Non-specific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation commonly includes physical and behavioural interventions, or a combination of these approaches. Physical interventions aim to enhance physical capacity by using methods such as exercise, manual therapy and ergonomics. Behavioural and/or psychologically informed interventions aim to enhance behaviours, cognitions or mood by using methods such as relaxation and cognitive behavioural therapy (CBT). Combined interventions aim to target both physical and behavioural and/or psychological factors contributing to patients' pain by using methods such as multidisciplinary pain management programmes. Since it remains unclear whether any of these approaches are superior, this review aimed to assess the comparative effectiveness of physical, behavioural and/or psychologically informed, and combined interventions on pain and disability in patients with NSCSP. Nine electronic databases were searched for randomised 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 (e.g. if the study compared two physical interventions). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical, behavioural and/or psychologically informed, and combined interventions were assessed using meta-analyses. 24 studies were included. No clinically significant differences were found for pain and disability between physical, behavioural and/or psychologically informed and combined interventions. The simple categorisation of interventions into physical, behavioural and/or psychologically informed and combined could be considered a limitation of this review, as these interventions may not be easily differentiated to allow accurate comparisons to be made. Further work should consider investigating whether tailoring Perspective: In this systematic review of RCTs in NSCSP, only small differences in pain or disability were observed between physical, behavioural and/or psychologically informed and combined interventions.
Background Population ageing is increasing rapidly worldwide. Older adults are frequent users of health care services including the Emergency Department (ED) and experience a number of adverse outcomes following an ED visit. Adverse outcomes include functional decline, unplanned hospital admission and an ED revisit. Given these adverse outcomes a number of interventions have been examined to improve the outcomes of older adults following presentation to the ED. The aim of this umbrella review was to evaluate the effectiveness of ED interventions in reducing adverse outcomes in older adults discharged from the ED. Methods Systematic reviews of randomised controlled trials investigating ED interventions for older adults presenting to the ED exploring clinical, patient experience and healthcare utilisation outcomes were included. A comprehensive search strategy was employed in eleven databases and the PROSPERO register up until June 2020. Grey literature was also searched. Quality was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2 tool. Overlap between systematic reviews was assessed using a matrix of evidence table. An algorithm to assign the Grading of Recommendations Assessment, Development and Evaluation to assess the strength of evidence was applied for all outcomes. Results Nine systematic reviews including 29 randomised controlled trials were included. Interventions comprised of solely ED-based or transitional interventions. The specific interventions delivered were highly variable. There was high overlap and low methodological quality of the trials informing the systematic reviews. There is low quality evidence to support ED interventions in reducing functional decline, improving patient experience and improving quality of life. The quality of evidence of the effectiveness of ED interventions to reduce mortality and ED revisits varied from very low to moderate. Results were presented narratively and summary of evidence tables created. Conclusion Older adults are the most important emerging group in healthcare for several economic, social and political reasons. The existing evidence for the effectiveness of ED interventions for older adults is limited. This umbrella review highlights the challenge of synthesising evidence due to significant heterogeneity in methods, intervention content and reporting of outcomes. Higher quality intervention studies in line with current geriatric medicine research guidelines are recommended, rather than the publication of further systematic reviews. Trial registration UMBRELLA REVIEW REGISTRATION: PROSPERO (CRD42020145315).
Background The implementation of condition-specific falls prevention interventions is proving challenging due to lack of critical mass and resources. Given the similarities in falls risk factors across stroke, Parkinson’s Disease (PD) and Multiple Sclerosis (MS), the development of an intervention designed for groups comprising of people with these three neurological conditions may provide a pragmatic solution to these challenges. The aims of this umbrella review were to investigate the effectiveness of falls prevention interventions in MS, PD and stroke, and to identify the commonalities and differences between effective interventions for each condition to inform the development of an intervention for mixed neurological groups. Methods A systematic literature search was conducted using 15 electronic databases, grey literature searches and hand-screening of reference lists. Systematic reviews of studies investigating the effects of falls prevention interventions in MS, PD and stroke were included. Methodological quality of reviews was assessed using the A MeaSurement Tool to Assess Systematic Reviews 2. A matrix of evidence table was used to assess the degree of overlap. The Grading of Recommendations Assessments, Development and Evaluation framework was used to rate the quality of evidence. Findings were presented through narrative synthesis and a summary of evidence table. Results Eighteen reviews were included; three investigating effectiveness of falls prevention interventions in MS, 11 in PD, three in stroke, and one in both PD and stroke. Exercise-based interventions were the most commonly investigated for all three conditions, but differences were identified in the content and delivery of these interventions. Low to moderate quality evidence was found for the effectiveness of exercise-based interventions at reducing falls in PD. Best available evidence suggests that exercise is effective at reducing falls in stroke but no evidence of effect was identified in MS. Conclusions The findings suggest that exercise-based interventions are effective at reducing falls in PD, however, the evidence for MS and stroke is less conclusive. A strong theoretical rationale remains for the use of exercise-based interventions to address modifiable physiological falls risk factors for people with MS, PD and stroke, supporting the feasibility of a mixed-diagnosis intervention. Given the high overlap and low methodological quality of primary studies, the focus should be on the development of high-quality trials investigating the effectiveness of falls prevention interventions, rather than the publication of further systematic reviews.
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