The bidirectional relationship between sleep problems and chronic musculoskeletal pain: a systematic review with meta-analysis.

ABSTRACT: Chronic musculoskeletal pain and sleep problems/disorders exhibit a recognized bidirectional relationship; yet, systematic investigations of this claim, particularly in a prospective context, are lacking. This systematic review with meta-analysis aimed to synthesize the literature on the prospective associations between sleep problems/disorders and chronic musculoskeletal pain. A comprehensive search across 6 databases identified prospective longitudinal cohort studies in adults examining the relationship between sleep problems/disorders and chronic musculoskeletal pain. Random-effects meta-analyses, using the Hartung-Knapp adjustment for 95% confidence intervals (CIs), were conducted, and all results were presented as odds ratios (ORs). Certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Including 16 articles from 11 study populations (116,746 participants), meta-analyses indicated that sleep problems at baseline may heighten the risk of chronic musculoskeletal pain in both short term (OR 1.64, 95% CI 1.01-2.65) and long term (OR 1.39, 95% CI 1.21-1.59). The evidence for different sleep problem categories was very uncertain. Chronic musculoskeletal pain at baseline may increase the risk of short-term sleep problems (OR 1.56, 95% CI 1.02-2.38), but long-term evidence was very uncertain. The impact of only local or only widespread pain on short-term sleep problems was very uncertain, whereas widespread pain may elevate the risk of long-term sleep problems (OR 2.0, 95% CI 1.81-2.21). In conclusion, this systematic review with meta-analysis suggests that sleep problems are associated with an increased risk of chronic musculoskeletal pain, but the bidirectional nature of this relationship requires further investigation.

The Physical Demands of Wheelchair Tennis Match Play: A Systematic Review with Meta-analysis.

BACKGROUND: Wheelchair tennis, a globally popular sport, features a professional tour spanning 40 countries and over 160 tournaments. Despite its widespread appeal, information about the physical demands of wheelchair tennis is scattered across various studies, necessitating a comprehensive systematic review to synthesise available data. OBJECTIVE: The aim was to provide a detailed synthesis of the physical demands associated with wheelchair tennis, encompassing diverse factors such as court surfaces, performance levels, sport classes, and sexes. METHODS: We conducted comprehensive searches in the PubMed, Embase, CINAHL, and SPORTDiscus databases, covering articles from inception to March 1, 2023. Forward and backward citation tracking from the included articles was carried out using Scopus, and we established eligibility criteria following the Population, Exposure, Comparison, Outcome, and Study design (PECOS) framework. Our study focused on wheelchair tennis players participating at regional, national, or international levels, including both juniors and adults, and open and quad players. We analysed singles and doubles matches and considered sex (male, female), sport class (open, quad), and court surface type (hard, clay, grass) as key comparative points. The outcomes of interest encompassed play duration, on-court movement, stroke performance, and physiological match variables. The selected study designs included observational cross-sectional, longitudinal, and intervention studies (baseline data only). We calculated pooled means or mean differences with 95% confidence intervals (CIs) and employed a random-effects meta-analysis with robust variance estimation. We assessed heterogeneity using Cochrane Q and 95% prediction intervals. RESULTS: Our literature search retrieved 643 records, with 24 articles meeting our inclusion criteria. Most available information focused on international male wheelchair tennis players in the open division, primarily competing in singles on hard courts. Key findings (mean [95% CI]) for these players on hard courts were match duration 65.9 min [55.0-78.8], set duration 35.0 min [28.2-43.5], game duration 4.6 min [0.92-23.3], rally duration 6.1 s [3.7-10.2], effective playing time 19.8% [18.9-20.7], and work-to-rest ratio 1:4.1 [1:3.7-1:4.4]. Insufficient data were available to analyse play duration for female players. However, for the available data on hard court matches, the average set duration was 34.8 min [32.5-37.2]. International male players on hard court covered an average distance per match of 3859 m [1917-7768], with mean and peak average forward speeds of 1.06 m/s [0.85-1.32] and 3.55 m/s [2.92-4.31], respectively. These players executed an average of 365.9 [317.2-422.1] strokes per match, 200.6 [134.7-299.0] per set, 25.4 [16.7-38.7] per game, and 3.4 [2.6-4.6] per rally. Insufficient data were available for a meta-analysis of female players' on-court movement and stroke performance. The average and peak heart rates of international male players on hard court were 134.3 [124.2-145.1] and 166.0 [132.7-207.6] beats per minute, and the average match heart rate expressed as a percentage of peak heart rate was 74.7% [46.4-100]. We found no studies concerning regional players or juniors, and only one study on doubles match play. CONCLUSIONS: While we present a comprehensive overview of the physical demands of wheelchair tennis, our understanding predominantly centres around international male players competing on hard courts in the open division. To attain a more comprehensive insight into the sport's physical requirements, future research should prioritise the inclusion of data on female and quad players, juniors, doubles, and matches played on clay and grass court surfaces. Such endeavours will facilitate the development of more tailored and effective training programmes for wheelchair tennis players and coaches. The protocol for this systematic review was registered a priori at the International Platform of Registered Systematic Review and Meta-analysis Protocols (Registration https://doi.org/10.37766/inplasy2023.3.0060 ).

