Effectiveness of physical therapist administered spinal manipulation for the treatment of low back pain: a systematic review of the literature. Effectiveness of Manual Physical Therapy for Painful Shoulder Conditions: A Systematic Review Intertester Reliability of McKenzie's Classifications of the Syndrome Types Present in Patients with Low Back Pain Effectiveness of manual therapies: the UK evidence report Intertester reliability of a modified version of McKenzie's lateral shift assessments obtained on patients with low back pain. Physical Impairment Index: Reliability, Validity, and Responsiveness in Patients with Acute Low Back Pain Bias in Systematic Reviews? Congruence between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America A systematic review of workplace interventions to prevent low back pain. Intertester reliability of judgments of the presence of trigger points in patients with low back pain. Reporting of Sex Effects by Systematic Reviews on Interventions for Depression, Diabetes, and Chronic Pain Acupuncture for Chronic Pain in Japan: A Review Evidence-based medicine and the challenge of low back pain: where are we now? 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 Does the non-randomized controlled study have a place in the systematic review? A pilot study. Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group. Reliability of physical examination items used for classification of patients with low back pain. The Use of a Classification Approach to Identify Subgroups of Patients With Acute Low Back Pain: Interrater Reliability and Short-Term Treatment Outcomes Both resistance and agility training reduce back pain and improve health-related quality of life in older women with low bone mass Comparative effectiveness of manipulation, mobilisation and the Activator instrument in treatment of non-specific neck pain: a systematic review Massage for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Back Review Group Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Reviewing studies with diverse designs: the development and evaluation of a new tool.
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 , SPORTD iscus , 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 ) r and omized control trials . The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Data base ( PEDro ) . RESULTS Six r and omized 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 result ing 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 Abstract Multiple disease-specific systematic review s on the effectiveness of physical therapy intervention for shoulder dysfunction have been inconclusive . To date , there have been two systematic review s that examined manual therapy specifically but both considered effects within diagnoses . The purpose of this systematic review was to identify the effectiveness of manual therapy to the glenohumeral joint across all painful shoulder conditions . A search of MEDLINE , CINAHL , Web of Science , and Cochrane Central Register of R and omized Controlled Trials for articles date d 1996 to June 2009 was performed . Inclusion for review were  manual therapy performed to the glenohumeral joint only ; non-surgical painful shoulder disorders ; subjects 18 - 80 years ; and outcomes of range of motion , pain , function , and /or quality of life . Quality assessment was performed using the PEDro scale with subsequent data extraction . Seventeen related articles were found with seven fitting the inclusion criteria . The average PEDro score was 7.86 , meeting the cutoff score for high quality . Significant heterogeneity in outcome measures prohibited meta- analysis . Five studies demonstrated benefits utilizing manual therapy for mobility , and four demonstrated a trend towards decreasing pain values . Functional outcomes and quality -of-life measures varied greatly among all studies . Manual therapy appears to increase either active or passive mobility of the shoulder . A trend was found favoring manual therapy for decreasing pain , but the effect on function and quality of life remains inconclusive . Future research utilizing consistent outcome measurements is necessary The McKenzie system for examining and treating patients with low back pain is frequently used by clinicians . The primary purpose of this multicenter study was the determine the intertester reliability of assessment s of patients with low back pain when physical therapists used the McKenzie method . A second purpose was to determine if previous postgraduate training in the McKenzie system affects reliability . Some therapists had previously undertaken postgraduate training in the McKenzie system .  All therapists were given written descriptions of the McKenzie method and the criteria used to classify patients , Classifications were made on 363 patients with low back pain by r and omly paired physical therapists in eight clinics . The Kappa value on agreement of patient classification was 0.26 , which suggests poor reliability . Therapists agreed on which syndrome was present 39 % of the time . Previous postgraduate training did not reliability . The results suggest that assessment s of the syndrome present in patients ; with low back pain appear to be unreliable when using the McKenzie system Background The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions . Methods The conclusions are based on the results of systematic review s of r and omized clinical trials ( RCTs ) , widely accepted and primarily UK and United States evidence -based clinical guidelines , plus the results of all RCTs not yet included in the first three categories . The strength/ quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs . Results By September 2009 , 26 categories of conditions were located containing RCT evidence for the use of manual therapy :  13 musculoskeletal conditions , four types of chronic headache and nine non-musculoskeletal conditions . We identified 49 recent relevant systematic review s and 16 evidence -based clinical guidelines plus an additional 46 RCTs not yet included in systematic review s and guidelines .Additionally , brief references are made to other effective non-pharmacological , non-invasive physical treatments . Conclusions Spinal manipulation/mobilization is effective in adults for : acute , subacute , and chronic low back pain ; migraine and cervicogenic headache ; cervicogenic dizziness ;  manipulation/mobilization is effective for several extremity joint conditions ; and thoracic manipulation/mobilization is effective for acute/subacute neck pain . The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration , and for manipulation/mobilization for mid back pain , sciatica , tension-type headache , coccydynia , temporom and ibular joint disorders , fibromyalgia , premenstrual syndrome , and pneumonia in older adults . Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation , or for Stage 1 hypertension when added to an antihypertensive diet . In children , the evidence is inconclusive regarding the effectiveness for otitis media and enuresis , and it is not effective for infantile colic and asthma when compared to sham manipulation . Massage is effective in adults for  chronic low back pain and chronic neck pain . The evidence is inconclusive for knee osteoarthritis , fibromyalgia , myofascial pain syndrome , migraine headache , and premenstrual syndrome . In children , the evidence is inconclusive for asthma and infantile colic BACKGROUND AND PURPOSE McKenzie described a two-step process for assessing patients with low back pain for a lateral shift . The purpose of this study was to determine whether reliable judgments about lateral shifts could be obtained . SUBJECTS Forty-nine patients with low back pain were each examined separately by two r and omly paired physical therapists . METHODS Assessment s of the presence and direction of lateral  shifts ( step 1 ) were obtained by use of a simple instrument . The relevance of the lateral shifts to the patients ' pain complaints ( step 1 ) also was assessed by use of the side-glide test sequence . RESULTS Generalized kappa coefficients were calculated to determine reliability . The kappa value for the two-step process of lateral shift assessment was .16 . The percentage of agreement was 47 % . CONCLUSION AND DISCUSSION Each step in this two-step process was examined separately for possible sources of error . The kappa value for determinations of the presence and direction of lateral shifts was .00 , indicating very poor reliability . The kappa value for the determination of the presence of a positive side-glide test sequence was .74 , indicating high reliability . The role of lateral shift assessment in the McKenzie system should be reconsidered , given the strong research evidence for poor reliability of determinations of the presence and direction of lateral shifts Study Design . Cohort study of patients with acute low back pain undergoing physical therapy .  Objectives . Examine the reliability and validity of the Physical Impairment Index in a group of patients with acute low back pain and determine the responsiveness and minimum detectable change of the index and its component tests . Summary of the Background Data . The Physical Impairment Index was originally described as a reliable and valid means of assessing physical impairment in patients with low back pain . The psychometric properties of the index have not been reported in patients with acute low back pain , nor has its responsiveness been examined . Methods . Seventy-eight patients with acute ( <3 weeks duration ) low back pain participating in a clinical trial were assessed at baseline and after 4 weeks .  Interrater reliability of the index was examined in a subgroup of 20 patients . Validity was examined through correlations with concurrent measures of pain , disability , and psychosocial variables . Changes in the index over 4 weeks were used to assess responsiveness and minimum detectable change . Results . Interrater reliability of the index was high ( intraclass correlation coefficient = 0.89 ) , and its validity was generally supported by the pattern of correlations . The index was more responsive to change than any of its component tests but was less responsive than the Oswestry disability score . The minimum detectable change on the index was approximately 1 point . Conclusions . The Physical Impairment Index appears to be a reliable and valid measure of physical impairment for patients with acute low back pain and may be useful as an adjunct outcome measure for studies involving these patients . Further research on patients with chronic pain is needed before it can be advocated for outcomes research with this population At an orthodontic meeting in recent years , a colleague recounted to me that when a presenter had finished their presentation on a systematic review , the person beside leaned over and said to my colleague ‘ not another systematic review where it ’s not possible to draw any firm conclusions ’ . So an element of frustration was clear based on the screening of a large volume of evidence to arrive at such a low point for a conclusion . This , however , is now a familiar outcome for many orthodontic systematic review s. In this short editorial , I have attempted to give a brief outline of the proposed benefits of systematic review s but more importantly , to highlight , some issues we all need to bear in mind in their regard . The increasing focus on evidence -based healthcare , including orthodontics , has shunned the narrative review and spawned the systematic review . Aim ing to identify , evaluate and summarize the findings of all relevant studies on a specific topic , its exacting systematic approach should minimize bias and provide conclusions based on reliable findings . Meta-analyses of r and omized clinical trials with low risk of bias are considered the highest level of evidence available for evaluating the effects of an intervention . Systematic review s are also important tools in setting the research agenda via their recommendations for future research and authors can alert research ers to the most pertinent outcomes in clinical practice . But systematic review s like any other study type are not without their variability , both in dentistry in general and specifically in orthodontics . Large differences have also been observed in the quality of reporting of several characteristics between Cochrane and non-Cochrane systematic review s. A key question that must be asked when looking at all Cochrane review s is whether the review has been undertaken in a way to avoid bias and whether the data and results from the included studies are valid . Conclusions may be distorted if bias is introduced to the review process at any stage . For example , incomplete search ing for all relevant studies may lead to publication bias ; there is strong association between publication and studies reporting significant or positive findings in medicine and also within orthodontics . With regard to studies included within the review , these need to be assessed to ensure that they are undertaken and reported in a manner that is free of bias ( systematic error ) . Outcome reporting bias ( ORB ) may also be relevant , e.g. in a study identified as relevant to a review , where data exist on the outcome of interest but only selected findings have been given based on the results . Although systematic review s have emphasized ‘ assessment of method ological quality ’ of included studies , the Cochrane h and book recommends a focus on ‘ risk of bias assessment ’ instead . The justifications are four-fold : it targets whether the results of included studies should be credible ; despite being carried out to the highest st and ards , a study may have risk of bias due to , e.g. impracticality/impossibility of blinding of participants / study personnel ; some quality markers , e.g. a power calculation is unlikely to directly affect risk of bias ; it overcomes ambiguity between quality of reporting