have no or limited focus on the evidence for the effect of pelvic floor muscle training (PFMT) in the prevention and treatment of UI. AIMS: Systematic review to address the effect of PFMT during pregnancy and after delivery in the prevention and treatment of UI. DATA SOURCES: PubMed, CENTRAL, Cochrane Library, EMBASE and PEDro databases and hand search of available reference lists and conference abstracts (June 2012). METHODS: STUDY ELIGIBILITY CRITERIA: Randomised controlled trials (RCTs) and

quasiexperimental trials published in the English language. PARTICIPANTS: Primiparous or multiparous pregnant or postpartum women. INTERVENTIONS: PFMT with or without biofeedback, vaginal cones or electrical stimulation. STUDY APPRAISAL AND SYNTHESIS METHODS: Both authors independently reviewed, grouped and qualitatively synthesised the trials. RESULTS: 22 randomised or quasiexperimental trials were found. There is a very large heterogeneity in the populations studied, inclusion and exclusion criteria, outcome measures and content of PFMT interventions. Based on the studies with relevant sample size, high adherence to a strength-training protocol and close follow-up, we found that PFMT during pregnancy and after delivery can prevent and treat UI. A supervised training protocol following strength-training principles, emphasising close to maximum contractions and lasting at least 8 weeks is recommended. CONCLUSIONS: PFMT is effective when supervised training is conducted. Further high-quality RCTs are needed especially after delivery. Given the prevalence of female UI and its impact on exercise participation, PFMT should be incorporated as a routine part of women's exercise programmes in general. PMID: 23365417 [PubMed - indexed for MEDLINE] 14. Br J Sports Med. 2014 Feb;48(4):290-5. doi: 10.1136/bjsports-2013-092596. Epub 2013 Sep 13. Physical activity during pregnancy and the risk of gestational diabetes mellitus: a systematic review and meta-analysis of randomised controlled trials. Yin YN(1), Li XL, Tao TJ, Luo BR, Liao SJ. Author information: (1)West China Second University Hospital, Sichuan University, , Chengdu, Sichuan, China. OBJECTIVES: We performed a systematic review and meta-analysis to assess the effects of physical activity in preventing gestational diabetes mellitus (GDM). SEARCH STRATEGY: We searched the literature in six electronic databases and bibliographies of relevant articles. SELECTION CRITERIA: We included randomised controlled trials on pregnant women who did not have GDM and other complications previously and had increased physical activity as the only intervention. The risk of developing GDM was documented separately for the intervention and control groups. DATA COLLECTION AND ANALYSIS: Two reviewers extracted data and assessed quality independently. Data from the included trials were combined using a fixed-effects model. The effect size was expressed as relative risk (RR) and 95% CI.

MAIN RESULTS: Of the 1110 studies identified, six randomised controlled trials met the inclusion criteria. In three trials, the incidence of GDM was lower in the intervention group than in the control group, whereas two trials showed a higher incidence of GDM in the intervention group and the remaining trial found no GDM in either the intervention or control group. The meta-analysis resulted in a relative risk (RR) of GDM of 0.91 (95% CI 0.57 to 1.44), suggesting no significant difference in the risk of developing GDM between the intervention and the control groups. No indication of publication bias was found. CONCLUSIONS: Evidence was insufficient to suggest that physical activity during pregnancy might be effective to lower the risk of developing GDM. PMID: 24037671 [PubMed - indexed for MEDLINE] 15. J Can Chiropr Assoc. 2013 Sep;57(3):260-70. Non-pharmacological interventions for sleep quality and insomnia during pregnancy: A systematic review. Hollenbach D(1), Broker R, Herlehy S, Stuber K. Author information: (1)Institution: Canadian Memorial Chiropractic College, Division of Graduate Education & Research. OBJECTIVE: To systematically review the literature regarding non-pharmacological inteventions for improving sleep quality and insomnia during pregnancy. METHODS: An electronic search strategy was conducted using several online databases (CINAHL, PubMed, Medline, Index to Chiropractic Literature) from inception to March 2013. Inclusion criteria consisted of studies evaluating non-pharmacological interventions, published in English in a peer reviewed journal, and assessed sleep quality or insomnia. The full text of suitable articles was reviewed by the authors, and scored using a risk of bias assessment. RESULTS: 160 articles were screened and seven studies met the inclusion criteria in the form of three prospective RCTs, one prospective longitudinal trial, one experimental pilot study, and two prospective quasi-randomized trials. Quality scores ranged from five to eight out of twelve on the risk of bias scoring criteria. CONCLUSIONS: Exercise, massage, and acupuncture may be associated with improved sleep quality during pregnancy, however, due to the low quality and heterogeneity of the studies yielded, a definitive recommendation cannot be made. Further higher quality research is indicated. Publisher: Abstract available from the publisher. PMCID: PMC3743652

PMID: 23997252 [PubMed] 16. Physiother Theory Pract. 2013 Aug;29(6):419-31. doi: 10.3109/09593985.2012.748114. Epub 2012 Dec 17. Effectiveness of physical therapy for pregnancy-related low back and/or pelvic pain after delivery: a systematic review. Ferreira CW(1), Alburquerque-Sendı N F. Author information: (1)Physiotherapy Department , Universidade Federal de Pernambuco , Recife, PE , Brazil. caroline.wanderley@ufpe.br The aim of this work was to investigate the effectiveness of physical therapy for the treatment of low back pain (LBP) and pelvic girdle pain (PGP) related to pregnancy after delivery. A systematic review of studies published since 1985 in the databases Medline, PEDro, SciELO, SCOPUS, LILACS, and the Cochrane Library was made. Studies that focused on postpartum LBP or PGP, without being related to pregnancy or in other non-pregnant patients, were excluded, as were papers addressing LBP or PGP indicating radiculopathy, rheumatism, or any other serious disease or pathologic condition. In accordance with the exclusion criteria and duplicate articles, of the 105 articles retrieved only six were considered for quality assessment with the PEDro Scale. Among these six papers, two were follow-ups, such that only four trials were included in this review. All trials used exercise for motor control and stability of the lumbopelvic region, but with different intervention approaches. The study affording the best evidence used individual guidance and adjustments given by the physiotherapists. Nevertheless, this systematic review was inconclusive and showed that more randomized clinical trials, with good quality, are needed. PMID: 23244038 [PubMed - indexed for MEDLINE] 17. PLoS One. 2013 Jun 14;8(6):e66385. doi: 10.1371/journal.pone.0066385. Print 2013. Reducing the decline in physical activity during pregnancy: a systematic review of behaviour change interventions. Currie S(1), Sinclair M, Murphy MH, Madden E, Dunwoody L, Liddle D. Author information: (1)Maternal, Fetal and Infant Research Centre, Institute of Nursing and Health Research, University of Ulster, Newtownabbey, Northern Ireland.

Currie-S4@email.ulster.ac.uk PURPOSE: Physical activity (PA) typically declines throughout pregnancy. Low levels of PA are associated with excessive weight gain and subsequently increase risk of pre-eclampsia, gestational diabetes mellitus, hypertension disorders, delivery by caesarean section and stillbirth. Systematic reviews on PA during pregnancy have not explored the efficacy of behaviour change techniques or related theory in altering PA behaviour. This systematic review evaluated the content of PA interventions to reduce the decline of PA in pregnant women with a specific emphasis on the behaviour change techniques employed to elicit this change. SEARCH AND REVIEW METHODOLOGY: Literature searches were conducted in eight databases. Strict inclusion and exclusion criteria were employed. Two reviewers independently evaluated each intervention using the behaviour change techniques (BCT) taxonomy to identify the specific behaviour change techniques employed. Two reviewers independently assessed the risk of bias using the guidelines from the Cochrane Collaboration. Overall quality was determined using the GRADE approach. FINDINGS: A total of 1140 potentially eligible papers were identified from which 14 studies were selected for inclusion. Interventions included counselling (n = 6), structured exercise (n = 6) and education (n = 2). Common behaviour change techniques employed in these studies were goal setting and planning, feedback, repetition and substitution, shaping knowledge and comparison of behaviours. Regular face-to-face meetings were also commonly employed. PA change over time in intervention groups ranged from increases of 28% to decreases of 25%. In 8 out of 10 studies, which provided adequate data, participants in the intervention group were more physically active post intervention than controls. CONCLUSIONS AND IMPLICATIONS: Physical activity interventions incorporating behaviour change techniques help reduce the decline in PA throughout pregnancy. Range of behaviour change techniques can be implemented to reduce this decline including goals and planning, shaping knowledge and comparison of outcomes. A lack of high quality interventions hampers conclusions of intervention effectiveness. PMCID: PMC3682976 PMID: 23799096 [PubMed - indexed for MEDLINE] 18. Am J Lifestyle Med. 2013 Jan 1;7(1). doi: 10.1177/1559827612446416. Strategies to Promote Physical Activity During Pregnancy: A Systematic Review of Intervention Evidence. Pearce EE(1), Evenson KR(2), Downs DS(3), Steckler A(4). Author information:

(1)Department of Health Behavior and Health Education, Gillings School of Global Public Health University of North Carolina at Chapel Hill 302 Rosenau Hall, Campus Box 7440 Chapel Hill NC 27599-7440 T: 919-699-2547 eidenier@email.unc.edu. (2)Department of Epidemiology, Gillings School of Global Public Health University of North Carolina at Chapel Hill Bank of America Center, 137 East Franklin Street, Suite 306 Chapel Hill NC 27514 T: 919-966-9800 kelly_evenson@unc.edu. (3)Department of Kinesiology 268Q Recreation Building The Pennsylvania State University University Park PA 16802 T: 814-863-0456 dsd11@psu.edu. (4)Department of Health Behavior and Health Education, Gillings School of Global Public Health University of North Carolina at Chapel Hill 302 Rosenau Hall, Campus Box 7440 Chapel Hill NC 27599-7440 T: 919-966-3904 Steckler@email.unc.edu. Physical activity during pregnancy has been associated with significant health benefits, however most women in the United States do not meet current guidelines. This systematic review evaluates evidence for interventions to improve physical activity during pregnancy in order to identify best practices and inform future research. Electronic databases (PubMed, CINAHL, SportDISCUS, Embase, ERIC, Psych Info and ISI Web of Science) were searched in July 2011 for peer-reviewed journal articles. Studies were included if they were English-language randomized control trials that measured the efficacy of an intervention targeted to pregnant women and designed to change physical activity as a primary or secondary outcome. Out of 777 studies identified through the systematic search, nine interventions were identified for inclusion by multiple reviewers. Data was abstracted using an abstraction form modeled after the "Guide to Community Preventive Services." Of the nine interventions included in the review, three reported statistically significant positive results for physical activity. While interventions included a variety of strategies and techniques, none were uniquely associated with positive outcomes. Overall this review suggests that little is known about the efficacy of interventions for physical activity during pregnancy. We provide several recommendations for future research and intervention design. PMCID: PMC3866032 PMID: 24363633 [PubMed] 19. Curr Opin Obstet Gynecol. 2012 Dec;24(6):387-94. doi: 10.1097/GCO.0b013e328359f131. Physical exercise during pregnancy: a systematic review. Nascimento SL(1), Surita FG, Cecatti JG. Author information: (1)Obstetric Unit, Department of Obstetrics and Gynecology, University of Campinas, Campinas, Sao Paulo, Brazil. simonylira@yahoo.com.br

PURPOSE OF REVIEW: This review aims to provide an update on the recent evidence concerning exercise during pregnancy including effects for mother and fetus and the types, frequency, intensity, duration and rate of progression of exercise performed. RECENT FINDINGS: Exercises during pregnancy are associated with higher cardiorespiratory fitness, prevention of urinary incontinence and low back pain, reduced symptoms of depression, gestational weight gain control, and for cases of gestational diabetes, reduced number of women who required insulin. There is no association with reduction in birth weight or preterm birth rate. The type of exercise shows no difference on results, and its intensity should be mild or moderate for previous sedentary women and moderate to high for active women. The exercise recommendations still are based on the current guidelines on moderate-intensity, low-impact, aerobic exercise at least three times a week. Yet, new guidelines propose increasing weekly physical-activity expenditure while incorporating vigorous exercise and adding light strength training to the exercise routine of healthy pregnant women. In the case of other chronic diseases like hypertension, there are still few data, and therefore more studies should be performed to assess the safety of the intervention. SUMMARY: Physical exercise is beneficial for women during pregnancy and also in the postpartum period; it is not associated with risks for the newborn and can lead to changes in lifestyle that imply long-term benefits. PMID: 23014142 [PubMed - indexed for MEDLINE] 20. Acta Obstet Gynecol Scand. 2012 Oct;91(10):1147-57. doi: 10.1111/j.1600-0412.2012.01483.x. Epub 2012 Jul 24. Exercise and physical activity in the prevention of pre-eclampsia: systematic review. Kasawara KT(1), do Nascimento SL, Costa ML, Surita FG, e Silva JL. Author information: (1)Department of Obstetrics and Gynecology, University of Campinas (UNICAMP), Campinas, Brazil. Exercise and physical activity have been studied and suggested as a way to reduce or minimize the effects of pre-eclampsia. Our aim was to evaluate the association between exercise and/or physical activity and occurrence of pre-eclampsia. We conducted electronic searches without year of publication and language limitations. This was a systematic review designed according to PRISMA. Different databases accessed were as follows: PubMed®; Latin-American and Caribbean Literature in Health Sciences (LILACS); Scientific Electronic Library On-line

(SciELO); Physiotherapy Evidence Database (PEDro); and ISI web of Knowledge(SM) . The Medical Subject Headings (MeSH) were as follows: ("exercise" OR "motor activity" OR "physical activity") AND ("pre-eclampsia" OR "eclampsia" OR "hypertension, pregnancy-induced"). Inclusion criteria were studies conducted in adults who were engaged in some physical activity. The selection and methodological evaluation were carried out by two independent reviewers. Risk assessment was made by the odds ratio (OR) and incidence of pre-eclampsia in the population who performed physical activity/exercise. A total of 231 articles were found, 214 of which were excluded based on title and full-text, so that 17 remained. Comparison of six case-control studies showed that physical activity had a protective effect on the development of pre-eclampsia [OR 0.77, 95% confidence interval (CI) 0.64-0.91, p < 0.01]. The 10 prospective cohort studies showed no significant difference (OR 0.99, 95% CI 0.93-1.05, p= 0.81). The only randomized clinical trial showed a protective effect on the development of pre-eclampsia in the stretching group (OR 6.34, 95% CI 0.72-55.37, p= 0.09). This systematic review indicates a trend toward a protective effect of physical activity in the prevention of pre-eclampsia. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 22708966 [PubMed - indexed for MEDLINE] 21. Acta Obstet Gynecol Scand. 2012 Sep;91(9):1038-45. doi: 10.1111/j.1600-0412.2012.01462.x. Epub 2012 Jul 2. Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review. Richards E(1), van Kessel G, Virgara R, Harris P. Author information: (1)School of Health Sciences, University of South Australia, Adelaide, SA 5001, Australia. OBJECTIVE: A systematic review was undertaken to update the understanding of the available evidence for antenatal physical therapy interventions for low back or pelvic pain in pregnant women to improve functional outcomes when compared with other treatments or no treatment. DATA SOURCES: Seven electronic databases were systematically searched and supplemented by hand searching through reference lists. METHODS OF STUDY SELECTION: Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials using the Clinical Appraisal Skills Program tool.

RESULTS: Four trials with 566 participants were identified that met the inclusion criteria. The validity of the trials was moderate. Exercise, pelvic support garments and acupuncture were found to improve functional outcomes in pregnant women with low back or pelvic pain. No meta-analysis was performed because of the heterogeneity of functional outcome measures. CONCLUSIONS: While there is some evidence that physical therapy using exercise, acupuncture and pelvic supports may be useful, further research needs to consider other treatment modalities used by physical therapists and establish an appropriate, reliable and valid functional outcome measure to assess low back and pelvic pain in pregnancy. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 22583125 [PubMed - indexed for MEDLINE] 22. Acta Obstet Gynecol Scand. 2012 May;91(5):538-45. doi: 10.1111/j.1600-0412.2012.01357.x. Epub 2012 Feb 28. Antenatal exercise to improve outcomes in overweight or obese women: A systematic review. Sui Z(1), Grivell RM, Dodd JM. Author information: (1)The Robinson Institute, Discipline of Obstetrics & Gynaecology, 55 King William Road, North Adelaide, South Australia 5006, Australia. zhixian.sui@adelaide.edu.au BACKGROUND: Women who are overweight or obese during pregnancy are at increased risk of a number of adverse pregnancy outcomes. OBJECTIVE: To review the literature systematically to assess the benefits and harms of an exercise intervention for pregnant women who are overweight or obese. SEARCH STRATEGY: A literature search of PUBMED, SCOPUS, the Cochrane Controlled Trials Register (CENTRAL) and the Australian and International Clinical Trials Registers was performed, as well as an additional hand search through bibliographies of various publications. There were no date or language restrictions. SELECTION CRITERIA: Studies included were randomized controlled trials comparing supervised antenatal exercise intervention with routine standard antenatal care in women who were overweight or obese during pregnancy. The primary outcome was maternal gestational weight gain. The quality of each study was assessed utilizing standard Cochrane systematic review methodology. Data collection and analysis. Six randomized controlled trials and one quasi-randomized trial were

identified and included, involving a total of 276 women who were overweight or obese during pregnancy. RESULTS: Provision of a supervised antenatal exercise intervention was associated with lower gestational weight gain (five trials, 216 participants, mean difference of -0.36 kg, 95% confidence interval -0.64 to -0.09 kg) when compared with standard antenatal care. CONCLUSIONS: A monitored physical activity intervention appears to be successful in limiting gestational weight gain; however, the effect on maternal and infant health is less certain. © 2012 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2012 Nordic Federation of Societies of Obstetrics and Gynecology. PMID: 22229625 [PubMed - indexed for MEDLINE] 23. Acta Obstet Gynecol Scand. 2003 Nov;82(11):983-90. Physical therapy for pregnancy-related low back and pelvic pain: a systematic review. Stuge B(1), Hilde G, Vøllestad N. Author information: (1)University of Oslo, Section for Health Science, Oslo, Norway. B.K.Stuge@helsefag.uio.no BACKGROUND: A systematic review of prospective controlled clinical trials was performed to assess the effectiveness of physical therapy interventions for the prevention and treatment of pregnancy-related back and pelvic pain. Pregnancy-related low back and pelvic pain has an impact on daily life for many women. Prevention and treatment of back and pelvic pain is therefore an important issue for all those concerned with women's health. METHODS: All prospective controlled clinical trials retrieved by systematic searching of electronic databases, checking of reference lists and contacting of authors were examined. Two reviewers independently selected trials for inclusion and independently assessed the internal validity of the included trials. Authors were contacted to obtain missing information. RESULTS: Nine trials with a total of 1350 patients were reviewed. Except for three high-quality studies, the validity of the trials was moderate to low. Two high-quality studies showed no difference in pain intensity and functional status between the exercise groups and the control groups. In the third high-quality study significant reduction in sick leave was found in favor of water gymnastics compared with no intervention. Because the included trials were considered heterogeneous with regard to study design, population intervention and outcome,

no meta-analysis was performed. CONCLUSIONS: Because of heterogeneity and the varying quality of the studies no strong evidence exists concerning the effect of physical therapy interventions on the prevention and treatment of back and pelvic pain related to pregnancy. Future studies should meet current methodological standards, and interventions to be evaluated should be based on established theoretical framework. PMID: 14616270 [PubMed - indexed for MEDLINE] 24. J Obstet Gynaecol Can. 2003 Jun;25(6):487-98. Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. Harvey MA(1). Author information: (1)Department of Obstetrics and Gynaecology and Department of Urology, Queen's University, Kingston, ON, Canada. Comment in J Obstet Gynaecol Can. 2003 Jun;25(6):451-3. OBJECTIVE: To review the literature on the origin, anatomical rationale, techniques, and evidence-based effectiveness of peripartum pelvic floor exercises (PFEs) in the prevention of pelvic floor problems including urinary and anal incontinence, and prolapse. DATA SOURCES: Literature was reviewed for background information. MEDLINE, EMBASE, CINAHL, and proceedings of scientific meetings were searched for evidence-based data. A comprehensive literature search was performed to find all studies that involved the use of antepartum and/or postpartum PFEs. For the MEDLINE (1966 to 2002) and CINAHL (1980 to 2002) searches, the following key words were used: urinary incontinence (prevention and control, rehabilitation, therapy), fecal incontinence, exercise or exercise therapy, Kegel, muscle contraction, muscle tonus, muscle development, pelvic floor, pregnancy, puerperium, puerperal disorders. For the EMBASE (1980 to 2002) search, the following key words were used: micturition disorder (prevention, rehab, disease management, therapy), fecal incontinence, labour complication, pregnancy disorder, puerperal disorder, antepartum care, pregnancy, kinesiotherapy, exercise, pelvic floor, bladder. A manual search was performed of available abstracts presented at the annual scientific meetings of the International Continence Society (1997, 1999 to 2002), American Urogynecologic Association (1997 to 1998, 2000 to 2002), and International Urogynecological Association (1997, 1999 to 2002). Twelve studies evaluating the role of antepartum PFE were

found, of which 3 randomized controlled trials (RCTs) comparing PFEs for the prevention of urinary incontinence to controls were included. Twelve studies evaluating postpartum PFEs for prevention of urinary incontinence were reviewed, of which 4 RCTs were included. Five studies evaluating postpartum PFEs for the prevention of anal incontinence were reviewed, of which 4 RCTs were included. Participants in the studies were primiparous women. DATA TABULATION AND INTEGRATION: Data were extracted using a standardized collection form. Quality of the data was evaluated using the Jadad scale. Where possible, a meta-analysis was conducted using a random effect model. Heterogeneity between trials was assessed and sensitivity analyses were performed. RESULTS: Antepartum PFEs, when used with biofeedback and taught by trained health care personnel, using a conservative model, does not result in significant short-term (3 months) decrease in postpartum urinary incontinence, or pelvic floor strength. Postpartum PFEs, when performed with a vaginal device providing resistance or feedback, appear to decrease postpartum urinary incontinence and to increase strength. Reminder and motivational systems to perform "Kegel" exercises are ineffective in preventing postpartum urinary incontinence. Postpartum PFEs do not consistently reduce the incidence of anal incontinence. CONCLUSION: Postpartum PFEs appear to be effective in decreasing postpartum urinary incontinence. Data regarding the effect of PFEs on prevention of anal incontinence are lacking, and also on its prevention of prolapse. PMID: 12806450 [PubMed - indexed for MEDLINE]

Exercise and Rheumatoid arthritis 1. Arthritis Care Res (Hoboken). 2015 Feb;67(2):169-79. doi: 10.1002/acr.22419. Best practices for cardiovascular disease prevention in rheumatoid arthritis: a systematic review of guideline recommendations and quality indicators. Barber CE(1), Smith A, Esdaile JM, Barnabe C, Martin LO, Faris P, Hazlewood G, Noormohamed R, Alvarez N, Mancini GB, Lacaille D, Keeling S, Aviña-Zubieta JA, Marshall D. Author information: (1)University of Calgary and Arthritis Research Centre of Canada, Calgary, Alberta, Canada. OBJECTIVE: Cardiovascular disease (CVD) is a leading cause of mortality in rheumatoid arthritis (RA). This study systematically reviewed and appraised guidelines and quality indicators (QIs) pertaining to CVD risk management in patients with RA. METHODS: Four electronic medical databases (Medline, Embase, CINAHL, and Web of Science) and gray literature publications were searched using terms and keywords pertaining to guidelines, QIs, RA, and CVD (RA and general population literature searched). Abstracts were screened for inclusion and rated using the Appraisal of Guidelines for Research and Evaluation II instrument independently by 2 of 3 reviewers. RESULTS: In total, 16,064 abstracts were screened and 808 underwent full-text review. A total of 17 guidelines and 3 QI sets published between 2008 and 2013 were included. A number of consistent themes emerged, including the increased CV risk faced by RA patients and the need to address modifiable risk factors on a regular basis. The role of the multidisciplinary team in risk optimization was also highlighted. Ten guidelines provided recommendations for CVD prevention in patients with RA. Unfortunately, most recommendations lacked the specificity required to determine adherence to the recommendation. Only 4 RA-specific CVD QIs were identified (1 general comorbidity screening, formal CVD risk estimation, exercise, and minimizing steroid use). CONCLUSION: Regular screening for CVD risk factors is an important part of care in patients with RA. Unfortunately, existing RA-specific CVD QIs do not adequately address risk factor management, and existing guideline recommendations lack specificity for measurement and use in quality improvement initiatives. Copyright © 2015 by the American College of Rheumatology. PMID: 25074725 [PubMed - indexed for MEDLINE]

2. Clin Rheumatol. 2014 Nov;33(11):1539-48. doi: 10.1007/s10067-014-2691-2. Epub 2014 Jun 22. A systematic review into the effectiveness of hand exercise therapy in the treatment of rheumatoid arthritis. Bergstra SA(1), Murgia A, Te Velde AF, Caljouw SR. Author information: (1)Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. Hand exercises are often part of the treatment of hand rheumatoid arthritis; however, it is still unclear whether and what type of exercises is effective in the treatment of this condition. Therefore, a systematic review into the effectiveness of hand exercises in the treatment of hand rheumatoid arthritis has been performed. Studies were identified in the literature databases by predefined search criteria. The eight included studies are peer-reviewed studies published between 2000 and 2014. Hand exercises differed between studies, but always included resistance and/or active range of motion exercises. Grip strength in various grip types (power grip, key pinch, precision pinch and tripod pinch) was found to improve by hand exercise therapy without having adverse effects on pain or disease activity. Adaptations in the range of motion in response to hand exercise therapy were less pronounced. There appears to be some transfer from the improvements on the body functioning level to the level of daily functioning, with the largest improvements found on grip ability. With regard to the intervention content, there was some evidence in favour of a longer therapy duration and a higher therapy intensity. No conclusions could be drawn on the effectiveness of the different types of exercises. Collectively, the studies indicate that hand exercises may have positive effects on strength and some aspects of daily functioning without aggravating disease activity or pain, although caution should be taken for subjects in the exacerbation period. PMID: 24952308 [PubMed - indexed for MEDLINE] 3. J Phys Act Health. 2014 Aug;11(6):1248-61. doi: 10.1123/jpah.2012-0194. Epub 2013 Aug 19. Correlates of physical activity in adults with rheumatoid arthritis: a systematic review. Larkin L(1), Kennedy N.

Author information: (1)Dept of Clinical Therapies, University of Limerick, Limerick, Ireland. BACKGROUND: Physical activity (PA) is an important component in the management of Rheumatoid Arthritis (RA). To date the correlates of PA have not been thoroughly investigated in the RA population. The aim of this systematic review was to determine the correlates of PA in the adult RA population. METHODS: A search of Medline, EMBASE, AMED, CINAHL plus, Pubmed, Web of Science, and the Cochrane Library was conducted. A manual search of reference lists was conducted to compliment the electronic search. Ten studies fulfilled the inclusion criteria and were assessed for methodological quality. RESULTS: Results determined correlates in 4 categories: sociodemographic, physical, psychological and social variables. The variables varied greatly and were inconsistently studied. Changes were noted from a previous review in 2005 in relation to the association between certain variables and PA, including age, gender, disease duration, pain, exercise beliefs and social support. CONCLUSIONS: Positive associations with PA were found for motivation, self-efficacy, health perception, and previous PA levels. Negative associations were found for fatigue, a coerced regulation style and certain physiological variables. In addition differences between correlates of PA in the adult RA population and other chronic disease and healthy adult populations have been demonstrated. PMID: 23963816 [PubMed - in process] 4. BMC Musculoskelet Disord. 2014 Apr 7;15:121. doi: 10.1186/1471-2474-15-121. Effects of exercise on depressive symptoms in adults with arthritis and other rheumatic disease: a systematic review of meta-analyses. Kelley GA(1), Kelley KS. Author information: (1)Department of Biostatistics, Robert C, Byrd Health Sciences Center, West Virginia University, PO Box 9190, 26506-9190 Morgantown, WV, USA. gkelley@hsc.wvu.edu. BACKGROUND: Depression is a major public health problem among adults with arthritis and other rheumatic disease. The purpose of this study was to conduct a systematic review of previous meta-analyses addressing the effects of exercise (aerobic, strength or both) on depressive symptoms in adults with osteoarthritis, rheumatoid arthritis, fibromyalgia and systemic lupus erythematous. METHODS: Previous meta-analyses of randomized controlled trials were included by searching nine electronic databases and cross-referencing. Methodological quality

was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) Instrument. Random-effects models that included the standardized mean difference (SMD) and 95% confidence intervals (CIs) were reported. The alpha value for statistical significance was set at p ≤ 0.05. The U3 index, number needed to treat (NNT) and number of US people who could benefit were also calculated. RESULTS: Of the 95 citations initially identified, two aggregate data meta-analyses representing 6 and 19 effect sizes in as many as 870 fibromyalgia participants were included. Methodological quality was 91% and 82%, respectively. Exercise minus control group reductions in depressive symptoms were found for both meta-analyses (SMD, -0.61, 95% CI, -0.99 to -0.23, p = 0.002; SMD, -0.32, 95% CI, -0.53 to -0.12, p = 0.002). Percentile improvements (U3) were equivalent to 22.9 and 12.6. The number needed to treat was 6 and 9 with an estimated 0.83 and 0.56 million US people with fibromyalgia potentially benefitting. CONCLUSIONS: Exercise improves depressive symptoms in adults with fibromyalgia. However, a need exists for additional meta-analytic work on this topic. PMCID: PMC4107718 PMID: 24708605 [PubMed - indexed for MEDLINE] 5. Rheumatology (Oxford). 2011 Oct;50(10):1879-88. doi: 10.1093/rheumatology/ker195. Epub 2011 Jul 9. Quality appraisal of clinical practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review. Hurkmans EJ(1), Jones A, Li LC, Vliet Vlieland TP. Author information: (1)Department of Rheumatology (C1-R), Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands. e.j.hurkmans@lumc.nl OBJECTIVE: To assess the quality of guidelines published in peer-reviewed literature concerning the role of physiotherapy in the management of patients with RA. METHODS: A systematic literature search for clinical practice guidelines that included physiotherapy interventions was performed in four electronic databases. We assessed the quality of the selected guidelines using the appraisal of guidelines for research and evaluation (AGREE) instrument. In addition, the recommendations of guidelines with the highest quality scores were summarized. RESULTS: Eight clinical practice guidelines fulfilled the inclusion criteria. Scope/purpose was the most often adequately addressed AGREE domain (in seven of the eight guidelines) and applicability the least (in two of the eight guidelines). Based on the AGREE domain scores, six guidelines could be recommended or strongly recommended for clinical use. Five out of these six

(strongly) recommended guidelines included a recommendation on exercise therapy and/or patient education, with these interventions being recommended in every case. Transcutaneous electrical nerve stimulation and thermotherapy were recommended in four of these six guidelines. US, thermotherapy, low-level laser therapy, massage, passive mobilization and balneotherapy were addressed in one or two of these six guidelines. CONCLUSION: Six of eight clinical practice guidelines addressing physiotherapy interventions were recommended or strongly recommended according to the AGREE instrument. In general, guideline recommendations on physiotherapy intervention, from both the recommended guidelines as well as from the not recommended guidelines, lacked detail concerning mode of delivery, intensity, frequency and duration. PMID: 21743086 [PubMed - indexed for MEDLINE] 6. Rheumatol Int. 2009 Dec;30(2):147-58. doi: 10.1007/s00296-009-1090-5. A systematic review of the effects of dynamic exercise in rheumatoid arthritis. Cairns AP(1), McVeigh JG. Author information: (1)Department of Rheumatology, Musgrave Park Hospital, Belfast, BT9 7JB, Northern Ireland, UK. andrew.cairns@belfasttrust.hscni.net Exercise is commonly used in the management of patients with rheumatoid arthritis (RA); however, there is little consensus in the literature to support its use. This systemic review aimed to determine the effects of dynamic exercise on patients with RA. A systematic search of Medline (1949–2007), Cinahl (1982–2007), Embase (1974–2007) and Cochrane library was performed for randomised-controlled trials using the keywords “rheumatoid arthritis” and “exercise” or “training” or “sport”. The methodological quality of studies was assessed using a ten-point scale. Eighteen papers relating to 12 different studies met inclusion criteria. The mean methodological quality score was 6.9/10. Studies using aerobic training, strength training and combinations of both were included. Patients with early, stable, and active RA were studied. A number of studies reported improvement in muscle strength, physical function and aerobic capacity with dynamic exercise. Some studies also reported improvements in disease activity measures, and small improvements in hip bone mineral density. One study reported significantly less progression of small joint radiographic damage of the feet in the dynamic exercise group. However, one study also reported worse large joint radiographic damage in patients using dynamic exercise who had pre-existing large joint damage, though this was a retrospective analysis. No studies reported worse outcomes for function, disease activity or aerobic capacity with dynamic

exercise. Cardiovascular outcomes were not reported in any study, and no data were presented to assess the effect of exercise on patients with significant underlying cardiovascular disease. This systematic review suggests that the majority of patients with RA should be encouraged to undertake aerobic and/or strength training exercise. Exercise programmes should be carefully tailored to the individual, particularly for patients with underlying large joint damage or pre-existing cardiovascular disease. PMID: 19701638 [PubMed - indexed for MEDLINE] 7. Rheumatology (Oxford). 2007 Nov;46(11):1648-51. Epub 2007 Jul 18. Tai chi for rheumatoid arthritis: systematic review. Lee MS(1), Pittler MH, Ernst E. Author information: (1)Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter, EX2 4NT, UK. myeong.lee@pms.ac.uk; drmslee@gmail.com The objective of this systematic review is to evaluate data from controlled clinical trials testing the effectiveness of tai chi for treating rheumatoid arthritis (RA). Systematic searches were conducted on Medline, Pubmed, AMED, British Nursing Index, CINAHL, EMBASE, PsycInfo, The Cochrane Library 2007, Issue 1, the UK National Research Register and ClinicalTrials.gov, Korean medical databases, Qigong and Energy Medicine Database and Chinese databases up to January 2007. Hand-searches included conference proceedings and our own files. There were no restrictions regarding the language of publication. All controlled trials of tai chi for patients with RA were considered for inclusion. Methodological quality was assessed using the Jadad score. The searches identified 45 potentially relevant studies. Two randomized clinical trials (RCTs) and three non-randomized controlled clinical trials (CCTs) met all inclusion criteria. The included RCTs reported some positive findings for tai chi on disability index, quality of life, depression and mood for RA patients. Two RCTs assessed pain outcomes and did not demonstrate effectiveness on pain reduction compared with education plus stretching exercise and usual activity control. The extent of heterogeneity in these RCTs prevented a meaningful meta-analysis. Currently there are few trials testing the effectiveness of tai chi in the management of RA. The studies that are available are of low methodological quality. Collectively this evidence is not convincing enough to suggest that tai chi is an effective treatment for RA. The value of tai chi for this indication therefore remains unproven.