Boosting treatment outcomes via the patient-practitioner relationship, treatment-beliefs or therapeutic setting. A systematic review with meta-analysis of contextual effects in chronic musculoskeletal pain.

OBJECTIVE: To ascertain whether manipulating contextual effects (e.g. interaction with patients, or beliefs about treatments) boosted the outcomes of non-pharmacological and non-surgicaltreatments for chronic primary musculoskeletal pain. DESIGN: Systematic review of randomized controlled trials. DATA SOURCES: We searched for trials in six databases, citation tracking, and clinical trials registers. We included trials that compared treatments with enhanced contextual effects with the same treatments without enhancement in adults with chronic primary musculoskeletal pain. DATA SYNTHESIS: The outcomes of interest were pain intensity, physical functioning, global ratings of improvement, quality of life, depression, anxiety, and sleep. We evaluated risk of bias and certainty of the evidence using Cochrane Risk of Bias tool 2.0 and the GRADE approach, respectively. RESULTS: Of 17637 records, we included 10 trials with 990 participants and identified 5 ongoing trials. The treatments were acupuncture, education, exercise training, and physical therapy. The contextual effects that were improved in the enhanced treatments were patient-practitioner relationship, patient beliefs and characteristics, therapeutic setting/environment, and treatment characteristics. Our analysis showed that improving contextual effects in non-pharmacological and non-surgical treatments may not make much difference on pain intensity (mean difference [MD] : -1.77, 95%-CI: [-8.71; 5.16], k = 7 trials, N = 719 participants, Scale: 0-100, GRADE: Low)) or physical functioning (MD: -0.27, 95%-CI: [-1.02; 0.49], 95%-PI: [-2.04; 1.51], k = 6 , N = 567, Scale: 0-10, GRADE: Low) in the short-term and at later follow-ups. Sensitivity analyses revealed similar findings. CONCLUSION: Whilst evidence gaps exist, per current evidence it may not be possible to achieve meaningful benefit for patients with chronic musculoskeletal pain by manipulating the context of non-pharmacological and non-surgical treatments. TRIAL REGISTRATION: This systematic review was prospectively registered in PROSPERO (registration number: CRD42023391601).

Contextual effects: how to, and how not to, quantify them.

The importance of contextual effects and their roles in clinical care controversial. A Cochrane review published in 2010 concluded that placebo interventions lack important clinical effects overall, but that placebo interventions can influence patient-reported outcomes such as pain and nausea. However, systematic reviews published after 2010 estimated greater contextual effects than the Cochrane review, which stems from the inappropriate methods employed to quantify contextual effects. The effects of medical interventions (i.e., the total treatment effect) can be divided into three components: specific, contextual, and non-specific. We propose that the most effective method for quantifying the magnitude of contextual effects is to calculate the difference in outcome measures between a group treated with placebo and a non-treated control group. Here, we show that other methods, such as solely using the placebo control arm or calculation of a 'proportional contextual effect,' are limited and should not be applied. The aim of this study is to provide clear guidance on best practices for estimating contextual effects in clinical research.

The Impact of Exercise Prescription Variables on Intervention Outcomes in Musculoskeletal Pain: An Umbrella Review of Systematic Reviews.

