-
BMC Musculoskeletal Disorders Feb 2017Lumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate... (Review)
Review
BACKGROUND
Lumbar radiculopathy remains a clinical challenge among primary care clinicians in both assessment and diagnosis. This often leads to misdiagnosis and inappropriate treatment of patients resulting in poor health outcomes, exacerbating this already debilitating condition. This review evaluated 12 primary diagnostic accuracy studies that specifically assessed the performance of various individual and grouped clinical neurological tests in detecting nerve root impingement, as established in the current literature.
METHODS
Eight electronic data bases were searched for relevant articles from inception until July 2016. All primary diagnostic studies which investigated the accuracy of clinical neurological test (s) in diagnosing lumbar radiculopathy among patients with low back and referred leg symptoms were screened for inclusion. Qualifying studies were retrieved and independently assessed for methodological quality using the 'Quality Assessment of Diagnostic tests Accuracy Studies' criteria.
RESULTS
A total of 12 studies which investigated standard components of clinical neurological examination of (sensory, motor, tendon reflex and neuro-dynamics) of the lumbo-sacral spine were included. The mean inter-observer agreement on quality assessment by two independent reviewers was fair (k = 0.3 - 0.7). The diagnostic performance of sensory testing using MR imaging as a reference standard demonstrated a sensitivity (confidence interval 95%) 0.61 (0.47-0.73) and a specificity of 0.63 (0.38-0.84). Motor tests sensitivity was poor to moderate, ranging from 0.13 (0.04-0.31) to 0.61 (0.36-0.83). Generally, the diagnostic performance of reflex testing was notably good with specificity ranging from (confidence interval 95%) 0.60 (0.51-0.69) to 0.93 (0.87-0.97) and sensitivity ranging from 0.14 (0.09-0.21) to 0.67 (0.21-0.94). Femoral nerve stretch test had a high sensitivity of (confidence interval 95%) 1.00 (0.40-1.00) and specificity of 0.83 (0.52-0.98) while SLR test recorded a mean sensitivity of 0.84 (0.72-0.92) and specificity of 0.78 (0.67-0.87).
CONCLUSIONS
There is a scarcity of studies on the diagnostic accuracy of clinical neurological examination testing. Furthermore there seem to be a disconnect among researchers regarding the diagnostic utility of lower limb neuro-dynamic tests which include the Straight Leg Raise and Femoral Nerve tests for sciatic and femoral nerve respectively. Whether these tests are able to detect the presence of disc herniation and subsequent nerve root compression or hyper-sensitivity of the sacral and femoral plexus due to mechanical irritation still remains debatable.
Topics: Humans; Intervertebral Disc Degeneration; Intervertebral Disc Displacement; Low Back Pain; Lumbar Vertebrae; Neurologic Examination; Radiculopathy; Sacrum
PubMed: 28231784
DOI: 10.1186/s12891-016-1383-2 -
Pain Physician Sep 2017The management of chronic pain is a complex challenge worldwide. Cannabis-based medicines (CBMs) have proven to be efficient in reducing chronic pain, although the topic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The management of chronic pain is a complex challenge worldwide. Cannabis-based medicines (CBMs) have proven to be efficient in reducing chronic pain, although the topic remains highly controversial in this field.
OBJECTIVES
This study's aim is to conduct a conclusive review and meta-analysis, which incorporates all randomized controlled trials (RCTs) in order to update clinicians' and researchers' knowledge regarding the efficacy and adverse events (AEs) of CBMs for chronic and postoperative pain treatment.
STUDY DESIGN
A systematic review and meta-analysis.
METHODS
An electronic search was conducted using Medline/Pubmed and Google Scholar with the use of Medical Subject Heading (MeSH) terms on all literature published up to July 2015. A follow-up manual search was conducted and included a complete cross-check of the relevant studies. The included studies were RCTs which compared the analgesic effects of CBMs to placebo. Hedges's g scores were calculated for each of the studies. A study quality assessment was performed utilizing the Jadad scale. A meta-analysis was performed utilizing random-effects models and heterogeneity between studies was statistically computed using I² statistic and tau² test.
RESULTS
The results of 43 RCTs (a total of 2,437 patients) were included in this review, of which 24 RCTs (a total of 1,334 patients) were eligible for meta-analysis. This analysis showed limited evidence showing more pain reduction in chronic pain -0.61 (-0.78 to -0.43, P < 0.0001), especially by inhalation -0.93 (-1.51 to -0.35, P = 0.001) compared to placebo. Moreover, even though this review consisted of some RCTs that showed a clinically significant improvement with a decrease of pain scores of 2 points or more, 30% or 50% or more, the majority of the studies did not show an effect. Consequently, although the primary analysis showed that the results were favorable to CBMs over placebo, the clinical significance of these findings is uncertain. The most prominent AEs were related to the central nervous and the gastrointestinal (GI) systems.
