ObjectivesPhysicians often refer patients with musculoskeletal conditions to physical therapy. However, it is unclear to what extent physical therapists’ treatment choices align with the evidence. The aim of this systematic review was to determine what percentage of physical therapy treatment choices for musculoskeletal conditions agree with management recommendations in evidence-based guidelines and systematic reviews.DesignSystematic review.SettingWe performed searches in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine, Scopus and Web of Science combining terms synonymous with ‘practice patterns’ and ‘physical therapy’ from the earliest record to April 2018.ParticipantsStudies that quantified physical therapy treatment choices for musculoskeletal conditions through surveys of physical therapists, audits of clinical notes and other methods (eg, audits of billing codes, clinical observation) were eligible for inclusion.Primary and secondary outcomesUsing medians and IQRs, we summarised the percentage of physical therapists who chose treatments that were recommended, not recommended and had no recommendation, and summarised the percentage of physical therapy treatments provided for various musculoskeletal conditions within the categories of recommended, not recommended and no recommendation. Results were stratified by condition and how treatment choices were assessed (surveys of physical therapists vs audits of clinical notes).ResultsWe included 94 studies. For musculoskeletal conditions, the median percentage of physical therapists who chose recommended treatments was 54% (n=23 studies; surveys completed by physical therapists) and the median percentage of patients that received recommended physical therapy-delivered treatments was 63% (n=8 studies; audits of clinical notes). For treatments not recommended, these percentages were 43% (n=37; surveys) and 27% (n=20; audits). For treatments with no recommendation, these percentages were 81% (n=37; surveys) and 45% (n=31; audits).ConclusionsMany physical therapists seem not to follow evidence-based guidelines when managing musculoskeletal conditions. There is considerable scope to increase use of recommended treatments and reduce use of treatments that are not recommended.PROSPERO registration numberCRD42018094979.

Background Video game technology increases adherence to home exercise and could support self-management for older people with chronic low back pain (LBP). Objective The objective was to investigate the effects of home-based video game exercises on pain self-efficacy and care-seeking in older people with chronic LBP. Design The study was a randomized controlled trial. Setting The setting was a community and waiting list. Participants Sixty participants, aged > 55 years with chronic LBP, were randomized (1:1) to Wii Fit U exercises or to continue their usual activities for 8 weeks. Intervention The intervention was home-based Wii Fit U flexibility, strengthening, and aerobic exercises for 60 minutes, 3 times per week, with fortnightly calls from a physical therapist. Measurements Measurements included pain self-efficacy and care-seeking (primary outcomes), and physical activity, pain, function, disability, fear of movement/reinjury, falls efficacy, recruitment and response rates, adherence, experience with the intervention, and adverse events (secondary outcomes). Results The mean age of participants was 67.8 (standard deviation = 6.0) years. Adherence to the total recommended exercise time was 70.8%, and no adverse events were reported. Participants completing Wii Fit U exercises had significantly higher pain self-efficacy at 6 months, but not immediately postintervention or at 3 months; there were no between-group differences in care-seeking. Compared with the control group, participants completing Wii Fit U exercises demonstrated significantly greater improvements in pain and function at 8 weeks and were more likely to engage in flexibility exercises at 6 months. There were no significant between-group differences for the remaining outcomes. Limitations Participants and therapists were not blinded. Conclusions Wii Fit U exercises improved pain self-efficacy at 6 months, and pain and function immediately postintervention in older people with chronic LBP, but the clinical importance of these changes is questionable. Wii Fit U exercises had no effect on care-seeking, physical activity, disability, fear of movement/reinjury, or falls efficacy.