BACKGROUND: Musculoskeletal pain conditions are the largest contributors to disability and healthcare burden globally. Exercise interventions improve physical function and quality of life in individuals with musculoskeletal pain, yet optimal exercise prescription variables (e.g. duration, frequency, intensity) are unclear. OBJECTIVE: We aimed to examine evidence gaps, methodological quality and exercise prescription recommendations in systematic reviews of exercise for musculoskeletal pain. METHODS: In our prospectively registered umbrella review, PubMed, SPORTDiscus, Cochrane Database of Systematic Reviews, EMBASE, and CINAHL were searched from inception to 14 February 2023. Backward citation tracking was performed. We included peer-reviewed, English language, systematic reviews and meta-analyses of randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that compared exercise with conservative treatment, placebo or other exercise interventions in adults with musculoskeletal pain. Data were extracted from the following groups of reviews based on their reporting of exercise prescription data and analysis of the relationship between prescription variables and outcomes: (1) those that did not report any exercise prescription data, (2) those that reported exercise prescription data but did not perform a quantitative analysis and (3) those that performed a quantitative analysis of the relationship between exercise prescription variables and outcomes. Outcome measures were physical function, pain, mental health, adverse effects and adherence to treatment. AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) was used to assess methodological quality. RESULTS: From 6757 records, 274 systematic reviews were included. 6.6% of reviews did not report any exercise prescription data, and only 10.9% quantitatively analyzed the relationship between prescription variables and the outcome(s). The overall methodological quality was critically low in 85% of reviews. CONCLUSION: High methodological quality evidence is lacking for optimal exercise training prescription variables in individuals with musculoskeletal pain. To better inform practice and evidence gaps, future systematic reviews should (1) identify optimum exercise prescription variables, for example, via dose-response (network) meta-analysis, (2) perform high-quality reviews per AMSTAR-2 criteria and (3) include outcomes of mental health, adverse events and exercise adherence. PROSPERO REGISTRATION NUMBER: CRD42021287440 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021287440 ).

Telemedicine for Patients with Musculoskeletal Pain Lacks High-Quality Evidence on Delivery Modes and Effectiveness: An Umbrella Review.

Background: Musculoskeletal (MSK) pain is the leading cause of disability worldwide. Telemedicine is of growing importance, yet impacts on treatment efficacy remain unclear. Objective: This umbrella review (CRD42022298047) examined the effectiveness of telemedicine interventions on pain intensity, disability, psychological function, quality of life, self-efficacy, and adverse events in MSK pain. Methods: PubMed, SPORTDiscus, Cochrane Library, EMBASE, and CINAHL were searched from inception to August 9, 2022, for systematic reviews with meta-analysis, including telemedicine-delivered exercise, education, and psychological interventions, in randomized controlled trials (RCTs). AMSTAR-2 was implemented. Standardized mean differences (SMDs; negative favors telemedicine) were extracted as effect estimates. Results: Of 1,135 records, 20 reviews (RCTs: n = 97, participants: n = 15,872) were included. Pain intensity SMDs were -0.66 to 0.10 for mixed pain (estimates: n = 16), -0.64 to -0.01 for low-back pain (n = 9), -0.31 to -0.15 for osteoarthritis (n = 7), -0.29 for knee pain (n = 1), -0.66 to -0.58 for fibromyalgia (n = 2), -0.16 for back pain (n = 1), and -0.09 for rheumatic disorders (n = 1). Disability SMDs were -0.50 to 0.10 for mixed pain (n = 14), -0.39 to 0.00 for low-back pain (n = 8), -0.41 to -0.04 for osteoarthritis (n = 7), -0.22 for knee pain (n = 1), and -0.56 for fibromyalgia (n = 1). Methodological quality was "critically low" for 17 reviews. Effectiveness tended to favor telemedicine for all secondary outcomes. Conclusions: Primary RCTs are required that compare telemedicine interventions with in-person delivery of the intervention (noninferiority trials), consider safety, assess videoconferencing, and combine different treatment approaches.