PMID: 17634188 [PubMed - indexed for MEDLINE] 8. Rheumatology (Oxford). 2008 Mar;47(3):239-48. Epub 2007 Nov 28. Rheumatoid arthritis, cardiovascular disease and physical exercise: a systematic review. Metsios GS(1), Stavropoulos-Kalinoglou A, Veldhuijzen van Zanten JJ, Treharne GJ, Panoulas VF, Douglas KM, Koutedakis Y, Kitas GD. Author information: (1)University of Wolverhampton, School of Sport, Performing Arts and Leisure, Walsall, West Midlands. gm@wlv.ac.uk This systematic review investigates the effectiveness of exercise interventions in improving disease-related characteristics in patients with rheumatoid arthritis (RA). It also provides suggestions for exercise programmes suitable for improving the cardiovascular profile of RA patients and proposes areas for future research in the field. Six databases (Medline, Cochrane Library, CINAHL, Google Scholar, EMBASE and PEDro) were searched to identify publications from 1974 to December 2006 regarding RA and exercise interventions. The quality of the studies included was determined by using the Jadad scale. Initial searches identified 1342 articles from which 40 met the inclusion criteria. No studies were found investigating exercise interventions in relation to cardiovascular disease in RA. There is strong evidence suggesting that exercise from low to high intensity of various modes is effective in improving disease-related characteristics and functional ability in RA patients. Future studies are required to investigate the effects of exercise in improving the cardiovascular status of this patient population. PMID: 18045810 [PubMed - indexed for MEDLINE] 9. J Adv Nurs. 2006 Dec;56(6):617-35. Effectiveness of non-pharmacological interventions for fatigue in adults with multiple sclerosis, rheumatoid arthritis, or systemic lupus erythematosus: a systematic review. Neill J(1), Belan I, Ried K. Author information: (1)School of Nursing and Midwifery, Flinders University, Adelaide, Australia. jane.neill@flinders.edu.au

Erratum in J Adv Nurs. 2007 Jan;57(2):225. AIM: This paper reports a systematic review of non-pharmacological interventions for fatigue in adults with three common autoimmune conditions. BACKGROUND: A considerable proportion of people with multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus experience compromised quality of life due to fatigue. Recent reviews of pharmacotherapies for fatigue in these conditions remain inconclusive, and systematic evidence for effectiveness of non-pharmacological interventions was unavailable. Our paper addresses this gap. METHODS: The literature search used the key words fatigue, energy, multiple sclerosis, rheumatoid arthritis and systemic lupus. It included 19 electronic databases and libraries, three evidence-based journals, two internet search engines, was dated 1987-2006, and limited to English. Non-pharmacological experimental studies about fatigue comprising more than five adults were included. Meta-analysis was not possible due to diverse interventions and outcome measures, therefore studies were analysed by types of interventions used to reduce fatigue. RESULTS: Of 653 hits, 162 papers were reviewed, and 36 met the inclusion criteria. Thirty-three primary studies reported 14 randomized controlled trials and 19 quasi-experimental designs. Most interventions were tested with people with multiple sclerosis. Exercise, behavioural, nutritional and physiological interventions were associated with statistically significant reductions in fatigue. Aerobic exercise was effective, appropriate and feasible for reducing fatigue among adults with chronic autoimmune conditions. Electromagnetic field devices showed promise. The diversity of interventions, designs, and using 24 different instruments to measure fatigue, limited comparisons. CONCLUSION: Low impact aerobic exercise gradually increasing in intensity, duration and frequency may be an effective strategy in reducing fatigue in some adults with chronic auto-immune conditions. However, fatigue is a variable and personal experience and a range of behavioural interventions may be required. Well-designed studies testing these promising strategies and consensus on outcome fatigue measures are needed. PMID: 17118041 [PubMed - indexed for MEDLINE] 10. Br J Rheumatol. 1998 Jun;37(6):677-87. Dynamic exercise therapy in rheumatoid arthritis: a systematic review. Van den Ende CH(1), Vliet Vlieland TP, Munneke M, Hazes JM.

Author information: (1)Department of Rheumatology, Leiden University Medical Center, The Netherlands. The aim of this systematic review was to determine the effectiveness of dynamic exercise therapy in improving joint mobility, muscle strength, aerobic capacity and daily functioning in patients with rheumatoid arthritis (RA). In addition, possible unwanted effects such as an increase in pain, disease activity and radiological progression were studied. A computer-aided search of the MEDLINE, Embase and SCISEARCH databases was performed to identify controlled trials on the effect of exercise therapy. Randomized trials were selected on the effect of dynamic exercise therapy in RA patients with an exercise programme fulfilling the following criteria: (a) intensity level such that heart rates exceeded 60% of maximal heart rate during at least 20 min; (b) exercise frequency > or = 2 a week; and (c) duration of intervention > or = 6 weeks. Two blinded reviewers independently selected eligible studies, rated the methodological quality and extracted data. Six out of 30 identified controlled trials met the inclusion criteria. Four of the six included studies fulfilled > or = 7/10 methodological criteria. Because of heterogeneity in outcome measures, data could not be pooled. The results suggest that dynamic exercise therapy is effective in increasing aerobic capacity and muscle strength. No detrimental effects on disease activity and pain were observed. The effects of dynamic exercise therapy on functional ability and radiological progression are unclear. It is concluded that dynamic exercise therapy has a positive effect on physical capacity. Research on the long-term effect of dynamic exercise therapy on radiological progression and functional ability is needed. PMID: 9667624 [PubMed - indexed for MEDLINE]

Exercise and rotator cuff 1. J Manipulative Physiol Ther. 2016 Feb;39(2):121-139.e1. doi: 10.1016/j.jmpt.2016.01.002. The Effectiveness of Multimodal Care for the Management of Soft Tissue Injuries of the Shoulder: A Systematic Review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Goldgrub R(1), Côté P(2), Sutton D(3), Wong JJ(4), Yu H(3), Randhawa K(5), Varatharajan S(5), Southerst D(6), Mior S(7), Shearer HM(8), Jacobs C(9), Stupar M(10), Chung CL(11), Abdulla S(12), Balogh R(13), Dogra S(14), Nordin M(15), Taylor-Vaisey A(16). Author information: (1)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), Oshawa, ON, Canada. (2)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), Oshawa, ON, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, ON, Canada. Electronic address: Pierre.Cote@uoit.ca. (3)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (4)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Associate Clinical Research Scientist, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Instructor, Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (5)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, ON, Canada. (6)Research Coordinator, Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Toronto, ON, Canada. (7)Professor, Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Adjunct Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, ON, Canada. (8)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Senior Clinical Research Scientist, Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (9)Director, Clinical Education and Patient Care, Canadian Memorial Chiropractic

College (CMCC), Toronto, ON, Canada. (10)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (11)Assistant to the Director, Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (12)Graduate Student, Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. (13)Assistant Professor, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), Oshawa, ON, Canada. (14)Assistant Professor, Faculty of Health Sciences, Kinesiology, University of Ontario Institute of Technology (UOIT), Oshawa, ON, Canada. (15)Professor, Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York, NY. (16)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, ON, Canada. OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of multimodal care for the management of soft tissue injuries of the shoulder. METHODS: We conducted a systematic review and searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Two independent reviewers critically appraised studies using the Scottish Intercollegiate Guidelines Network criteria. We used best evidence synthesis to synthesize evidence from studies with low risk of bias. RESULTS: We screened 5885 articles, and 19 were eligible for critical appraisal. Ten randomized controlled trials had low risk of bias. For persistent subacromial impingement syndrome, multimodal care leads to similar outcomes as sham therapy, radial extracorporeal shock-wave therapy, or surgery. For subacromial impingement syndrome, multimodal care may be associated with small and nonclinically important improvement in pain and function compared with corticosteroid injections. For rotator cuff tendinitis, dietary-based multimodal care may be more effective than conventional multimodal care (exercise, soft tissue and manual therapy, and placebo tablets). For nonspecific shoulder pain, multimodal care may be more effective than wait list or usual care by a general practitioner, but it leads to similar outcomes as exercise or corticosteroid injections. CONCLUSIONS: The current evidence suggests that combining multiple interventions into 1 program of care does not lead to superior outcomes for patients with subacromial impingement syndrome or nonspecific shoulder pain. One randomized controlled trial suggested that dietary-based multimodal care (dietary advice, acupuncture, and enzyme tablets) may provide better outcomes over conventional multimodal care. However, these results need to be replicated. Copyright © 2016 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 26976375 [PubMed - in process]

2. Physiotherapy. 2016 Mar;102(1):20-8. doi: 10.1016/j.physio.2015.08.003. Epub 2015 Sep 8. Rehabilitation following surgical repair of the rotator cuff: a systematic review. Thomson S(1), Jukes C(2), Lewis J(3). Author information: (1)School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK; Physiotherapy Department, St George's Hospital NHS Trust, Tooting, London, UK. Electronic address: sophiethomson@hotmail.com. (2)Physiotherapy Department, St George's Hospital NHS Trust, Tooting, London, UK. (3)School of Health and Social Work, University of Hertfordshire, Hatfield, Hertfordshire, UK; Physiotherapy Department, St George's Hospital NHS Trust, Tooting, London, UK; Musculoskeletal Services, Central London Community Healthcare NHS Trust, London, UK. BACKGROUND: Surgery to repair rotator cuff (RC) tears is a commonly performed orthopaedic procedure with the aim of reducing pain and improving function. Surgery is followed by rehabilitation and recommendations for postoperative rehabilitation include; exercise therapy, continuous passive motion machines and aquatic therapy. Currently, there is uncertainty in the literature as to what constitutes best postsurgical rehabilitation. OBJECTIVE: To systematically review postsurgical research investigations to provide clinical guidance regarding postsurgical management. DATA SOURCES: A keyword search of Medline, Cinahl, Amed, Embase and Cochrane databases from September 1993 to September 2013. STUDY SELECTION: Reviewer assessment using inclusion and exclusion criteria of randomised controlled trials. DATA EXTRACTION: Data pertaining to research design, intervention and subjects was extracted from included papers by one author. The data was grouped by reference to the objectives of the study and collated in themes. DATA SYNTHESIS: Narrative synthesis of the data was used to describe the effects of the intervention. The methodological quality and risk of bias of the included studies was assessed using the standardised Physiotherapy Evidence Database scale. Eleven studies met the inclusion criteria. All the studies were of fair to good methodological quality. No one rehabilitation protocol was found to be superior to another. The findings of this review suggested that following RC repair, patients should expect improvement in pain, ROM and function. CONCLUSION: This review concludes that no single rehabilitation protocol is superior to another following RC repair. Studies with larger study populations and longer term follow up are required to investigate this further. Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 26510584 [PubMed - in process] 3. Man Ther. 2015 Oct;20(5):646-56. doi: 10.1016/j.math.2015.03.013. Epub 2015 Apr

1. Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Abdulla SY(1), Southerst D(2), Côté P(3), Shearer HM(4), Sutton D(4), Randhawa K(4), Varatharajan S(4), Wong JJ(5), Yu H(4), Marchand AA(1), Chrobak K(1), Woitzik E(1), Shergill Y(6), Ferguson B(1), Stupar M(4), Nordin M(7), Jacobs C(8), Mior S(9), Carroll LJ(10), van der Velde G(11), Taylor-Vaisey A(12). Author information: (1)Department of Graduate Studies, Canadian Memorial Chiropractic College, Canada. (2)Division of Undergraduate Education, Canadian Memorial Chiropractic College, Canada; Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto, Canada; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College, Canada. Electronic address: dsoutherst@mtsinai.on.ca. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology, Canada; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), Canada. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College, Canada; Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Canada. (5)Division of Undergraduate Education, Canadian Memorial Chiropractic College, Canada; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College, Canada; Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Canada. (6)Department of Graduate Studies, Canadian Memorial Chiropractic College, Canada; Department of Anaesthesia, The Ottawa Hospital, Canada. (7)Departments of Orthopedic Surgery and Environmental Medicine, NYU School of Medicine, New York University, USA. (8)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto, Canada; Division of Clinical Education, Canadian Memorial Chiropractic College, Canada. (9)Faculty of Health Sciences, University of Ontario Institute of Technology, Canada; Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Canada. (10)Department of Public Health Sciences, Injury Prevention Centre, School of Public Health, University of Alberta, Canada. (11)Toronto Health Economics and Technology Assessment (THETA) Collaborative, Canada; Faculty of Pharmacy, University of Toronto, Canada; Institute for Work and Health, Canada. (12)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology and Canadian Memorial Chiropractic College, Canada. BACKGROUND: Exercise is a key component of rehabilitation for soft tissue injuries of the shoulder; however its effectiveness remains unclear.

OBJECTIVE: Determine the effectiveness of exercise for shoulder pain. METHODS: We searched seven databases from 1990 to 2015 for randomized controlled trials (RCTs), cohort and case control studies comparing exercise to other interventions for shoulder pain. We critically appraised eligible studies using the Scottish Intercollegiate Guidelines Network (SIGN) criteria. We synthesized findings from scientifically admissible studies using best-evidence synthesis methodology. RESULTS: We retrieved 4853 articles. Eleven RCTs were appraised and five had a low risk of bias. Four studies addressed subacromial impingement syndrome. One study addressed nonspecific shoulder pain. For variable duration subacromial impingement syndrome: 1) supervised strengthening leads to greater short-term improvement in pain and disability over wait listing; and 2) supervised and home-based strengthening and stretching leads to greater short-term improvement in pain and disability compared to no treatment. For persistent subacromial impingement syndrome: 1) supervised and home-based strengthening leads to similar outcomes as surgery; and 2) home-based heavy load eccentric training does not add benefits to home-based rotator cuff strengthening and physiotherapy. For variable duration low-grade nonspecific shoulder pain, supervised strengthening and stretching leads to similar short-term outcomes as corticosteroid injections or multimodal care. CONCLUSION: The evidence suggests that supervised and home-based progressive shoulder strengthening and stretching are effective for the management of subacromial impingement syndrome. For low-grade nonspecific shoulder pain, supervised strengthening and stretching are equally effective to corticosteroid injections or multimodal care. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42013003928. Copyright © 2015 Elsevier Ltd. All rights reserved. PMID: 25920340 [PubMed - in process] 4. Int J Rehabil Res. 2015 Jun;38(2):95-106. doi: 10.1097/MRR.0000000000000113. Therapeutic exercise for rotator cuff tendinopathy: a systematic review of contextual factors and prescription parameters. Littlewood C(1), Malliaras P, Chance-Larsen K. Author information: (1)aSchool of Health & Related Research, University of Sheffield, Sheffield bCentre for Sports and Exercise Medicine, Queen Mary, University of London, Mile End Hospital, London cSchool of Health Sciences, Queen Margaret University, Edinburgh, UK. Exercise is widely regarded as an effective intervention for symptomatic rotator cuff tendinopathy but the prescription is diverse and the important components of such programmes are not well understood. The objective of this study was to systematically review the contextual factors and prescription parameters of published exercise programmes for rotator cuff tendinopathy, to generate recommendations based on current evidence. An electronic search of AMED, CiNAHL,

CENTRAL, MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to June 2014 and supplemented by hand searching. Eligible studies included randomized controlled trials evaluating the effectiveness of exercise in participants with rotator cuff tendinopathy. Included studies were appraised using the Cochrane risk of bias tool and synthesized narratively. Fourteen studies were included, and suggested that exercise programmes are widely applicable and can be successfully designed by physiotherapists with varying experience; whether the exercise is completed at home or within a clinic setting does not appear to matter and neither does pain production or pain avoidance during exercise; inclusion of some level of resistance does seem to matter although the optimal level is unclear, the optimal number of repetitions is also unclear but higher repetitions might confer superior outcomes; three sets of exercise are preferable to two or one set but the optimal frequency is unknown; most programmes should demonstrate clinically significant outcomes by 12 weeks. This systematic review has offered preliminary guidance in relation to contextual factors and prescription parameters to aid development and application of exercise programmes for rotator cuff tendinopathy. PMID: 25715230 [PubMed - in process] 5. Am J Sports Med. 2015 May;43(5):1265-73. doi: 10.1177/0363546514544698. Epub 2014 Aug 20. Early Versus Delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials. Chang KV(1), Hung CY(2), Han DS(3), Chen WS(2), Wang TG(2), Chien KL(4). Author information: (1)Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital-Bei-Hu Branch, National Taiwan University College of Medicine, Taipei, Taiwan Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan. (2)Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan. (3)Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital-Bei-Hu Branch, National Taiwan University College of Medicine, Taipei, Taiwan. (4)Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan klchien@ntu.edu.tw. Erratum in Am J Sports Med. 2015 Aug;43(8):NP26. BACKGROUND: Postoperative shoulder stiffness complicates functional recovery after arthroscopic rotator cuff repair. PURPOSE: To compare early passive range of motion (ROM) exercise with a delayed rehabilitation protocol with regard to the effectiveness of stiffness reduction and functional improvements and rates of improper healing in patients undergoing

arthroscopic repair for torn rotator cuffs. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Randomized controlled trials (RCTs) comparing both rehabilitation approaches were identified in PubMed and Scopus. Between-group differences in shoulder function were transformed to effect sizes for comparisons, whereas the effectiveness against stiffness and the risk of tendon failure were reported using standardized mean differences of ROM degrees and odds ratios (ORs) of recurrent tears, respectively. RESULTS: Six RCTs were included, consisting of 482 patients. No significant difference in shoulder function existed across both protocols. The early ROM group demonstrated more improvement in shoulder forward flexion than the delayed rehabilitation group, with a standardized mean difference of 7.45° (95% CI, 3.20°-11.70°) at 6 months and 3.51° (95% CI, 0.31°-6.71°) at 12 months. Early ROM exercise tended to cause a higher rate of recurrent tendon tears (OR, 1.43; 95% CI, 0.90-2.28), and the effect became statistically significant (OR, 1.93; 95% CI, 1.04-3.60) after excluding 2 RCTs that recruited only those patients with small to medium-sized tears. CONCLUSION: Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair but was likely to result in improper tendon healing in shoulders with large-sized tears. The choice of either protocol should be based on an accommodation of the risks of recurrent tears and postoperative shoulder stiffness. © 2014 The Author(s). PMID: 25143489 [PubMed - indexed for MEDLINE] 6. Disabil Rehabil. 2015;37(1):1-8. doi: 10.3109/09638288.2014.907364. Epub 2014 Apr 2. Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Saltychev M(1), Äärimaa V, Virolainen P, Laimi K. Author information: (1)Department of Physical and Rehabilitation Medicine and. OBJECTIVE: To investigate the evidence on effectiveness of surgery for shoulder impingement compared with conservative treatment. DATA SOURCES: Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL and Science Citation Index databases were searched in March 2013 unrestricted by date or language. STUDY SELECTION: Controlled randomized (RCT) or quasi-randomized clinical trials comparing surgery and conservative treatment of shoulder impingement were included. DATA EXTRACTION: The methodological quality of each included trial was assessed according to the Cochrane Collaboration's domain-based evaluation framework. DATA SYNTHESIS: Of seven included RCTs, risk of systematic bias was considered to be low for two, high for four, and unclear for one RCT. The random-effect

meta-analysis was conducted on four RCTs involving 347 subjects (173 surgically treated cases and 174 controls). There was no significant difference in changes in pain intensity between surgically and conservatively treated subjects (Hedges's g = 0.01 in favor of conservative treatment, 95% CI -0.27 to 0.30). CONCLUSION: Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was, however, moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Implications for Rehabilitation Based on the review of seven RCTs, the evidence on effectiveness of surgical or conservative treatment of shoulder impingement was found to be limited. There was moderate evidence that surgical treatment is not more effective than active exercises on reducing pain intensity caused by shoulder impingement. Because of surgery's higher costs and susceptibility for complications compared with costs and risks of conservative treatment, conservative treatment can be recommended as a first choice of treatment of shoulder impingement in first or second grade. PMID: 24694286 [PubMed - indexed for MEDLINE] 7. Chiropr Man Therap. 2014 Mar 28;22(1):12. doi: 10.1186/2045-709X-22-12. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P(1). Author information: (1)Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, England. p.a.sutcliffe@warwick.ac.uk. BACKGROUND: This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report. METHODS: A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added. RESULTS: 25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for

rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive. CONCLUSIONS: Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted. PMCID: PMC3997823 PMID: 24679336 [PubMed] 8. Semin Arthritis Rheum. 2012 Dec;42(3):297-316. doi: 10.1016/j.semarthrit.2012.03.015. Epub 2012 May 18. The effectiveness of physiotherapy exercises in subacromial impingement syndrome: a systematic review and meta-analysis. Hanratty CE(1), McVeigh JG, Kerr DP, Basford JR, Finch MB, Pendleton A, Sim J. Author information: (1)Health and Rehabilitation Sciences Research Centre, School of Health Sciences, University of Ulster, Jordanstown, Northern Ireland. OBJECTIVE: To evaluate the effectiveness of exercise in the treatment of people with subacromial impingement syndrome (SAIS). METHODS: A systematic review and meta-analysis were conducted. Ten electronic databases were searched from the dates of their inception until August 2010. Included studies were randomized controlled trials investigating exercise in the management of SAIS. Outcomes were pain, strength, function, and quality of life. Data were summarized qualitatively using a best evidence synthesis. Treatment effect size and variance of individual studies were used to give an overall summary effect and data were converted to standardized mean difference with 95% confidence intervals (standardized mean difference (SMD) (CI)). RESULTS: Sixteen studies were included (n = 1162). There was strong evidence that exercise decreases pain and improves function at short-term follow-up. There was also moderate evidence that exercise results in short-term improvement in mental well-being and a long-term improvement in function for those with SAIS. The most common risk of bias across the studies was inadequately concealed treatment allocation. Six studies in the review were suitable for meta-analysis. Exercise had a small positive effect on strength of the rotator cuff in the short term (SMD -0.46 (-0.76, 0.16); P = 0.003) and a small positive effect on long-term function (SMD -0.31 (-0.57, 0.04); P = 0.02). CONCLUSIONS: Physiotherapy exercises are effective in the management of SAIS. However, heterogeneity of the exercise interventions, coupled with poor reporting of exercise protocols, prevented conclusions being drawn about which specific components of the exercise protocols (ie, type, intensity, frequency and duration) are associated with best outcomes. Copyright © 2012 Elsevier Inc. All rights reserved.

PMID: 22607807 [PubMed - indexed for MEDLINE] 9. Physiotherapy. 2012 Jun;98(2):101-9. doi: 10.1016/j.physio.2011.08.002. Epub 2011 Oct 5. Exercise for rotator cuff tendinopathy: a systematic review. Littlewood C(1), Ashton J, Chance-Larsen K, May S, Sturrock B. Author information: (1)School of Health & Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK. c.littlewood@sheffield.ac.uk BACKGROUND: Shoulder pain due to rotator cuff tendinopathy is a common problem. Exercise is one intervention used to address this problem but conclusions from previous reviews have been mixed. OBJECTIVE: To systematically review the effectiveness of exercise, incorporating loaded exercise (against gravity or resistance), for rotator cuff tendinopathy. DATA SOURCES: An electronic search of AMED, CiNAHL, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PEDro and SPORTDiscus was undertaken from their inception to November 2010 and supplemented by hand searching related articles and contact with topic experts. STUDY ELIGIBILITY CRITERIA: Randomised controlled trials evaluating the effectiveness of exercise, incorporating loaded exercise, in participants with rotator cuff tendinopathy. STUDY APPRAISAL AND SYNTHESIS METHODS: Included studies were appraised for risk of bias using the tool developed by the Cochrane Back review Group. Due to heterogeneity of studies, a narrative synthesis was undertaken based upon levels of evidence. RESULTS: Five articles detailing four studies were included, all of which were regarded as presenting a low risk of bias. Overall, the literature was supportive of the use of exercise in terms of pain and functional disability. LIMITATIONS: The results should be regarded with some degree of caution due to limitations associated with the studies including lack of blinding, no intervention control groups and limitations of the outcome measures used. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: The available literature is supportive of the use of exercise but due to the paucity of research and associated limitations further study is indicated. Copyright © 2011 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 22507359 [PubMed - indexed for MEDLINE] 10. J Shoulder Elbow Surg. 2009 Jul-Aug;18(4):e33; author reply e33-4. doi: 10.1016/j.jse.2009.03.015. Epub 2009 May 28. Regarding "Exercise in the treatment of rotator cuff impingement: a systematic

review and a synthesized evidence-based rehabilitation protocol". Østerås H, Aamodt A. Comment on J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):138-60. PMID: 19481475 [PubMed - indexed for MEDLINE] 11. Br J Sports Med. 2007 Apr;41(4):200-10. Epub 2007 Jan 30. Exercise therapy for the conservative management of full thickness tears of the rotator cuff: a systematic review. Ainsworth R(1), Lewis JS. Author information: (1)South Devon NHS Healthcare Trust, Torbay Hospital, Torquay, UK. PURPOSE: To review the evidence for the effectiveness of therapeutic exercise for the treatment of full thickness (including massive and inoperable) tears of the rotator cuff. RELEVANCE: There is little consensus as to the most effective treatment of full thickness and massive tears of the rotator cuff. There is consensus that the outcome of rotator cuff tendon surgery in the elderly is generally very poor. As such, exercise therapy is usually recommended for this patient group. Although commonly prescribed, the evidence to support this approach is equivocal. The aim of this study was to conduct a systematic review of the literature to determine the efficacy of exercise therapy for the management of full thickness rotator cuff tears. METHODS: A systematic review was conducted to synthesise the available research literature on the effectiveness of exercise therapy for full thickness tears of the rotator cuff. DATA SOURCE: Reports up to and including September 2006 were located from MEDLINE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), AMED, EMBASE, the Cochrane Database of Systematic Reviews and the Physiotherapy Evidence Database (PEDro) using the terms "rotator cuff" and "tear/s" and "exercise" or "physiotherapy" or "physical therapy" or "rehabilitation". STUDY SELECTION: Studies were included if they related to full thickness rotator cuff tears and exercise. DATA EXTRACTION: Two independent reviewers assessed the methodological quality of the studies. Differences were resolved by consensus. ANALYSIS/DATA SYNTHESIS: Ten studies met the inclusion criteria: eight were observational case series and two were single case studies. There were no randomised clinical trials. RESULTS: Four studies were specific to massive rotator cuff tears. One study had a sub-group with massive cuff tears and five studies were not specific as to the size of the full thickness tear. Due to the heterogeneity of outcome measures used, it was not possible to combine results. In all studies an improvement in outcome scores was reported. Exercise programmes were well documented in five studies.