and quality of the underlying research The direct and indirect costs of low back pain , one of the most common symptoms in adults , are estimated at $ 60 billion annually in the United States [ 1 , 2 ] . Practice guidelines recently developed in the United States recommend spinal manipulation for patients with uncomplicated acute low back pain [ 3 ] . If followed , these guidelines can be expected to significantly increase the number of patients referred by medical physicians to chiropractors , who provide most manipulative therapy delivered in the United States [ 4 ] . Concerns have been raised about the quality of chiropractic care [ 5 ] , but systematic data are lacking . How are patients and medical physicians to have confidence in chiropractors in the absence of data on the quality of chiropractic care ? To assess the appropriateness of the use of spinal manipulation for patients with low back pain , we used a method for assessing appropriateness that has been used to study various medical procedures in North America and Europe [ 6 - 16 ] . In these studies , predetermined criteria for the appropriateness ( as defined by expected risk versus benefit ) of the study procedure ( for example , hysterectomy or coronary angioplasty ) are used to retrospectively assess the care delivered . We report the results of our evaluation of the use of chiropractic spinal manipulation at five geographic sites in the United States and one site in Canada . Methods Development of Appropriateness Criteria and Record Abstract ion System For our study , spinal manipulation was defined as a manual procedure that involves specific short-lever dynamic thrusts ( or spinal adjustments ) or nonspecific long-lever manipulation . Nonthrust procedures , such as flexion-distraction and mobilization , were not considered part of manipulative therapy . The development of appropriateness criteria for spinal manipulation for low back pain has been described in detail elsewhere [ 17 ] . In brief , we first performed a systematic review of the literature . A 9-member panel of back experts was convened , consisting of 3 chiropractors , 2 orthopedic spine surgeons , 1 osteopathic spine surgeon , 1 neurologist , 1 internist , and 1 family practitioner . Six panel members were in academic practice , 3 were in private practice , and 4 performed spinal manipulation as part of their practice . The panel members represented all major geographic regions of the United States . The panel used a scale of expected risk and benefit ( ranging from 1 to 9 ) to rate the appropriateness of a comprehensive array of indications , or clinical scenarios , in patients who might present to a chiropractor 's office . We defined appropriate as an indication for which the expected health benefits exceeded the expected health risks by a sufficiently wide margin that spinal manipulation was worth doing . We used a formal group-judgment process , which incorporated two rounds of ratings , a group discussion , and feedback of group ratings between rounds . Experts were to use their best clinical judgment in addition to the evidence from the systematic review we presented them . Panel disagreement on an indication occurred when two or more panelists rated the indication as appropriate and two or more panelists rated it as inappropriate . This definition of disagreement is arbitrary but is based on a face-value assessment of what constitutes disagreement among experts . The final result of the process is a rating of appropriate , inappropriate , or uncertain ( depending on net expected health benefits ) for each indication . Indications with a median panel rating of 7 to 9 , without disagreement , were classified as appropriate . Indications with a median panel rating of 1 to 3 , without disagreement , were classified as inappropriate . Indications with a median panel rating of 4 to 6 and all indications with disagreement were classified as uncertain . The panel of experts met in April 1990 , before the beginning of the Agency for Health Care Policy and Research ( AHCPR ) Low Back Problems Clinical Practice Guideline effort in 1992 . Four members of our panel later participated in the AHCPR process . The AHCPR guidelines cover patients with acute and subacute low back pain only and are similar to the appropriateness criteria created for our project . We developed a chiropractic record abstract ion system that allows collection of data from a chiropractic office record about the patient , history of the back problem , findings on physical examination and diagnostic studies , and treatment rendered . The system is design ed to collect sufficient information to allow the classification of delivered care as appropriate , inappropriate , or uncertain , according to the panel 's ratings . The abstract ion instrument collects data on more than 70 clinical variables that may be present in the record . The instrument uses skip-pattern logic so that only relevant clinical variables are sought . For example , if the patient 's onset of back pain was associated with trauma , additional information about the type of trauma was sought . We pilot-tested our system on numerous chiropractic records obtained from colleagues around the United States and pilot-tested our methods for data collection and analysis on a small sample of chiropractors in southern California [ 18 ] . Identification of Sample We chose San Diego , California ; Portl and , Oregon ; Vancouver , Washington ; Minneapolis-St . Paul , Minnesota ; Miami , Florida ; and Toronto , Ontario , Canada , as sites for our study because of their geographic diversity and because they reflect a varying concentration of practicing chiropractors and differ in the chiropractic scope of practice allowed . We also included the rural areas surrounding the Portl and , Minneapolis-St . Paul , and Toronto areas . We have previously shown that the base population s at the U.S. sites are similar to the general U.S. population in terms of the variables known to affect chiropractic use [ 19 ] . The geographic sampling area around Toronto encompasses 75 % of the population of Ontario . At each site , we constructed our sampling frame from a combination of the telephone book yellow pages , the state or provincial board licensing list , and the mailing list of the local chiropractic college , if any . The final list was the summation ( excluding duplicates ) of the individual lists . We drew a r and om sample from this list and sent the sample d chiropractors a letter that explained the study and invited them to participate . Each letter was accompanied by cover letters from the national chiropractic association and the local chiropractic association or chiropractic college , indicating support for the study . We followed this mailing with a telephone call to determine eligibility and request participation . To be eligible , a chiropractor must have been practicing in the geographic area since 1990 . Eligible chiropractors who declined our initial invitation were