The importance of context (placebo effects) in conservative interventions for musculoskeletal pain: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Contextual effects (e.g. patient expectations) may play a role in treatment effectiveness. This study aimed to estimate the magnitude of contextual effects for conservative, non-pharmacological interventions for musculoskeletal pain conditions. A systematic review and meta-analysis of randomized controlled trials (RCTs) that compared placebo conservative non-pharmacological interventions to no treatment for musculoskeletal pain. The outcomes assessed included pain intensity, physical functioning, health-related quality of life, global rating of change, depression, anxiety and sleep at immediate, short-, medium- and/or long-term follow-up. DATABASES AND DATA TREATMENT: MEDLINE, EMBASE, CINAHL, Web of Science Core Collection, CENTRAL and SPORTDiscus were searched from inception to September 2021. Trial registry searches, backward and forward citation tracking and searches for prior systematic reviews were completed. The Cochrane risk of bias 2 tool was implemented. RESULTS: The study included 64 RCTs (N = 4314) out of 8898 records. For pain intensity, a mean difference of (MD: -5.32, 95% confidence interval (CI): -7.20, -3.44, N = 57 studies with 74 outcomes, GRADE: very low) was estimated for placebo interventions. A small effect in favour of the placebo interventions for physical function was estimated (SMD: -0.22, 95% CI: -0.35, -0.09; N = 37 with 48 outcomes, GRADE: very low). Similar results were found for a broad range of patient-reported outcomes. Meta-regression analyses did not explain heterogeneity among analyses. CONCLUSION: The study found that the contextual effect of non-pharmacological conservative interventions for musculoskeletal conditions is likely to be small. However, given the known effect sizes of recommended evidence-based treatments for musculoskeletal conditions, it may still contribute an important component. SIGNIFICANCE: Contextual effects of non-pharmacological conservative interventions for musculoskeletal conditions are likely to be small for a broad range of patient-reported outcomes (pain intensity, physical function, quality of life, global rating of change and depression). Contextual effects are unlikely, in isolation, to offer much clinical care. But these factors do have relevance in an overall treatment context as they provide almost 30% of the minimally clinically important difference.

Effectiveness of Exercise Interventions for Preventing Neck Pain: A Systematic Review With Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To update the evidence on the effectiveness of exercise interventions to prevent episodes of neck pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, SPORTDiscus, PEDro, and trial registries from inception to December 2, 2022. Forward and backward citation searches. STUDY SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled adults without neck pain at baseline and compared exercise interventions to no intervention, placebo/sham, attention control, or minimal intervention. Military populations and astronauts were excluded. DATA SYNTHESIS: Random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 tool. The certainty of evidence was judged according to the GRADE approach. RESULTS: Of 4703 records screened, 5 trials (1722 participants at baseline) were included and eligible for meta-analysis. Most (80%) participants were office workers. Risk of bias was rated as some concerns for 2 trials and high for 3 trials. There was moderate-certainty evidence that exercise interventions probably reduce the risk of a new episode of neck pain (OR, 0.49; 95% confidence interval: 0.31, 0.76) compared to no or minimal intervention in the short-term (≤12 months). The results were not robust to sensitivity analyses for missing outcome data. CONCLUSION: There was moderate-certainty evidence supporting exercise interventions for reducing the risk for an episode of neck pain in the next 12 months. The clinical significance of the effect is unclear. J Orthop Sports Phys Ther 2023;53(10):1-16. Epub: 8 September 2023. doi:10.2519/jospt.2023.12063.

Physical Demands of Tennis Across the Different Court Surfaces, Performance Levels and Sexes: A Systematic Review with Meta-analysis.

BACKGROUND: Tennis is a multidirectional high-intensity intermittent sport for male and female individuals played across multiple surfaces. Although several studies have attempted to characterise the physical demands of tennis, a meta-analysis is still lacking. OBJECTIVE: We aimed to describe and synthesise the physical demands of tennis across the different court surfaces, performance levels and sexes. METHODS: PubMed, Embase, CINAHL and SPORTDiscus were searched from inception to 19 April, 2022. A backward citation search was conducted for included articles using Scopus. The PECOS framework was used to formulate eligibility criteria. POPULATION: tennis players of regional, national or international playing levels (juniors and adults). EXPOSURE: singles match play. Comparison: sex (male/female), court surface (hard, clay, grass). OUTCOME: duration of play, on-court movement and stroke performance. STUDY DESIGN: cross-sectional, longitudinal. Pooled means or mean differences with 95% confidence intervals were calculated. A random-effects meta-analysis with robust variance estimation was performed. The measures of heterogeneity were Cochrane Q and 95% prediction intervals. Subgroup analysis was used for different court surfaces. RESULTS: The literature search generated 7736 references; 64 articles were included for qualitative and 42 for quantitative review. Mean [95% confidence interval] rally duration, strokes per rally and effective playing time on all surfaces were 5.5 s [4.9, 6.3], 4.1 [3.4, 5.0] and 18.6% [15.8, 21.7] for international male players and 6.4 s [5.4, 7.6], 3.9 [2.4, 6.2] and 20% [17.3, 23.3] for international female players. Mean running distances per point, set and match were 9.6 m [7.6, 12.2], 607 m [443, 832] and 2292 m [1767, 2973] (best-of-5) for international male players and 8.2 m [4.4, 15.2], 574 m [373, 883] and 1249 m [767, 2035] for international female players. Mean first- and second-serve speeds were 182 km·h-1 [178, 187] and 149 km·h-1 [135, 164] for international male players and 156 km·h-1 95% confidence interval [151, 161] and 134 km·h-1 [107, 168] for international female players. CONCLUSIONS: The findings from this study provide a comprehensive summary of the physical demands of tennis. These results may guide tennis-specific training programmes. We recommend more consistent measuring and reporting of data to enable future meta-analysts to pool meaningful data. CLINICAL TRIAL REGISTRATION: The protocol for this systematic review was registered a priori at the Open Science Framework (Registration DOI https://doi.org/10.17605/OSF.IO/MDWFY ).