Objective To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo. Design Systematic review and meta-analysis. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, International Pharmaceutical Abstracts, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to 15 November and updated on 12 May 2020. Eligibility criteria for study selection Randomised controlled trials comparing the efficacy or safety, or both of any antidepressant drug with placebo (active or inert) in participants with low back or neck pain, sciatica, or hip or knee osteoarthritis. Data extraction and synthesis Two independent reviewers extracted data. Pain and disability were primary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). A random effects model was used to calculate weighted mean differences and 95% confidence intervals. Safety (any adverse event, serious adverse events, and proportion of participants who withdrew from trials owing to adverse events) was a secondary outcome. Risk of bias was assessed with the Cochrane Collaboration’s tool and certainty of evidence with the grading of recommendations assessment, development and evaluation (GRADE) framework. Results 33 trials (5318 participants) were included. Moderate certainty evidence showed that serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain (mean difference −5.30, 95% confidence interval −7.31 to −3.30) at 3-13 weeks and low certainty evidence that SNRIs reduced osteoarthritis pain (−9.72, −12.75 to −6.69) at 3-13 weeks. Very low certainty evidence showed that SNRIs reduced sciatica at two weeks or less (−18.60, −31.87 to −5.33) but not at 3-13 weeks (−17.50, −42.90 to 7.89). Low to very low certainty evidence showed that tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less (−7.55, −18.25 to 3.15) but did at 3-13 weeks (−15.95, −31.52 to −0.39) and 3-12 months (−27.0, −36.11 to −17.89). Moderate certainty evidence showed that SNRIs reduced disability from back pain at 3-13 weeks (−3.55, −5.22 to −1.88) and disability due to osteoarthritis at two weeks or less (−5.10, −7.31 to −2.89), with low certainty evidence at 3-13 weeks (−6.07, −8.13 to −4.02). TCAs and other antidepressants did not reduce pain or disability from back pain. Conclusion Moderate certainty evidence shows that the effect of SNRIs on pain and disability scores is small and not clinically important for back pain, but a clinically important effect cannot be excluded for osteoarthritis. TCAs and SNRIs might be effective for sciatica, but the certainty of evidence ranged from low to very low. Systematic review registration PROSPERO CRD42020158521.

The aim of this review was to investigate the association between total and domain-specific physical activity (PA) and non-specific low back pain (LBP) in adults. Seven databases were searched for cohort and cross-sectional studies. Pooled estimates of the association of medium and high levels PA and LBP, using the generic inverse-variance method with fixed- and random-effects models were calculated. Twenty-four studies (15 cohort and nine cross-sectional; 95,796 participants) were included. The pooled fully adjusted risk ratios (RR) from cohort studies comparing medium with lowest activity levels were 0.90 (95%CI 0.85 to 0.96) for total PA, and 0.90 (95%CI 0.85 to 0.96) for leisure-time PA (LTPA). The pooled RR comparing highest with lowest activity levels were 1.00 (95%CI 0.92 to 1.08) for total PA, and 1.01 (95%CI 0.93 to 1.10) for LTPA. The pooled fully adjusted odds ratios (OR) from cross-sectional studies comparing medium with lowest activity levels were 0.93 (95%CI 0.65 to 1.32) for total PA, and 0.77 (95%CI 0.62 to 0.96) for LTPA. The pooled OR comparing highest with lowest activity levels were 1.05 (95%CI 0.89 to 1.23) for total PA, and 0.85 (95%CI 0.79 to 0.93) for LTPA. PA seems to be associated with lower prevalence of LBP.

BackgroundThe Cochrane risk of bias (CROB) tool and Physiotherapy Evidence Database (PEDro) scale are used to evaluate risk of bias of randomized controlled trials. We assessed the level of agreement between the instruments.MethodsWe searched the Cochrane Library to identify trials included in systematic reviews evaluating physical therapy interventions. For trials that met our inclusion criteria (primary reference in Cochrane review, review used CROB (2008 version), indexed in PEDro), CROB items were extracted from the reviews and PEDro items and total score were downloaded from PEDro. Kappa statistics were used to determine the agreement between CROB and PEDro scale items that evaluate similar constructs (e.g., randomization). The total PEDro score was compared to the CROB summary score (% of items met) using an Intraclass Correlation Coefficient. Sensitivity analyses explored the impact of the CROB “unclear” category and variants of CROB blinding items. Kappa statistics were used to determine agreement between different thresholds for “acceptable” risk of bias between CROB and PEDro scale summary scores.ResultsWe included 1442 trials from 108 Cochrane reviews. Agreement was “moderate” for three of the six CROB and PEDro scale items that evaluate similar constructs (allocation concealment, participant blinding, assessor blinding; Kappa = 0.479–0.582). Agreement between the summary scores was “poor” (Intraclass Correlation Coefficient = 0.285). Agreement was highest when the CROB “unclear” category was collapsed with “high” and when participant, personnel and assessor blinding were evaluated separately in CROB. Agreement for different thresholds for “acceptable” risk of bias between CROB and PEDro summary scores was, at best, “fair”.ConclusionThere was moderate agreement for half of the PEDro and CROB items that evaluate similar constructs. Interpretation of the CROB “unclear” category and variants of the CROB blinding items substantially influenced agreement. Either instrument can be used to quantify risk of bias, but they can’t be used interchangeably.