contacted by one or more influential state , provincial , or local chiropractors and were again urged to participate . Participating chiropractors and their staff were given , in total , a $ 130 ( in both U.S. and Canadian dollars ) honorarium for participation . Data Collection Trained chiropractic data collectors ( senior chiropractic students or recent graduates ) visited participating chiropractors during regular working hours . These data collectors underwent 2 days of training conducted by two of the authors . The data collectors were unaware of the details of the appropriateness criteria . The reliability and accuracy of the data collection were assessed in several ways . First , after classroom training , the data collectors abstract ed a common set of test records obtained from various different practice s and geographic areas . These were returned to one of the authors for correction , and any errors in abstract ion were review ed with the data collectors . Second , the same author accompanied the data collectors on a practice session with a local volunteer chiropractor , who agreed to let the collectors practice sampling and data abstract ion in his or her office during working hours . Again , errors in either process were review ed with the data collectors . Finally , the same author accompanied the data collectors on one of the early office visits to a chiropractor included in the sample at each geographic site . Here , the author review ed all abstract ed records ; if more than one data collector was working , both data collectors abstract ed a few records . Any discrepancies were review ed with this author . In all , about 4 % of records included in the sample were assessed for reliability and validity . We did not calculate formal reliability statistics . To select records , all office records were measured in inches as if they were books on a shelf . A r and om-number table was used to select a r and om number of inches measured from the start . To avoid fat-chart bias , we selected the record immediately to the right of the record located at the specified number of inches . This chart was then pulled and examined to see whether it described a first visit for low back pain that occurred between 1 January 1985 and 31 December 1991 . If so , data were abstract ed by using the research instrument . This process was repeated until 10 records for low back pain were abstract ed from each participating practitioner 's office . If more than one chiropractor practice d in the same office , we abstract ed data from the records of only one practitioner . Consultation with back pain experts suggested that 10 records per office is a sufficient number that is likely to fairly represent the diversity of that office 's practice . Data Analysis We compiled descriptive data on the patients and the care that they received . The care of patients was classified into appropriateness categories by using the criteria determined by the expert panel . This was done with a computer program that uses unique combinations of variables that define individual indications . The reliability of this program was verified by drawing a r and om sample of records and A systematic review of r and omised controlled trials was undertaken to evaluate the effectiveness of  workplace interventions  to prevent low back pain .  Potential trials were located by a computerised search supplemented with citation tracking . The method ological quality of the trials was assessed on 11 criteria and the level of evidence for each intervention was determined , based upon the amount , consistency and quality of evidence from the trials . The review located 13 trials that were generally of moderate quality . The trials suggest that work place exercise is effective , braces and education are ineffective , and workplace modification plus education is of unknown value in preventing low back pain The purpose of this study was to determine the intertester reliability of assessment s of the presence of trigger points in the region of the lumbar spine of patients with low back pain ( LBP ) . A total of six trigger points described by Travell and Simons were studied . The trigger point examination procedures described by Travell and Simons were used by 12 physical therapists . R and omly paired therapists examined 50 patients for 197 trigger points . The Kappa coefficient , percent agreement , the observed proportion of positive agreement ( Ppos ) , and the observed proportion of negative agreement ( Pneg ) were used to describe reliability . Kappa values ranged from .29 to .38 . Percent agreement ranged from 76 % to 79 % . Ppos ranged from .43 to .52 . The low Kappa and Ppos values suggest different therapists are unable to reliably determine when a trigger point is present in a patient with LBP . This study suggests the usefulness of examining for the presence of trigger points in patients with LBP should be question ed Differences in disease prevalence , clinical manifestations , and health outcomes exist between men and women . Sources for this variation range from biological differentiation at the cellular level to behavioral differences influenced by societal gender norms . Typically , biologically based differences between men and women are called sex differences , whereas gender differences describe health differences related , at least in part , to societal constructs of gender ( 13 ) . For example , biological events unique to women , such as pregnancy and menopause , are probably associated with sex differences in occurrence of certain conditions or in response to some medical therapies ( 48 ) . Gender differences probably exist in health-related perceptions and behaviors for women and men with medical conditions that are prevalent for both sexes ( for example , heart disease and chronic pain ) ( 9 –16 ) . Although sex and gender differences are theoretically distinct , they remain difficult to disentangle when differences between men and women in health outcomes and treatment effectiveness are being examined . For this reason , and for brevity , we hereafter refer to sex and gender differences collectively as sex effects . In the past 2 decades , recognition of the importance of sex effects for health outcomes and treatment heterogeneity has been growing . Beginning in 1993 , the National Institutes of Health has issued policies requiring the inclusion of women and minorities in all clinical research and trial design s with valid analysis of sex effects or differences between racial and ethnic groups ( 17 , 18 ) . Since then , the inclusion of women in clinical trials has increased ( 19 , 20 ) , and sex effects have been identified for medications , such as nicotine replacement therapy , analgesics , and aspirin ( 13 , 14 , 21 ) . Recently , sex effects in adverse reactions led to sex-specific dosage recommendations for a widely used sedative ( 7 ) . Despite this progress , representation of women in clinical studies remains inadequate for many conditions ( 22 ) . Further , published clinical trials infrequently report sex effects or discuss the appropriateness of sex-specific analyses ( 19 , 20 , 23 ) . To advance the clinical evidence base and improve health outcomes for women , clinical research must include adequate numbers of women , appropriately conduct sex-specific analyses , and consistently report sex effects . Systematic review s ( SRs ) are a key source of information for clinicians , research ers , and guideline panels . By synthesizing the overall body of evidence for key clinical and research questions , SRs could potentially make a unique contribution to the evaluation of sex effects . To our knowledge , however , the reporting of sex effects by SRs has not been previously examined . Here , we use evidence mapping to systematic ally evaluate the reporting of sex effects by SRs examining a diverse set of interventions for chronic conditions common to women ( that is , depression , diabetes , and chronic pain ) . Evidence mapping is an emerging approach that describes key characteristics of studies for a broad area of medicine ( 2426 ) . Our evidence map addresses the volume and characteristics of eligible SRs , including the representation of women in primary studies , whether and how review s reported sex effects , and findings about sex effects . Methods This work was part of a larger report for the Veterans Health Administration ( VHA ) Evidence -based Synthesis Program ( ESP ) . The complete technical report is available online ( www.hsrd . research .va.gov/publications/esp ) and includes additional information on our methods . We focused on SRs to determine the reporting of sex effects , provide high-level information about the volume of current clinical evidence , and summarize information about actual sex effects . Prioritization of Conditions for Inclusion We used forced-ranking prioritization ( 27 ) with our VHA stakeholders to determine our conditions of interest . These stakeholders included representatives from the Health Services Research & Development Center for the Study of Healthcare Innovation , Implementation and Policy ; Health Services Research & Development Women 's Health Research Network ; Women 's Health Research in the Office of Research & Development ; Women 's Health Services ; and Mental Health Services . We initially selected 34 conditions ( Appendix Table 1 ) based on disease prevalence in women , disease burden in women , availability and breadth of effective treatments for men or women , and women veterans ' priorities for gender-specific care . Stakeholders ranked this initial set of conditions , discussed the rankings , and reranked conditions that initially received intermediate priority rankings . After 2 rounds of iterative prioritization , the following conditions were selected : depressive disorders , type 2 diabetes mellitus , and chronic pain ( that is , chronic low back pain , fibromyalgia , and chronic knee pain due to osteoarthritis ) . Appendix Table 1 . Conditions Presented to Stakeholders for Prioritization * Data Sources and Search es In collaboration with an expert reference librarian , we search ed PubMed and Cochrane Data base of Systematic Review s to identify eligible SRs published after 1 October 2009 through 31 October 2014 for depression , 13 February 2015 for diabetes , and 27 February 2015 for chronic pain . Search strategies used Medical Subject Headings and free-text terms for the conditions of interest , eligible interventions , and SRs ( Appendix Table 2 ) . We restricted the search to the past 6 years because SRs are typically out date d within 5 years of publication ( 28 ) , and our goal was to describe the current state of the clinical literature . In addition to electronic search ing , we screened published review s of review s for eligible articles . Appendix Table 2 . Search Strategies Study Selection and Quality Assessment Eligible SRs evaluated interventions in several broad categories ( that is , medications , behavioral interventions , supervised exercise , and quality improvement or organizational interventions ) . We also included condition-specific interventions , such as bariatric surgery for diabetes . Review s that evaluated mixed conditions or multiple interventions must have reported results separately for at least 1 eligible condition or intervention . We included review s of interventions in any setting , with any type of active or inactive comparator , and with any duration of follow-up . Detailed inclusion and exclusion criteria are provided in Appendix Table 3 . Appendix Table 3 . Detailed Inclusion and Exclusion Criteria for Review Eligibility Two investigators screened citations for eligibility , and citations that were considered to be relevant by either person were retained for full-text review . Full-text articles were review ed by 2 investigators , and disagreements were resolved through discussion or adjudicated by a third person . Formal assessment of review quality was beyond the scope of this project . However , we noted whether review s originated from organizations known for high- quality review s ( that is , Cochrane Collaboration , Agency for Healthcare Research and Quality Evidence -based Practice Centers , and VHA ESP ) . For review s reporting sex effects , we also assessed industry funding and whether statistical power was considered . Data Abstract ion Data were abstract ed by 1 investigator and review ed by a second person . Disagreements were resolved by discussion or by a third review er . Abstract ed data included the analysis method ( that is , qualitative synthesis , meta- analysis , network meta- analysis , or individual-patient data [ IPD ] meta- analysis ) ; clinical conditions ; interventions ; main outcomes ; number and design of primary studies ( for example , r and omized , controlled trials [ RCTs ] or observational cohorts ) ; proportion of women in the included primary studies ; and if sex effects were part of the study aims , analysis plan , or results . For review s reporting sex effects , we also recorded the number of primary studies used for sex-specific analyses , effect estimates , and the method used ( for example , metaregression , subgroup analysis , or IPD meta- analysis ) . All eligible review s on depressive disorders and chronic pain conditions were fully abstract ed . All diabetes review s of nonpharmacologic interventions were also fully abstract ed . For eligible diabetes medication review s ( n= 120 ) , we applied an additional prioritization procedure before full abstract ion . We prioritized review s that examined multiple classes of medications or evaluated a single class of medications when 6 or fewer eligible review s were identified . For SRs evaluating a single class ( > 6 eligible review s were identified ) , we used additional prioritization criteria ( for example , the most recent review published in a high-impact journal or work done by an organization known for high- quality review s ) . The remaining