CONCLUSIONS: No randomised controlled trials met the inclusion criteria and the evaluation has been based on observational studies of lower scientific merit. The findings suggest that some evidence exists to support the use of exercise in the management of full thickness rotator cuff tears. There is a definite need for well-planned randomised controlled trials investigating the efficacy of exercise in the management of full thickness and massive rotator cuff tears. PMCID: PMC2658945 PMID: 17264144 [PubMed - indexed for MEDLINE] 12. J Hand Ther. 2004 Apr-Jun;17(2):152-64. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. Michener LA(1), Walsworth MK, Burnet EN. Author information: (1)Department of Physical Therapy, Virginia Commonwealth University-Medical College of Virginia, Richmond, Virginia 23298, USA. lmichene@hsc.vcu.edu Comment in J Athl Train. 2005 Jul-Sep;40(3):221-3. Prior systematic reviews of rehabilitation for nondescript shoulder pain have not yielded clinically applicable results for those patients with subacromial impingement syndrome (SAIS). The purpose of this study was to examine the evidence for rehabilitation interventions for SAIS. The authors used data source as the method. The computerized bibliographic databases of Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Database of Systematic Reviews were searched from 1966 up to and including October 2003. Key words used were "shoulder," "shoulder impingement syndrome," "bursitis," and "rotator cuff" combined with "rehabilitation," "physical therapy," "electrotherapy," "ultrasound," "acupuncture," and "exercise," limited to clinical trials. Randomized clinical trials that investigated physical interventions used in the rehabilitation of patients with SAIS with clinically relevant outcome measures of pain and quality of life were selected. The search resulted in 635 potential studies, 12 meeting inclusion criteria. Two independent reviewers graded all 12 trials with a quality checklist averaged for a final quality score. The mean quality score for 12 trials was 37.6 out of a possible 69 points. Various treatments were evaluated: exercise in six trials, joint mobilizations in two trials, laser in three trials, ultrasound in two trials, and acupuncture in two trials. The limited evidence currently available suggests that exercise and joint mobilizations are efficacious for patients with SAIS. Laser therapy appears to be of benefit only when used in isolation, not in combination with therapeutic exercise. Ultrasound is of no benefit, and acupuncture trials present equivocal evidence. The low to mediocre methodologic quality, small sample sizes, and general lack of long-term follow-up limit these findings for the development of useful clinical practice guidelines. Further trials are needed to investigate these rehabilitation interventions, the

superiority of one intervention over another, and the long-term outcomes of rehabilitation. Moreover, it is imperative that clinical guidelines are developed to indicate those patients who are likely to respond to rehabilitation. PMID: 15162102 [PubMed - indexed for MEDLINE] 13. Clin J Sport Med. 2003 May;13(3):176-82. Therapeutic exercise and orthopedic manual therapy for impingement syndrome: a systematic review. Desmeules F(1), Côté CH, Frémont P. Author information: (1)Laval University Hospital Research Centre, Laval University, Quebec, Canada. OBJECTIVE: To review randomized controlled trials evaluating the effectiveness of therapeutic exercise and orthopedic manual therapy for the treatment of impingement syndrome. DATA SOURCE: Reports up to October 2002 were located from MEDLINE, the Cochrane Database of Systematic Reviews, the Physiotherapy Evidence Database (PEDro), the TRIP database, and the Cumulative Index to Nursing & Allied Health Literature (CINAHL) using "shoulder" and "clinical trial"/"randomized controlled trial" as search terms. STUDY SELECTION: Studies were included if (1) they were a randomized controlled trial; (2) they were related to impingement syndrome, rotator cuff tendinitis, or bursitis; (3) one of the treatments included therapeutic exercise or manual therapy. DATA EXTRACTION: Two independent observers reviewed the methodological quality of the studies using an assessment tool developed by the Cochrane Musculoskeletal Injuries Group. Differences were resolved by consensus. DATA SYNTHESIS: Seven trials met our inclusion criteria. After consensus, the mean methodological score for all studies was 13.9 +/- 2.4 (of 24). Four studies of 7, including the 3 trials with the best methodological score (67%), suggested some benefit of therapeutic exercise or manual therapy compared with other treatments such as acromioplasty, placebo, or no intervention. CONCLUSIONS: There is limited evidence to support the efficacy of therapeutic exercise and manual therapy to treat impingement syndrome. More methodologically sound studies are needed to further evaluate these interventions.

Exercise and TMJ Disorders 1. Chiropr Man Therap. 2016 Mar 7;24:8. doi: 10.1186/s12998-016-0089-8. eCollection 2016. Multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Sutton D(1), Gross DP(2), Côté P(3), Randhawa K(4), Yu H(1), Wong JJ(5), Stern P(6), Varatharajan S(4), Southerst D(7), Shearer HM(1), Stupar M(8), Goldgrub R(9), van der Velde G(10), Nordin M(11), Carroll LJ(12), Taylor-Vaisey A(8). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (2)Faculty of Rehabilitation Medicine, Department of Physical Therapy, University of Alberta, 8205 114 St, 3-28 Corbett Hall, Edmonton, AB Canada T6G 2G4 ; Rehabilitation Research Centre, University of Alberta, 8205 114 St, 3-48 Corbett Hall, Edmonton, AB Canada T6G 2G4. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, Ontario Canada L1H 7L7. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (5)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (6)Division of Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (7)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1 ; Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, Ontario Canada M5T 3L9. (8)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation,

University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, Ontario Canada M2H 3J1. (9)Graduate Student, Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, L1H 7L7 Ontario Canada. (10)Toronto Health Economics and Technology Assessment (THETA) Collaborative, 6th Floor, Room 658, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, Ontario Canada M5S 3M2 ; Institute for Work and Health, 481 University Avenue, Toronto, Ontario Canada M5G 2E9. (11)Departments of Orthopedic Surgery and Environmental Medicine, Occupational and Industrial Orthopedic Center, NYU School of Medicine, New York University, 550 1st Avenue, New York, NY 10016 USA. (12)School of Public Health and Injury Prevention Centre, University of Alberta, 3-300 Edmonton Clinic Health Academy 11405 - 87 Ave, Edmonton, Alberta Canada T6G 1C9. BACKGROUND: Musculoskeletal disorders of the elbow, forearm, wrist and hand are associated with pain, functional impairment and decreased productivity in the general population. Combining several interventions in a multimodal program of care is reflective of current clinical practice; however there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of multimodal care for the management of musculoskeletal disorders of the elbow, forearm, wrist and hand on self-rated recovery, functional recovery, or clinical outcomes in adults or children. METHODS: We conducted a systematic review of the literature and best evidence synthesis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from January 1990 to March 2015. Randomized controlled trials, cohort studies, and case-control studies were eligible. Random pairs of independent reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with a low risk of bias were synthesized following best evidence synthesis principles. RESULTS: We screened 5989 articles, and critically appraised eleven articles. Of those, seven had a low risk of bias; one addressed carpal tunnel syndrome and six addressed lateral epicondylitis. Our search did not identify any low risk of bias studies examining the effectiveness of multimodal care for the management of other musculoskeletal disorders of the elbow, forearm, wrist or hand. The evidence suggests that multimodal care for the management of lateral epicondylitis may include education, exercise (strengthening, stretching, occupational exercise), manual therapy (manipulation) and soft tissue therapy (massage). The evidence does not support the use of multimodal care for the management of carpal tunnel syndrome. CONCLUSIONS: The current evidence on the effectiveness of multimodal care for musculoskeletal disorders of the elbow, forearm, wrist and hand is limited. The available evidence suggests that there may be a role for multimodal care in the management of patients with persistent lateral epicondylitis. Future research is needed to examine the effectiveness of multimodal care and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009093. PMCID: PMC4780149 PMID: 26955466 [PubMed]

2. J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):143-201. doi: 10.1016/j.jmpt.2013.04.001. Epub 2013 May 20. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Brantingham JW(1), Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C. Author information: (1)Murdoch University, Murdoch, Australia. jimbrant2002@yahoo.com OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence. Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 23697915 [PubMed - indexed for MEDLINE] 3. Clin Rehabil. 2007 Apr;21(4):299-314. A systematic review of conservative treatment of carpal tunnel syndrome.

Piazzini DB(1), Aprile I, Ferrara PE, Bertolini C, Tonali P, Maggi L, Rabini A, Piantelli S, Padua L. Author information: (1)Department of Physical Medicine and Rehabilitation, Catholic University, Rome, Italy. OBJECTIVE: To assess the effectiveness of conservative therapy in carpal tunnel syndrome. DATA SOURCES: A computer-aided search of MEDLINE and the Cochrane Collaboration was conducted for randomized controlled trials (RCTs) from January 1985 to May 2006. REVIEW METHODS: RCTs were included if: (1) the patients, with clinically and electrophysiologically confirmed carpal tunnel syndrome, had not previously undergone surgical release, (2) the efficacy of one or more conservative treatment options was evaluated, (3) the study was designed as a randomized controlled trial. Two reviewers independently selected the studies and performed data extraction using a standardized form. In order to assess the methodological quality, the criteria list of the Cochrane Back Review Group for systematic reviews was applied. The different treatment methods were grouped (local injections, oral therapies, physical therapies, therapeutic exercises and splints). RESULTS: Thirty-three RCTs were included in the review. The studies were analysed to determine the strength of the available evidence for the efficacy of the treatment. Our review shows that: (1) locally injected steroids produce a significant but temporary improvement, (2) vitamin B6 is ineffective, (3) steroids are better than non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, but they can produce side-effects, (4) ultrasound is effective while laser therapy shows variable results, (5) exercise therapy is not effective, (6) splints are effective, especially if used full-time. CONCLUSION: There is: (1) strong evidence (level 1) on efficacy of local and oral steroids; (2) moderate evidence (level 2) that vitamin B6 is ineffective and splints are effective and (3) limited or conflicting evidence (level 3) that NSAIDs, diuretics, yoga, laser and ultrasound are effective whereas exercise therapy and botulinum toxin B injection are ineffective. PMID: 17613571 [PubMed - indexed for MEDLINE] 4. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD003471. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. Verhagen AP, Karels C, Bierma-Zeinstra SM, Burdorf L, Feleus A, Dahaghin S, de Vet HC, Koes BW. Update in Cochrane Database Syst Rev. 2009;(3):CD003471.

Update of Cochrane Database Syst Rev. 2004;(1):CD003471. BACKGROUND: Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS). OBJECTIVES: This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in adults. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied. SELECTION CRITERIA: We included randomised and non-randomised controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence. MAIN RESULTS: For this update we included six additional studies; 21 trials in total. Seventeen trials included people with chronic non-specific neck or shoulder complaints, or non-specific upper extremity disorders. Over 25 interventions were evaluated; five main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, and energised splint. Overall, the quality of the studies was poor. In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome. AUTHORS' CONCLUSIONS: There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage; breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy; and manual therapy as an add-on treatment to exercises. PMID: 16856010 [PubMed - indexed for MEDLINE] 5. J Clin Epidemiol. 2007 Feb;60(2):110-7. Epub 2006 Sep 7. Exercise proves effective in a systematic review of work-related complaints of

the arm, neck, or shoulder. Verhagen AP(1), Karels C, Bierma-Zeinstra SM, Feleus A, Dahaghin S, Burdorf A, Koes BW. Author information: (1)Department of General Practice, Erasmus Medical Centre, Rotterdam, The Netherlands. a.verhagen@erasmusmc.nl OBJECTIVE: Interventions such as physiotherapy and ergonomic adjustments play a major role in the treatment of most work-related complaints of the arm, neck, and/or shoulder (CANS). We evaluated whether conservative interventions have a significant impact on outcomes for work-related CANS. STUDY DESIGN AND SETTING: A systematic review was conducted. Only (randomized) trials studying interventions for patients suffering from work-related CANS were included. Interventions may include exercises, relaxation, physical applications, and workplace adjustments. Two authors independently selected the trials, assessed methodological quality, and extracted data. RESULTS: We included 26 studies (in total 2,376 patients); 23 studies included patients with chronic nonspecific complaints. Over 30 interventions were evaluated and 7 main subgroups of interventions could be determined, of which the subgroup "exercises" was the largest one. Overall, the quality of the studies appeared to be poor. CONCLUSION: There is limited evidence for the effectiveness of exercises when compared to massage, adding breaks during computer work, massage as add-on treatment to manual therapy, manual therapy as add-on treatment to exercises, and some keyboards in people with carpal tunnel syndrome when compared to other keyboards or placebo. For other interventions no clear effectiveness could be demonstrated. PMID: 17208116 [PubMed - indexed for MEDLINE]

Exercise and Upper extremity 1. Occup Environ Med. 2016 Jan;73(1):62-70. doi: 10.1136/oemed-2015-102992. Epub 2015 Nov 8. Effectiveness of workplace interventions in the prevention of upper extremity musculoskeletal disorders and symptoms: an update of the evidence. Van Eerd D(1), Munhall C(2), Irvin E(2), Rempel D(3), Brewer S(4), van der Beek AJ(5), Dennerlein JT(6), Tullar J(7), Skivington K(8), Pinion C(4), Amick B(9). Author information: (1)Institute for Work & Health, Toronto, Ontario, Canada School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada. (2)Institute for Work & Health, Toronto, Ontario, Canada. (3)Division of Occupational and Environmental Medicine, School of Medicine, University of California, San Francisco, Richmond, California, USA. (4)CB&I, Inc, The Woodlands, Texas, USA. (5)Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands. (6)Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands Department of Physical Therapy, Movement & Rehabilitation Science, Northeastern University, Boston, Massachusetts, USA. (7)School of Public Health, Institute for Health Policy, University of Texas Health Science Center at Houston, Houston, Texas, USA. (8)Institute for Work & Health, Toronto, Ontario, Canada MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. (9)Institute for Work & Health, Toronto, Ontario, Canada Florida International University, Robert Stempel College of Public Health and Social Work, Miami, Florida, USA. The burden of disabling musculoskeletal pain and injuries (musculoskeletal disorders, MSDs) arising from work-related causes in many workplaces remains substantial. There is little consensus on the most appropriate interventions for MSDs. Our objective was to update a systematic review of workplace-based interventions for preventing and managing upper extremity MSD (UEMSD). We followed a systematic review process developed by the Institute for Work & Health and an adapted best evidence synthesis. 6 electronic databases were searched (January 2008 until April 2013 inclusive) yielding 9909 non-duplicate references. 26 high-quality and medium-quality studies relevant to our research question were combined with 35 from the original review to synthesise the evidence on 30 different intervention categories. There was strong evidence for one intervention category, resistance training, leading to the recommendation: Implementing a workplace-based resistance training exercise programme can help prevent and manage UEMSD and symptoms. The synthesis also revealed moderate evidence for stretching programmes, mouse use feedback and forearm supports in preventing UEMSD or symptoms. There was also moderate evidence for no benefit for EMG biofeedback, job stress management training, and office workstation adjustment for UEMSD and symptoms. Messages are proposed for both these and other intervention categories. Published by the BMJ Publishing Group Limited. For permission to use (where not

already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/ PMCID: PMC4717459 PMID: 26552695 [PubMed - indexed for MEDLINE] 2. J Sci Med Sport. 2016 Jun;19(6):438-53. doi: 10.1016/j.jsams.2015.06.007. Epub 2015 Jun 15. Effectiveness of the eccentric exercise therapy in physically active adults with symptomatic shoulder impingement or lateral epicondylar tendinopathy: A systematic review. Ortega-Castillo M(1), Medina-Porqueres I(2). Author information: (1)Department of Physical Therapy, University of Malaga, Malaga, Spain. (2)Department of Physical Therapy, University of Malaga, Malaga, Spain. Electronic address: imp@uma.es. OBJECTIVES: To identify and criticize the evidence for the effectiveness of the eccentric exercise to treat upper limb tendinopathies. DESIGN: Systematic review. METHODS: Relevant randomized controlled trials (RCTs) were sourced using MEDLINE, SPORT Discus, Physiotherapy Evidence Database (PEDro) and CINAHL databases. Inclusion criteria were: (1) studies in English or Spanish; (2) adult participants with clinical diagnosis of tendinopathy; (3) RCT study design; (4) results regarding pain or strength were assessed; and (5) eccentric exercise was employed to treat upper extremity tendinopathies. Two blinded reviewers independently extracted data concerning trial methods, quality and outcomes. PEDro scale was employed to assess methodological quality. Results were summarized in a best evidence synthesis. RESULTS: The selected studies (n=12) scored an average of 6/10 based on the PEDro score. In 11 studies, pain decreased significantly with eccentric exercise, but only in five studies, the reduction was significantly better than in the non-eccentric group (in all or some of the parameters). Strength was assessed in nine studies; within-group evaluations show that strength significantly improved in the eccentric-group in seven studies, whereas inter-group changes were only significantly better in the eccentric-group in three studies for all the parameters and in two studies for some of the parameters. CONCLUSIONS: Eccentric exercise may reduce pain and improve strength in upper limb tendinopathies, but whether its effectiveness is much better than other forms of treatment remains questionable. Further investigations are needed, not only focused on shoulder impingement or epicondylar tendinopathy, but on tendinopathies in other areas of the upper limb. Copyright © 2015 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved. PMID: 26304796 [PubMed - in process]

3. J Manipulative Physiol Ther. 2015 Sep;38(7):507-20. doi: 10.1016/j.jmpt.2015.06.002. Epub 2015 Jun 27. The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Menta R(1), Randhawa K(2), Côté P(3), Wong JJ(4), Yu H(5), Sutton D(6), Varatharajan S(7), Southerst D(8), D'Angelo K(1), Cox J(1), Brown C(1), Dion S(1), Mior S(9), Stupar M(10), Shearer HM(11), Lindsay GM(12), Jacobs C(13), Taylor-Vaisey A(14). Author information: (1)Graduate Student, Department of Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (2)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. Electronic address: Kristi.randhawa@uoit.ca. (3)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology, Oshawa, Ontario, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, Ontario, Canada. (4)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Instructor, Department of Graduate Studies, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (5)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (6)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (7)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Instructor, Division of Undergraduate Education, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (8)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of

Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Research Coordinator, Department of Medicine, Division of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada. (9)Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Adjunct Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada. (10)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Postdoctoral Fellow, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, Ontario, Canada. (11)Adjunct Professor, Division of Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Clinical Research Manager, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Toronto, Ontario, Canada. (12)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada; Associate Professor, Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada. (13)Assistant Clinical Professor, Graduate Education and Research, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada; Director, Division of Clinical Education and Patient Care, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (14)Research Associate, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario, Canada. OBJECTIVE: The purpose of this systematic review was to evaluate the effectiveness of exercise compared to other interventions, placebo/sham intervention, or no intervention in improving self-rated recovery, functional recovery, clinical, and/or administrative outcomes in individuals with musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand. METHODS: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers independently screened studies for relevance and assessed the risk of bias using the Scottish Intercollegiate Guidelines Network criteria. We synthesized the evidence using the best evidence synthesis methodology. RESULTS: We identified 5 studies with a low risk of bias. Our review suggests that, for patients with persistent lateral epicondylitis, (1) adding concentric or eccentric strengthening exercises to home stretching exercises provides no additional benefits; (2) a home program of either eccentric or concentric strengthening exercises leads to similar outcomes; (3) home wrist extensor strengthening exercises lead to greater short-term improvements in pain reduction compared to "wait and see"; and (4) clinic-based, supervised exercise may be more beneficial than home exercises with minimal improvements in pain and function. For hand pain of variable duration, supervised progressive strength training added to advice to continue normal physical activity provides no additional benefits. CONCLUSION: The relative effectiveness of stretching vs strengthening for the wrist extensors remains unknown for the management of persistent lateral epicondylitis. The current evidence shows that the addition of supervised progressive strength training does not provide further benefits over advice to continue normal physical activity for hand pain of variable duration.

Copyright © 2015 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 26130104 [PubMed - in process] 4. Br J Sports Med. 2015 Jul;49(14):935-42. doi: 10.1136/bjsports-2014-094228. Epub 2015 Feb 18. A systematic review of the effects of upper body warm-up on performance and injury. McCrary JM(1), Ackermann BJ(1), Halaki M(2). Author information: (1)School of Medical Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia. (2)Discipline of Exercise and Sport Science, The University of Sydney, Sydney, New South Wales, Australia. PURPOSE: This systematic review was conducted to identify the impact of upper body warm-up on performance and injury prevention outcomes. METHODS: Web of Science, MEDLINE, SPORTDiscus, PsycINFO and Cochrane databases were searched using terms related to upper extremity warm-up. Inclusion criteria were English language randomised controlled trials from peer-reviewed journals in which investigation of upper body warm-up on performance and injury prevention outcomes was a primary aim. Included studies were assessed for methodological quality using the PEDro scale. A wide variety of warm-up modes and outcomes precluded meta-analysis except for one group of studies. The majority of warm-ups were assessed as having 'positive', 'neutral', 'negative' or 'specific' effects on outcomes. RESULTS: Thirty-one studies met the inclusion criteria with 21 rated as having 'good' methodological quality. The studies investigated a total of 25 warm-up modes and 43 outcome factors that could be grouped into eight mode and performance outcome categories. No studies of upper body warm-up effects on injury prevention were discovered. CONCLUSIONS: Strong research-based evidence was found for the following: high-load dynamic warm-ups enhance power and strength performance; warm-up swings with a standard weight baseball bat are most effective for enhancing bat speed; short-duration static stretching warm-up has no effect on power outcomes; and passive heating/cooling is a largely ineffective warm-up mode. A clear knowledge gap in upper body warm-up literature is the lack of investigation of injury prevention outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions. PMID: 25694615 [PubMed - indexed for MEDLINE]

5. Work. 2012;42(1):153-72. Effective interventions for cumulative trauma disorders of the upper extremity in computer users: practice models based on systematic review. Goodman G(1), Kovach L, Fisher A, Elsesser E, Bobinski D, Hansen J. Author information: (1)Cleveland State University, Cleveland, OH 44115, USA. g.goodman@csuohio.edu OBJECTIVE: A systematic review of over 4600 abstracts was performed to address the effectiveness of the current cumulative trauma disorder (CTD) interventions focused on the upper extremities of computer users. PARTICIPANTS: The researchers were the study participants. They included one Professor of Occupational Therapy and five Masters of Occupational Therapy Students from a Midwestern University. The Professor of Occupational Therapy has been practicing for 29 years. METHODS: The researchers employed stringent inclusion criteria for this review based on similar systematic review papers. Criteria for high quality qualitative research were incorporated to include studies other than randomized-controlled trials. This approach considered knowledge gained from specific interventions that were studied in greater detail with fewer clients. RESULTS: The results of this study identified 25 articles that met the inclusion criteria. Further review ranked the selected articles into high, medium, or low quality based on criteria adapted from other studies. The highest levels of evidence were found for education and training in ergonomics, forearm supports, ergonomic keyboards, ergonomic mice, and exercise/rest breaks. CONCLUSIONS: Two models of practice were created from this review to assist occupational therapists or other professionals with intervention strategies for computer users with CTDs. PMID: 22799052 [PubMed - indexed for MEDLINE] 6. Eura Medicophys. 2007 Sep;43(3):391-405. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. A Cochrane systematic review. Verhagen AP(1), Karels C, Bierma-Zeinstra SM, Feleus A, Dahaghin S, Burdorf A, De Vet HC, Koes BW. Author information: (1)Erasmus MC, University Mediacal Center Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands. a.verhagen@erasmusmc.nl BACKGROUND: Conservative interventions such as physiotherapy and ergonomic adjustments (such as keyboard adjustments or ergonomic advice) play a major role in the treatment of most work-related complaints of the arm, neck or shoulder (CANS). Objectives. This systematic review aims to determine whether conservative interventions have a significant impact on outcomes for work-related CANS in

adults. Search strategy. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2005) and Cochrane Rehabilitation and Related Therapies Field Specialised Register (March 2005), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2005), PubMed, EMBASE, CINAHL, AMED and reference lists of articles. The date of the last search was March 2005. No language restrictions were applied. Selection criteria. We included randomised controlled trials and concurrent controlled trials studying conservative interventions (e.g. exercises, relaxation, physical applications, biofeedback, myofeedback and work-place adjustments) for adults suffering CANS. Data collection and analysis. Two authors independently selected trials from the search yield, assessed the methodological quality using the Delphi list, and extracted relevant data. We pooled data or, in the event of clinical heterogeneity or lack of data, we used a rating system to assess levels of evidence. MAIN RESULTS: For this update we included six additional studies; twenty-one trials in total. Seventeen trials included people with chronic nonspecific neck or shoulder complaints, or nonspecific upper extremity disorders. Over twenty-five interventions were evaluated; six main subgroups of interventions could be determined: exercises, manual therapy, massage, ergonomics, energised splint and individual treatment versus group therapy. Overall, the quality of the studies was poor. In 14 studies a form of exercise was evaluated, and contrary to the previous review we now found limited evidence about the effectiveness of exercises when compared to massage and conflicting evidence when exercises are compared to no treatment. In this update there is limited evidence for adding breaks during computer work; massage as add-on treatment on manual therapy, manual therapy as add-on treatment on exercises; and some keyboard designs when compared to other keyboards or placebo in participants with carpal tunnel syndrome. CONCLUSIONS: There is limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage, breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy, and manual therapy as an add-on treatment to exercises. PMID: 17921965 [PubMed - indexed for MEDLINE] 7. J Hand Ther. 2004 Apr-Jun;17(2):118-31. Therapy interventions for improving joint range of motion: A systematic review. Michlovitz SL(1), Harris BA, Watkins MP. Author information: (1)Department of Physical Therapy, Temple University, Philadelphia, Pennsylvania 19140, USA. michlovitz@temple.edu The authors conducted a systematic review of the published evidence on conservative interventions for loss of upper extremity joint range of motion following selected musculoskeletal conditions. Several databases (Medline, CINAHL, PEDRO, PubMed, and Cochrane) were searched for articles that met

inclusion criteria. Two reviewers determined abstract selection; two reviews performed critical appraisal of 26 articles. Level of evidence and quality on a 24-item quantitative critical appraisal form were determined for all articles meeting selection criteria. The primary outcome considered was range-of-motion measurement. Overall, the quantity and quality of evidence were moderate to low. Sackett's levels 2b, 3, and 4 evidence has shown that joint mobilization, a supervised exercise program, and splinting can all increase joint range of motion. There were no studies found in the literature that examined techniques of physical agent or electrotherapeutic modalities. Future studies are needed to delineate selection of appropriate candidates for these techniques and effective dosage. PMID: 15162100 [PubMed - indexed for MEDLINE]

Manipulation and ankle 1. Chiropr Man Therap. 2015 Oct 27;23:30. doi: 10.1186/s12998-015-0075-6. eCollection 2015. The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Southerst D(1), Yu H(2), Randhawa K(3), Côté P(4), D'Angelo K(5), Shearer HM(2), Wong JJ(6), Sutton D(2), Varatharajan S(3), Goldgrub R(7), Dion S(5), Cox J(5), Menta R(5), Brown CK(5), Stern PJ(8), Stupar M(2), Carroll LJ(9), Taylor-Vaisey A(10). Author information: (1)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario Canada M5G 1X5. (2)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (3)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Division of Undergraduate Education, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (4)Canada Research Chair in Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4 ; UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (5)Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (6)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Department of Graduate Studies, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (7)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe St N, Science building, Room 3000, Oshawa, Ontario Canada L1H 7K4. (8)Graduate Education Program, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1 ; Graduate Education and Research, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. (9)Injury Prevention Centre and School of Public Health, University of Alberta, 4075 Research Transition Facility, 8308-114 St, Edmonton, Alberta Canada T6G 2E1. (10)UOIT-CMCC Centre for

the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie St, Toronto, Ontario Canada M2H 3J1. BACKGROUND: Musculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity. METHODS: Randomized controlled trials (RCTs), cohort studies, and case-control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI. RESULTS: We screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults. CONCLUSIONS: The current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42014009899. PMCID: PMC4623271 PMID: 26512315 [PubMed] 2. Br J Sports Med. 2014 Mar;48(5):365-70. doi: 10.1136/bjsports-2013-092763. Epub 2013 Aug 26. The efficacy of manual joint mobilisation/manipulation in treatment of lateral ankle sprains: a systematic review. Loudon JK(1), Reiman MP, Sylvain J. Author information:

(1)Department of Physical Therapy Education, Rockhurst University, , Overland Park, Kansas, USA. BACKGROUND: Lateral ankle sprains are common and can have detrimental consequences to the athlete. Joint mobilisation/manipulation may limit these outcomes. OBJECTIVE: Systematically summarise the effectiveness of manual joint techniques in treatment of lateral ankle sprains. METHODS: This review employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A computer-assisted literature search of MEDLINE, CINHAL, EMBASE, OVID and Physiotherapy Evidence Database (PEDro) (January 1966 to March 2013) was used with the following keywords alone and in combination 'ankle', 'sprain', 'injuries', 'lateral', 'manual therapy', and 'joint mobilisation'. The methodological quality of individual studies was assessed using the PEDro scale. RESULTS: After screening of titles, abstracts and full articles, eight articles were kept for examination. Three articles achieved a score of 10 of 11 total points; one achieved a score of 9; two articles scored 8; one article scored a 7 and the remaining article scored a 5. Three articles examined joint techniques for acute sprains and the remainder examined subacute/chronic ankle sprains. Outcome measures included were pain level, ankle range of motion, swelling, functional score, stabilometry and gait parameters. The majority of the articles only assessed these outcome measures immediately after treatment. No detrimental effects from the joint techniques were revealed in any of the studies reviewed. CONCLUSIONS: For acute ankle sprains, manual joint mobilisation diminished pain and increased dorsiflexion range of motion. For treatment of subacute/chronic lateral ankle sprains, these techniques improved ankle range-of-motion, decreased pain and improved function. PMID: 23980032 [PubMed - indexed for MEDLINE] á

Manipulation and Carpal tunnel 1. J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):143-201. doi: 10.1016/j.jmpt.2013.04.001. Epub 2013 May 20. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Brantingham JW(1), Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C. Author information: (1)Murdoch University, Murdoch, Australia. jimbrant2002@yahoo.com OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence. Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 23697915 [PubMed - indexed for MEDLINE]

Manipulation and carpal tunnel 1. J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):143-201. doi: 10.1016/j.jmpt.2013.04.001. Epub 2013 May 20. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Brantingham JW(1), Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C. Author information: (1)Murdoch University, Murdoch, Australia. jimbrant2002@yahoo.com OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence. Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 23697915 [PubMed - indexed for MEDLINE]

Manipulation and cervical radiculopathy 1. Clin Rehabil. 2016 Feb;30(2):145-55. doi: 10.1177/0269215515570382. Epub 2015 Feb 13. Does cervical spine manipulation reduce pain in people with degenerative cervical radiculopathy? A systematic review of the evidence, and a meta-analysis. Zhu L(1), Wei X(2), Wang S(3). Author information: (1)Department of Spine, Wangjing Hospital, Beijing, People's Republic of China. (2)Department of Scientific Research, Wangjing Hospital, Beijing, People's Republic of China weixu.007@163.com. (3)Department of General Orthopedics, Wangjing Hospital, Beijing, People's Republic of China. OBJECTIVE: To access the effectiveness and safety of cervical spine manipulation for cervical radiculopathy. DATA SOURCES: PubMed, the Cochrane Central Registry of Controlled Trials (CENTRAL) in the Cochrane Library, EMBASE, Chinese Biomedical Literature Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), Wanfang data, the website of Chinese clinical trial registry and international clinical trial registry by US National Institutes of Health. REVIEW METHODS: Randomized controlled trials that investigated the effects of cervical manipulation compared with no treatment, placebo or conventional therapies on pain measurement in patients with degenerative cervical radiculopathy were searched. Two authors independently evaluated the quality of the trials according to the risk of bias assessment provided by the PEDro (physiotherapy evidence database) scale. RevMan V.5.2.0 software was employed for data analysis. The GRADE approach was used to evaluate the overall quality of the evidence. RESULTS: Three trials with 502 participants were included. Meta-analysis suggested that cervical spine manipulation (mean difference 1.28, 95% confidence interval 0.80 to 1.75; P < 0.00001; heterogeneity: Chi(2) = 8.57, P = 0.01, I(2) = 77%) improving visual analogue scale for pain showed superior immediate effects compared with cervical computer traction. The overall strength of evidence was judged to be moderate quality. One out of three trials reported the adverse events and none with a small sample size. CONCLUSION: There was moderate level evidence to support the immediate effectiveness of cervical spine manipulation in treating people with cervical radiculopathy. The safety of cervical manipulation cannot be taken as an exact conclusion so far. © The Author(s) 2015. PMID: 25681406 [PubMed - in process]

2. Physiotherapy. 2014 Dec;100(4):290-304. doi: 10.1016/j.physio.2014.04.007. Epub 2014 May 2. The clinical utility of cervical range of motion in diagnosis, prognosis, and evaluating the effects of manipulation: a systematic review. Snodgrass SJ(1), Cleland JA(2), Haskins R(3), Rivett DA(4). Author information: (1)Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Hunter Building, Callaghan, NSW 2308, Australia. Electronic address: Suzanne.Snodgrass@newcastle.edu.au. (2)Physical Therapy Program, Franklin Pierce University, 670 N. Commercial St. Suite 301, Manchester, NH 03101, USA. Electronic address: clelandj@franklinpierce.edu. (3)Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Hunter Building, Callaghan, NSW 2308, Australia. Electronic address: Robin.Haskins@newcastle.edu.au. (4)School of Health Sciences, The University of Newcastle, Hunter Building, Callaghan, NSW 2308, Australia. Electronic address: Darren.Rivett@newcastle.edu.au. BACKGROUND: Clinicians commonly assess cervical range of motion (ROM), but it has rarely been critically evaluated for its ability to contribute to patient diagnosis or prognosis, or whether it is affected by mobilisation/manipulation. OBJECTIVES: This review summarises the methods used to measure cervical ROM in research involving patients with cervical spine disorders, reviews the evidence for using cervical ROM in patient diagnosis, prognosis, and evaluation of the effects of mobilisation/manipulation on cervical ROM. DATA SOURCES AND STUDY SELECTION: A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted, addressing one of four constructs related to cervical ROM: measurement, diagnosis, prognosis, and the effects of mobilisation/manipulation on cervical ROM. STUDY APPRAISAL AND SYNTHESIS: Two independent raters appraised methodological quality using the QUADAS-2 tool for diagnostic studies, the QUIPS tool for prognostic studies and the PEDro scale for interventional studies. Heterogeneity of studies prevented meta-analysis. RESULTS: Thirty-six studies met the criteria and findings showed there is limited evidence for the diagnostic value of cervical ROM in cervicogenic headache, cervical radiculopathy and cervical spine injury. There is conflicting evidence for the prognostic value of cervical ROM, though restricted ROM appears associated with negative outcomes while greater ROM is associated with positive outcomes. There is conflicting evidence as to whether cervical ROM increases or decreases following mobilisation/manipulation. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: Cervical ROM has value as one component of assessment, but clinicians should be cautious about making clinical judgments primarily on the basis of cervical ROM. FUNDING: This collaboration was supported by an internal grant from the Faculty of Health, The University of Newcastle. Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

PMID: 25037534 [PubMed - indexed for MEDLINE] 3. J Man Manip Ther. 2011 Aug;19(3):135-42. doi: 10.1179/2042618611Y.0000000011. Effectiveness of manual physical therapy in the treatment of cervical radiculopathy: a systematic review. Boyles R(1), Toy P, Mellon J Jr, Hayes M, Hammer B. Author information: (1)Program of Physical Therapy, University of Puget Sound, Tacoma, WA, USA. STUDY DESIGN: Systematic review of randomized clinical trials. OBJECTIVE: Review of current literature regarding the effectiveness of manual therapy in the treatment of cervical radiculopathy. BACKGROUND: Cervical radiculopathy (CR) is a clinical condition frequently encountered in the physical therapy clinic. Cervical radiculopathy is a result of space occupying lesions in the cervical spine: either cervical disc herniations, spondylosis, or osteophytosis. These affect the pain generators of bony and ligamentous tissues, producing radicular symptoms (i.e. pain, numbness, weakness, paresthesia) observed in the upper extremity of patients with cervical nerve root pathology. Cervical radiculopathy has a reported annual incidence of 83·2 per 100 000 and an increased prevalence in the fifth decade of life among the general population. RESULTS: Medline and CINAHL via EBSCO, Cochrane Library, and Google Scholar were used to retrieve the randomized clinical trial studies for this review between the years of 1995 and February of 2011. Four studies met inclusion criteria and were considered to be high quality (PEDro scores of ⩾5). Manual therapy techniques included muscle energy techniques, non-thrust/thrust manipulation/mobilization of the cervical and/or thoracic spine, soft-tissue mobilization, and neural mobilization. In each study, manual therapy was either a stand-alone intervention or part of a multimodal approach which included therapeutic exercise and often some form of cervical traction. Although no clear cause and effect relationship can be established between improvement in radicular symptoms and manual therapy, results are generally promising. CONCLUSION: Although a definitive treatment progression for treating CR has not been developed a general consensus exists within the literature that using manual therapy techniques in conjunction with therapeutic exercise is effective in regard to increasing function, as well as AROM, while decreasing levels of pain and disability. High quality RCTs featuring control groups are necessary to establish clear and effective protocols in the treatment of CR. PMCID: PMC3143012 PMID: 22851876 [PubMed] 4. J Can Chiropr Assoc. 2012 Mar;56(1):18-28. Cervical radiculopathy: a systematic review on treatment by spinal manipulation and measurement with the Neck Disability Index.