Interventions for promoting evidence-based guideline-consistent surgery in low back pain: a systematic review and meta-analysis of randomised controlled trials.

PURPOSE: Examine the effectiveness of interventions to approach guideline-adherent surgical referrals for low back pain assessed via systematic review and meta-analysis. METHODS: Five databases (10 September 2021), Google Scholar, reference lists of relevant systematic reviews were searched and forward and backward citation tracking of included studies were implemented. Randomised controlled/clinical trials in adults with low back pain of interventions to optimise surgery rates or referrals to surgery or secondary referral were included. Bias was assessed using the Cochrane ROB2 tool and evidence certainty via Grading of Recommendations Assessment, Development and Evaluation (GRADE). A random effects meta-analysis with a Paule Mandel estimator plus Hartung-Knapp-Sidik-Jonkman method was used to calculate the odds ratio and 95% confidence interval, respectively. RESULTS: Of 886 records, 6 studies were included (N = 258,329) participants; cluster sizes ranged from 4 to 54. Five studies were rated as low risk of bias and one as having some concerns. Two studies reporting spine surgery referral or rates could only be pooled via combination of p values and gave evidence for a reduction (p = 0.021, Fisher's method, risk of bias: low). This did not persist with sensitivity analysis (p = 0.053). For secondary referral, meta-analysis revealed a non-significant odds ratio of 1.07 (95% CI [0.55, 2.06], I2 = 73.0%, n = 4 studies, Grading of Recommendations Assessment, Development and Evaluation [GRADE] evidence certainty: very low). CONCLUSION: Few RCTs exist for interventions to improve guideline-adherent spine surgery rates or referral. Clinician education in isolation may not be effective. Future RCTs should consider organisational and/or policy level interventions. PROSPERO REGISTRATION: CRD42020215137.

Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis.

OBJECTIVE: Compare the effectiveness of primarily surgical versus primarily rehabilitative management for anterior cruciate ligament (ACL) rupture. DESIGN: Living systematic review and meta-analysis. DATA SOURCES: Six databases, six trial registries and prior systematic reviews. Forward and backward citation tracking was employed. ELIGIBILITY CRITERIA: Randomised controlled trials that compared primary reconstructive surgery and primary rehabilitative treatment with or without optional reconstructive surgery. DATA SYNTHESIS: Bayesian random effects meta-analysis with empirical priors for the OR and standardised mean difference and 95% credible intervals (CrI), Cochrane RoB2, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. RESULTS: Of 9514 records, 9 reports of three studies (320 participants in total) were included. No clinically important differences were observed at any follow-up for self-reported knee function (low to very low certainty of evidence). For radiological knee osteoarthritis, we found no effect at very low certainty of evidence in the long term (OR (95% CrI): 1.45 (0.30 to 5.17), two studies). Meniscal damage showed no effect at low certainty of evidence (OR: 0.85 (95% CI 0.45 to 1.62); one study) in the long term. No differences were observed between treatments for any other secondary outcome. Three ongoing randomised controlled trials were identified. CONCLUSIONS: There is low to very low certainty of evidence that primary rehabilitation with optional surgical reconstruction results in similar outcome measures as early surgical reconstruction for ACL rupture. The findings challenge a historical paradigm that anatomic instability should be addressed with primary surgical stabilisation to provide optimal outcomes. PROSPERO REGISTRATION NUMBER: CRD42021256537.

Reducing Low-Value Imaging for Low Back Pain: Systematic Review With Meta-analysis.