unselected but eligible review s ( n= 58 ) had a keyword text search for sex effects and were fully abstract ed only when this search yielded positive results ( n= 13 ) . Data Synthesis and Analysis of SRs We grouped eligible review s by intervention category and described the overall volume of clinical literature for interventions addressing each condition of interest . We also determined the number of review s reporting sex effects and summarized these results . Time trends for the proportion of these review s were examined for depression and diabetes . Examination of Primary RCTs for Selected Interventions We anticipated that some interventions for each condition would have few or no eligible SRs that addressed sex effects . Thus , for a subset of interventions for each condition , we evaluated primary RCTs to determine the feasibility of conducting a future review to evaluate sex effects . Specifically , we examined  quality improvement interventions and psychotherapy for depression ; diet , physical activity , and culturally tailored psychoeducation for diabetes ; behavioral interventions for chronic low back pain ; and exercise interventions Many Japanese reports of acupuncture and moxibustion for chronic pain are not listed in medical data bases such as Medline . Therefore , they are not easily accessible to research ers outside of Japan . To complement existing review s of acupuncture and moxibustion for chronic pain and to provide more detailed discussion and analysis , we did a literature search using ‘ Igaku Chuo Zasshi We d ’ ( Japana Centra Revuo Medicina ) and ‘ Citation Information by National Institute of Information ’ covering the period 1978–2006 . Original articles and case reports of acupuncture and moxibustion treatment of chronic pain were included . Animal studies , surveys , and news articles were excluded . Two independent review ers extracted data from located articles in a pre-defined structured way , and assessed the likelihood of causality in each case . We located 57 papers written in Japanese ( 20 full papers , 37 case reports ) . Conditions examined were headache ( 12 trials ) , chronic low back pain ( 9 trials ) , rheumatoid arthritis ( 8 trials ) , temporom and ibular dysfunction ( 8 trials ) , katakori ( 8 trials ) and others ( 12 trials ) . While 23 were described as clinical control trials ( CCTs ) , 11 employed a quasi-r and om method . Applying the 5-point Jadad quality assessment scoring system , the mean score was 1.5 ± 1.3 ( SD ) . Eleven ( 52 % ) of the CCTs were conducted to determine a more effective procedure for acupuncture ; these compared a certain type of acupuncture with another type of acupuncture or specific additional points . In particular , the trigger point acupuncture was widely used to treat chronic low back pain in Japan . Many reports of chronic pain treatment by acupuncture and moxibustion are listed in Japanese data bases . From the data , we conclude that there is limited evidence that acupuncture is more effective than no treatment , and inconclusive evidence that trigger point acupuncture is more effective than placebo , sham acupuncture or st and ard care Low  back pain  has long been described as a challenge for both primary care physicians and specialists . Management of  low back pain  has also been criticized as frequently arbitrary , inappropriate , or ineffective . Contributing factors have been an inadequate evidence base and a need for more rigorous appraisal s of the available literature . Evidence -based medicine , an approach to clinical problem solving , is predicated on the premise that high- quality health care will result from practice s consistent with the best evidence . In contrast to the traditional medical paradigm that placed a heavy reliance on expert opinion , authority , and un systematic clinical observations , evidence -based medicine emphasizes the need for rigorous critical appraisal s of the scientific literature to inform medical decision making . Evidence -based medicine places strong weight on the requirement for valid studies , particularly r and omized controlled trials , to appropriately evaluate the effectiveness of health care interventions . Because of the rapidly increasing volume of medical literature , however , most clinicians are unable to keep up-to- date with all the new data . Two types of preprocessed evidence that can aid busy clinicians in medical decision making are systematic review s and evidence -based clinical practice guidelines . Like primary studies , systematic review s and clinical practice guidelines must adhere to high method ologic st and ards to reduce error and bias . As in other areas of medicine , the approach to the management of low back pain has been positively affected by the availability of more clinical trials and better use of critical appraisal techniques to evaluate and apply research findings . In addition to more rigorous primary studies , an increasing number of high- quality systematic review s and evidence -based clinical practice guidelines for low back pain are also available . Although some research gaps and method ologic shortcomings persist , the richer evidence base has greatly improved our underst and ing of what does and does not work for low back pain . Despite these advances , the best available evidence often does not inform everyday clinical decisions for low back pain . Nonetheless , there is widespread agreement that adherence to evidence -based practice will help improve low back pain patient outcomes and reduce arbitrary variations in care . This article review s basic principles of evidence -based medicine , discusses evidence -based medicine in the context of low back pain management , and summarizes some useful evidence -based medicine re sources Abstract 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 systematic ally search ed six data bases from 2000 to 2014 . R and om pairs of independent review ers critically appraised eligible systematic review s using the Scottish Intercollegiate Guidelines Network criteria . We included systematic review s with a low risk of bias in our best evidence synthesis . Results We screened 706 citations and 14 systematic review s were eligible for critical appraisal . Eight systematic review s 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 BACKGROUND A major issue in any systematic review is deciding which trials or studies to include and which to exclude . The Cochrane Collaboration and similar respected organizations have traditionally viewed the r and omized trial ( RCT ) as the only acceptable evidence on treatment outcome . However , many systematic review s are indeterminate because they include insufficient RCTs whilst they reject large numbers of non-r and omized controlled studies . This is particularly true in forensic mental health , a domain where RCT methodology can be problematic . Systematic review s could become more informative if review ers knew when , and under what circumstances , non-r and omized