Rodine RJ(1), Vernon H. Author information: (1)Graduate Student, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, Ontario. Private Practice, Smiths Falls, Ontario.12 William Street West, Smiths Falls, Ontario, K7A 1M9.Tel.: (613) 205-0978. E-mail: drrr@restorativehealth.ca. Cervical radiculopathy (CR), while less common than conditions with neck pain alone, can be a significant cause of neck pain and disability; thus the determination of adequate treatment options for patients is essential. Currently, inadequate scientific literature restricts specific conservative management recommendations for CR. Despite a paucity of evidence for high-velocity low-amplitude (HVLA) spinal manipulation in the treatment for CR, this strategy has been frequently labeled as contraindicated. Scientific support for appropriate outcome measures for CR is equally deficient. While more scientific data is needed to draw firm conclusions, the present review suggests that spinal manipulation may be cautiously considered as a therapeutic option for patients suffering from CR. With respect to outcome measures, the Neck Disability Index appears well-suited for spinal manipulative treatment of CR. PMCID: PMC3280115 PMID: 22457538 [PubMed]

Manipulation and coccydynia 1. J Man Manip Ther. 2013 Nov;21(4):213-9. doi: 10.1179/2042618613Y.0000000040. A comparison of conservative interventions and their effectiveness for coccydynia: a systematic review. Howard PD(1), Dolan AN(1), Falco AN(1), Holland BM(1), Wilkinson CF(1), Zink AM(1). Author information: (1)Department of Physical Therapy, Jefferson School of Health Professions, Thomas Jefferson University, Philadelphia, PA, USA. STUDY DESIGN: Systematic literature review. OBJECTIVE: To investigate the various conservative interventions for coccydynia and determine their effectiveness. BACKGROUND: Coccydynia is the term used to describe pain in the coccygeal region. Pain in this region is typically caused by local trauma. Sitting is typically the most painful position for patients having coccydynia. Various methods of treating coccydynia are found in the literature but to our knowledge no systematic review has been performed that compared the effectiveness of these interventions. METHODS: Searches were performed for research studies using electronic databases (Cochrane Library, CINAHL, Medline, PEDro, Scopus, and Sports Discus) from January 2002 through July 2012. The quality of the papers was assessed using the GRADE approach. RESULTS: Seven papers were located that satisfied the inclusion and exclusion criteria (2 RCTs, 5 observational studies). The level of evidence ranged from moderate to very low quality and recommendations for use ranged from weak recommendations for use to weak recommendations against use. CONCLUSIONS: Due to the dearth of research available and the low levels of evidence in the published studies that were located we are unable to recommend the most effective conservative intervention for the treatment of coccydynia. Additional research is needed regarding the treatment for this painful condition. PMCID: PMC3822321 PMID: 24421634 [PubMed]

Manipulation and elbow 1. Br J Sports Med. 2013 Nov;47(17):1112-9. doi: 10.1136/bjsports-2012-091990. Epub 2013 May 24. Does effectiveness of exercise therapy and mobilisation techniques offer guidance for the treatment of lateral and medial epicondylitis? A systematic review. Hoogvliet P(1), Randsdorp MS, Dingemanse R, Koes BW, Huisstede BM. Author information: (1)Department of Rehabilitation Medicine and Physical Therapy, Erasmus MC-University Medical Center Rotterdam, , Rotterdam, The Netherlands. BACKGROUND: Owing to the change in paradigm of the histological nature of epicondylitis, therapeutic modalities as exercises such as stretching and eccentric loading and mobilisation are considered for its treatment. OBJECTIVE: To assess the evidence for effectiveness of exercise therapy and mobilisation techniques for both medial and lateral epicondylitis. METHODS: Searches in PubMed, Embase, Cinahl and Pedro were performed to identify relevant randomised clinical trials (RCTs) and systematic reviews. Two reviewers independently extracted data and assessed the methodological quality. RESULTS: One review and 12 RCTs, all studying lateral epicondylitis, were included. Different therapeutic regimes were evaluated: stretching, strengthening, concentric/eccentric exercises and manipulation of the cervical or thoracic spine, elbow or wrist. No statistical pooling of the results could be performed owing to heterogeneity of the included studies. Therefore, a best-evidence synthesis was used to summarise the results. Moderate evidence for the short-term effectiveness was found in favour of stretching plus strengthening exercises versus ultrasound plus friction massage. Moderate evidence for short-term and mid-term effectiveness was found for the manipulation of the cervical and thoracic spine as add-on therapy to concentric and eccentric stretching plus mobilisation of wrist and forearm. For all other interventions only limited, conflicting or no evidence was found. CONCLUSIONS: Although not yet conclusive, these results support the belief that strength training decreases symptoms in tendinosis. The short-term analgesic effect of manipulation techniques may allow more vigorous stretching and strengthening exercises resulting in a better and faster recovery process of the affected tendon in lateral epicondylitis. PMID: 23709519 [PubMed - indexed for MEDLINE] 2. J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):143-201. doi: 10.1016/j.jmpt.2013.04.001. Epub 2013 May 20. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Brantingham JW(1), Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V,

Korporaal C. Author information: (1)Murdoch University, Murdoch, Australia. jimbrant2002@yahoo.com OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence. Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 23697915 [PubMed - indexed for MEDLINE] 3. J Sport Rehabil. 2012 Nov;21(4):343-53. Epub 2011 Dec 30. Deep friction massage to treat tendinopathy: a systematic review of a classic treatment in the face of a new paradigm of understanding. Joseph MF(1), Taft K, Moskwa M, Denegar CR. Author information: (1)Kinesiology Department, Physical Therapy Program, University of Connecticut, Storrs, CT, USA.

Comment in J Sport Rehabil. 2012 Nov;21(4):305. STUDY DESIGN: Systematic literature review. OBJECTIVE: To assess the efficacy of deep friction massage (DFM) in the treatment of tendinopathy. CONTEXT: Anecdotal evidence supports the efficacy of DFM for the treatment of tendinopathy. An advanced understanding of the etiopathogenesis of tendinopathy and the resultant paradigm shift away from an active inflammatory model has taken place since the popularization of the DFM technique by Cyriax for the treatment of "tendinitis." However, increasing mechanical load to the tendinopathic tissue, as well as reducing molecular cross-linking during the healing process via transverse massage, offers a plausible explanation for observed responses in light of the contemporary understanding of tendinopathy. EVIDENCE ACQUISITION: The authors surveyed research articles in all languages by searching PubMed, Scopus, Pedro, CINAHL, PsycINFO, and the Cochrane Library using the terms deep friction massage, deep tissue massage, deep transverse massage, Cyriax, soft tissue mobilization, soft tissue mobilisation, cross friction massage, and transverse friction massage. They included 4 randomized comparison trials, 3 at the extensor carpi radialis brevis (ECRB) and 1 supraspinatus outlet tendinopathy; 2 nonrandomized comparison trials, both receiving DFM at the ECRB; and 3 prospective noncomparison trials-supraspinatus, ECRB, and Achilles tendons. Articles meeting inclusion criteria were assessed based on PEDro and Centre for Evidence-Based Medicine rating scales. RESULTS: Nine studies met the inclusion criteria. EVIDENCE SYNTHESIS: The heterogeneity of dependent measures did not allow for meta-analysis. CONCLUSION: The varied locations, study designs, etiopathogenesis, and outcome tools used to examine the efficacy of DFM make a unified conclusion tenuous. There is some evidence of benefit at the elbow in combination with a Mills manipulation, as well as for supraspinatus tendinopathy in the presence of outlet impingement and along with joint mobilization. The examination of DFM as a single modality of treatment in comparison with other methods and control has not been undertaken, so its isolated efficacy has not been established. Excellent anecdotal evidence remains along with a rationale for its use that fits the current understanding of tendinopathy. PMID: 22234925 [PubMed - indexed for MEDLINE] 4. J Man Manip Ther. 2008;16(4):225-37. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. Herd CR, Meserve BB. Lateral epicondylalgia is a commonly encountered musculoskeletal complaint. Currently, there is no agreement regarding the exact underlying pathoanatomical cause or the most effective management strategy. Various forms of joint manipulation have been recommended as treatment. The purpose of this study was to

systematically review available literature regarding the effectiveness of manipulation in treating lateral epicondylalgia. A comprehensive search of Medline, CINAHL, Health Source, SPORTDiscus, and the Physiotherapy Evidence Database ending in November 2007 was conducted. Thirteen studies, both randomized and non-randomized clinical trials, met inclusion criteria. Articles were assessed for quality by one reviewer using the 10-point PEDro scale. Quality scores ranged from 1-8 with a mean score of 5.15 +/- 1.85. This score represented fair quality overall; however, trends indicated the presence of consistent methodological flaws. Specifically, no study achieved successful blinding of the patient or treating therapist, and less than 50% used a blinded outcome assessor. Additionally, studies varied significantly in terms of outcome measures, follow-up, and comparison treatments, thus making comparing results across studies difficult. Results of this review support the use of Mulligan's mobilization with movement in providing immediate, short-, and long-term benefits. In addition, positive results were demonstrated with manipulative therapy directed at the cervical spine, although data regarding long-term effects were limited. Currently, limited evidence exists to support a synthesis of any particular technique whether directed at the elbow or cervical spine. Overall, this review identified the need for further high-quality studies using larger sample sizes, valid functional outcome measures, and longer follow-up periods. PMCID: PMC2716156 PMID: 19771195 [PubMed] 5. Br J Sports Med. 2005 Jul;39(7):411-22; discussion 411-22. A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. Bisset L(1), Paungmali A, Vicenzino B, Beller E. Author information: (1)Division of Physiotherapy, University of Queensland, St Lucia, QLD 4072, Australia. A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia (tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated. PMCID: PMC1725258 PMID: 15976161 [PubMed - indexed for MEDLINE] 6. BMJ Clin Evid. 2011 Jun 27;2011. pii: 1117.

Tennis elbow. Bisset L(1), Coombes B, Vicenzino B. Author information: (1)Department of Health and Rehabilitation, University of Queensland, Brisbane, Australia. INTRODUCTION: Lateral pain in the elbow affects up to 3% of the population, and is considered an overload injury of the extensor tendons of the forearm where they attach at the lateral epicondyle. Although usually self-limiting, symptoms may persist for over 1 year in up to 20% of people. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for tennis elbow? We searched: Medline, Embase, The Cochrane Library, and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, autologous whole blood injections, corticosteroid injections, combination physical therapies, exercise, extracorporeal shock wave therapy, iontophoresis, low-level laser therapy, manipulation, non-steroidal anti-inflammatory drugs (oral and topical), orthoses (bracing), platelet-rich plasma injections, pulsed electromagnetic field treatment, surgery, and ultrasound. PMCID: PMC3217754 PMID: 21708051 [PubMed - in process]

Manipulation and frozen shoulder 1. World J Orthop. 2015 Mar 18;6(2):263-8. doi: 10.5312/wjo.v6.i2.263. eCollection 2015. Frozen shoulder: A systematic review of therapeutic options. Uppal HS(1), Evans JP(1), Smith C(1). Author information: (1)Harpal Singh Uppal, Jonathan Peter Evans, Christopher Smith, Shoulder Unit, Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter Hospital, EX2 5DW Exeter, United Kingdom. Frozen shoulder is a common disease which causes significant morbidity. Despite over a hundred years of treating this condition the definition, diagnosis, pathology and most efficacious treatments are still largely unclear. This systematic review of current treatments for frozen shoulder reviews the evidence base behind physiotherapy, both oral and intra articular steroid, hydrodilatation, manipulation under anaesthesia and arthroscopic capsular release. Key areas in which future research could be directed are identified, in particular with regard to the increasing role of arthroscopic capsular release as a treatment. PMCID: PMC4363808 PMID: 25793166 [PubMed] 2. J Shoulder Elbow Surg. 2013 Aug;22(8):1135-45. doi: 10.1016/j.jse.2013.01.010. Epub 2013 Mar 17. Comparison of manipulation and arthroscopic capsular release for adhesive capsulitis: a systematic review. Grant JA(1), Schroeder N, Miller BS, Carpenter JE. Author information: (1)Department of Orthopaedic Surgery, Saint John Regional Hospital & Dalhousie University, Saint John, New Brunswick, Canada. JGrantOrthoSports@gmail.com BACKGROUND: It is currently unclear as to whether there is a difference in the clinical effectiveness of an arthroscopic capsular release compared to a manipulation under anaesthesia (MUA) in patients with recalcitrant idiopathic adhesive capsulitis. METHODS: A systematic review was performed using computerized keyword searches of MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Two reviewers independently performed searches and article reduction. Studies that reported outcomes data following either a manipulation under regional or general anaesthesia or an arthroscopic capsular release in patients with idiopathic adhesive capsulitis

were included. Data on clinical measures of shoulder range of motion and subjective outcome measures were extracted and summarized. RESULTS: Twenty-two studies (21 studies provided level IV evidence) including 989 patients were included resulting in a comparison of 9 MUA and 17 capsular release groups. Patients were 60% female with a median age of 52 years old (range, 24-91 years). Median duration of symptoms and follow-up were 9 months (range, 3-50) and 35 months (range, 3-189), respectively. There were minimal differences in the median changes in abduction, flexion, and external rotation range of motion (ROM), and final Constant score between the MUA and capsular release groups. CONCLUSION: The quality of evidence available is low and the data available demonstrate little benefit for a capsular release instead of, or in addition to, an MUA. A high quality study is required to definitively evaluate the relative benefits of these procedures. Copyright © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved. PMID: 23510748 [PubMed - indexed for MEDLINE] 3. Health Technol Assess. 2012;16(11):1-264. doi: 10.3310/hta16110. Management of frozen shoulder: a systematic review and cost-effectiveness analysis. Maund E(1), Craig D, Suekarran S, Neilson A, Wright K, Brealey S, Dennis L, Goodchild L, Hanchard N, Rangan A, Richardson G, Robertson J, McDaid C. Author information: (1)Centre for Reviews and Dissemination, University of York, York, UK. BACKGROUND: Frozen shoulder is condition in which movement of the shoulder becomes restricted. It can be described as either primary (idiopathic) whereby the aetiology is unknown, or secondary, when it can be attributed to another cause. It is commonly a self-limiting condition, of approximately 1 to 3 years' duration, though incomplete resolution can occur. OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of treatments for primary frozen shoulder, identify the most appropriate intervention by stage of condition and highlight any gaps in the evidence. DATA SOURCES: A systematic review was conducted. Nineteen databases and other sources including the Cumulative Index to Nursing and Allied Health (CINAHL), Science Citation Index, BIOSIS Previews and Database of Abstracts of Reviews of Effects (DARE) were searched up to March 2010 and EMBASE and MEDLINE up to January 2011, without language restrictions. MEDLINE, CINAHL and PsycINFO were searched in June 2010 for studies of patients' views about treatment. REVIEW METHODS: Randomised controlled trials (RCTs) evaluating physical therapies, arthrographic distension, steroid injection, sodium hyaluronate injection, manipulation under anaesthesia, capsular release or watchful waiting, alone or in combination were eligible for inclusion. Patients with primary frozen shoulder (with or without diabetes) were included. Quasi-experimental studies were included in the absence of RCTs and case series for manipulation under

anaesthesia (MUA) and capsular release only. Full economic evaluations meeting the intervention and population inclusion criteria of the clinical review were included. Two researchers independently screened studies for relevance based on the inclusion criteria. One reviewer extracted data and assessed study quality; this was checked by a second reviewer. The main outcomes of interest were pain, range of movement, function and disability, quality of life and adverse events. The analysis comprised a narrative synthesis and pair-wise meta-analysis. A mixed-treatment comparison (MTC) was also undertaken. An economic decision model was intended, but was found to be implausible because of a lack of available evidence. Resource use was estimated from clinical advisors and combined with quality-adjusted life-years obtained through mapping to present tentative cost-effectiveness results. RESULTS: Thirty-one clinical effectiveness studies and one economic evaluation were included. The clinical effectiveness studies evaluated steroid injection, sodium hyaluronate, supervised neglect, physical therapy (mainly physiotherapy), acupuncture, MUA, distension and capsular release. Many of the studies identified were at high risk of bias. Because of variation in the interventions and comparators few studies could be pooled in a meta-analysis. Based on single RCTs, and for some outcomes only, short-wave diathermy may be more effective than home exercise. High-grade mobilisation may be more effective than low-grade mobilisation in a population in which most patients have already had treatment. Data from two RCTs showed that there may be benefit from adding a single intra-articular steroid injection to home exercise in patients with frozen shoulder of < 6 months' duration. The same two trials showed that there may be benefit from adding physiotherapy (including mobilisation) to a single steroid injection. Based on a network of nine studies the MTC found that steroid combined with physiotherapy was the only treatment showing a statistically and clinically significant beneficial treatment effect compared with placebo for short-term pain (standardised mean difference -1.58, 95% credible interval -2.96 to -0.42). This analysis was based on only a subset of the evidence, which may explain why the findings are only partly supportive of the main analysis. No studies of patients' views about the treatments were identified. Average costs ranged from £36.16 for unguided steroid injections to £2204 for capsular release. The findings of the mapping suggest a positive relationship between outcome and European Quality of Life-5 Dimensions (EQ-5D) score: a decreasing visual analogue scale score (less pain) was accompanied by an increasing (better) EQ-5D score. The one published economic evaluation suggested that low-grade mobilisation may be more cost-effective than high-grade mobilisation. Our tentative cost-effectiveness analysis suggested that steroid alone may be more cost-effective than steroid plus physiotherapy or physiotherapy alone. These results are very uncertain. LIMITATIONS: The key limitation was the lack of data available. It was not possible to undertake the planned synthesis exploring the influence of stage of frozen shoulder or the presence of diabetes on treatment effect. As a result of study diversity and poor reporting of outcome data there were few instances where the planned quantitative synthesis was possible or appropriate. Most of the included studies had a small number of participants and may have been underpowered. The lack of available data made the development of a decision-analytic model implausible. We found little evidence on treatment related to stage of condition, treatment pathways, the impact on quality of life, associated resource use and no information on utilities. Without making a number of questionable assumptions modelling was not possible.

CONCLUSIONS: There was limited clinical evidence on the effectiveness of treatments for primary frozen shoulder. The economic evidence was so limited that no conclusions can be made about the cost-effectiveness of the different treatments. High-quality primary research is required. PMID: 22405512 [PubMed - indexed for MEDLINE]

Manipulation and headache 1. Physiotherapy. 2014 Dec;100(4):290-304. doi: 10.1016/j.physio.2014.04.007. Epub 2014 May 2. The clinical utility of cervical range of motion in diagnosis, prognosis, and evaluating the effects of manipulation: a systematic review. Snodgrass SJ(1), Cleland JA(2), Haskins R(3), Rivett DA(4). Author information: (1)Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Hunter Building, Callaghan, NSW 2308, Australia. Electronic address: Suzanne.Snodgrass@newcastle.edu.au. (2)Physical Therapy Program, Franklin Pierce University, 670 N. Commercial St. Suite 301, Manchester, NH 03101, USA. Electronic address: clelandj@franklinpierce.edu. (3)Discipline of Physiotherapy, School of Health Sciences, The University of Newcastle, Hunter Building, Callaghan, NSW 2308, Australia. Electronic address: Robin.Haskins@newcastle.edu.au. (4)School of Health Sciences, The University of Newcastle, Hunter Building, Callaghan, NSW 2308, Australia. Electronic address: Darren.Rivett@newcastle.edu.au. BACKGROUND: Clinicians commonly assess cervical range of motion (ROM), but it has rarely been critically evaluated for its ability to contribute to patient diagnosis or prognosis, or whether it is affected by mobilisation/manipulation. OBJECTIVES: This review summarises the methods used to measure cervical ROM in research involving patients with cervical spine disorders, reviews the evidence for using cervical ROM in patient diagnosis, prognosis, and evaluation of the effects of mobilisation/manipulation on cervical ROM. DATA SOURCES AND STUDY SELECTION: A systematic search of MEDLINE, EMBASE, CINAHL, AMED and ICL databases was conducted, addressing one of four constructs related to cervical ROM: measurement, diagnosis, prognosis, and the effects of mobilisation/manipulation on cervical ROM. STUDY APPRAISAL AND SYNTHESIS: Two independent raters appraised methodological quality using the QUADAS-2 tool for diagnostic studies, the QUIPS tool for prognostic studies and the PEDro scale for interventional studies. Heterogeneity of studies prevented meta-analysis. RESULTS: Thirty-six studies met the criteria and findings showed there is limited evidence for the diagnostic value of cervical ROM in cervicogenic headache, cervical radiculopathy and cervical spine injury. There is conflicting evidence for the prognostic value of cervical ROM, though restricted ROM appears associated with negative outcomes while greater ROM is associated with positive outcomes. There is conflicting evidence as to whether cervical ROM increases or decreases following mobilisation/manipulation. CONCLUSION AND IMPLICATIONS OF KEY FINDINGS: Cervical ROM has value as one component of assessment, but clinicians should be cautious about making clinical judgments primarily on the basis of cervical ROM. FUNDING: This collaboration was supported by an internal grant from the Faculty of Health, The University of Newcastle.

Copyright © 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. PMID: 25037534 [PubMed - indexed for MEDLINE] 2. J Man Manip Ther. 2013 May;21(2):113-24. doi: 10.1179/2042618612Y.0000000025. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. Racicki S(1), Gerwin S(1), Diclaudio S(1), Reinmann S(1), Donaldson M(1). Author information: (1)Department of Physical Therapy, Walsh University, North Canton, OH, USA. PURPOSE: The purpose of this systematic review was to assess the effectiveness of conservative physical therapy management of cervicogenic headache (CGH). INTRODUCTION: CGH affects 22-25% of the adult population with females being four times more affected than men. CGHs are thought to arise from musculoskeletal impairments in the neck with symptoms most commonly consisting of suboccipital neck pain, dizziness, and lightheadedness. Currently, both invasive and non-invasive techniques are available to address these symptoms; however, the efficacy of non-invasive treatment techniques has yet to be established. METHODS: Computerized searches of CINAHL, ProQuest, PubMed, MEDLINE, and SportDiscus, were performed to obtain a qualitative analysis of the literature. Inclusion criteria were: randomized controlled trial design, population diagnosed with CGH using the International Headache Society classification, at least one baseline measurement and one outcomes measure, and assessment of a conservative technique. Physiotherapy evidence-based database scale was utilized for quality assessment. RESULTS: One computerized database search and two hand searches yielded six articles. Of the six included randomized controlled trials, all were considered to be of 'good quality' utilizing the physiotherapy evidence-based database scale. The interventions utilized were: therapist-driven cervical manipulation and mobilization, self-applied cervical mobilization, cervico-scapular strengthening, and therapist-driven cervical and thoracic manipulation. With the exception of one study, all reported reduction in pain and disability, as well as improvement in function. CONCLUSION: Calculated effect sizes allowed comparison of intervention groups between studies. A combination of therapist-driven cervical manipulation and mobilization with cervico-scapular strengthening was most effective for decreasing pain outcomes in those with CGH. PMCID: PMC3649358 PMID: 24421621 [PubMed] 3. J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):672-6. doi: 10.1016/j.jmpt.2013.09.005. Epub 2014 Jan 3.

The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. Chung CL(1), Côté P(2), Stern P(3), L'Espérance G(4). Author information: (1)Tutor, Graduate Education Research Programs, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. Electronic address: cchung@cmcc.ca. (2)Canada Research Chair in Disability Prevention and Rehabilitation, Canada Research Chairs, Canadian Federal Government; Associate Professor, Health Sciences Department, University of Ontario Institute of Technology, Oshawa, Ontario, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Institute of Technology, Oshawa, Ontario, Canada. (3)Director, Graduate Education Research Programs, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (4)President, Quebec Society of Experts in Medicolegal Evaluation, Montreal, Quebec, Canada. OBJECTIVE: Controversy surrounds the safety of cervical spine manipulation. Ischemic stroke secondary to cervical spine manipulation is a hypothesized adverse event. In Canada, the seriousness of these events and their perceived association to cervical spine manipulation has led some members of the public to call for a ban of the procedure. The primary objective of this study was to determine the incidence of internal carotid artery (ICA) dissection after cervical spine manipulation in patients who experience neck pain and its associated disorders. The secondary objective was to determine whether cervical spine manipulation is associated with an increased risk of ICA dissection in patients with neck pain, upper back pain, or headaches. METHODS: We systematically searched MEDLINE, CINAHL, Alternative Health, AMED, Index to Chiropractic Literature, and EMBASE from 1970 to November 2012. Two independent reviewers used standardized criteria to screen the eligibility of articles. We considered cohort studies, case-control studies, and randomized clinical trials that addressed our objectives. We planned to critically appraise eligible articles using the Scottish Intercollegiate Guideline Network methodology. RESULTS: We did not find any epidemiologic studies that measured the incidence of cervical spine manipulation and ICA dissection. Similarly, we did not find any studies that determined whether cervical spine manipulation is associated with ICA dissection. CONCLUSIONS: The incidence of ICA dissection after cervical spine manipulation is unknown. The relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is also unknown. Although several case reports and case series raise the hypothesis of an association, we found no epidemiologic studies that validate this hypothesis. Copyright © 2013 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 24387889 [PubMed - in process]

4. Pain Med. 2013 Apr;14(4):460-8. doi: 10.1111/pme.12041. Epub 2013 Feb 22. What are the clinical criteria justifying spinal manipulative therapy for neck pain?- a systematic review of randomized controlled trials. Smith J(1), Bolton PS. Author information: (1)School of Biomedical Sciences and Pharmacy, Faculty of Health, University of Newcastle, Callaghan, New South Wales, Australia. OBJECTIVE: Manipulation and mobilization are used to treat neck pain. However, little is known about the diagnostic criteria used to determine the need for manipulation in cases of neck pain. The primary aim of this study was to determine what diagnostic criteria are used to identify which neck pain sufferers should receive spinal manipulation or mobilization. DESIGN: We systematically reviewed randomized controlled trials (RCT) involving mobilization or manipulation for neck pain. A data extraction pro forma was developed and trialled before two independent assessors extracted data sets from each RCT. A descriptive analysis was undertaken. RESULTS: Thirty RCTs met the inclusion criteria. Acute and chronic "Mechanical" neck pain was the most common (43%) diagnosis at recruitment to the RCTs but some (10%) included patients with cervicogenic headache. Clinical criteria were used to determine the need for neck manipulation in over half (63%) of the RCTs. This usually involved exclusion of serious conditions, manual examination for tenderness on palpation, and/or altered vertebral motion in the neck or upper thoracic region which are known to lack validity. The remainder of the RCTs did not report a diagnostic strategy. All RCTs lacked detail descriptions of diagnostic criteria or interventions used. CONCLUSIONS: This systematic review highlights the absence of reliable and valid diagnostic protocols to determine the need for spinal manipulation in persons presenting with non-serious, idiopathic, or whiplash-associated (grade II) neck pain. Guidelines requiring the reporting of valid diagnostic criteria are needed to improve the quality of RCTs concerning manual therapy. Wiley Periodicals, Inc. PMID: 23432939 [PubMed - indexed for MEDLINE] 5. Complement Ther Med. 2012 Aug;20(4):232-9. doi: 10.1016/j.ctim.2011.12.001. Epub 2011 Dec 29. Spinal manipulations for tension-type headaches: a systematic review of randomized controlled trials. Posadzki P(1), Ernst E. Author information: (1)Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, Veysey Building, Salmon Pool Lane, Exeter EX2 4SG, United Kingdom.