OBJECTIVE: To examine the effectiveness of implementing interventions to improve guideline-recommended imaging referrals in low back pain. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, Web of Science Core Collection, and the Cochrane Central Register of Controlled Trials from inception to June 14, 2021, as well as Google Scholar and reference lists of relevant systematic reviews published in the last 10 years. We conducted forward and backward citation tracking. STUDY SELECTION CRITERIA: Randomized controlled or clinical trials in adults with low back pain to improve imaging referrals. DATA SYNTHESIS: Bias was assessed using the Cochrane Risk of Bias 2 tool. Data were synthesized using narrative synthesis and random-effects meta-analysis (Hartung-Knapp-Sidik-Jonkman method). We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: Of the 2719 identified records, 8 trials were included, with 6 studies eligible for meta-analysis (participants: N = 170 460). All trials incorporated clinician education; 4 included audit and/or feedback components. Comparators were no-intervention control and passive dissemination of guidelines. Five trials were rated as low risk of bias, and 2 trials were rated as having some concerns. There was low-certainty evidence that implementing interventions to improve guideline-recommended imaging referrals had no effect (odds ratio [95% confidence interval]: 0.87 [0.72, 1.05]; I2 = 0%; studies: n = 6). The main finding was robust to sensitivity analyses. CONCLUSION: We found low-certainty evidence that interventions to reduce imaging referrals or use in low back pain had no effect. Education interventions are unlikely to be effective. Organizational- and policy-level interventions are more likely to be effective. J Orthop Sports Phys Ther 2022;52(4):175-191. Epub 05 Feb 2022. doi:10.2519/jospt.2022.10731.

Clinician education unlikely effective for guideline-adherent medication prescription in low back pain: systematic review and meta-analysis of RCTs.

BACKGROUND: Effectiveness of implementing interventions to optimise guideline-recommended medical prescription in low back pain is not well established. METHODS: A systematic review and random-effects meta-analyses for dichotomous outcomes with a Paule-Mandel estimator. Five databases and reference lists were searched from inception to 4th August 2021. Randomised controlled/clinical trials in adults with low back pain to optimise medication prescription were included. Cochrane Risk of Bias 2 tool and GRADE were implemented. The review was registered prospectively with PROSPERO (CRD42020219767). FINDINGS: Of 3352 unique records identified in the search, seven studies were included and five were eligible for meta-analysis (N=11339 participants). Six of seven studies incorporated clinician education, three studies included audit/feedback components and one study implemented changes in medical records systems. Via meta-analysis, we estimated a non-significant odds-ratio of 0·94 (95% CI (0·77; 1.16), I² = 0%; n=5 studies, GRADE: low) in favour of the intervention group. The main finding was robust to sensitivity analyses. INTERPRETATION: There is low quality evidence that existing interventions to optimise medication prescription or usage in back pain had no impact. Peer-to-peer education alone does not appear to lead to behaviour change. Organisational and policy interventions may be more effective. FUNDING: This work was supported by internal institutional funding only.

Author Response to "Concerns About the Methodology and Data Collection in a Systematic Review".

Author response to the JOSPT Letter to the Editor-in-Chief "Concerns About the Methodology and Data Collection in a Systematic Review". J Orthop Sports Phys Ther 2022;52(1):50-51. doi:10.2519/jospt.2022.0201-R.

[Consequences of anterior cruciate ligament rupture: a systematic umbrella review]. / Folgen einer vorderen Kreuzbandruptur ­ Ein systematisches Umbrella-Review.