design s are acceptable for inclusion alongside RCTs . METHOD This pilot study explores whether good- quality , controlled , non-r and omized studies can be reliable surrogates for RCTs . We examined two published review s from the Cochrane Schizophrenia Group . We compared outcomes between ( a )  r and omized trials  ( that had been included ) and non-r  and omized studies  ( that had been excluded ) , and ( b ) between high- and low- quality studies using an established quality checklist  . RESULTS In the first review , effect scores were similar for r and omized and non-r and omized studies and relatively insensitive to study quality . In the second review , the treatment effect was considerably lower for the RCT group - here , however , studies of high- quality showed much smaller effect scores than those of low- quality on two separate outcomes . CONCLUSIONS Non-r and omized controlled studies of high quality can produce outcomes that approximate to those found in RCTs . Trial quality may have a greater impact on treatment effect size than r and omization alone , suggesting that r and omization should not be seen as a reliable proxy for overall quality . The problems and issues still to be resolved are discussed with recommendations for future research STUDY DESIGN A systematic review of r and omized and nonr and omized controlled trials . SUMMARY OF BACKGROUND DATA Lumbar supports are used in the treatment of low back pain , but also to prevent the onset ( primary prevention ) or recurrences of a low back pain episode ( secondary prevention ) . OBJECTIVES To assess the effects of lumbar sup-ports for prevention and treatment of nonspecific low back pain .  METHODS The Medline , Cinahl , and Current Contents data bases ; the Cochrane Controlled Trials Register up to September 1999 ; and the Embase data base up to September 1998 were all search ed . References of identified trials and systematic review s were review ed and the Science Citation Index used to identify additional trials . Method ologic quality assessment and data extraction were performed by two review ers independently . A quantitative analysis was performed in which the strength of evidence was classified as strong , moderate , limited or conflicting , and no evidence . RESULTS Five r and omized and two nonr and omized preventive trials and six r and omized therapeutic trials were included in the review . Only 4 of the 13 studies were of high quality . There was moderate evidence that lumbar supports are not effective for primary prevention . No evidence was found on the effectiveness of lumbar supports for secondary prevention . The systematic review of therapeutic trials showed that there is limited evidence that lumbar supports are more effective than no treatment , whereas it is still unclear whether lumbar supports are more effective than other interventions for treatment of low back pain . CONCLUSIONS There continues to be a need for high quality r and omized trials on the effectiveness of lumbar supports . One of the most essential issues to tackle in these future trials seems to be the realization of adequate compliance BACKGROUND AND PURPOSE The purpose of this study was to examine the interrater reliability of measurements obtained by examiners administering tests proposed to be important for classifying low back pain ( LBP ) problems . SUBJECTS Ninety-five subjects with LBP ( 41 men , 54 women ) and 43 subjects without LBP ( 17 men , 26 women ) were examined by 5 therapists trained in the techniques used . METHODS A manual was developed by the first author that described the clinical examination procedures . The therapists were trained by the first author in the test procedures and definitions . The training included instruction through videotapes , practice and a written examination . Each examination was conducted by a pair of therapists . Within a pair , a therapist was the primary examiner for half of the subjects and an observer was the primary examiner for half of the subjects . Examination findings were recorded independently , without discussion . RESULTS Percentage of agreement and generalized kappa coefficients were used to analyzed the data . Kappa values were > or = .75 for all 28 items related to the symptoms elicited and > or = .40 for 72 % of the 25 items related to alignment and movement . CONCLUSION AND DISCUSSION The results suggest that experienced therapist who had trained together were able to agree on the results of examinations and obtain an acceptable level of reliability . Future work should focus on testing of reliability when more than one therapist performs the examination and when therapist not trained by the test developer to administer the examination perform the tests . [ Van Dillen LR , Sahrmann SA , Norton BJ , et al. Reliability of physical examination items used for classification of patients with low back pain Study Design . A prospect i ve , consecutive , cohort study of patients with acute low back pain classified into subgroups based on examination data and treated with a specific treatment approach . Objective . To calculate the interrater reliability of a classification system , and to compare initial patient characteristics and outcomes of physical therapy treatment when a classification approach is used . Summary of Background Data . Classification of patients with low back pain into homogeneous subgroups has been identified as a research priority . Identifying relevant subgroups of patients could improve clinical outcomes and research efficiency . Methods . Consecutive patients referred to physical therapy for treatment of acute low back pain were evaluated and classified into one of four subgroups ( immobilization , mobilization , specific exercise , or traction ) before treatment . Physical therapy treatment was based on the patient ’s classification . The classifications were compared for initial patient characteristics , frequency and duration of physical therapy , and improvement in Oswestry scores . Results . In this study , 120 patients were evaluated and classified . Analysis of interrater reliability showed a kappa value of 0.56 . Differences were found among the classifications for age , initial Oswestry score , history of low back pain , symptom distribution , and average change in Oswestry score with treatment . Conclusions . Reaching a consensus regarding relevant patient subgroups requires data on the reliability and validity of existing classification systems . Further work is required to vali date improvement in treatment outcomes using a classification approach The purpose of the study was to compare the effects of three different types of group-based exercise programs ( resistance training , agility training and general stretching ) on back pain and health-related quality of life in older ( aged 75–85 years ) community-dwelling women with low bone mass ( i.e. , osteopenia or osteoporosis ) . The design was a 25-week r and omized controlled trial . Participating were 98 