Paul.Posadzki@pcmd.ac.uk AIMS: The objective of this systematic review was to assess the effectiveness of spinal manipulations as treatment option for tension type headaches. METHODS: Eight databases were searched from their inception to May 2011. All randomized trials were considered, if they investigated spinal manipulations performed by any type of healthcare professional for treating tension type headaches in human subjects. The selection of studies, data extraction, and validation were performed independently by two reviewers. The Cochrane tool and the Jadad score were used to assess methodological quality of trials. RESULTS: Five randomized clinical trials (RCTs) met the inclusion criteria. Their methodological quality was mostly high and ranged between 2 and 4 on the Jadad score. Four RCTs suggested that spinal manipulations are more effective than drug therapy, spinal manipulation plus placebo, sham spinal manipulation plus amitriptyline or sham spinal manipulation plus placebo, usual care or no intervention. One RCT showed no difference in daily hours of headache, pain intensity, and daily analgesic use compared to soft tissue therapy plus placebo laser. CONCLUSIONS: The evidence that spinal manipulation alleviates tension type headaches is encouraging, but inconclusive. The low quantity of the available data prevent firm conclusion. Copyright © 2011 Elsevier Ltd. All rights reserved. PMID: 22579436 [PubMed - indexed for MEDLINE] 6. N Z Med J. 2011 Aug 12;124(1340):55-71. Spinal manipulation: an update of a systematic review of systematic reviews. Posadzki P(1), Ernst E. Author information: (1)Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, 25 Victoria Park Road, Exeter EX2 4NT UK. Paul.Posadzki@pcmd.ac.uk Comment in N Z Med J. 2011 Oct 14;124(1344):117-9. N Z Med J. 2011 Sep 23;124(1343):94-5. OBJECTIVES: The aim of this update is to critically evaluate the evidence for or against the effectiveness of spinal manipulation in patients with any type of clinical condition. DESIGN: Four electronic databases were searched to identify all relevant systematic reviews of the effectiveness of spinal manipulation in any condition published between 2005 and January 2011. Reviews were defined as systematic, if they included an explicit and repeatable inclusion and exclusion criteria for studies. RESULTS: Forty-five systematic reviews were included relating to the following conditions: low back pain (n=7), headache (n=6), neck pain (n=4), asthma (n=4),

musculoskeletal conditions (n=3), any non-musculoskeletal conditions (n=2), fibromyalgia (n=2), infant colic (n=2), any medical problem (n=1), any paediatric conditions (n=1), carpal tunnel syndrome (n=1), cervicogenic dizziness (n=1), dysmenorrhoea (n=1), gastrointestinal problems (n=1), hypertension (n=1), idiopathic scoliosis (n=1), lateral epicondylitis (n=1), lower extremity conditions (n=1), pregnancy and related conditions (n=1), psychological outcome (n=1), shoulder pain (n=1), upper extremity conditions (n=1) and whiplash injury (n=1). Positive or, for multiple SR, unanimously positive conclusions were drawn for psychological outcomes (n=1) and whiplash (n=1). CONCLUSION: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition. PMID: 21952385 [PubMed - indexed for MEDLINE] 7. Man Ther. 2010 Jun 1. [Epub ahead of print] Manual therapy and exercise for neck pain: A systematic review. Miller J(1), Gross A, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Author information: (1)School of Rehabilitation Science, McMaster University, Hamilton, Canada. Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:-1.69,-0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:-0.76,-0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made. Copyright © 2010 Elsevier Ltd. All rights reserved. PMID: 20627797 [PubMed - as supplied by publisher]

8. Man Ther. 2010 Oct;15(5):415-33. doi: 10.1016/j.math.2010.04.003. Epub 2010 Jun 9. Manual therapy with or without physical medicine modalities for neck pain: a systematic review. D'Sylva J(1), Miller J, Gross A, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL; Cervical Overview Group. Author information: (1)School of Rehabilitation Science, McMaster University, 1400 Main Street West, Hamilton, Ontario L8S 1C7, Canada. Manual therapy interventions are often used with or without physical medicine modalities to treat neck pain. This review assessed the effect of 1) manipulation and mobilisation, 2) manipulation, mobilisation and soft tissue work, and 3) manual therapy with physical medicine modalities on pain, function, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults with neck pain. A computerised search for randomised trials was performed up to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (RR) and standardised mean differences (SMD) were calculated when possible. We included 19 trials, 37% of which had a low risk of bias. Moderate quality evidence (1 trial, 221 participants) suggested mobilisation, manipulation and soft tissue techniques decrease pain and improved satisfaction when compared to short wave diathermy, and that this treatment combination paired with advice and exercise produces greater improvements in GPE and satisfaction than advice and exercise alone for acute neck pain. Low quality evidence suggests a clinically important benefit favouring mobilisation and manipulation in pain relief [1 meta-analysis, 112 participants: SMD -0.34(95% CI: -0.71, 0.03), improved function and GPE (1 trial, 94 participants) for participants with chronic cervicogenic headache when compared to a control at intermediate and long term follow-up; but no difference when used with various physical medicine modalities. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 20538501 [PubMed - indexed for MEDLINE] 9. J Man Manip Ther. 2008;16(2):E42-52. Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized controlled trials of a single session. Vernon H(1), Humphreys BK. Author information: (1)Professor, Division of Research, Canadian Memorial Chiropractic College, Toronto, ON, Canada. We report a systematic analysis of group change scores of subjects with chronic

neck pain not due to whiplash and without headache or arm pain, in randomized clinical trials of a single session of manual therapy. A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2006 was conducted. Trials that scored above 60% on the PEDro Scale were included. Change scores were analyzed for absolute, percentage change and effect size (ES) whenever possible. Nine trials were identified: 6 for spinal manipulation, 4 for spinal mobilization or non-manipulative manual therapy (2 overlapping trials), and 1 trial using ischemic compression. No trials were identified for massage therapy or manual traction. Four manipulation trials (five groups) reported mean immediate changes in 100-mm VAS of -18.94 (9.28) mm. ES for these changes ranged from .33 to 2.3. Two mobilization trials reported immediate VAS changes of -11.5 and -4 mm (ES of .36 and .22, respectively); one trial reported no difference in immediate pain scores versus sham mobilization. The ischemic compression study showed statistically significant immediate decreases in 100-mm pain VAS (average = -14.6 mm). There is moderate-to-high quality evidence that immediate clinically important improvements are obtained from a single session of spinal manipulation. The evidence for mobilization is less substantial, with fewer studies reporting smaller immediate changes. There is insufficient evidence for ischemic compression to draw conclusions. There is no evidence for a single session of massage or manual traction for chronic neck pain. PMCID: PMC2565115 PMID: 19119388 [PubMed] 10. J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):215-27. Chronic mechanical neck pain in adults treated by manual therapy: a systematic review of change scores in randomized clinical trials. Vernon H(1), Humphreys K, Hagino C. Author information: (1)Canadian Memorial Chiropractic College, Toronto, ON, Canada. hvernon@cmcc.ca Erratum in J Manipulative Physiol Ther. 2007 Jul;30(6):473-8. OBJECTIVE: This study provides a systematic analysis of group change scores in randomized clinical trials of chronic neck pain not due to whiplash and not including headache or arm pain treated with manual therapy. METHODS: A comprehensive literature search of clinical trials of chronic neck pain treated with manual therapies up to December 2005. Only clinical trials scoring above 11.5 (Amsterdam-Maastricht Scale) were included in the analysis. RESULTS: From 1980 citations, 19 publications were selected. Of the 16 trials analyzed (3 were rejected for poor quality), 9 involved spinal manipulation (12 groups), 5 trials (5 groups) were for spinal mobilization or nonmanipulative manual therapy (1 trial overlapped), and 2 trials (2 groups) involved massage therapy. No trials included trigger point therapy or manual traction of the neck. For manipulation studies, the mean effect size (ES) at 6 weeks for 7 trials (10

groups) was 1.63 (95% confidence interval [CI], 1.13-2.13); 1.56 (95% CI, 0.73-2.39) at 12 weeks for 4 trials (5 groups); 1.22 (95% CI, 0.38-2.06) from 52 to 104 weeks for 2 trials (2 groups). For mobilization studies, 1 trial reported an ES of 2.5 at 6 weeks, 2 trials reported full recovery in 63.8% to 71.7% of subjects at 7 to 52 weeks, and 1 trial reported greater than 2/10 point pain score reduction in 78.3% of subjects at 4 weeks. For massage studies, 1 reported an ES of 0.03 at 6 weeks, whereas the other reported mean change scores of 7.89/100 and 14.4/100 at 1 and 12 weeks of, respectively. CONCLUSIONS: There is moderate- to high-quality evidence that subjects with chronic neck pain not due to whiplash and without arm pain and headaches show clinically important improvements from a course of spinal manipulation or mobilization at 6, 12, and up to 104 weeks posttreatment. The current evidence does not support a similar level of benefit from massage. PMID: 17416276 [PubMed - indexed for MEDLINE] 11. Clin J Pain. 2006 Mar-Apr;22(3):278-85. Are manual therapies effective in reducing pain from tension-type headache?: a systematic review. Fernández-de-Las-Peñas C(1), Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA. Author information: (1)Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, Madrid, Spain. cesarfdlp@yahoo.es OBJECTIVES: A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH). METHODS: Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence. RESULTS: Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8+/-2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited

evidence (level 3). CONCLUSIONS: The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH. PMID: 16514329 [PubMed - indexed for MEDLINE] 12. Pain. 2004 Dec;112(3):381-8. The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Lenssinck ML(1), Damen L, Verhagen AP, Berger MY, Passchier J, Koes BW. Author information: (1)Department of General Practice, Erasmus MC, University Medical Centre Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands. The study design is a systematic review of randomised clinical trials (RCTs). The objectives of the present study are to assess the effectiveness of physiotherapy and (spinal) manipulation in patients with tension-type headache (TTH). No systematic review exists concerning the effectiveness of physiotherapy and (spinal) manipulation primarily focussing on TTH. Literature was searched using a computerised search of MEDLINE, EMBASE and the Cochrane library. Only RCTs including physiotherapy and/or (spinal) manipulation used in the treatment of TTH in adults were selected. Two reviewers independently assessed the methodological quality of the RCTs using the Delphi-list. A study was considered of high quality if it satisfied at least six points on the methodological quality list. Twelve publications met the inclusion criteria, including three dual or overlapping publications resulting in eight studies included. These studies showed a large variety of interventions, such as chiropractic spinal manipulation, connective tissue manipulation or physiotherapy. Only two studies were considered to be of high quality, but showed inconsistent results. Because of clinical heterogeneity and poor methodological quality in many studies, it appeared to be not possible to draw valid conclusions. Therefore, we conclude that there is insufficient evidence to either support or refute the effectiveness of physiotherapy and (spinal) manipulation in patients with TTH. PMID: 15561394 [PubMed - indexed for MEDLINE] 13. Spine (Phila Pa 1976). 2004 Jul 15;29(14):1541-8. A Cochrane review of manipulation and mobilization for mechanical neck disorders. Gross AR(1), Hoving JL, Haines TA, Goldsmith CH, Kay T, Aker P, Bronfort G; Cervical Overview Group. Author information:

(1)McMaster University, Faculty of Health Sciences, School of Rehabilitation Sciences, Institute of Applied Health Sciences, Hamilton, Ontario, Canada. grossa@mcmaster.ca Comment in Spine (Phila Pa 1976). 2005 Jan 1;30(1):166. STUDY DESIGN AND OBJECTIVES: Our systematic review of randomized trials assessed whether manipulation and mobilization relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders. SUMMARY OF BACKGROUND DATA: Neck disorders are common, disabling, and costly. METHODS: Computerized bibliographic databases were searched up to March 2002. Two independent reviewers conducted study selection, data abstraction, and methodologic quality assessment. Relative risk and standardized mean differences were calculated. In the absence of heterogeneity, pooled effect measures were calculated using a random effects model. RESULTS: Of the 33 selected trials, 42% were high quality trials. Single or multiple (3-11) sessions of manipulation or mobilization showed no benefit in pain relief when assessed against placebo, control groups, or other treatments for acute/subacute/chronic mechanical neck disorders with or without headache. There was strong evidence of benefit favoring multimodal care (mobilization and/or manipulation plus exercise) over a waiting list control for pain reduction [pooled standardized mean differences -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [standardized mean differences -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic mechanical neck disorders with or without headache. CONCLUSIONS: Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. Factorial design would help determine the active agent(s) within a treatment mix. PMID: 15247576 [PubMed - indexed for MEDLINE] 14. Cephalalgia. 2002 Oct;22(8):617-23. The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. Astin JA(1), Ernst E. Author information: (1)California Pacific Medical Center Research Institute, USA. john@integrativearts.com. Comment in Cephalalgia. 2003 Jul;23(6):479-80; author reply 480-1.

To carry out a systematic review of the literature examining the effectiveness of spinal manipulation for the treatment of headache disorders, computerized literature searches were carried out in Medline, Embase, Amed and CISCOM. Studies were included only if they were randomized trials of (any type of) spinal manipulation for (any type of) headache in human patients in which spinal manipulation was compared either to no treatment, usual medical care, a 'sham' intervention, or to some other active treatment. Two investigators independently extracted data on study design, sample size and characteristics, type of intervention, type of control/comparison, direction and nature of the outcome(s). Methodological quality of the trials was also assessed using the Jadad scale. Eight trials were identified that met our inclusion criteria. Three examined tension-type headaches, three migraine, one 'cervicogenic' headache, and one 'spondylogenic' chronic headache. In two studies, patients receiving spinal manipulation showed comparable improvements in migraine and tension headaches compared to drug treatment. In the 4 studies employing some 'sham' interventions (e.g. laser light therapy), results were less conclusive with 2 studies showing a benefit for manipulation and 2 studies failing to find such an effect. Considerable methodological limitations were observed in most trials, the principal one being inadequate control for nonspecific (placebo) effects. Despite claims that spinal manipulation is an effective treatment for headache, the data available to date do not support such definitive conclusions. It is unclear to what extent the observed treatment effects can be explained by manipulation or by nonspecific factors (e.g. of personal attention, patient expectation). Whether manipulation produces any long-term changes in these conditions is also uncertain. Future studies should address these two crucial questions and overcome the methodological limitations of previous trials. PMID: 12383058 [PubMed - indexed for MEDLINE] 15. Man Ther. 2002 Aug;7(3):131-49. Manual therapy for mechanical neck disorders: a systematic review. Gross AR(1), Kay T, Hondras M, Goldsmith C, Haines T, Peloso P, Kennedy C, Hoving J. Author information: (1)Hamilton Health Sciences, Hamilton, Ont., Canada. grossa@mcmaster.ca Neck disorders are common, disabling and costly. Randomized trials were reviewed using a Cochrane format, to determine if manual therapy improves pain, function and patient satisfaction in adults suffering from neck disorders with and without radicular findings or headache. Sequenced computerized searches ended in December 1997. Two independent reviewers extracted data while three assessed trial quality. Standard mean difference and relative risks were translated to number needed to treat (NNT) and the percent treatment advantage. The 20 selected trials' quality was 2.4 (SD: 1.04) on the 5-point scale described by Jadad. Trials were clinically heterogenous. Manipulation alone, mobilizations alone, manipulation/mobilization and treatments including massage consistently showed similar effects to placebo, wait period or control. Multimodal manual therapy

care including exercise were superior to a control, to certain physical medicine methods and to rest for pain and patient satisfaction. The NNT for a clinically important reduction in pain varied from 2 to 11 and treatment advantage from 6% to 41% at the cost of benign transient side-effects. While results remain inconclusive, some clinical themes have emerged. For mechanical neck disorder with or without headache, it appears that to be most beneficial, manual therapies should be done with exercise for improving pain and patient satisfaction. Manipulation and mobilization alone appear to be less effective. Factorial design would help delineate the magnitude of effect for each component of care. PMID: 12372310 [PubMed - indexed for MEDLINE] 16. J Manipulative Physiol Ther. 2001 Sep;24(7):457-66. Efficacy of spinal manipulation for chronic headache: a systematic review. Bronfort G(1), Assendelft WJ, Evans R, Haas M, Bouter L. Author information: (1)Department of Research, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, Bloomington, MN 55431, USA. gbronfort@nwhealth.edu BACKGROUND: Chronic headache is a prevalent condition with substantial socioeconomic impact. Complementary or alternative therapies are increasingly being used by patients to treat headache pain, and spinal manipulative therapy (SMT) is among the most common of these. OBJECTIVE: To assess the efficacy/effectiveness of SMT for chronic headache through a systematic review of randomized clinical trials. STUDY SELECTION: Randomized clinical trials on chronic headache (tension, migraine and cervicogenic) were included in the review if they compared SMT with other interventions or placebo. The trials had to have at least 1 patient-rated outcome measure such as pain severity, frequency, duration, improvement, use of analgesics, disability, or quality of life. Studies were identified through a comprehensive search of MEDLINE (1966-1998) and EMBASE (1974-1998). Additionally, all available data from the Cumulative Index of Nursing and Allied Health Literature, the Chiropractic Research Archives Collection, and the Manual, Alternative, and Natural Therapies Information System were used, as well as material gathered through the citation tracking, and hand searching of non-indexed chiropractic, osteopathic, and manual medicine journals. DATA EXTRACTION: Information about outcome measures, interventions and effect sizes was used to evaluate treatment efficacy. Levels of evidence were determined by a classification system incorporating study validity and statistical significance of study results. Two authors independently extracted data and performed methodological scoring of selected trials. DATA SYNTHESIS: Nine trials involving 683 patients with chronic headache were included. The methodological quality (validity) scores ranged from 21 to 87 (100-point scale). The trials were too heterogeneous in terms of patient clinical characteristic, control groups, and outcome measures to warrant statistical pooling. Based on predefined criteria, there is moderate evidence that SMT has short-term efficacy similar to amitriptyline in the prophylactic treatment of

chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft-tissue massage for episodic tension-type headache. There is moderate evidence that SMT is more efficacious than massage for cervicogenic headache. Sensitivity analyses showed that the results and the overall study conclusions remained the same even when substantial changes in the prespecified assumptions/rules regarding the evidence determination were applied. CONCLUSIONS: SMT appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications for tension-type headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality. Before any firm conclusions can be drawn, further testing should be done in rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length. PMID: 11562654 [PubMed - indexed for MEDLINE] 17. Spine (Phila Pa 1976). 1996 Aug 1;21(15):1746-59; discussion 1759-60. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Hurwitz EL(1), Aker PD, Adams AH, Meeker WC, Shekelle PG. Author information: (1)RAND, Santa Monica, CA, USA. Comment in Spine (Phila Pa 1976). 1997 Jul 15;22(14):1676-7. STUDY DESIGN: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. OBJECTIVES: To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache. SUMMARY OF BACKGROUND DATA: Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache. METHODS: A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients' pain status. RESULTS: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache.

The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. CONCLUSIONS: Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death. PMID: 8855459 [PubMed - indexed for MEDLINE] 18. Complement Ther Med. 1999 Sep;7(3):142-55. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Vernon H(1), McDermaid CS, Hagino C. Author information: (1)Canadian Memorial Chiropractic College, Toronto, Canada. OBJECTIVES: To conduct a systematic review of the randomized controlled clinical trials (RCTs) of complementary/alternative (CAM) therapies in the treatment of non-migrainous headache (i.e. excluding migraine, cluster and organic headaches). DESIGN: Systematic review with quality scoring and evidence tables. MAIN OUTCOME MEASURES: Number of RCTs per therapy, quality scores, evidence tables. RESULTS: Twenty-four RCTs were identified in the categories of acupuncture, spinal manipulation, electrotherapy, physiotherapy, homeopathy and other therapies. Headache categories included tension-type (under various names pre-1988), cervicogenic and post-traumatic. Quality scores for the RCT reports ranged from approximately 30 to 80 on a 100 point scale. CONCLUSION: RCTs for CAM therapies of the treatment of non-migrainous headache exist in the literature and demonstrate that clinical experimental studies of these forms of headache can be conducted. Evidence from a sub-set of high quality studies indicates that some CAM therapies may be useful in the treatment of these common forms of headache. PMID: 10581824 [PubMed - indexed for MEDLINE]

Manipulation and hip 1. Clin Rehabil. 2015 Dec 22. pii: 0269215515622670. [Epub ahead of print] The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: A systematic review and meta-analysis. Sampath KK(1), Mani R(2), Miyamori T(2), Tumilty S(2). Author information: (1)Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand kesava.kovanur-sampath@otago.ac.nz. (2)Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand. OBJECTIVE: To determine whether manual therapy or exercise therapy or both is beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life. METHODS: Databases such as Medline, AMED, EMBASE, CINAHL, SPORTSDiscus, PubMed, Cochrane Library, Web of Science, Physiotherapy Evidence Database, and SCOPUS were searched from their inception till September 2015. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures (pain, physical function and quality of life) were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for assessing the quality of the body of evidence for each outcome of interest. RESULTS: Seven trials (886 participants) that met the inclusion criteria were included in the meta-analysis. There was high quality evidence that exercise therapy was beneficial at post-treatment (pain-SMD-0.27,95%CI-0.5to-0.04;physical function-SMD-0.29,95%CI-0.47to-0.11) and follow-up (pain-SMD-0.24,95%CI- 0.41to-0.06; physical function-SMD-0.33,95%CI-0.5to-0.15). There was low quality evidence that manual therapy was beneficial at post-treatment (pain-SMD-0.71,95%CI-1.08to-0.33; physical function-SMD-0.71,95%CI-1.08to-0.33) and follow-up (pain-SMD-0.43,95%CI-0.8to-0.06; physical function-SMD-0.47,95%CI-0.84to-0.1). Low quality evidence indicated that combined treatment was beneficial at post-treatment (pain-SMD-0.43,95%CI-0.78to-0.08; physical function-SMD-0.38,95%CI-0.73to-0.04) but not at follow-up (pain-SMD0.25,95%CI-0.35to0.84; physical function-SMD0.09,95%CI-0.5to0.68). There was no effect of any interventions on quality of life. CONCLUSION: An Exercise therapy intervention provides short-term as well as long-term benefits in terms of reduction in pain, and improvement in physical function among people with hip osteoarthritis. The observed magnitude of the treatment effect would be considered small to moderate. © The Author(s) 2015. PMID: 26701903 [PubMed - as supplied by publisher] 2. J Manipulative Physiol Ther. 2009 Jan;32(1):53-71. doi: 10.1016/j.jmpt.2008.09.013.

Manipulative therapy for lower extremity conditions: expansion of literature review. Brantingham JW(1), Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Author information: (1)Cleveland Chiropractic College Los Angeles (CCCLA), Los Angeles, Calif. 90004, USA. james.brantingham@cleveland.edu OBJECTIVE: The purpose of this study was to conduct a systematic review on manipulative therapy for lower extremity conditions and expand on a previously published literature review. METHODS: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. The Cumulative Index to Nursing and Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Science Direct; and Index to Chiropractic Literature were searched from December 2006 to February 2008. Search terms included chiropractic, osteopathic, orthopedic, or physical therapy and MeSH terms for each region. Inclusion criteria required a diagnosis and manipulative therapy (mobilization and manipulation grades I-V) with or without adjunctive care. Exclusion criteria were pain referred from spinal sites (without diagnosis), referral for surgery, and conditions contraindicated for manipulative therapy. Clinical trials were assessed using a modified Scottish Intercollegiate Guidelines Network ranking system. RESULTS: Of the total 389 citations captured, 39 were determined to be relevant. There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy for hip osteoarthritis. There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain, and of the ankle and/or foot, combined with multimodal or exercise therapy for knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is also a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for plantar fasciitis, metatarsalgia, and hallux limitus/rigidus. There is also a level of I or insufficient evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux abducto valgus. CONCLUSIONS: There are a growing number of peer-reviewed studies of manipulative therapy for lower extremity disorders. PMID: 19121464 [PubMed - indexed for MEDLINE]

Manipulation and hypertension 1. J Cardiovasc Nurs. 2016 Jan-Feb;31(1):73-83. doi: 10.1097/JCN.0000000000000217. Effects of Massage on Blood Pressure in Patients With Hypertension and Prehypertension: A Meta-analysis of Randomized Controlled Trials. Liao IC(1), Chen SL, Wang MY, Tsai PS. Author information: (1)I-Chen Liao, MSN, RN Doctoral Student, Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei; and Department of Nursing, College of Medicine and Nursing, Hung Kuang University, Taichung, Taiwan. Shiah-Lian Chen, PhD Associate Professor, Department of Nursing, National Tai-Chung University of Science and Technology, Taichung, Taiwan. Mei-Yeh Wang, PhD Associate Professor, Department of Nursing, Cardinal Tien Junior College of Healthcare and Management, New Taipei City, Taiwan. Pei-Shan Tsai, PhD Professor and Associate Dean, Graduate Institute of Nursing, College of Nursing, Taipei Medical University; and Sleep Science Center, Taipei Medical University Hospital, Taipei, Taiwan. BACKGROUND: Massage may help reduce blood pressure; previous studies on the effect of massage on blood pressure have presented conflicting findings. In addition, no systematic review is available. OBJECTIVE: The aim of this study was to evaluate the evidence concerning the effect of massage on blood pressure in patients with hypertension or prehypertension. METHODS: A search was performed on electronic database records up to October 31, 2013, based on the following medical subject headings or keywords: hypertension, massage, chiropractic, manipulation, and blood pressure. The methodological quality of randomized controlled trials was assessed based on the Cochrane collaboration tool. A meta-analysis was performed to evaluate the effect of massage on hypertension. The study selection, data extraction, and validation were performed independently by 2 reviewers. RESULTS: Nine randomized controlled trials met our inclusion criteria. The results of this study show that massage contributes to significantly enhanced reduction in both systolic blood pressure (SBP) (mean difference, -7.39 mm Hg) and diastolic blood pressure (DBP) (mean difference, -5.04 mm Hg) as compared with control treatments in patients with hypertension and prehypertension. The effect size (Hedges g) for SBP and DBP was -0.728 (95% confidence interval, -1.182 to -0.274; P = .002) and -0.334 (95% confidence interval, -0.560 to -0.107; P = .004), respectively. CONCLUSION: This systematic review found a medium effect of massage on SBP and a small effect on DBP in patients with hypertension or prehypertension. High-quality randomized controlled trials are urgently required to confirm these results, although the findings of this study can be used to guide future research. PMID: 25419947 [PubMed - in process]

Manipulation and low back pain 1. J Physiother. 2015 Jul;61(3):106-16. doi: 10.1016/j.jphys.2015.05.018. Epub 2015 Jun 17. Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review. Bervoets DC(1), Luijsterburg PA(1), Alessie JJ(2), Buijs MJ(2), Verhagen AP(1). Author information: (1)Department of General Practice, Erasmus MC, University Medical Center, Rotterdam. (2)Avans University of Applied Science, Breda, The Netherlands. QUESTION: Is massage therapy effective for people with musculoskeletal disorders compared to any other treatment or no treatment? DESIGN: Systematic review of randomised clinical trials. PARTICIPANTS: People with musculoskeletal disorders. INTERVENTIONS: Massage therapy (manual manipulation of the soft tissues) as a stand-alone intervention. OUTCOME: The primary outcomes were pain and function. RESULTS: The 26 eligible randomised trials involved 2565 participants. The mean sample size was 95 participants (range 16 to 579) per study; 10 studies were considered to be at low risk of bias. Overall, low-to-moderate-level evidence indicated that massage reduces pain in the short term compared to no treatment in people with shoulder pain and osteoarthritis of the knee, but not in those with low back pain or neck pain. Furthermore, low-to-moderate-level evidence indicated that massage improves function in the short term compared to no treatment in people with low back pain, knee arthritis or shoulder pain. Low-to-very-low-level evidence from single studies indicated no clear benefits of massage over acupuncture, joint mobilisation, manipulation or relaxation therapy in people with fibromyalgia, low back pain and general musculoskeletal pain. CONCLUSIONS: Massage therapy, as a stand-alone treatment, reduces pain and improves function compared to no treatment in some musculoskeletal conditions. When massage is compared to another active treatment, no clear benefit was evident. Copyright © 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. PMID: 26093806 [PubMed - in process] 2. Eur Spine J. 2016 Jan;25(1):34-61. doi: 10.1007/s00586-015-3891-4. Epub 2015 Apr 1. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Wong JJ(1,)(2,)(3), Côté P(4,)(5), Ameis A(6), Varatharajan S(4,)(7),

Varatharajan T(4,)(8), Shearer HM(4,)(7), Brison RJ(9,)(10), Sutton D(4,)(7), Randhawa K(4,)(7), Yu H(4,)(7), Southerst D(4,)(11), Goldgrub R(5), Mior S(5,)(7), Stupar M(4), Carroll LJ(12), Taylor-Vaisey A(4). Author information: (1)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. jessica.wong@uoit.ca. (2)Undergraduate Education, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. jessica.wong@uoit.ca. (3)Division of Graduate Studies, Canadian Memorial Chiropractic College, 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. jessica.wong@uoit.ca. (4)UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, University of Ontario Institute of Technology (UOIT) and Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (5)Faculty of Health Sciences, University of Ontario Institute of Technology (UOIT), 2000 Simcoe Street North, Oshawa, ON, L1H 7L7, Canada. (6)Certification Program in Insurance Medicine and Medico-legal Expertise, Faculty of Medicine, University of Montreal, N-414, Roger-Gaudry Building, 2900, Boulevard Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada. (7)Graduate Education and Research Programs, Canadian Memorial Chiropractic College (CMCC), 6100 Leslie Street, Toronto, ON, M2H 3J1, Canada. (8)Graduate Studies in Masters of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK, S7N 5E5, Canada. (9)Kingston General Hospital, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada. (10)Department of Emergency Medicine, School of Medicine, Queen's University, Kingston, ON, Canada. (11)Rebecca MacDonald Centre for Arthritis and Autoimmune Disease, Mount Sinai Hospital, Joseph and Wolf Lebovic Health Complex, 60 Murray Street, 2nd Floor (Main), Toronto, ON, M5T 3L9, Canada. (12)Injury Prevention Centre, University of Alberta, 4075 RTF, 8308 114 Street, Edmonton, T6G 2E1, AB, Canada. PURPOSE: To evaluate the effectiveness of non-steroidal anti-inflammatory drugs (NSAIDs) for the management of neck pain and associated disorders (NAD), whiplash-associated disorders, and non-specific low back pain (LBP) with or without radiculopathy. METHODS: We systematically searched six databases from 2000 to 2014. Random pairs of independent reviewers critically appraised eligible systematic reviews using the Scottish Intercollegiate Guidelines Network criteria. We included systematic reviews with a low risk of bias in our best evidence synthesis. RESULTS: We screened 706 citations and 14 systematic reviews were eligible for critical appraisal. Eight systematic reviews had a low risk of bias. For recent-onset NAD, evidence suggests that intramuscular NSAIDs lead to similar outcomes as combined manipulation and soft tissue therapy. For NAD (duration not specified), oral NSAIDs may be more effective than placebo. For recent-onset LBP, evidence suggests that: (1) oral NSAIDs lead to similar outcomes to placebo or a muscle relaxant; and (2) oral NSAIDs with bed rest lead to similar outcomes as placebo with bed rest. For persistent LBP, evidence suggests that: (1) oral NSAIDs are more effective than placebo; and (2) oral NSAIDs may be more effective than acetaminophen. For recent-onset LBP with radiculopathy, there is inconsistent evidence on the effectiveness of oral NSAIDs versus placebo. Finally, different oral NSAIDs lead to similar outcomes for neck and LBP with or without radiculopathy.