INTRODUCTION: The treatment of an anterior cruciate ligament rupture is still controversial. In particular, this applies to the question of conservative versus surgical treatment. The answer to this question is often based on consequential damage such as the development of posttraumatic osteoarthritis, secondary damage to the meniscus or cartilage, and participation in sports. If there are significant differences in these parameters between the individual treatment options, the results will be of great importance for the development of evidence-based treatment pathways. Therefore, the aim of this work was to evaluate the development of knee osteoarthritis after rupture of the anterior cruciate ligament and the corresponding treatment (conservative or surgical). MATERIAL AND METHODS: To answer the above question, a systematic literature search was conducted in Medline via Pubmed, the Cochrane Library and in CINAHL. Only systematic reviews with a minimum follow-up period of 10 years were included. The search was conducted in January 2020 and updated in January 2021. Investigated cohorts included patients with a rupture of the anterior cruciate ligament who had undergone either conservative or surgical treatment. Osteoarthritis was diagnosed either radiologically (recognized scores) or clinically (pain and impaired function). Appropriate reviews were qualitatively evaluated using the AMSTAR-2 questionnaire. RESULTS: The literature research initially identified n = 42 reviews from which 14 reviews were included. After full-text review and qualitative evaluation, only n = 2 systematic reviews remained for evaluation. The results of both papers show imprecise data with a high variability. However, it can be assumed with high probability that the development of osteoarthritis of the knee is increased after a rupture of the anterior cruciate ligament. There is no evidence that the incidence of joint degeneration may be reduced by reconstruction of the anterior cruciate ligament, nor is there a difference when comparing conservative and surgical treatment directly. CONCLUSION: Patients with an anterior cruciate ligament rupture are likely to be at a greater risk of developing progressive joint degeneration. A protective effect of cruciate ligament surgery has not been found in the evaluated studies. A general argument in favour of cruciate ligament surgery aiming to achieve a protective effect on hyaline articular cartilage seems obsolete based on the results and should therefore not be used in patient education in the future.

Classification Approaches for Treating Low Back Pain Have Small Effects That Are Not Clinically Meaningful: A Systematic Review With Meta-analysis.

OBJECTIVE: To determine whether classification systems improve patient-reported outcomes for people with low back pain (LBP). DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: The MEDLINE, Embase, CINAHL, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials databases were searched from inception to June 21, 2021. Reference lists of prior systematic reviews and included trials were screened. STUDY SELECTION CRITERIA: We included randomized trials comparing a classification system (eg, the McKenzie method or the STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (eg, fractures or tumors) were excluded. DATA SYNTHESIS: Outcomes were patient-reported LBP intensity, leg pain intensity, and disability. We used the revised Cochrane Collaboration Risk of Bias Tool to assess risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation approach to judge the certainty of evidence. We used random-effects meta-analysis, with the Hartung-Knapp-Sidik- Jonkman adjustment, to estimate the standardized mean difference (SMD; Hedges' g) and 95% confidence interval (CI). Subgroup analyses explored classification system, comparator type, pain type, and pain duration. RESULTS: Twenty-four trials assessing classification systems and 34 assessing subclasses were included. There was low certainty of a small effect at the end of intervention for LBP intensity (SMD, -0.31; 95% CI: -0.54, -0.07; P = .014, n = 4416, n = 21 trials) and disability (SMD, -0.27; 95% CI: -0.46, -0.07; P = .011, n = 4809, n = 24 trials), favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful. CONCLUSION: For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems over generalized interventions when managing LBP. J Orthop Sports Phys Ther 2022;52(2):67-84. Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.

Association between the level of partial foot amputation and gait: a scoping review with implications for the minimum impairment criteria for wheelchair tennis.

OBJECTIVE: This scoping review examines how different levels and types of partial foot amputation affect gait and explores how these findings may affect the minimal impairment criteria for wheelchair tennis. METHODS: Four databases (PubMed, Embase, CINAHL and SPORTDiscus) were systematically searched in February 2021 for terms related to partial foot amputation and ambulation. The search was updated in February 2022. All study designs investigating gait-related outcomes in individuals with partial foot amputation were included and independently screened by two reviewers based on Arksey and O'Malley's methodological framework and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. RESULTS: Twenty-nine publications with data from 252 participants with partial foot amputation in 25 studies were analysed. Toe amputations were associated with minor gait abnormalities, and great toe amputations caused loss of push-off in a forward and lateral direction. Metatarsophalangeal amputations were associated with loss of stability and decreased gait speed. Ray amputations were associated with decreased gait speed and reduced lower extremity range of motion. Transmetatarsal amputations and more proximal amputations were associated with abnormal gait, substantial loss of power generation across the ankle and impaired mobility. CONCLUSIONS: Partial foot amputation was associated with various gait changes, depending on the type of amputation. Different levels and types of foot amputation are likely to affect tennis performance. We recommend including first ray, transmetatarsal, Chopart and Lisfranc amputations in the minimum impairment criteria, excluding toe amputations (digits two to five), and we are unsure whether to include or exclude great toe, ray (two to five) and metatarsophalangeal amputations. TRIAL REGISTRATION: The protocol of this scoping review was previously registered at the Open Science Framework Registry (https://osf.io/8gh9y) and published.