Special physical examination tests for superior labrum anterior posterior shoulder tears are clinically limited and invalid: a diagnostic systematic review

Calvert, Chambers, Regan et al

Objective

The diagnosis of a superior labrum anterior posterior (SLAP) lesion through physical examination has been widely reported in the literature. Most of these studies report high sensitivities and specificities, and claim to be accurate, valid, and reliable. The purpose of this study was to critically evaluate these studies to determine if there was sufficient evidence to support the use of the SLAP physical examination tests as valid and reliable diagnostic test procedures.

Study Design and Setting

Strict epidemiologic methodology was used to obtain and collate all relevant articles. Sackett’s guidelines were applied to all articles. Confidence intervals and likelihood ratios were determined.

Results

Fifteen of 29 relevant studies met the criteria for inclusion. Only one article met all of Sackett’s critical appraisal criteria. Confidence intervals for both the positive and negative likelihood ratios contained the value 1.

Conclusion

The current literature being used as a resource for teaching in medical schools and continuing education lacks the validity necessary to be useful. There are no good physical examination tests that exist for effectively diagnosing a SLAP lesion.

Journal of Clinical Epidemiology, Volume 62, Issue 5, May 2009, Pages 558-563 – abstract

doi:10.1016/j.jclinepi.2008.04.010

Filed under: Physical examination, Shoulder, Topic review , Diagnostic accuracy, Physical examination, Sensitivity, Shoulder, Superior labrum anterior posterior (SLAP) lesion, Systematic review

Insoles for prevention and treatment of back pain

Tali Sahar, Matan J Cohen, Vered Ne’eman et al

Background

There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. The high incidence of back pain and the popularity of shoe insoles call for a systematic review of this practice.

Objectives

To determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

Search strategy

We searched the following databases: The Cochrane Back Group Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL to October 2008; reviewed reference lists in review articles, guidelines and in the included trials; conducted citation tracking; contacted individuals with expertise in this domain.

Selection criteria

We included randomised controlled trials that examined the use of customized or non-customized insoles, for the prevention or treatment of back pain, compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: self-reported incidence or physician diagnosis of back pain; pain intensity; duration of back pain; absenteeism; functional status. Studies of insoles designed to treat limb length inequality were excluded.

Data collection and analysis

One review author conducted the searches and blinded the retrieved references for authors, institution and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using a standardized form.

Main results

Six randomised controlled trials met inclusion criteria: Three examined prevention of back pain (2061 participants) and three examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities.

Limitations
This review largely reflects limitations of the literature, including low quality studies with heterogeneous interventions and outcome measures, poor blinding and poor reporting.

Authors’ conclusions

There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low-back pain does not allow any conclusions.

High quality trials are required for stronger conclusions.

Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005275.- full text

DOI: 10.1002/14651858.CD005275.pub2.

Filed under: Lumbar spine, Spine, Topic review

Nonsurgical interventional therapies for low back pain: a review of the evidence for an american pain society clinical practice guideline

Chou R, Atlas SJ, Stanos SP, et al

STUDY DESIGN: Systematic review.
OBJECTIVE: To systematically assess benefits and harms of nonsurgical interventional therapies for low back and radicular pain.

SUMMARY OF BACKGROUND DATA: Although use of certain interventional therapies is common or increasing, there is also uncertainty or controversy about their efficacy.

METHODS: Electronic database searches on Ovid MEDLINE and the Cochrane databases were conducted through July 2008 to identify randomized controlled trials and systematic reviews of local injections, botulinum toxin injection, prolotherapy, epidural steroid injection, facet joint injection, therapeutic medial branch block, sacroiliac joint injection, intradiscal steroid injection, chemonucleolysis, radiofrequency denervation, intradiscal electrothermal therapy, percutaneous intradiscal radiofrequency thermocoagulation, Coblation nucleoplasty, and spinal cord stimulation. All relevant studies were methodologically assessed by 2 independent reviewers using criteria developed by the Cochrane Back Review Group (for trials) and by Oxman (for systematic reviews). A qualitative synthesis of results was performed using methods adapted from the US Preventive Services Task Force.

RESULTS: For sciatica or prolapsed lumbar disc with radiculopathy, we found good evidence that chemonucleolysis is moderately superior to placebo injection but inferior to surgery, and fair evidence that epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. We found fair evidence that spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. We found good or fair evidence that prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. Insufficient evidence exists to reliably evaluate other interventional therapies.

CONCLUSION: Few nonsurgical interventional therapies for low back pain have been shown to be effective in randomized, placebo-controlled trials.

Spine. 2009 May 1;34(10):1078-93  – abstract

Full text available in  through MTABC member only website (link) under the research tab and then library.

Filed under: Lumbar spine, Topic review, therapies , interventional, Low back, nonsurgical, radicular pain, therapies