CONCLUSIONS: For NAD, oral NSAIDs may be more effective than placebo. Oral NSAIDs are more effective than placebo for persistent LBP, but not for recent-onset LBP. Different oral NSAIDs lead to similar outcomes for neck pain and LBP. PMID: 25827308 [PubMed - in process] 3. Glob Adv Health Med. 2014 Sep;3(5):49-64. doi: 10.7453/gahmj.2014.043. Integrative therapies for low back pain that include complementary and alternative medicine care: a systematic review. Kizhakkeveettil A(1), Rose K(1), Kadar GE(1). Author information: (1)Southern California University of Health Sciences, Whittier, United States. STUDY DESIGN: Systematic review of the literature. OBJECTIVE: To evaluate whether an integrated approach that includes different Complementary and Alternative Medicine (CAM) therapies combined or CAM therapies combined with conventional medical care is more effective for the management of low back pain (LBP) than single modalities alone. SUMMARY OF BACKGROUND DATA: LBP is one of the leading causes of disability worldwide, yet its optimal management is still unresolved. METHODS: The PRISMA Statement guidelines were followed. The Cochrane Back Review Group scale was used to rate the quality of the studies found. RESULTS: Twenty-one studies were found that met the inclusion criteria. The CAM modalities used in the studies included spinal manipulative therapy, acupuncture, exercise therapy, physiotherapy, massage therapy, and a topical ointment. Twenty studies included acupuncture and/or spinal manipulative therapy. Nine high quality studies showed that integrative care was clinically effective for the management of LBP. Spinal manipulative therapy combined with exercise therapy and acupuncture combined with conventional medical care or with exercise therapy appears to be promising approaches to the management of chronic cases of LBP. CONCLUSIONS: There is support in the literature for integrated CAM and conventional medical therapy for the management of chronic LBP. Further research into the integrated management of LBP is clearly needed to provide better guidance for patients and clinicians. Publisher: Abstract available from the publisher. Publisher: Abstract available from the publisher. PMCID: PMC4268606 PMID: 25568825 [PubMed] 4. J Man Manip Ther. 2014 May;22(2):59-74. doi: 10.1179/2042618613Y.0000000041. The efficacy of manual therapy and exercise for different stages of non-specific low back pain: an update of systematic reviews. Hidalgo B(1), Detrembleur C(1), Hall T(2), Mahaudens P(3), Nielens H(3).

Author information: (1)Institute of Neuroscience, Faculty of Motor Sciences, University of Louvain, Brussels, Belgium. (2)School of Physiotherapy, Curtin Innovation Health Research Institute, Curtin University of Technology, Perth, WA, Australia. (3)Institute of Neuroscience, Faculty of Motor Sciences, University of Louvain, Brussels, Belgium ; Rehabilitation and Physical Medicine, Saint-Luc Hospital University of Louvain, Brussels, Belgium. OBJECTIVE: to review and update the evidence for different forms of manual therapy (MT) for patients with different stages of non-specific low back pain (LBP). DATA SOURCES: MEDLINE, Cochrane-Register-of-Controlled-Trials, PEDro, EMBASE. METHOD: A systematic review of MT with a literature search covering the period of January 2000 to April 2013 was conducted by two independent reviewers according to Cochrane and PRISMA guidelines. A total of 360 studies were evaluated using qualitative criteria. Two stages of LBP were categorized; combined acute-subacute and chronic. Further sub-classification was made according to MT intervention: MT1 (manipulation); MT2 (mobilization and soft-tissue-techniques); and MT3 (MT1 combined with MT2). In each sub-category, MT could be combined or not with exercise or usual medical care (UMC). Consequently, quantitative evaluation criteria were applied to 56 eligible randomized controlled trials (RCTs), and hence 23 low-risk of bias RCTs were identified for review. Only studies providing new updated information (11/23 RCTs) are presented here. RESULTS: Acute-subacute LBP: STRONG-evidence in favour of MT1 when compared to sham for pain, function and health improvements in the short-term (1-3 months). MODERATE-evidence to support MT1 and MT3 combined with UMC in comparison to UMC alone for pain, function and health improvements in the short-term. Chronic LBP: MODERATE to STRONG-evidence in favour of MT1 in comparison to sham for pain, function and overall-health in the short-term. MODERATE-evidence in favour of MT3 combined with exercise or UMC in comparison to exercise and back-school was established for pain, function and quality-of-life in the short and long-term. LIMITED-evidence in favour of MT2 combined with exercise and UMC in comparison to UMC alone for pain and function from short to long-term. LIMITED-evidence of no effect for MT1 with extension-exercise compared to extension-exercise alone for pain in the short to long-term. CONCLUSION: This systematic review updates the evidence for MT with exercise or UMC for different stages of LBP and provides recommendations for future studies. PMCID: PMC4017797 PMID: 24976749 [PubMed] 5. Int J Sports Phys Ther. 2012 Dec;7(6):647-62. Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Kuczynski JJ(1), Schwieterman B, Columber K, Knupp D, Shaub L, Cook CE. Author information:

(1)Walsh University, North Canton, OH, USA. BACKGROUND CONTEXT: Low back pain (LBP) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses. A common intervention for LBP is spinal manipulation, a technique that is not specific to one scope of practice or profession. PURPOSE: The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain. METHODS: A search of the current literature was conducted using PubMed, CINAHL, SPORTDiscus, Pro Quest Nursing and Allied Health Source, Scopus, and Cochrane Controlled Trials Register. Studies were included if each involved: 1) individuals with LBP; 2) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations; 3) measurable clinical outcomes or efficiency of treatment measures, and 4) randomized control trials. The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Database (PEDro). RESULTS: Six randomized control trials met the inclusion criteria of this systematic review. The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported statistically significantly less medication use, health care utilization, and lost work time. CONCLUSION: Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain. PMCID: PMC3537457 PMID: 23316428 [PubMed] 6. Spine (Phila Pa 1976). 2013 Feb 1;38(3):E158-77. doi: 10.1097/BRS.0b013e31827dd89d. Spinal manipulative therapy for acute low back pain: an update of the cochrane review. Rubinstein SM(1), Terwee CB, Assendelft WJ, de Boer MR, van Tulder MW. Author information: (1)Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands. sm.rubinstein@vumc.nl STUDY DESIGN: Systematic review of interventions. OBJECTIVE: To assess the effects of spinal manipulative therapy (SMT) for acute low back pain. SUMMARY OF BACKGROUND DATA: SMT is one of many therapies for the treatment of low

back pain, which is a worldwide, extensively practiced intervention. METHODS: An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to March 13, 2011. RCTs that examined manipulation or mobilization in adults with acute low back pain (<6-week duration) were included. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life. Two authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE (grading of recommendations assessment, development, and evaluation) was used to assess the quality of the evidence. The effects were examined for SMT versus (1) inert interventions, (2) sham SMT, (3) other interventions, and (4) SMT as adjunct therapy. RESULTS: We identified 20 RCTs (total participants = 2674), 12 (60%) of which were not included in the previous review. In total, 6 trials (30% of all included studies) had a low risk of bias. In general, for the outcomes of pain and functional status, there is low- to very low-quality evidence suggesting no difference in effect for SMT when compared with inert interventions, sham SMT or as adjunct therapy. There was varying quality of evidence (from very low to moderate) suggesting no difference in effect for SMT when compared with other interventions. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT. CONCLUSION: SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation. PMID: 23169072 [PubMed - indexed for MEDLINE] 7. J Electromyogr Kinesiol. 2012 Oct;22(5):670-91. doi: 10.1016/j.jelekin.2012.03.006. Epub 2012 Apr 24. Patient-centered outcomes of high-velocity, low-amplitude spinal manipulation for low back pain: a systematic review. Goertz CM(1), Pohlman KA, Vining RD, Brantingham JW, Long CR. Author information: (1)Palmer College of Chiropractic, 741 Brady St., Davenport, IA, United States. christine.goertz@palmer.edu Low back pain (LBP) is a well-recognized public health problem with no clear gold standard medical approach to treatment. Thus, those with LBP frequently turn to treatments such as spinal manipulation (SM). Many clinical trials have been conducted to evaluate the efficacy or effectiveness of SM for LBP. The primary objective of this paper was to describe the current literature on patient-centered outcomes following a specific type of commonly used SM, high-velocity low-amplitude (HVLA), in patients with LBP. A systematic search strategy was used to capture all LBP clinical trials of HVLA using our predefined

patient-centered outcomes: visual analogue scale, numerical pain rating scale, Roland-Morris Disability Questionnaire, and the Oswestry Low Back Pain Disability Index. Of the 1294 articles identified by our search, 38 met our eligibility criteria. Like previous SM for LBP systematic reviews, this review shows a small but consistent treatment effect at least as large as that seen in other conservative methods of care. The heterogeneity and inconsistency in reporting within the studies reviewed makes it difficult to draw definitive conclusions. Future SM studies for LBP would benefit if some of these issues were addressed by the scientific community before further research in this area is conducted. Copyright © 2012. Published by Elsevier Ltd. PMID: 22534288 [PubMed - indexed for MEDLINE] 8. Evid Based Complement Alternat Med. 2012;2012:953139. doi: 10.1155/2012/953139. Epub 2011 Nov 24. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Furlan AD(1), Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L, Gagnier J, Ammendolia C, Dryden T, Doucette S, Skidmore B, Daniel R, Ostermann T, Tsouros S. Author information: (1)Clinical Epidemiology Methods Centre, Ottawa Hospital Research Institute, University of Ottawa Evidence-Based Practice Center, Box 208, Ottawa, ON, Canada K1H 8L6. Background. Back pain is a common problem and a major cause of disability and health care utilization. Purpose. To evaluate the efficacy, harms, and costs of the most common CAM treatments (acupuncture, massage, spinal manipulation, and mobilization) for neck/low-back pain. Data Sources. Records without language restriction from various databases up to February 2010. Data Extraction. The efficacy outcomes of interest were pain intensity and disability. Data Synthesis. Reports of 147 randomized trials and 5 nonrandomized studies were included. CAM treatments were more effective in reducing pain and disability compared to no treatment, physical therapy (exercise and/or electrotherapy) or usual care immediately or at short-term follow-up. Trials that applied sham-acupuncture tended towards statistically nonsignificant results. In several studies, acupuncture caused bleeding on the site of application, and manipulation and massage caused pain episodes of mild and transient nature. Conclusions. CAM treatments were significantly more efficacious than no treatment, placebo, physical therapy, or usual care in reducing pain immediately or at short-term after treatment. CAM therapies did not significantly reduce disability compared to sham. None of the CAM treatments was shown systematically as superior to one another. More efforts are needed to improve the conduct and reporting of studies of CAM treatments. PMCID: PMC3236015

PMID: 22203884 [PubMed] 9. Spine (Phila Pa 1976). 2011 Oct 1;36(21 Suppl):S120-30. doi: 10.1097/BRS.0b013e31822ef878. Comparative effectiveness of exercise, acupuncture, and spinal manipulation for low back pain. Standaert CJ(1), Friedly J, Erwin MW, Lee MJ, Rechtine G, Henrikson NB, Norvell DC. Author information: (1)Department of Rehabilitation Medicine, University of Washington, Seattle, WA 98104, USA. cjs1@uw.edu STUDY DESIGN: Systematic review. OBJECTIVE: We sought to answer the following clinical questions: (1) Is structured exercise more effective in the treatment of chronic low back pain (LBP) than spinal manipulative therapy (SMT)? (2) Is structured exercise more effective in the treatment of chronic LBP than acupuncture? (3) Is SMT more effective in the treatment of chronic LBP than acupuncture? (4) Do certain subgroups respond more favorably to specific treatments? (5) Are any of these treatments more cost-effective than the others? SUMMARY OF BACKGROUND DATA: Exercise, SMT, and acupuncture are widely used interventions in the treatment of chronic LBP. There is evidence that all of these approaches may offer some benefit for patients with chronic LBP when compared with usual care or no treatment. The relative benefits or cost-effectiveness of any one of these treatments when compared with the others are less well-defined, and it is difficult to identify specific subgroups of those with chronic LBP who may preferentially respond to a particular treatment modality. METHODS: A systematic review of the literature was performed to identify randomized controlled trials comparing a structured exercise program, SMT, or acupuncture with one another in patients with chronic LBP. RESULTS: Two studies were identified comparing the use of structured exercise with SMT that met our inclusion criteria. Although these studies utilized different approaches for the exercise and SMT treatment groups, patients in both groups improved in terms of pain and function in both studies. Using random-effects modeling, there was no difference between the exercise and SMT groups when the data from these studies were pooled. We identified no studies meeting our inclusion criteria that compared acupuncture with either structured exercise or SMT or that addressed the relative cost-effectiveness of these approaches in the treatment of patients with chronic LBP. CONCLUSION: The studies identified indicate that structured exercise and SMT appear to offer equivalent benefits in terms of pain and functional improvement for those with chronic LBP with clinical benefits evident within 8 weeks of care. However, the level of evidence is low. There is insufficient evidence to comment on the relative benefit of acupuncture compared with either structured exercise or SMT or to address the differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is also

insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP. CLINICAL RECOMMENDATIONS: Structured exercise and SMT appear to offer equivalent benefits in the management of pain and function for patients with nonspecific chronic LBP. If no clinical benefit is appreciated after using one of these approaches for 8 weeks, then the treatment plan should be reevaluated and consideration should be given to modifying the treatment approach or using alternate forms of care. Strength of recommendation: Weak.There is insufficient evidence regarding the relative benefits of the acupuncture compared with either structured exercise or SMT in the treatment of chronic LBP.There is insufficient evidence to address differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP. PMID: 21952184 [PubMed - indexed for MEDLINE] 10. Spine (Phila Pa 1976). 2011 Jun;36(13):E825-46. doi: 10.1097/BRS.0b013e3182197fe1. Spinal manipulative therapy for chronic low-back pain: an update of a Cochrane review. Rubinstein SM(1), van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Author information: (1)Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands. sm.rubinstein@vumc.nl Comment in Evid Based Med. 2012 Jun;17(3):81-2. STUDY DESIGN: Systematic review of interventions. OBJECTIVE: To assess the effects of spinal manipulative therapy (SMT) for chronic low-back pain. SUMMARY OF BACKGROUND DATA: SMT is one of the many therapies for the treatment of low-back pain, which is a worldwide, extensively practiced intervention. METHODS: Search methods. An experienced librarian searched for randomized controlled trials (RCTs) in multiple databases up to June 2009. Selection criteria. RCTs that examined manipulation or mobilization in adults with chronic low-back pain were included. The primary outcomes were pain, functional status, and perceived recovery. Secondary outcomes were return-to-work and quality of life. Data collection and analysis. Two authors independently conducted the study selection, risk of bias assessment, and data extraction. GRADE was used to assess the quality of the evidence. RESULTS: We included 26 RCTs (total participants = 6070), 9 of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. There is a high-quality evidence that SMT has a small, significant, but not clinically relevant, short-term effect on pain relief

(mean difference -4.16, 95% confidence interval -6.97 to -1.36) and functional status (standardized mean difference -0.22, 95% confidence interval -0.36 to -0.07) in comparison with other interventions. There is varying quality of evidence that SMT has a significant short-term effect on pain relief and functional status when added to another intervention. There is a very low-quality evidence that SMT is not more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT. CONCLUSIONS: High-quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. PMID: 21593658 [PubMed - indexed for MEDLINE] 11. BMJ Clin Evid. 2011 May 9;2011. pii: 1102. Low back pain (acute). McIntosh G(1), Hall H. Author information: (1)CBI Health Group Research Dept, Toronto, ON, Canada. INTRODUCTION: Low back pain affects about 70% of people in resource-rich countries at some point in their lives. Acute low back pain can be self-limiting; however, 1 year after an initial episode, as many as 33% of people still have moderate-intensity pain and 15% have severe pain. Acute low back pain has a high recurrence rate; 75% of those with a first episode have a recurrence. Although acute episodes may resolve completely, they may increase in severity and duration over time. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments for acute low back pain? What are the effects of local injections for acute low back pain? What are the effects of non-drug treatments for acute low back pain? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 49 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, advice to stay active, analgesics (paracetamol, opioids), back exercises, back schools, bed rest, behavioural therapy, electromyographic biofeedback, epidural corticosteroid injections, lumbar supports, massage, multidisciplinary treatment programmes,

muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulation, temperature treatments (short-wave diathermy, ultrasound, ice, heat), traction, and transcutaneous electrical nerve stimulation (TENS). PMCID: PMC3217769 PMID: 21549023 [PubMed - in process] 12. Spine (Phila Pa 1976). 2011 Feb 1;36(3):230-42. doi: 10.1097/BRS.0b013e318202ac73. A Cochrane review of combined chiropractic interventions for low-back pain. Walker BF(1), French SD, Grant W, Green S. Author information: (1)Faculty of Health Sciences, School of Chiropractic and Sports Science, Murdoch University, Murdoch, Australia. bruce.walker@murdoch.edu.au STUDY DESIGN: Cochrane systematic review of randomized controlled trials. OBJECTIVE: To determine the effects of combined chiropractic interventions on pain, disability, back-related function, overall improvement, and patient satisfaction in adults with low-back pain (LBP). SUMMARY OF BACKGROUND DATA: Chiropractors commonly use a combination of interventions to treat people with LBP, but little is known about the effects of this care. METHODS: We used a comprehensive search strategy. All randomized trials comparing combined chiropractic interventions (rather than spinal manipulation alone) with no treatment or other therapies were included. At least two authors selected studies, assessed bias risk, and extracted data. Descriptive synthesis and meta-analyses were performed. RESULTS: We included 12 studies involving 2887 LBP participants. Three studies had low risk of bias. Included studies evaluated a range of chiropractic procedures in a variety of subpopulations with LBP. For acute and subacute LBP, chiropractic interventions improved short- and medium-term pain (standardized mean difference [SMD] -0.25 [95% CI: -0.46 to -0.04] and MD -0.89 [95%CI: -1.60 to -0.18]) compared with other treatments, but there was no significant difference in long-term pain (MD -0.46 [95% CI -1.18 to 0.26]). Short-term improvement in disability was greater in the chiropractic group compared to other therapies (SMD -0.36 [95% CI: -0.70 to -0.02]). However, the effect was small and studies contributing to these results had high risk of bias. There was no difference in medium- and long-term disability. No difference was demonstrated for combined chiropractic interventions for chronic LBP and studies that had a mixed population of LBP. CONCLUSION: Combined chiropractic interventions slightly improved pain and disability in the short term and pain in the medium term for acute/subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions. PMID: 21248591 [PubMed - indexed for MEDLINE]

13. Eur Spine J. 2011 Jul;20(7):1024-38. doi: 10.1007/s00586-010-1676-3. Epub 2011 Jan 13. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Lin CW(1), Haas M, Maher CG, Machado LA, van Tulder MW. Author information: (1)The George Institute for Global Health and Sydney Medical School, The University of Sydney, PO Box M201, Missenden Rd, Sydney, NSW 2050, Australia. clin@george.org.au Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline. PMCID: PMC3176706 PMID: 21229367 [PubMed - indexed for MEDLINE] 14. Eur Spine J. 2011 Jul;20(7):1012-23. doi: 10.1007/s00586-010-1675-4. Epub 2011 Jan 4. Cost-effectiveness of general practice care for low back pain: a systematic review. Lin CW(1), Haas M, Maher CG, Machado LA, van Tulder MW. Author information:

(1)The George Institute for Global Health and Sydney Medical School, The University of Sydney, PO Box M201, Missenden Rd, Sydney, NSW 2050, Australia. clin@george.org.au Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves. PMCID: PMC3176699 PMID: 21203890 [PubMed - indexed for MEDLINE] 15. Spine J. 2010 Oct;10(10):918-40. doi: 10.1016/j.spinee.2010.07.389. NASS Contemporary Concepts in Spine Care: spinal manipulation therapy for acute low back pain. Dagenais S(1), Gay RE, Tricco AC, Freeman MD, Mayer JM. Author information: (1)Palladian Health, 2732 Transit Rd, West Seneca, NY 14224, USA. simon@spine-research.com BACKGROUND CONTEXT: Low back pain (LBP) continues to be a very prevalent, disabling, and costly spinal disorder. Numerous interventions are routinely used for symptoms of acute LBP. One of the most common approaches is spinal manipulation therapy (SMT). PURPOSE: To assess the current scientific literature related to SMT for acute LBP. PATIENT SAMPLE: Not applicable. OUTCOME MEASURES: Not applicable. DESIGN: Systematic review (SR). METHODS: Literature was identified by searching MEDLINE using indexed and free

text terms. Studies were included if they were randomized controlled trials (RCTs) published in English, and SMT was administered to a group of patients with LBP of less than 3 months. RCTs included in two previous SRs were also screened, as were reference lists of included studies. Combined search results were screened for relevance by two reviewers. Data related to methods, risk of bias, harms, and results were abstracted independently by two reviewers. RESULTS: The MEDLINE search returned 699 studies, of which six were included; an additional eight studies were identified from two previous SRs. There were 2,027 participants in the 14 included RCTs, which combined SMT with education (n=5), mobilization (MOB) (n=4), exercise (n=3), modalities (n=3), or medication (n=2). The groups that received SMT were most commonly compared with those receiving physical modalities (n=7), education (n=6), medication (n=5), exercise (n=5), MOB (n=3), or sham SMT (n=2). The most common providers of SMT were chiropractors (n=5) and physical therapists (n=5). Most studies (n=6) administered 5 to 10 sessions of SMT over 2 to 4 weeks for acute LBP. Outcomes measured included pain (n=10), function (n=10), health-care utilization (n=6), and global effect (n=5). Studies had a follow-up of less than 1 month (n=7), 3 months (n=1), 6 months (n=3), 1 year (n=2), or 2 years (n=1). When compared with various control groups, results for improvement in pain in the SMT groups were superior in three RCTs and equivalent in three RCTs in the short term, equivalent in four RCTs in the intermediate term, and equivalent in two RCTs in the long term. For improvement in function, results from the SMT groups were superior in one RCT and equivalent in four RCTs in the short term, superior in one RCT and equivalent in one RCT in the intermediate term, and equivalent in one RCT and inferior in one RCT in the long term. No harms related to SMT were reported in these RCTs. CONCLUSIONS: Several RCTs have been conducted to assess the efficacy of SMT for acute LBP using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone. Copyright © 2010 Elsevier Inc. All rights reserved. PMID: 20869008 [PubMed - indexed for MEDLINE] 16. Spine J. 2010 Jun;10(6):514-29. doi: 10.1016/j.spinee.2010.03.032. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Dagenais S(1), Tricco AC, Haldeman S. Author information: (1)Palladian Health, 2732 Transit Rd, West Seneca, NY 14224, USA. simon@spine-research.com Comment in

Spine J. 2010 Jun;10(6):512-3. BACKGROUND CONTEXT: Low back pain (LBP) is a prevalent, costly, and challenging condition to manage. Clinicians must choose among numerous assessment and management options. Several recent clinical practice guidelines (CPGs) on LBP have attempted to inform these decisions by evaluating and summarizing the best available supporting evidence. The quality and consistency of recommendations from these CPGs are currently unknown. PURPOSE: To conduct a systematic review of recent CPGs and synthesize their recommendations on assessing and managing LBP for clinicians. STUDY DESIGN/SETTING: Systematic review. METHODS: Literature search using MEDLINE, National Guidelines Clearinghouse, National Institute for Clinical Excellence, Internet search engines, and references of known articles. Only CPGs related to both assessment and management of LBP written in English were eligible; CPGs that summarized evidence from before the year 2000 were excluded. Data related to methods and recommendations for assessment and management of LBP were abstracted independently by two reviewers. Methodological quality was assessed using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument by two reviewers. RESULTS: The search uncovered 669 citations, of which 95 were potentially relevant and 10 were included in the review; 6 discussed acute LBP, 6 chronic LBP, and 6 LBP with neurologic involvement. Methods used to develop CPGs varied, but the overall methodological quality was high as defined by AGREE scores. Recommendations for assessment of LBP emphasized the importance of ruling out potentially serious spinal pathology, specific causes of LBP, and neurologic involvement, as well as identifying risk factors for chronicity and measuring the severity of symptoms and functional limitations, through the history, physical, and neurologic examination. Recommendations for management of acute LBP emphasized patient education, with short-term use of acetaminophen, nonsteroidal anti-inflammatory drugs, or spinal manipulation therapy. For chronic LBP, the addition of back exercises, behavioral therapy, and short-term opioid analgesics was suggested. Management of LBP with neurologic involvement was similar, with additional consideration given to magnetic resonance imaging or computed tomography to identify appropriate candidates willing to undergo epidural steroid injections or decompression surgery if more conservative approaches are not successful. CONCLUSIONS: Recommendations from several recent CPGs regarding the assessment and management of LBP were similar. Clinicians who care for patients with LBP should endeavor to adopt these recommendations to improve patient care. Future CPGs may wish to invite coauthors from targeted clinician user groups, increase patient participation, update their literature searches before publication, conduct their own quality assessment of studies, and consider cost-effectiveness and other aspects in their recommendations more explicitly. Copyright 2010 Elsevier Inc. All rights reserved. PMID: 20494814 [PubMed - indexed for MEDLINE] 17. Spine (Phila Pa 1976). 2008 Apr 15;33(8):914-8. doi: 10.1097/BRS.0b013e31816b4be4.

The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review. Johnston BC(1), da Costa BR, Devereaux PJ, Akl EA, Busse JW; Expertise-Based RCT Working Group. Author information: (1)Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. STUDY DESIGN: Systematic review. OBJECTIVE: To assess current use of expertise-based randomization in trials of acupuncture or spinal manipulation for low back pain. SUMMARY OF BACKGROUND DATA: The randomized clinical trial is often referred to as the gold standard for providing evidence to guide therapeutic decisions. Random allocation of participants to intervention and control groups theoretically should balance these groups for both known and unknown prognostic factors; however, when randomizing patients to competing interventions in which the clinician's skill is a central aspect of the intervention, (e.g., surgery, chiropractic, rehabilitation) a differential expertise bias may exist if a majority of clinicians participating have greater expertise in 1 of the 2 interventions under evaluation. Randomizing patients to therapists experienced in the interventions under investigation can overcome this bias. METHODS: We systematically identified relevant randomized controlled trials published up to December 2005. Two independent reviewers extracted data in duplicate using a standardized form. RESULTS: Of 12 eligible trials, none made use of an expertise-based randomized trial design. CONCLUSION: Investigators designing acupuncture or spinal manipulation trials in which 2 or more active therapies are compared should consider expertise-based randomization to increase the validity and feasibility of their efforts. PMID: 18404113 [PubMed - indexed for MEDLINE] 18. Spine J. 2008 Jan-Feb;8(1):213-25. doi: 10.1016/j.spinee.2007.10.023. Evidence-informed management of chronic low back pain with spinal manipulation and mobilization. Bronfort G(1), Haas M, Evans R, Kawchuk G, Dagenais S. Author information: (1)Northwestern Health Sciences University, 2501 W 84th St, Bloomington, MN 55431, USA. gbronfort@nwhealth.edu The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care

resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP. PMID: 18164469 [PubMed - indexed for MEDLINE] 19. Spine J. 2008 Jan-Feb;8(1):142-9. doi: 10.1016/j.spinee.2007.09.010. Evidence-informed management of chronic low back pain with medicine-assisted manipulation. Dagenais S(1), Mayer J, Wooley JR, Haldeman S. Author information: (1)Division of Orthopaedic Surgery and Department of Epidemiology and Community Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. simon@camresearch.com The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing among available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to CLBP, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence Informed Management of Chronic Low Back Pain Without Surgery. Articles in this supplement were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid

in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP. PMID: 18164462 [PubMed - indexed for MEDLINE] 20. BMC Musculoskelet Disord. 2005 Aug 4;6:43. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. Licciardone JC(1), Brimhall AK, King LN. Author information: (1)Osteopathic Research Center, University of North Texas Health Science Center, Fort Worth, TX 76107, USA. jlicciar@hsc.unt.edu BACKGROUND: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain. METHODS: Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature. Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, stratified meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and stratified meta-analyses. RESULTS: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up. CONCLUSION: OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.

PMCID: PMC1208896 PMID: 16080794 [PubMed - indexed for MEDLINE] 21. Spine J. 2004 May-Jun;4(3):335-56. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Bronfort G(1), Haas M, Evans RL, Bouter LM. Author information: (1)Department of Research, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W, 84th Street Bloomington, MN 55431, USA. gbronfort@nwhealth.edu BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when

compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. CONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care. PMID: 15125860 [PubMed - indexed for MEDLINE] 22. Clin Rehabil. 2002 Dec;16(8):811-20. Systematic review of conservative interventions for subacute low back pain. Pengel HM(1), Maher CG, Refshauge KM. Author information: (1)School of Physiotherapy, University of Sydney, Sydney, NSW, Australia. hpen1533@mail.usyd.edu.au OBJECTIVE: To evaluate the effect of conservative interventions on clinically relevant outcome measures for patients with subacute low back pain. This is particularly important because effective treatment for subacute low back pain will prevent the transition to chronic low back pain, a condition that is largely responsible for the high health care costs of low back pain. DESIGN: Systematic review of randomized controlled trials. MAIN OUTCOME MEASURES: Methodological quality of each trial was assessed. Effect sizes and 95% confidence intervals were calculated for pain and disability and risk ratios for return to work. RESULTS: Thirteen trials were located, evaluating the following interventions: manipulation, back school, exercise, advice, transcutaneous electrical nerve stimulation (TENS), hydrotherapy, massage, corset, cognitive behavioural treatment and co-ordination of primary health care. Most studies were of low quality and did not show a statistically significant effect of intervention. For the strict duration of low back pain (six weeks to three months), no evidence of high internal validity was found but when other methodological criteria were considered, evidence was found for the efficacy of advice. Furthermore, there is evidence that when a broader view is taken of the duration of subacute low back pain (seven days to six months), other treatments (e.g. manipulation, exercise,

TENS) may be effective. CONCLUSIONS: Our review identified a major gap in the evidence for interventions that are currently recommended in clinical practice guidelines for the treatment of subacute low back pain. Lack of a uniform definition of subacute low back pain further limited current evidence. PMID: 12501942 [PubMed - indexed for MEDLINE] 23. Aust J Physiother. 2002;48(4):277-84. Does spinal manipulative therapy help people with chronic low back pain? Ferreira ML(1), Ferreira PH, Latimer J, Herbert R, Maher CG. Author information: (1)The University of Sydney, Australia. mfer5142@mail.usyd.edu.au Comment in Aust J Physiother. 2003;49(2):139. A systematic review of randomised clinical trials was conducted to assess the effect of spinal manipulative therapy on clinically relevant outcomes in patients with chronic low back pain. Databases searched included EMBASE, CINAHL, MEDLINE and PEDro. Methodological assessment of the trials was performed using the PEDro scale. Where there was sufficient homogeneity, a meta-analysis was conducted. Nine trials of mostly moderate quality were included in the review. Two trials were pooled comparing spinal manipulative therapy and placebo treatment, and two other trials were pooled comparing spinal manipulative therapy and non-steroidal anti-inflammatory drugs (NSAIDs). Spinal manipulative therapy reduced pain by 7mm on a 100mm visual analogue scale (95% CI 1 to 14) at one month follow-up when compared with placebo treatment, and by 14mm (95% CI -11 to 40) when compared with NSAIDs. Spinal manipulative therapy reduced disability by 6 points (95% CI 1 to 12) on a 100-point disability questionnaire when compared with NSAIDs. It is concluded that spinal manipulation does not produce clinically worthwhile decreases in pain compared with sham treatment, and does not produce clinically worthwhile reductions in disability compared with NSAIDs for patients with chronic low back pain. It is not clear whether spinal manipulation is more effective than NSAIDs in reducing pain of patients with chronic low back pain. PMID: 12443522 [PubMed - indexed for MEDLINE] 24. Spine (Phila Pa 1976). 2002 Sep 1;27(17):1896-910. Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Furlan AD(1), Brosseau L, Imamura M, Irvin E. Author information:

(1)Institute for Work & Health, Toronto, Canada. afurlan@iwh.on.ca BACKGROUND: Low back pain (LBP) is one of the most common and costly musculoskeletal problems in modern society. Proponents of massage therapy claim it can minimize pain and disability and speed return-to-normal function. OBJECTIVES: To assess the effects of massage therapy for nonspecific LBP. SEARCH STRATEGY: We searched MEDLINE, Embase, Cochrane Controlled Trials Register, HealthSTAR, CINAHL, and dissertation abstracts through May 2001 with no language restrictions. References in the included studies and in reviews of the literature were screened. Contact with content experts and massage associations was also made. SELECTION CRITERIA: The studies had to be randomized or quasirandomized trials investigating the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific LBP. DATA COLLECTION AND ANALYSIS: Two reviewers blinded to authors, journals, and institutions selected the studies, assessed the methodologic quality using the criteria recommended by the Cochrane Collaboration Back Review Group, and extracted the data using standardized forms. The studies were analyzed in a qualitative way because of heterogeneity of population, massage technique, comparison groups, timing, and type of outcome measured. RESULTS: Nine publications reporting on eight randomized trials were included. Three had low and five had high methodologic quality scores. One study was published in German, and the rest, in English. Massage was compared with an inert treatment (sham laser) in one study that showed that massage was superior, especially if given in combination with exercises and education. In the other seven studies, massage was compared with different active treatments. They showed that massage was inferior to manipulation and transcutaneous electrical nerve stimulation; massage was equal to corsets and exercises; and massage was superior to relaxation therapy, acupuncture, and self-care education. The beneficial effects of massage in patients with chronic LBP lasted at least 1 year after the end of the treatment. One study comparing two different techniques of massage concluded in favor of acupuncture massage over classic (Swedish) massage. CONCLUSIONS: Massage might be beneficial for patients with subacute and chronic nonspecific LBP, especially when combined with exercises and education. The evidence suggests that acupuncture massage is more effective than classic massage, but this needs confirmation. More studies are needed to confirm these conclusions, to assess the effect of massage on return-to-work, and to measure longer term effects to determine cost-effectiveness of massage as an intervention for LBP. PMID: 12221356 [PubMed - indexed for MEDLINE] 25. Spine (Phila Pa 1976). 1996 Dec 15;21(24):2860-71; discussion 2872-3. Spinal manipulation for low back pain. An updated systematic review of randomized clinical trials. Koes BW(1), Assendelft WJ, van der Heijden GJ, Bouter LM. Author information:

(1)Institute for Research in Extramural Medicine, Vrije Universiteit Amsterdam, The Netherlands. STUDY DESIGN: Systematic review of randomized clinical trials. OBJECTIVES: To assess the efficacy of spinal manipulation for patients with low back pain. SUMMARY OF BACKGROUND DATA: The management of low back pain remains controversial. Spinal manipulation is a widely used treatment option for low back pain. Recently issued clinical guidelines suggest that spinal manipulation may be effective for patients with acute low back pain. METHODS: A computer-aided search for published papers was conducted, and the methods of the studies identified were assessed. Scores were assigned for quality of methods (based on four main categories: study population, interventions, measurement of effect, and data presentation and analysis), the conclusion of authors regarding spinal manipulation, and the results based on the main outcome measure. RESULTS: Thirty-six randomized clinical trials comparing spinal manipulation with other treatments were identified. The highest score of a trial was 60 points (maximum score was set at 100 points), indicating that most were of poor quality. Nineteen studies (53%) showed favorable results for manipulation. In addition, five studies (14%) reported positive results in one or more subgroups only. Among the five studies with 50-60 points, three were positive, and two were positive only for a subgroup of the study population. Eleven trials compared manipulation with some placebo therapy, with inconsistent results. There appeared to be no clear relation between the methodologic score and the overall outcome of the studies. Twelve trials included patients with acute low back pain only. Of these, five reported positive results, four reported negative results, and three reported positive results in a subgroup of the study population only. There were eight trials comparing manipulation with other conservative treatment modalities, focusing on patients with subacute or chronic low back pain. Of these, five reported positive results, two reported negative results, and in one study no conclusion was presented. There were only 16 studies that included an effect measurement of at least 3 months. In only six of these do the authors report positive effects of manipulation. CONCLUSIONS: The efficacy of spinal manipulation for patients with acute or chronic low back pain has not been demonstrated with sound randomized clinical trials. There certainly are indications that manipulation might be effective in some subgroups of patients with low back pain. These impressions justify additional research efforts on this topic. Methodologic quality remains a critical aspect that should be dealt with in future studies. PMID: 9112710 [PubMed - indexed for MEDLINE] 26. Spine (Phila Pa 1976). 1997 Sep 15;22(18):2128-56. Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. van Tulder MW(1), Koes BW, Bouter LM.