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Background: Low back pain (LBP) is the leading cause of years lived with disability worldwide. Current intervention strategies are failing to reduce the enormous global burden of LBP and are prompting researchers to investigate alternative management strategies, such as vitamin D supplementation. Vitamin D supplementation appears to down regulate pro-inflammatory cytokines which lead to pain and up regulate anti-inflammatory cytokines that reduce inflammation. These mechanisms might explain the increasing interest in the use of vitamin D supplementation for LBP. Objectives: To determine whether vitamin D supplementation improves pain more than a control intervention for individuals with LBP. Study Design: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Methods: We performed searches in numerous electronic databases combining key words relating to “vitamin D” and “LBP” until March 2017. Studies were included if they investigated vitamin D supplementation in participants with LBP, provided there was a comparison intervention. There was no restriction on the type of LBP, the intervention parameters investigated, or the type of clinical trial (e.g., randomized, non-randomized). Two reviewers independently performed the selection of studies, extracted data, rated the methodological quality of the included studies, and evaluated the overall quality of the evidence using the Grading of Recommendations Assessment, Delevopment, and Evaulation (GRADE) approach. Results: After screening 3,534 articles, 8 clinical trials were included in this systematic review. There is very low quality evidence (based on the GRADE approach) that vitamin D supplementation is not more effective than any intervention (including placebo, no intervention, and other conservative/ pharmacological interventions) (continuous pain measures [0–100]: mean difference [MD] = -2.65, 95% confidence interval [CI]: -10.42 to 5.12, P = 0.504, n = 5; self-reported reduction in pain: pooled odds ratio [OR] = 1.07, 95% CI: 0.35 to 3.26, P = 0.906, n = 5) or placebo/no intervention for individuals with LBP (continuous pain measures: MD = 1.29, 95% CI: -3.81 to 6.39, P = 0.620, n = 4; self-reported reduction in pain: pooled OR = 1.53, 95% CI: 0.38 to 6.20, P = 0.550, n = 4), where ‘n’ is the number of studies included in the meta-analysis. These results did not change when we stratified the meta-analyses by the type of vitamin supplementation (vitamin D3 vs. alfacalcidol) or the type of LBP (non-specific vs. LBP resulting from osteoporosis or vertebral fractures). Limitations: The overall quality of evidence was “very low” due to the poor methodological quality and small sample sizes of the included studies. Conclusions: Vitamin D supplementation is not more effective than placebo, no intervention, or other conservative/pharmacological interventions for LBP (based on very low quality evidence). These results are consistent, regardless of the type of LBP or vitamin D supplementation. Until well-designed and adequately powered clinical trials suggest otherwise, the prescription of vitamin D for LBP cannot be recommended. PROSPERO Registration No: CRD42016046874. www.crd.york.ac.uk/PROSPERO/display_record. asp?ID = CRD42016046874 Key words: Vitamin D, low back pain, chronic low back pain, alfacalcidol, osteoporosis, vertebral fractures, serum 25-hydroxyvitamin D, systematic review

Background: Low back pain is a highly prevalent and disabling musculoskeletal disorder. Physical activity is widely used as a prevention strategy for numerous musculoskeletal disorders; however, there is still conflicting evidence as to whether physical activity is a protective or risk factor for low back pain or whether activity levels differ between people with and without low back pain. Objective: To investigate the association between low back pain and different types (occupational and leisure) and intensities (moderate and vigorous) of physical activity. Methods: This is cross-sectional observational study. We included in this study a total of 1059 individuals recruited from a Spanish twin registry with data available on low back pain. Outcome: Self-reported leisure and occupational physical activity were the explanatory variables. The low back pain outcome used in this study was recurrent low back pain. Results: Our results indicate that leisure physical activity is associated with a lower prevalence of recurrent low back pain. In contrast, occupational physical activity, such as carrying, lifting heavy weight while inclined, awkward postures (e.g. bending, twisting, squatting, and kneeling) are associated with a higher prevalence of recurrent low back pain. There was no statistically significant association between other occupational physical activities, such as sitting or standing, and low back pain. Conclusion: Leisure and occupational physical activity are likely to have an opposed impact on low back pain. While leisure physical activity appears to be protective, occupational physical activity appears to be harmful to low back pain. Future longitudinal studies should assist