community-dwelling women with low bone mass between the ages of 75 to 85 years old . We assessed back pain and its related disability and health-related quality of life . All three types of group-based exercise programs significantly reduced back pain and its related disabilities , but only resistance and agility training significantly improved health-related quality of life in community-dwelling older women with low bone mass . Baseline physical activity level and class attendance were significant predictors of change in health-related quality of life . Change in back pain and its related disabilities after 25 weeks of exercise intervention was significantly correlated with change in health-related quality of life and changes in the domains of pain and physical function . Resistance and agility training significantly enhanced health-related quality of life and may have done so by increasing social interactions and support , enhancing self-efficacy of physical abilities and modifying the experience of back pain . These data provide valuable insight into the specifics of exercise prescription for older women with low bone mass . Future studies may wish to use individualized quality of life measures to further delineate the effects of different types of exercise on quality of life in older adults with low bone mass 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 data bases ( MEDLINE , MANTIS and CINAHL ) were search ed from their inception to October 2005 for all English language r and omised 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 vali date d criteria . Results Five such studies were identified . The method ological 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 Study Design . Systematic Review . Objectives . To assess the effects of massage therapy for nonspecific low back pain . Summary of Background Data . Low back pain is one of the most common and costly musculoskeletal problems in modern society . Proponents of massage therapy cl aim it can minimize pain and disability , and speed return to normal function . Methods . We search ed MEDLINE , EMBASE , CINAHL from their beginning to May 2008 . We also search ed the Cochrane Central Register of Controlled Trials ( The Cochrane Library 2006 , issue 3 ) , HealthSTAR and Dissertation abstract s up to 2006 . There were no language restrictions . References in the included studies and in review s of the literature were screened . The studies had to be r and omized or quasi-r and omized trials investigating the use of any type of massage ( using the h and s or a mechanical device ) as a treatment for nonspecific low back pain . Two review authors selected the studies , assessed the risk of bias using the criteria recommended by the Cochrane Back Review Group , and extracted the data using st and ardized forms . Both qualitative and meta-analyses were performed . Results . Thirteen r and omized trials were included . Eight had a high risk and 5 had a low risk of bias . One study was published in German and the rest in English . Massage was compared to an inert therapy ( sham treatment ) in 2 studies that showed that massage was superior for pain and function on both short- and long-term follow-ups . In 8 studies , massage was compared to other active treatments . They showed that massage was similar to exercises , and massage was superior to joint mobilization , relaxation therapy , physical therapy , acupuncture , and self-care education . One study showed that reflexology on the feet had no effect on pain and functioning . The beneficial effects of massage in patients with chronic low back pain  lasted at least 1 year after the end of the treatment . Two studies compared 2 different techniques of massage . One concluded that acupuncture massage produces better results than classic ( Swedish ) massage and another concluded that Thai massage produces similar results to classic ( Swedish ) massage . Conclusion . Massage might be beneficial for patients with subacute and chronic nonspecific low back pain , especially when combined with exercises and education . The evidence suggests that acupuncture massage is more effective than classic massage , but this need confirmation . More studies are needed to confirm these conclusions , to assess the impact of massage on return-to-work , and to determine cost-effectiveness of massage  as an intervention for low back pain Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied UNLABELLED RATIONALE , AIMS & OBJECTIVE : Tools for the assessment of the quality of research studies tend to be specific to a particular research design ( e.g. r and omized controlled trials , or qualitative interviews ) . This makes it difficult to assess the quality of a body of research that addresses the same or a similar research question but using different approaches . The aim of this paper is to describe the development and preliminary evaluation of a  quality assessment tool that can be applied to a method ologically diverse set of research articles . METHODS The  16-item quality assessment tool ( QATSDD )  was assessed to determine its reliability and validity when used by health services research ers in the disciplines of psychology , sociology and nursing . Qualitative feedback was also gathered from mixed- methods health research ers regarding the comprehension , content , perceived value and usability of the tool . RESULTS Reference to existing widely used quality assessment tools and experts in systematic review confirmed that the components of the tool represented the construct of ' good research technique ' being assessed . Face validity was subsequently established through feedback from a sample of nine health research ers .  Inter-rater reliability was established through substantial agreement between three review ers when applying the tool to a set of three research papers ( κ = 71.5 % ) , and good to substantial agreement between their scores at time 1 and after a 6-week interval at time 2 confirmed test-retest reliability . CONCLUSIONS The QATSDD shows good reliability and validity for use in the quality assessment of a diversity of studies , and may be an extremely useful tool for review ers to st and ardize and increase the rigour of their assessment s in review s of the published papers which include qualitative and quantitative work
Based on the upper threshold used ( kappa/ICC > 0.85 ) most procedures demonstrated either conflicting evidence or moderate to strong evidence of low reliability .
When the lower threshold was used ( kappa/ICC > 0.70 ) evidence about pain response to repeated movements changed from contradictory to moderate evidence for high reliability .
Most procedures commonly used by clinicians in the examination of patients with back pain demonstrate low reliability
The purpose of this systematic review was to determine the quality of the research and to assess the reliability of different types of physical examination procedures used in the assessment of patients with non-specific low back pain .