Author information: (1)Institute for Research in Extramural Medicine, Vrije Universiteit, Amsterdam, The Netherlands. Comment in ACP J Club. 1998 May-Jun;128(3):65. Spine (Phila Pa 1976). 1998 Jun 1;23(11):1288-91. STUDY DESIGN: A systematic review of randomized controlled trials. OBJECTIVES: To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain. SUMMARY OF BACKGROUND DATA: Many treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy. METHODS: A rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results. RESULTS: The number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti-inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term effects. CONCLUSIONS: The quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain. PMID: 9322325 [PubMed - indexed for MEDLINE]

Manipulation and neck pain 1. J Man Manip Ther. 2014 Aug;22(3):141-53. doi: 10.1179/2042618613Y.0000000043. Thoracic manipulation versus mobilization in patients with mechanical neck pain: a systematic review. Young JL(1), Walker D(1), Snyder S(1), Daly K(1). Author information: (1)Franklin Pierce University, Goodyear, AZ, USA. OBJECTIVES: Thoracic manipulation is widely used in physical therapy and has been shown to be effective at addressing mechanical neck pain. However, thoracic mobilization may produce similar effects. The purpose of this systematic review was to evaluate the current literature regarding the effectiveness of thoracic manipulation versus mobilization in patients with mechanical neck pain. METHODS: ProQuest, NCBI-PubMed, APTA's Hooked on Evidence, Cochrane Library, CINAHL and SPORTDiscus were searched to identify relevant studies. Fourteen studies meeting the inclusion criteria were analyzed using the Physiotherapy Evidence Database (PEDro) scale and the GRADE approach. RESULTS: The literature as assessed by the PEDro scale was fair and the GRADE method showed overall quality ranging from very low to moderate quality. The 14 included studies showed positive outcomes on cervical pain levels, range of motion, and/or disability with the use of thoracic manipulation or mobilization. There was a paucity of literature directly comparing thoracic manipulation and mobilization. DISCUSSION: Current limitations in the body of research, specifically regarding the use of thoracic mobilization, limit the recommendation of its use compared to thoracic manipulation for patients with mechanical neck pain. There is, however, a significant amount of evidence, although of varied quality, for the short-term benefits of thoracic manipulation in treating patients with this condition. Further high quality research is necessary to determine which technique is more effective in treating patients with mechanical neck pain. PMCID: PMC4101553 PMID: 25125936 [PubMed] 2. Evid Based Spine Care J. 2013 Apr;4(1):30-41. doi: 10.1055/s-0033-1341605. The outcomes of manipulation or mobilization therapy compared with physical therapy or exercise for neck pain: a systematic review. Schroeder J(1), Kaplan L(2), Fischer DJ(3), Skelly AC(3). Author information: (1)Department of Spine Surgery, The Hospital for Special Surgery, New York, New York, United States. (2)Department of Orthopedic Surgery, Spine Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel. (3)Spectrum Research, Inc., Tacoma, Washington, United States.

Study Design Systematic review. Study Rationale Neck pain is a prevalent condition. Spinal manipulation and mobilization procedures are becoming an accepted treatment for neck pain. However, data on the effectiveness of these treatments have not been summarized. Objective To compare manipulation or mobilization of the cervical spine to physical therapy or exercise for symptom improvement in patients with neck pain. Methods A systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Database, and bibliographies of key articles, which compared spinal manipulation or mobilization therapy with physical therapy or exercise in patients with neck pain. Articles were included based on predetermined criteria and were appraised using a predefined quality rating scheme. Results From 197 citations, 7 articles met all inclusion and exclusion criteria. There were no differences in pain improvement when comparing spinal manipulation to exercise, and there were inconsistent reports of pain improvement in subjects who underwent mobilization therapy versus physical therapy. No disability improvement was reported between treatment groups in studies of acute or chronic neck pain patients. No functional improvement was found with manipulation therapy compared with exercise treatment or mobilization therapy compared with physical therapy groups in patients with acute pain. In chronic neck pain subjects who underwent spinal manipulation therapy compared to exercise treatment, results for short-term functional improvement were inconsistent. Conclusion The data available suggest that there are minimal short- and long-term treatment differences in pain, disability, patient-rated treatment improvement, treatment satisfaction, health status, or functional improvement when comparing manipulation or mobilization therapy to physical therapy or exercise in patients with neck pain. This systematic review is limited by the variability of treatment interventions and lack of standardized outcomes to assess treatment benefit. PMCID: PMC3699243 PMID: 24436697 [PubMed] 3. J Man Manip Ther. 2013 May;21(2):113-24. doi: 10.1179/2042618612Y.0000000025. Conservative physical therapy management for the treatment of cervicogenic headache: a systematic review. Racicki S(1), Gerwin S(1), Diclaudio S(1), Reinmann S(1), Donaldson M(1). Author information: (1)Department of Physical Therapy, Walsh University, North Canton, OH, USA. PURPOSE: The purpose of this systematic review was to assess the effectiveness of conservative physical therapy management of cervicogenic headache (CGH). INTRODUCTION: CGH affects 22-25% of the adult population with females being four times more affected than men. CGHs are thought to arise from musculoskeletal impairments in the neck with symptoms most commonly consisting of suboccipital neck pain, dizziness, and lightheadedness. Currently, both invasive and non-invasive techniques are available to address these symptoms; however, the efficacy of non-invasive treatment techniques has yet to be established. METHODS: Computerized searches of CINAHL, ProQuest, PubMed, MEDLINE, and

SportDiscus, were performed to obtain a qualitative analysis of the literature. Inclusion criteria were: randomized controlled trial design, population diagnosed with CGH using the International Headache Society classification, at least one baseline measurement and one outcomes measure, and assessment of a conservative technique. Physiotherapy evidence-based database scale was utilized for quality assessment. RESULTS: One computerized database search and two hand searches yielded six articles. Of the six included randomized controlled trials, all were considered to be of 'good quality' utilizing the physiotherapy evidence-based database scale. The interventions utilized were: therapist-driven cervical manipulation and mobilization, self-applied cervical mobilization, cervico-scapular strengthening, and therapist-driven cervical and thoracic manipulation. With the exception of one study, all reported reduction in pain and disability, as well as improvement in function. CONCLUSION: Calculated effect sizes allowed comparison of intervention groups between studies. A combination of therapist-driven cervical manipulation and mobilization with cervico-scapular strengthening was most effective for decreasing pain outcomes in those with CGH. PMCID: PMC3649358 PMID: 24421621 [PubMed] 4. J Manipulative Physiol Ther. 2015 Nov-Dec;38(9):672-6. doi: 10.1016/j.jmpt.2013.09.005. Epub 2014 Jan 3. The Association Between Cervical Spine Manipulation and Carotid Artery Dissection: A Systematic Review of the Literature. Chung CL(1), Côté P(2), Stern P(3), L'Espérance G(4). Author information: (1)Tutor, Graduate Education Research Programs, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. Electronic address: cchung@cmcc.ca. (2)Canada Research Chair in Disability Prevention and Rehabilitation, Canada Research Chairs, Canadian Federal Government; Associate Professor, Health Sciences Department, University of Ontario Institute of Technology, Oshawa, Ontario, Canada; Director, UOIT-CMCC Centre for the Study of Disability Prevention and Rehabilitation, Institute of Technology, Oshawa, Ontario, Canada. (3)Director, Graduate Education Research Programs, Canadian Memorial Chiropractic College, Toronto, Ontario, Canada. (4)President, Quebec Society of Experts in Medicolegal Evaluation, Montreal, Quebec, Canada. OBJECTIVE: Controversy surrounds the safety of cervical spine manipulation. Ischemic stroke secondary to cervical spine manipulation is a hypothesized adverse event. In Canada, the seriousness of these events and their perceived association to cervical spine manipulation has led some members of the public to call for a ban of the procedure. The primary objective of this study was to determine the incidence of internal carotid artery (ICA) dissection after cervical spine manipulation in patients who experience neck pain and its associated disorders. The secondary objective was to determine whether cervical

spine manipulation is associated with an increased risk of ICA dissection in patients with neck pain, upper back pain, or headaches. METHODS: We systematically searched MEDLINE, CINAHL, Alternative Health, AMED, Index to Chiropractic Literature, and EMBASE from 1970 to November 2012. Two independent reviewers used standardized criteria to screen the eligibility of articles. We considered cohort studies, case-control studies, and randomized clinical trials that addressed our objectives. We planned to critically appraise eligible articles using the Scottish Intercollegiate Guideline Network methodology. RESULTS: We did not find any epidemiologic studies that measured the incidence of cervical spine manipulation and ICA dissection. Similarly, we did not find any studies that determined whether cervical spine manipulation is associated with ICA dissection. CONCLUSIONS: The incidence of ICA dissection after cervical spine manipulation is unknown. The relative risk of ICA dissection after cervical spine manipulation compared with other health care interventions for neck pain, back pain, or headache is also unknown. Although several case reports and case series raise the hypothesis of an association, we found no epidemiologic studies that validate this hypothesis. Copyright © 2013 National University of Health Sciences. Published by Elsevier Inc. All rights reserved. PMID: 24387889 [PubMed - in process] 5. Disabil Rehabil. 2013 Sep;35(20):1677-85. doi: 10.3109/09638288.2012.750689. Epub 2013 Jan 23. The effect of thoracic spine manipulation on pain and disability in patients with non-specific neck pain: a systematic review. Huisman PA(1), Speksnijder CM, de Wijer A. Author information: (1)Paramedical Centre Katwijk-Rijnsburg , Rijnsburg , the Netherlands . PURPOSE: The aim of this systematic review was to determine the efficacy of thoracic spine manipulation (TSM) in reducing pain and disability in patients diagnosed with non-specific neck pain. METHODS: An extensive literature search of PubMed, The Cochrane Library, CINAHL and EMBASE was conducted in February 2012. Randomized controlled trials (RCTs) or controlled clinical trials evaluating the effect of TSM in patients aged 18 to 65 years with non-specific neck pain were eligible. Methodological quality of the studies was assessed according to the Physiotherapy Evidence Database scale (PEDro). Qualitative analyses were conducted by means of the best evidence synthesis of van Peppen et al. RESULTS: The methodological quality of the 10 included RCTs (677 patients) varied between four and eight points. Eight studies reported significant reduction in pain and/or disability by TSM. Overall, according to the best evidence synthesis, there is insufficient evidence that TSM is more effective than control

interventions in reducing pain and disability in patients with non-specific neck pain. CONCLUSIONS: TSM has a therapeutic benefit to some patients with neck pain, when compared to the effect of interventions such as electrotherapy/thermal programme, infrared radiation therapy, spinal mobilization and exercises. However, in comparison to cervical spine manipulation, no evidence is found that TSM is more effective in reducing pain and disability. Implications for Rehabilitation TSM is often used in the treatment of non-specific neck pain, which is a major health problem in the Western society. There is insufficient evidence that TSM is more effective in reducing pain and disability than control treatments in patients with non-specific neck pain. Despite the insufficient evidence that TSM is more effective than control treatments, TSM has a therapeutic benefit to some patients with neck pain. Therefore, TSM alone or in combination with other interventions is a suitable intervention to use in the treatment of non-specific neck pain. PMID: 23339721 [PubMed - indexed for MEDLINE] 6. Joint Bone Spine. 2013 Oct;80(5):508-15. doi: 10.1016/j.jbspin.2012.10.006. Epub 2012 Nov 16. Systematic review of manual therapies for nonspecific neck pain. Vincent K(1), Maigne JY, Fischhoff C, Lanlo O, Dagenais S. Author information: (1)Société franco-européenne de chiropratique (SOFEC), 25, avenue du Raincy, 93250 Villemomble, France. OBJECTIVE: To evaluate the effectiveness of manual therapies in the treatment of nonspecific neck pain. MATERIALS AND METHODS: Medline and the Cochrane Library were searched for randomized controlled trials of manual therapy or mobilization, used alone or with exercises to treat pain and functional impairment related to nonspecific neck pain. Cochrane Back Review Group criteria were used to assess the quality of the trials and the level of evidence (unclear, limited, moderate, or high) for short-, medium-, and long-term effects. RESULTS: Of 27 identified trials, 18 were of high quality. In acute neck pain, effective treatments were thoracic manipulation combined with electrothermal therapy in the short term and cervical manipulation in the long term. In chronic neck pain and neck pain of variable duration, both pain and function improved consistently at all follow-up time points. None of the manual therapies used alone or in combination was superior over the others. In the long term, exercises alone or combined with manual therapies were superior over manual therapies used alone. CONCLUSION: Manual therapies contribute usefully to the management of nonspecific neck pain. The level of evidence is moderate for short-term effects of upper thoracic manipulation in acute neck pain, limited for long-term effects of neck manipulation, and limited for all techniques and follow-up durations in chronic neck pain.

Copyright © 2012 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved. PMID: 23165183 [PubMed - indexed for MEDLINE] 7. J Can Chiropr Assoc. 2012 Mar;56(1):18-28. Cervical radiculopathy: a systematic review on treatment by spinal manipulation and measurement with the Neck Disability Index. Rodine RJ(1), Vernon H. Author information: (1)Graduate Student, Graduate Education and Research Programs, Canadian Memorial Chiropractic College, Toronto, Ontario. Private Practice, Smiths Falls, Ontario.12 William Street West, Smiths Falls, Ontario, K7A 1M9.Tel.: (613) 205-0978. E-mail: drrr@restorativehealth.ca. Cervical radiculopathy (CR), while less common than conditions with neck pain alone, can be a significant cause of neck pain and disability; thus the determination of adequate treatment options for patients is essential. Currently, inadequate scientific literature restricts specific conservative management recommendations for CR. Despite a paucity of evidence for high-velocity low-amplitude (HVLA) spinal manipulation in the treatment for CR, this strategy has been frequently labeled as contraindicated. Scientific support for appropriate outcome measures for CR is equally deficient. While more scientific data is needed to draw firm conclusions, the present review suggests that spinal manipulation may be cautiously considered as a therapeutic option for patients suffering from CR. With respect to outcome measures, the Neck Disability Index appears well-suited for spinal manipulative treatment of CR. PMCID: PMC3280115 PMID: 22457538 [PubMed] 8. N Z Med J. 2011 Aug 12;124(1340):55-71. Spinal manipulation: an update of a systematic review of systematic reviews. Posadzki P(1), Ernst E. Author information: (1)Complementary Medicine, Peninsula Medical School, Universities of Exeter and Plymouth, 25 Victoria Park Road, Exeter EX2 4NT UK. Paul.Posadzki@pcmd.ac.uk Comment in N Z Med J. 2011 Oct 14;124(1344):117-9. N Z Med J. 2011 Sep 23;124(1343):94-5. OBJECTIVES: The aim of this update is to critically evaluate the evidence for or

against the effectiveness of spinal manipulation in patients with any type of clinical condition. DESIGN: Four electronic databases were searched to identify all relevant systematic reviews of the effectiveness of spinal manipulation in any condition published between 2005 and January 2011. Reviews were defined as systematic, if they included an explicit and repeatable inclusion and exclusion criteria for studies. RESULTS: Forty-five systematic reviews were included relating to the following conditions: low back pain (n=7), headache (n=6), neck pain (n=4), asthma (n=4), musculoskeletal conditions (n=3), any non-musculoskeletal conditions (n=2), fibromyalgia (n=2), infant colic (n=2), any medical problem (n=1), any paediatric conditions (n=1), carpal tunnel syndrome (n=1), cervicogenic dizziness (n=1), dysmenorrhoea (n=1), gastrointestinal problems (n=1), hypertension (n=1), idiopathic scoliosis (n=1), lateral epicondylitis (n=1), lower extremity conditions (n=1), pregnancy and related conditions (n=1), psychological outcome (n=1), shoulder pain (n=1), upper extremity conditions (n=1) and whiplash injury (n=1). Positive or, for multiple SR, unanimously positive conclusions were drawn for psychological outcomes (n=1) and whiplash (n=1). CONCLUSION: Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition. PMID: 21952385 [PubMed - indexed for MEDLINE] 9. J Orthop Sports Phys Ther. 2011 Sep;41(9):633-42. doi: 10.2519/jospt.2011.3670. Epub 2011 Aug 31. Thoracic spine thrust manipulation improves pain, range of motion, and self-reported function in patients with mechanical neck pain: a systematic review. Cross KM, Kuenze C, Grindstaff TL, Hertel J. STUDY DESIGN: Systematic review. BACKGROUND: Neck pain is a common diagnosis in the physical therapy setting, yet there is no gold standard for treatment. This study is part of a growing body of literature on the use of thoracic spine thrust manipulation for the treatment of individuals with mechanical neck pain. OBJECTIVE: The purpose of this systematic review was to determine the effects of thoracic spine thrust manipulation on pain, range of motion, and self-reported function in patients with mechanical neck pain. METHODS: Six online databases were comprehensively searched from their respective inception to October 2010. The primary search terms included "thoracic mobilization," "thoracic spine mobilization," "thoracic manipulation," and "thoracic spine manipulation." Of the 44 studies assessed for inclusion, 6 randomized controlled trials were retained. Between-group mean differences and effect sizes for pretreatment-to-posttreatment change scores, using Cohen's d formula, were calculated for pain, range of motion, and subjective function at all stated time intervals. RESULTS: Effect size point estimates for the pain change scores were significant for global assessment across all studies (range, 0.38-4.03) but not conclusively

significant at the end range of active rotation (range, 0.02-1.79). Effect size point estimates were large among all range-of-motion change measures (range, 1.40-3.52), and the effect size point estimates of the change scores among the functional questionnaires (range, 0.47-3.64) also indicated a significant treatment effect. CONCLUSIONS: Thoracic spine thrust manipulation may provide short-term improvement in patients with acute or subacute mechanical neck pain. However, the body of literature is weak, and these results may not be generalizable. LEVEL OF EVIDENCE: Therapy, level 1b-. PMID: 21885904 [PubMed - indexed for MEDLINE] 10. Man Ther. 2010 Jun 1. [Epub ahead of print] Manual therapy and exercise for neck pain: A systematic review. Miller J(1), Gross A, D'Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Author information: (1)School of Rehabilitation Science, McMaster University, Hamilton, Canada. Manual therapy is often used with exercise to treat neck pain. This cervical overview group systematic review update assesses if manual therapy, including manipulation or mobilisation, combined with exercise improves pain, function/disability, quality of life, global perceived effect, and patient satisfaction for adults with neck pain with or without cervicogenic headache or radiculopathy. Computerized searches were performed to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (pRR) and standardized mean differences (pSMD) were calculated. Of 17 randomized controlled trials included, 29% had a low risk of bias. Low quality evidence suggests clinically important long-term improvements in pain (pSMD-0.87(95% CI:-1.69,-0.06)), function/disability, and global perceived effect when manual therapy and exercise are compared to no treatment. High quality evidence suggests greater short-term pain relief [pSMD-0.50(95% CI:-0.76,-0.24)] than exercise alone, but no long-term differences across multiple outcomes for (sub)acute/chronic neck pain with or without cervicogenic headache. Moderate quality evidence supports this treatment combination for pain reduction and improved quality of life over manual therapy alone for chronic neck pain; and suggests greater short-term pain reduction when compared to traditional care for acute whiplash. Evidence regarding radiculopathy was sparse. Specific research recommendations are made. Copyright © 2010 Elsevier Ltd. All rights reserved. PMID: 20627797 [PubMed - as supplied by publisher] 11. Man Ther. 2010 Oct;15(5):415-33. doi: 10.1016/j.math.2010.04.003. Epub 2010 Jun 9.

Manual therapy with or without physical medicine modalities for neck pain: a systematic review. D'Sylva J(1), Miller J, Gross A, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL; Cervical Overview Group. Author information: (1)School of Rehabilitation Science, McMaster University, 1400 Main Street West, Hamilton, Ontario L8S 1C7, Canada. Manual therapy interventions are often used with or without physical medicine modalities to treat neck pain. This review assessed the effect of 1) manipulation and mobilisation, 2) manipulation, mobilisation and soft tissue work, and 3) manual therapy with physical medicine modalities on pain, function, patient satisfaction, quality of life (QoL), and global perceived effect (GPE) in adults with neck pain. A computerised search for randomised trials was performed up to July 2009. Two or more authors independently selected studies, abstracted data, and assessed methodological quality. Pooled relative risk (RR) and standardised mean differences (SMD) were calculated when possible. We included 19 trials, 37% of which had a low risk of bias. Moderate quality evidence (1 trial, 221 participants) suggested mobilisation, manipulation and soft tissue techniques decrease pain and improved satisfaction when compared to short wave diathermy, and that this treatment combination paired with advice and exercise produces greater improvements in GPE and satisfaction than advice and exercise alone for acute neck pain. Low quality evidence suggests a clinically important benefit favouring mobilisation and manipulation in pain relief [1 meta-analysis, 112 participants: SMD -0.34(95% CI: -0.71, 0.03), improved function and GPE (1 trial, 94 participants) for participants with chronic cervicogenic headache when compared to a control at intermediate and long term follow-up; but no difference when used with various physical medicine modalities. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 20538501 [PubMed - indexed for MEDLINE] 12. Man Ther. 2010 Oct;15(5):434-44. doi: 10.1016/j.math.2010.02.006. Epub 2010 Mar 12. Adverse events associated with the use of cervical manipulation and mobilization for the treatment of neck pain in adults: a systematic review. Carlesso LC(1), Gross AR, Santaguida PL, Burnie S, Voth S, Sadi J. Author information: (1)Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada. carlesl@mcmaster.ca Adverse events (AE) are a concern for practitioners utilizing cervical manipulation or mobilization. While efficacious, these techniques are associated

with rare but serious adverse events. Five bibliographic databases (PubMed, CINAHL, PEDro, AMED, EMBASE) and the gray literature were searched from 1998 to 2009 for any AE associated with cervical manipulation or mobilization for neck pain. Randomized controlled trials (RCTs), prospective or cross-sectional observational studies were included. Two independent reviewers conducted study selection, method quality assessment and data abstraction. Pooled relative risks (RR) were calculated. Study quality was assessed using the Cochrane system, a modified Critical Appraisal Skills Program form and the McHarm scale to assess the reporting of harms. Seventeen of 76 identified citations resulted in no major AE. Two pooled estimates for minor AE found transient neurological symptoms [RR 1.96 (95% CI: 1.09-3.54) p < 0.05]; and increased neck pain [RR 1.23 (95% CI: 0.85-1.77) p > .05]. Forty-four studies (58%) were excluded for not reporting AE. No definitive conclusions can be made due to a small number of studies, weak association, moderate study quality, and notable ascertainment bias. Improved reporting of AE in manual therapy trials as recommended by the CONSORT statement extension on harms reporting is warranted. Copyright 2010 Elsevier Ltd. All rights reserved. PMID: 20227325 [PubMed - indexed for MEDLINE] 13. Chiropr Osteopat. 2006 Apr 19;14:7. Comparative effectiveness of manipulation, mobilisation and the activator instrument in treatment of non-specific neck pain: a systematic review. Gemmell H(1), Miller P. Author information: (1)Department of Academic Affairs, Anglo-European College of Chiropractic, Bournemouth, UK. hgemmell@aecc.ac.uk BACKGROUND: Neck pain is a common problem and different forms of manual therapy are used in its treatment. The purpose of this systematic review was to critically appraise the literature that directly compared manipulation, mobilisation and the Activator instrument for non-specific neck pain. METHODS: Electronic databases (MEDLINE, MANTIS and CINAHL) were searched from their inception to October 2005 for all English language randomised clinical trials that directly compared manipulation, mobilisation and the Activator instrument. Inclusion and exclusion criteria were applied to select the studies and these studies were then evaluated using validated criteria. RESULTS: Five such studies were identified. The methodological quality was mostly poor. Findings from the studies were mixed and no one therapy was shown to be more effective than the others. CONCLUSION: Further high quality research has to be done before a recommendation can be made as to the most effective manual method for non-specific neck pain. PMCID: PMC1459176 PMID: 16623934 [PubMed]

14. J Manipulative Physiol Ther. 2005 Jul-Aug;28(6):443-8. A systematic review of conservative treatments for acute neck pain not due to whiplash. Vernon HT(1), Humphreys BK, Hagino CA. Author information: (1)Center for Studies of the Cervical Spine, Graduate Education and Research, Canadian Memorial Chiropractic College, Graduate Education and Research, Toronto, Ontario, Canada M2H 3J1. hvernon@cmcc.ca OBJECTIVE: To identify the evidence base of clinical trials of conservative treatments for acute neck pain not due to whiplash injury. DESIGN AND SETTING: A comprehensive literature search was performed in MEDLINE, CINHAHL, AMED, MANTIS, Index to Chiropractic Literature, Alt HealthWatch, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Registry, and several EBSCO Information Services databases. Systematic retrieval and evaluation procedures were used. RESULTS: The search generated 1980 citations. Four trials (5 publications) were accepted according to the inclusion/exclusion criteria. Three trials used a form of spinal manual therapy. One of these trials used only one manipulation and reported immediate effects on pain, with real manipulation producing significantly greater pain reduction than control procedure. The other 2 of these trials reported on outcomes over 1 to 3 weeks. In 1 trial, the group receiving manipulation showed significantly greater pain reduction at 1 week than did the group receiving only medication. In the other trial, the group receiving transcutaneous electrical nerve stimulation had a significantly greater level of pain reduction at 3 weeks. In the fourth trial, exercise was compared to passive physiotherapy; however, outcomes were not reported until 6 and 12 months, so the results cannot be compared to the natural history of acute neck pain not due to whiplash. CONCLUSION: There is limited evidence of the benefit of spinal manipulation and transcutaneous electrical nerve stimulation in the treatment of acute neck pain not due to whiplash injury. There is a dearth of high-quality clinical trials of conservative treatments for this condition. PMID: 16096044 [PubMed - indexed for MEDLINE] 15. Spine J. 2004 May-Jun;4(3):335-56. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Bronfort G(1), Haas M, Evans RL, Bouter LM. Author information: (1)Department of Research, Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W, 84th Street Bloomington, MN 55431, USA.

gbronfort@nwhealth.edu BACKGROUND CONTEXT: Despite the many published randomized clinical trials (RCTs), a substantial number of reviews and several national clinical guidelines, much controversy still remains regarding the evidence for or against efficacy of spinal manipulation for low back pain and neck pain. PURPOSE: To reassess the efficacy of spinal manipulative therapy (SMT) and mobilization (MOB) for the management of low back pain (LBP) and neck pain (NP), with special attention to applying more stringent criteria for study admissibility into evidence and for isolating the effect of SMT and/or MOB. STUDY DESIGN: RCTs including 10 or more subjects per group receiving SMT or MOB and using patient-oriented primary outcome measures (eg, patient-rated pain, disability, global improvement and recovery time). METHODS: Articles in English, Danish, Swedish, Norwegian and Dutch reporting on randomized trials were identified by a comprehensive search of computerized and bibliographic literature databases up to the end of 2002. Two reviewers independently abstracted data and assessed study quality according to eight explicit criteria. A best evidence synthesis incorporating explicit, detailed information about outcome measures and interventions was used to evaluate treatment efficacy. The strength of evidence was assessed by a classification system that incorporated study validity and statistical significance of study results. Sixty-nine RCTs met the study selection criteria and were reviewed and assigned validity scores varying from 6 to 81 on a scale of 0 to 100. Forty-three RCTs met the admissibility criteria for evidence. RESULTS: Acute LBP: There is moderate evidence that SMT provides more short-term pain relief than MOB and detuned diathermy, and limited evidence of faster recovery than a commonly used physical therapy treatment strategy. Chronic LBP: There is moderate evidence that SMT has an effect similar to an efficacious prescription nonsteroidal anti-inflammatory drug, SMT/MOB is effective in the short term when compared with placebo and general practitioner care, and in the long term compared to physical therapy. There is limited to moderate evidence that SMT is better than physical therapy and home back exercise in both the short and long term. There is limited evidence that SMT is superior to sham SMT in the short term and superior to chemonucleolysis for disc herniation in the short term. However, there is also limited evidence that MOB is inferior to back exercise after disc herniation surgery. Mix of acute and chronic LBP: SMT/MOB provides either similar or better pain outcomes in the short and long term when compared with placebo and with other treatments, such as McKenzie therapy, medical care, management by physical therapists, soft tissue treatment and back school. Acute NP: There are few studies, and the evidence is currently inconclusive. Chronic NP: There is moderate evidence that SMT/MOB is superior to general practitioner management for short-term pain reduction but that SMT offers at most similar pain relief to high-technology rehabilitative exercise in the short and long term. Mix of acute and chronic NP: The overall evidence is not clear. There is moderate evidence that MOB is superior to physical therapy and family physician care, and similar to SMT in both the short and long term. There is limited evidence that SMT, in both the short and long term, is inferior to physical therapy. CONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials

distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care. PMID: 15125860 [PubMed - indexed for MEDLINE] 16. Spine (Phila Pa 1976). 1996 Aug 1;21(15):1746-59; discussion 1759-60. Manipulation and mobilization of the cervical spine. A systematic review of the literature. Hurwitz EL(1), Aker PD, Adams AH, Meeker WC, Shekelle PG. Author information: (1)RAND, Santa Monica, CA, USA. Comment in Spine (Phila Pa 1976). 1997 Jul 15;22(14):1676-7. STUDY DESIGN: Cervical spine manipulation and mobilization were reviewed in an analysis of the literature from 1966 to the present. OBJECTIVES: To assess the evidence for the efficacy and complications of cervical spine manipulation and mobilization for the treatment of neck pain and headache. SUMMARY OF BACKGROUND DATA: Although recent research has demonstrated the efficacy of spinal manipulation for some patients with low back pain, little is known about its efficacy for neck pain and headache. METHODS: A structured search of four computerized bibliographic data bases was performed to identify articles on the efficacy and complications of cervical spine manual therapy. Data were summarized, and randomized controlled trials were critically appraised for study quality. The confidence profile method of meta-analysis was used to estimate the effect of spinal manipulation on patients' pain status. RESULTS: Two of three randomized controlled trials showed a short-term benefit for cervical mobilization for acute neck pain. The combination of three of the randomized controlled trials comparing spinal manipulation with other therapies for patients with subacute or chronic neck pain showed an improvement on a 100-mm visual analogue scale of pain at 3 weeks of 12.6 mm (95% confidence interval, -0.15, 25.5) for manipulation compared with muscle relaxants or usual medical care. The highest quality randomized controlled trial demonstrated that spinal manipulation provided short-term relief for patients with tension-type headache. The complication rate for cervical spine manipulation is estimated to be between 5 and 10 per 10 million manipulations. CONCLUSIONS: Cervical spine manipulation and mobilization probably provide at least short-term benefits for some patients with neck pain and headaches. Although the complication rate of manipulation is small, the potential for adverse outcomes must be considered because of the possibility of permanent impairment or death. PMID: 8855459 [PubMed - indexed for MEDLINE]

Manipulation and osteoarthritis 1. Clin Rehabil. 2015 Dec 22. pii: 0269215515622670. [Epub ahead of print] The effects of manual therapy or exercise therapy or both in people with hip osteoarthritis: A systematic review and meta-analysis. Sampath KK(1), Mani R(2), Miyamori T(2), Tumilty S(2). Author information: (1)Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand kesava.kovanur-sampath@otago.ac.nz. (2)Centre for Health, Activity, and Rehabilitation Research, School of Physiotherapy, University of Otago, New Zealand. OBJECTIVE: To determine whether manual therapy or exercise therapy or both is beneficial for people with hip osteoarthritis in terms of reduced pain, improved physical function and improved quality of life. METHODS: Databases such as Medline, AMED, EMBASE, CINAHL, SPORTSDiscus, PubMed, Cochrane Library, Web of Science, Physiotherapy Evidence Database, and SCOPUS were searched from their inception till September 2015. Two authors independently extracted and assessed the risk of bias in included studies. Standardised mean differences for outcome measures (pain, physical function and quality of life) were used to calculate effect sizes. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was used for assessing the quality of the body of evidence for each outcome of interest. RESULTS: Seven trials (886 participants) that met the inclusion criteria were included in the meta-analysis. There was high quality evidence that exercise therapy was beneficial at post-treatment (pain-SMD-0.27,95%CI-0.5to-0.04;physical function-SMD-0.29,95%CI-0.47to-0.11) and follow-up (pain-SMD-0.24,95%CI- 0.41to-0.06; physical function-SMD-0.33,95%CI-0.5to-0.15). There was low quality evidence that manual therapy was beneficial at post-treatment (pain-SMD-0.71,95%CI-1.08to-0.33; physical function-SMD-0.71,95%CI-1.08to-0.33) and follow-up (pain-SMD-0.43,95%CI-0.8to-0.06; physical function-SMD-0.47,95%CI-0.84to-0.1). Low quality evidence indicated that combined treatment was beneficial at post-treatment (pain-SMD-0.43,95%CI-0.78to-0.08; physical function-SMD-0.38,95%CI-0.73to-0.04) but not at follow-up (pain-SMD0.25,95%CI-0.35to0.84; physical function-SMD0.09,95%CI-0.5to0.68). There was no effect of any interventions on quality of life. CONCLUSION: An Exercise therapy intervention provides short-term as well as long-term benefits in terms of reduction in pain, and improvement in physical function among people with hip osteoarthritis. The observed magnitude of the treatment effect would be considered small to moderate. © The Author(s) 2015. PMID: 26701903 [PubMed - as supplied by publisher]

2. J Physiother. 2015 Jul;61(3):106-16. doi: 10.1016/j.jphys.2015.05.018. Epub 2015 Jun 17. Massage therapy has short-term benefits for people with common musculoskeletal disorders compared to no treatment: a systematic review. Bervoets DC(1), Luijsterburg PA(1), Alessie JJ(2), Buijs MJ(2), Verhagen AP(1). Author information: (1)Department of General Practice, Erasmus MC, University Medical Center, Rotterdam. (2)Avans University of Applied Science, Breda, The Netherlands. QUESTION: Is massage therapy effective for people with musculoskeletal disorders compared to any other treatment or no treatment? DESIGN: Systematic review of randomised clinical trials. PARTICIPANTS: People with musculoskeletal disorders. INTERVENTIONS: Massage therapy (manual manipulation of the soft tissues) as a stand-alone intervention. OUTCOME: The primary outcomes were pain and function. RESULTS: The 26 eligible randomised trials involved 2565 participants. The mean sample size was 95 participants (range 16 to 579) per study; 10 studies were considered to be at low risk of bias. Overall, low-to-moderate-level evidence indicated that massage reduces pain in the short term compared to no treatment in people with shoulder pain and osteoarthritis of the knee, but not in those with low back pain or neck pain. Furthermore, low-to-moderate-level evidence indicated that massage improves function in the short term compared to no treatment in people with low back pain, knee arthritis or shoulder pain. Low-to-very-low-level evidence from single studies indicated no clear benefits of massage over acupuncture, joint mobilisation, manipulation or relaxation therapy in people with fibromyalgia, low back pain and general musculoskeletal pain. CONCLUSIONS: Massage therapy, as a stand-alone treatment, reduces pain and improves function compared to no treatment in some musculoskeletal conditions. When massage is compared to another active treatment, no clear benefit was evident. Copyright © 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved. PMID: 26093806 [PubMed - in process] 3. J Manipulative Physiol Ther. 2009 Jan;32(1):53-71. doi: 10.1016/j.jmpt.2008.09.013. Manipulative therapy for lower extremity conditions: expansion of literature review. Brantingham JW(1), Globe G, Pollard H, Hicks M, Korporaal C, Hoskins W. Author information: (1)Cleveland Chiropractic College Los Angeles (CCCLA), Los Angeles, Calif. 90004,

USA. james.brantingham@cleveland.edu OBJECTIVE: The purpose of this study was to conduct a systematic review on manipulative therapy for lower extremity conditions and expand on a previously published literature review. METHODS: The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. The Cumulative Index to Nursing and Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Science Direct; and Index to Chiropractic Literature were searched from December 2006 to February 2008. Search terms included chiropractic, osteopathic, orthopedic, or physical therapy and MeSH terms for each region. Inclusion criteria required a diagnosis and manipulative therapy (mobilization and manipulation grades I-V) with or without adjunctive care. Exclusion criteria were pain referred from spinal sites (without diagnosis), referral for surgery, and conditions contraindicated for manipulative therapy. Clinical trials were assessed using a modified Scottish Intercollegiate Guidelines Network ranking system. RESULTS: Of the total 389 citations captured, 39 were determined to be relevant. There is a level of C or limited evidence for manipulative therapy combined with multimodal or exercise therapy for hip osteoarthritis. There is a level of B or fair evidence for manipulative therapy of the knee and/or full kinetic chain, and of the ankle and/or foot, combined with multimodal or exercise therapy for knee osteoarthritis, patellofemoral pain syndrome, and ankle inversion sprain. There is also a level of C or limited evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for plantar fasciitis, metatarsalgia, and hallux limitus/rigidus. There is also a level of I or insufficient evidence for manipulative therapy of the ankle and/or foot combined with multimodal or exercise therapy for hallux abducto valgus. CONCLUSIONS: There are a growing number of peer-reviewed studies of manipulative therapy for lower extremity disorders. PMID: 19121464 [PubMed - indexed for MEDLINE] 4. Clin J Pain. 2004 Jul-Aug;20(4):244-55. Complementary and alternative approaches to the treatment of persistent musculoskeletal pain. Weiner DK(1), Ernst E. Author information: (1)Department of Medicine, Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213-3313, USA. dweiner@pitt.edu OBJECTIVE: To review common complementary and alternative treatment modalities

for the treatment of persistent musculoskeletal pain in older adults. METHODS: A critical review of the literature on acupuncture and related modalities, herbal therapies, homeopathy, and spinal manipulation was carried out. Review included 678 cases within 21 randomized trials and 2 systematic reviews of herbal therapies: 798 cases within 2 systematic reviews of homeopathy; 1,059 cases within 1 systematic review of spinal manipulation for low back pain, and 419 cases within 4 randomized controlled trials for neck pain. The review of acupuncture and related modalities was based upon a paucity of well-controlled studies combined with our clinical experience. RESULTS: Insufficient experimental evidence exists to recommend the use of traditional Chinese acupuncture over other modalities for older adults with persistent musculoskeletal pain. Promising preliminary evidence exists to support the use of percutaneous electrical nerve stimulation for persistent low back pain. While some herbals appear to have modest analgesic benefits, insufficient evidence exists to definitively recommend their use. Drug-herb interactions must also be considered. Some evidence exists to support the superiority of homeopathic remedies over placebo for treating osteoarthritis and rheumatoid arthritis. The benefits of spinal manipulation for persistent low back and neck pain have not been convincingly shown to outweigh its risks. DISCUSSION: While the use of complementary and alternative modalities for the treatment of persistent musculoskeletal pain continues to increase, rigorous clinical trials examining their efficacy are needed before definitive recommendations regarding the application of these modalities can be made. PMID: 15218409 [PubMed - indexed for MEDLINE]

Manipulation and pregnancy 1. J Manipulative Physiol Ther. 2008 Jul-Aug;31(6):447-54. doi: 10.1016/j.jmpt.2008.06.009. Chiropractic treatment of pregnancy-related low back pain: a systematic review of the evidence. Stuber KJ(1), Smith DL. Author information: (1)School of Health and Related Research, The University of Sheffield, Sheffield, UK. kjstuber@hotmail.com OBJECTIVE: This study systematically reviewed the published evidence regarding chiropractic care, including spinal manipulation, for pregnancy-related low back pain (LBP). METHODS: A multimodal search strategy was conducted, including multiple database searches along with reference and journal hand searching. Studies were limited to those published in English and in a peer-reviewed journal or conference proceeding between January 1982 and July 2007. All study designs were considered except single case reports, personal narratives, and qualitative designs. Retrieved articles that met the inclusion criteria were rated for quality by using a validated and reliable checklist. RESULTS: Six studies met the review's inclusion criteria in the form of 1 quasi-experimental single-group pretest-posttest design, 4 case series, and 1 cross-sectional case series study; their quality scores ranged from 5 to 14 of 27. All of the included studies reported positive results for chiropractic care of LBP during pregnancy. Outcome measure use between the studies was inconsistent as were descriptions of patients, treatments, and treatment schedules. CONCLUSIONS: Results from the 6 included studies showed that chiropractic care is associated with improved outcomes in pregnancy-related LBP. However, the low-to-moderate quality of evidence of the included studies preclude any definitive statement as to the efficacy of such care because all studies lacked both randomization and control groups. Given the relatively common use of chiropractic care during pregnancy, there is need for higher quality observational studies and controlled trials to determine efficacy. PMID: 18722200 [PubMed - indexed for MEDLINE]

Manipulation and repetitive strain 1. Scand J Work Environ Health. 2001 Oct;27(5):299-310. Conservative treatment for repetitive strain injury. Konijnenberg HS(1), de Wilde NS, Gerritsen AA, van Tulder MW, de Vet HC. Author information: (1)Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands. Comment in Scand J Work Environ Health. 2001 Oct;27(5):297-8. Various conservative treatment options for repetitive strain injury are widely used, despite questionable evidence of their effectiveness. This systematic review evaluates the effectiveness of these treatment options for relieving symptoms of repetitive strain injury and improving activities of daily living. Searches in Medline and Embase, with additional reference checking resulted in 15 eligible trials for this review. Methodological quality was assessed, and data-extraction was performed. With the use of a "best-evidence synthesis", no strong evidence was found for the effectiveness of any of the treatment options. There is limited evidence that multidisciplinary rehabilitation, ergonomic intervention measures, exercises, and spinal manipulation combined with soft tissue therapy are effective in providing symptom relief or improving activities of daily living. There is conflicting evidence for the effectiveness of behavioral therapy. In conclusion, little is known about the effectiveness of conservative treatment options for repetitive strain injury. To establish strong evidence, more high-quality trials are needed. PMID: 11712610 [PubMed - indexed for MEDLINE]

Manipulation and rotator cuff 1. Chiropr Man Therap. 2014 Mar 28;22(1):12. doi: 10.1186/2045-709X-22-12. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Clar C, Tsertsvadze A, Court R, Hundt GL, Clarke A, Sutcliffe P(1). Author information: (1)Populations, Evidence and Technologies, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, England. p.a.sutcliffe@warwick.ac.uk. BACKGROUND: This systematic review updated and extended the "UK evidence report" by Bronfort et al. (Chiropr Osteopath 18:3, 2010) with respect to conditions/interventions that received an 'inconclusive' or 'negative' evidence rating or were not covered in the report. METHODS: A literature search of more than 10 general medical and specialised databases was conducted in August 2011 and updated in March 2013. Systematic reviews, primary comparative studies and qualitative studies of patients with musculoskeletal or non-musculoskeletal conditions treated with manual therapy and reporting clinical outcomes were included. Study quality was assessed using standardised instruments, studies were summarised, and the results were compared against the evidence ratings of Bronfort. These were either confirmed, updated, or new categories not assessed by Bronfort were added. RESULTS: 25,539 records were found; 178 new and additional studies were identified, of which 72 were systematic reviews, 96 were randomised controlled trials, and 10 were non-randomised primary studies. Most 'inconclusive' or 'moderate' evidence ratings of the UK evidence report were confirmed. Evidence ratings changed in a positive direction from inconclusive to moderate evidence ratings in only three cases (manipulation/mobilisation [with exercise] for rotator cuff disorder; spinal mobilisation for cervicogenic headache; and mobilisation for miscellaneous headache). In addition, evidence was identified on a large number of non-musculoskeletal conditions not previously considered; most of this evidence was rated as inconclusive. CONCLUSIONS: Overall, there was limited high quality evidence for the effectiveness of manual therapy. Most reviewed evidence was of low to moderate quality and inconsistent due to substantial methodological and clinical diversity. Areas requiring further research are highlighted. PMCID: PMC3997823 PMID: 24679336 [PubMed] 2. J Manipulative Physiol Ther. 2011 Jun;34(5):314-46. doi: 10.1016/j.jmpt.2011.04.002. Manipulative therapy for shoulder pain and disorders: expansion of a systematic

review. Brantingham JW(1), Cassa TK, Bonnefin D, Jensen M, Globe G, Hicks M, Korporaal C. Author information: (1)Department of Research, Cleveland Chiropractic College, Los Angeles, CA, USA. James.brantingham@cleveland.edu OBJECTIVE: The purpose of this study was to conduct a systematic review on manual and manipulative therapy (MMT) for common shoulder pain and disorders. METHODS: A search of the literature was conducted using the Cumulative Index of Nursing Allied Health Literature; PubMed; Manual, Alternative, and Natural Therapy Index System; Physiotherapy Evidence Database; and Index to Chiropractic Literature dating from January 1983 to July 7, 2010. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, musculoskeletal, physical therapies, shoulder, etc. Inclusion criteria required a shoulder peripheral diagnosis and MMT with/without multimodal therapy. Exclusion criteria included pain referred from spinal sites without a peripheral shoulder diagnosis. Articles were assessed primarily using the Physiotherapy Evidence Database scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring were complete, with subsequent participant review and agreement, evidence grades of A, B, C, and I were applied. RESULTS: A total of 211 citations were retrieved, and 35 articles were deemed useful. There is fair evidence (B) for the treatment of a variety of common rotator cuff disorders, shoulder disorders, adhesive capsulitis, and soft tissue disorders using MMT to the shoulder, shoulder girdle, and/or the full kinetic chain (FKC) combined with or without exercise and/or multimodal therapy. There is limited (C) and insufficient (I) evidence for MMT treatment of minor neurogenic shoulder pain and shoulder osteoarthritis, respectively. CONCLUSIONS: This study found a level of B or fair evidence for MMT of the shoulder, shoulder girdle, and/or the FKC combined with multimodal or exercise therapy for rotator cuff injuries/disorders, disease, or dysfunction. There is a fair or B level of evidence for MMT of the shoulder/shoulder girdle and FKC combined with a multimodal treatment approach for shoulder complaints, dysfunction, disorders, and/or pain. Copyright © 2011 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 21640255 [PubMed - indexed for MEDLINE] 3. BMJ Clin Evid. 2010 Jul 22;2010. pii: 1107. Shoulder pain. Murphy RJ(1), Carr AJ. Author information: (1)University of Oxford, Oxford, UK.

INTRODUCTION: Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. About 1% of adults aged over 45 years consult their GP with a new presentation of shoulder pain every year in the UK. The aetiology of shoulder pain is diverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment, topical drug treatment, local injections, non-drug treatment, and surgical treatment? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 71 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, arthroscopic subacromial decompression, autologous whole blood injection, corticosteroids (oral, subacromial injection, or intra-articular injection), electrical stimulation, excision of distal clavicle, extracorporeal shock wave therapy, ice, laser treatment, manipulation under anaesthesia, suprascapular nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, physiotherapy (manual treatment, exercises), platelet-rich plasma injection, rotator cuff repair, shoulder arthroplasty, and ultrasound. PMCID: PMC3217726 PMID: 21418673 [PubMed - in process] 4. BMJ. 1998 Jan 31;316(7128):354-60. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. Green S(1), Buchbinder R, Glazier R, Forbes A. Author information: (1)Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. Comment in BMJ. 1998 May 30;316(7145):1676-7. BMJ. 1998 May 30;316(7145):1676; author reply 1677. OBJECTIVE: To review the efficacy of common interventions for shoulder pain.

DESIGN: All randomised controlled trials of non-steroidal anti-inflammatory drugs, intra-articular and subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, and surgery for shoulder pain that were identified by computerised and hand searches of the literature and had a blinded assessment of outcome were included. MAIN OUTCOME MEASURES: Methodological quality (score out of 40), selection criteria, and outcome measures. Effect sizes were calculated and combined in a pooled analysis if study population, end point, and intervention were comparable. RESULTS: Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5-22). Selection criteria varied widely, even for the same diagnostic label. There was no uniformity in the outcome measures used, and their measurement properties were rarely reported. Effect sizes for individual trials were small (range -1.4 to 3.0). The results of only three studies investigating "rotator cuff tendinitis" could be pooled. The only positive finding was that subacromial steroid injection is better than placebo in improving the range of abduction (weighted difference between means 35 degrees (95% confidence interval 14 to 55)). CONCLUSIONS: There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable, and responsive in affected people. PMCID: PMC2665551 PMID: 9487172 [PubMed - indexed for MEDLINE]

Manipulation and upper extremity 1. J Manipulative Physiol Ther. 2013 Mar-Apr;36(3):143-201. doi: 10.1016/j.jmpt.2013.04.001. Epub 2013 May 20. Manipulative and multimodal therapy for upper extremity and temporomandibular disorders: a systematic review. Brantingham JW(1), Cassa TK, Bonnefin D, Pribicevic M, Robb A, Pollard H, Tong V, Korporaal C. Author information: (1)Murdoch University, Murdoch, Australia. jimbrant2002@yahoo.com OBJECTIVE: The purpose of this study was to complete a systematic review of manual and manipulative therapy (MMT) for common upper extremity pain and disorders including the temporomandibular joint (TMJ). METHODS: A literature search was conducted using the Cumulative Index of Nursing Allied Health Literature, PubMed, Manual, Alternative, and Natural Therapy Index System (MANTIS), Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, Google Scholar, and hand search inclusive of literature from January 1983 to March 5, 2012. Search limits included the English language and human studies along with MeSH terms such as manipulation, chiropractic, osteopathic, orthopedic, and physical therapies. Inclusion criteria required an extremity peripheral diagnosis (for upper extremity problems including the elbow, wrist, hand, finger and the (upper quadrant) temporomandibular joint) and MMT with or without multimodal therapy. Studies were assessed using the PEDro scale in conjunction with modified guidelines and systems. After synthesis and considered judgment scoring was complete, evidence grades of "A, B, C and I" were applied. RESULTS: Out of 764 citations reviewed, 129 studies were deemed possibly to probably useful and/or relevant to develop expert consensus. Out of 81 randomized controlled or clinical trials, 35 were included. Five controlled or clinical trials were located and 4 were included. Fifty case series, reports and/or single-group pre-test post-test prospective case series were located with 32 included. There is Fair (B) level of evidence for MMT to specific joints and the full kinetic chain combined generally with exercise and/or multimodal therapy for lateral epicondylopathy, carpal tunnel syndrome, and temporomandibular joint disorders, in the short term. CONCLUSION: The information from this study will help guide practitioners in the use of MMT, soft tissue technique, exercise, and/or multimodal therapy for the treatment of a variety of upper extremity complaints in the context of the hierarchy of published and available evidence. Copyright © 2013 National University of Health Sciences. Published by Mosby, Inc. All rights reserved. PMID: 23697915 [PubMed - indexed for MEDLINE]

OMT and IBS 1. J Am Osteopath Assoc. 2014 Jun;114(6):470-9. doi: 10.7556/jaoa.2014.098. Effectiveness of osteopathic manipulative therapy for managing symptoms of irritable bowel syndrome: a systematic review. Müller A(1), Franke H(1), Resch KL(1), Fryer G(2). Author information: (1)From the Institute for Osteopathic Studies in Siegen, Germany (Mr Müller and Mr Franke); the University of Dresden and German Institute for Health Research (Dr Resch); and the College of Health and Biomedicine and the Institute of Sport, Exercise and Active Living at Victoria University in Melbourne, Australia (Dr Fryer). (2)From the Institute for Osteopathic Studies in Siegen, Germany (Mr Müller and Mr Franke); the University of Dresden and German Institute for Health Research (Dr Resch); and the College of Health and Biomedicine and the Institute of Sport, Exercise and Active Living at Victoria University in Melbourne, Australia (Dr Fryer) gary.fryer@vu.edu.au. CONTEXT: Irritable bowel syndrome (IBS) is a common and often lifelong functional gastrointestinal disorder. There is a scarcity of effective management options for IBS. OBJECTIVE: To assess the effectiveness of osteopathic manipulative therapy (OMTh) for managing the symptoms of IBS. DATA SOURCES: Articles without language or publication-date restriction were searched in PubMed, Embase, Cochrane Library, PEDro, OSTMED.DR, and Osteopathic Research Web. Search terms included irritable bowel syndrome, IBS, functional colonic disease, colon irritable, osteopath*, osteopathic manipulation, osteopathic medicine, clinical trial, and randomized clinical trial. Experts in the field of visceral osteopathy were also contacted to identify additional studies. STUDY SELECTION: The authors evaluated randomized controlled trials (RCTs) of OMTh for IBS in adults in whom IBS was diagnosed using Rome (I-III) criteria. If OMTh was not the sole intervention in the intervention group and if the same additional interventions were not applied to the control group, the study was excluded. DATA EXTRACTION: Citation identification, study selection, and data extraction were independently undertaken by 2 reviewers with a data extraction form from the Cochrane Collaboration. A consensus method was used to resolve disagreements concerning the assessment of the methodologic quality of the RCTs that were reviewed. RESULTS: The search identified 10 studies that examined OMTh for patients with IBS; 5 studies (204 patients) met the inclusion criteria. All studies were assessed as having low risk of bias according to the Cochrane Collaboration criteria, although there was heterogeneity in the outcome measures and control interventions. Three studies used visual analog scales for abdominal pain, whereas others used the IBS severity score and the Functional Bowel Disorder Severity Index. A variety of secondary outcomes were used. All studies reported more pronounced short-term improvements with OMTh compared with sham therapy or

standard care only. These differences remained statistically significant after variable lengths of follow-up in 3 studies. CONCLUSION: The present systematic review provides preliminary evidence that OMTh may be beneficial in the treatment of patients with IBS. However, caution is required in the interpretation of these findings because of the limited number of studies available and the small sample sizes. © 2014 The American Osteopathic Association. PMID: 24917634 [PubMed - indexed for MEDLINE]

OMT and low back pain 1. BMC Musculoskelet Disord. 2014 Aug 30;15:286. doi: 10.1186/1471-2474-15-286. Osteopathic manipulative treatment for nonspecific low back pain: a systematic review and meta-analysis. Franke H, Franke JD, Fryer G(1). Author information: (1)College of Health & Biomedicine; ISEAL, Victoria University, Melbourne, Australia. gary.fryer@vu.edu.au. BACKGROUND: Nonspecific back pain is common, disabling, and costly. Therefore, we assessed effectiveness of osteopathic manipulative treatment (OMT) in the management of nonspecific low back pain (LBP) regarding pain and functional status. METHODS: A systematic literature search unrestricted by language was performed in October 2013 in electronic and ongoing trials databases. Searches of reference lists and personal communications identified additional studies. Only randomized clinical trials were included; specific back pain or single treatment techniques studies were excluded. Outcomes were pain and functional status. Studies were independently reviewed using a standardized form. The mean difference (MD) or standard mean difference (SMD) with 95% confidence intervals (CIs) and overall effect size were calculated at 3 months posttreatment. GRADE was used to assess quality of evidence. RESULTS: We identified 307 studies. Thirty-one were evaluated and 16 excluded. Of the 15 studies reviewed, 10 investigated effectiveness of OMT for nonspecific LBP, 3 effect of OMT for LBP in pregnant women, and 2 effect of OMT for LBP in postpartum women. Twelve had a low risk of bias. Moderate-quality evidence suggested OMT had a significant effect on pain relief (MD, -12.91; 95% CI, -20.00 to -5.82) and functional status (SMD, -0.36; 95% CI, -0.58 to -0.14) in acute and chronic nonspecific LBP. In chronic nonspecific LBP, moderate-quality evidence suggested a significant difference in favour of OMT regarding pain (MD, -14.93; 95% CI, -25.18 to -4.68) and functional status (SMD, -0.32; 95% CI, -0.58 to -0.07). For nonspecific LBP in pregnancy, low-quality evidence suggested a significant difference in favour of OMT for pain (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23), whereas moderate-quality evidence suggested a significant difference in favour of OMT for pain (MD, -41.85; 95% CI, -49.43 to -34.27) and functional status (SMD, -1.78; 95% CI, -2.21 to -1.35) in nonspecific LBP postpartum. CONCLUSION: Clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women at 3 months posttreatment. However, larger, high-quality randomized controlled trials with robust comparison groups are recommended. PMCID: PMC4159549 PMID: 25175885 [PubMed - indexed for MEDLINE]

2. BMC Musculoskelet Disord. 2005 Aug 4;6:43. Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. Licciardone JC(1), Brimhall AK, King LN. Author information: (1)Osteopathic Research Center, University of North Texas Health Science Center, Fort Worth, TX 76107, USA. jlicciar@hsc.unt.edu BACKGROUND: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used by osteopathic physicians to complement their conventional treatment of musculoskeletal disorders. Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressed OMT and generally have focused on spinal manipulation as an alternative to conventional treatment. The purpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain. METHODS: Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials were supplemented with additional database and manual searches of the literature. Six trials, involving eight OMT vs control treatment comparisons, were included because they were randomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatory settings. Data on trial methodology, OMT and control treatments, and low back pain outcomes were abstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overall meta-analysis, stratified meta-analyses were performed according to control treatment, country where the trial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overall and stratified meta-analyses. RESULTS: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 - -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up. CONCLUSION: OMT significantly reduces low back pain. The level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. Additional research is warranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are long lasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain. PMCID: PMC1208896 PMID: 16080794 [PubMed - indexed for MEDLINE]

OMT and pregnancy 1. J Bodyw Mov Ther. 2013 Jan;17(1):11-8. doi: 10.1016/j.jbmt.2012.05.001. Epub 2012 Jun 17. Osteopathic manipulative treatment (OMT) for lower urinary tract symptoms (LUTS) in women. Franke H(1), Hoesele K. Author information: (1)Institute for Osteopathic Studies, Siegen, Germany. info@helge-franke.de Erratum in J Bodyw Mov Ther. 2014 Jan;18(1):92. BACKGROUND: Because of its prevalence and impact on women's well-being, and its high financial costs, female LUTS is an important health problem that requires serious attention from health professionals. OBJECTIVE: The objective of this review was to determine the clinical effects of osteopathic treatment on female lower urinary tract disorders. DATA SOURCES: A systematic literature search was performed in May 2011 in the electronic databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PEDro, OSTMED-DR, OSTEOPATHIC WEBRESEARCH and databases of ongoing trials. A manual search in reference lists and a personal communication with experts in the field of osteopathy was also conducted to identify additional studies. STUDY SELECTION: Only randomized clinical studies (RCT) or controlled clinical studies (CCT) were included. Inclusion criteria of the participants were female, at least 18 years old and a diagnosed female urinary tract disorder. Exclusion criteria were neurologic disorders, tumors, urinary tract infections or antibiotic treatment, and pregnancy. DATA EXTRACTION: Two review authors independently extracted the data of the studies using a standardized data extraction form. The updated Cochrane Risk of bias tool from 2011 was used to assess the methodological quality. RESULTS: The quantitative analysis shows a statistically significant and clinically relevant improvement when the osteopathic intervention was compared to an untreated group. Two studies which compare OMT with the pelvic floor muscle training as a reference treatment document almost the same therapeutic effect. CONCLUSION: The findings of this systematic review and meta-analysis are promising and encouraging to conduct larger, rigorous osteopathic intervention studies for female urination disorders. Future studies should compare the osteopathic treatment with established standard procedures in the control group. Copyright © 2012 Elsevier Ltd. All rights reserved. PMID: 23294678 [PubMed - indexed for MEDLINE]