LIMITATIONS
Publication limitation could have been present due to the inclusion of English-only published studies. Additionally, the included studies were extremely heterogeneous. Only 7 studies reported on the patients' history of prior consumption of CBMs. Furthermore, since cannabinoids are surrounded by considerable controversy in the media and society, cannabinoids have marked effects, so that inadequate blinding of the placebo could constitute an important source of limitation in these types of studies.
CONCLUSIONS
The current systematic review suggests that CBMs might be effective for chronic pain treatment, based on limited evidence, primarily for neuropathic pain (NP) patients. Additionally, GI AEs occurred more frequently when CBMs were administered via oral/oromucosal routes than by inhalation.Key words: Cannabis, CBMs, chronic pain, postoperative pain, review, meta-analysis.
Topics: Cannabidiol; Cannabis; Chronic Pain; Dronabinol; Drug Combinations; Humans; Medical Marijuana; Neuralgia; Pain Management; Pain, Postoperative; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 28934780
DOI: No ID Found -
Journal of Foot and Ankle Research 2019Morton's neuroma (MN) is a compressive neuropathy of the common plantar digital nerve. It is a common compressive neuropathy often causing significant pain which limits... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Morton's neuroma (MN) is a compressive neuropathy of the common plantar digital nerve. It is a common compressive neuropathy often causing significant pain which limits footwear choices and weight bearing activities. This paper aims to review non-surgical interventions for MN, to evaluate the evidence base for the clinical management of MN.
METHODS
Electronic biomedical databases (CINAHL, EMBASE, MEDLINE and Cochrane) were searched to January 2018 for studies evaluating the effectiveness of non-surgical interventions for Morton's neuroma. Outcome measures of interest were treatment success rate (SR) (binary) and pain as measured using 100-point visual analogue scale (VAS) (continuous). Studies with and without control groups were included and were evaluated for methodological quality using the Downs and Black Quality Index. Results from randomised controlled trials (RCT) were compared between-groups, and case series were compared pre- versus post-treatment. Effect estimates are presented as odds ratios (OR) for binary data or mean differences (MD) for continuous data. Random effects models were used to pool effect estimates across studies where similar treatments were used. Heterogeneity was assessed using the statistic.
RESULTS
A total of 25 studies met the inclusion criteria, seven RCTs and 18 pre/post case series. Eight different interventions were identified, with corticosteroid or sclerosing injections being the most often reported (seven studies each). Results from a meta-analysis of two RCTs found corticosteroid injection decreased pain more than control on VAS (WMD: -5.3, 95%CI: -7.5 to - 3.2). Other RCTs reported efficacy of: manipulation/mobilisation versus control (MD: -15.3, 95%CI: -29.6 to - 1.0); extracorporeal shockwave therapy versus control (MD: -5.9, 95%CI: -21.9 to 10.1). Treatment success was assessed for extracorporeal shockwave therapy versus control (OR: 0.3, 95%CI: 0.0 to 7.1); and corticosteroid injection vs footwear/padding (OR: 6.0, 95%CI: 1.9 to 19.2). Sclerosing and Botox injections, radiofrequency ablation and cryoneurolysis have been investigated by case series studies, however these were of limited methodological quality.
CONCLUSIONS
Corticosteroid injections and manipulation/mobilisation are the two interventions with the strongest evidence for pain reduction, however high-quality evidence for a gold standard intervention was not found. Although the evidence base is expanding, further high quality RCTs are needed.
Topics: Foot Orthoses; Glucocorticoids; Humans; Morton Neuroma; Musculoskeletal Manipulations; Pain Management; Randomized Controlled Trials as Topic; Sclerotherapy
PubMed: 30809275
DOI: 10.1186/s13047-019-0320-7 -
Medicine Nov 2019Cervical radiculopathy (CR), which is most often stems from degenerative disease in the cervical spine, has increasingly become a common and frequently occurring disease... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Cervical radiculopathy (CR), which is most often stems from degenerative disease in the cervical spine, has increasingly become a common and frequently occurring disease in clinic due to the popularity of electronic products, such as computes and cell phones. Some studies have shown that exercise or exercise combined with other treatments can effectively decrease pain and improve functional status. The objective was to analyze the effects of exercise for treating patients with CR.
METHODS
Seven databases were searched from inception to December 2018. Randomized controlled trials involving exercise alone or exercise combined with conventional treatment were enrolled. Data were pooled after trials quality assessment for meta-analysis. Outcomes were pain (visual analog scale [VAS]), quality of life (12-short form health survey, 36-short form health survey), and physical function accessed by neck disability index (NDI).
RESULTS
Ten studies involving 871 participants with CR were included. Meta-analysis revealed that compared with control group, there was a reduction in VAS (standardized mean difference = -0.89; 95% confidence interval [CI]: -1.34 to -0.44; Z = 3.89; P < .001). There was also an improvement of NDI (mean difference = -3.60; 95% CI: -6.27 to -0.94; Z = 2.65; P = .008)]. Additionally, although the results of subgroup analyses were changed due to the paucity of the quantity and quality of the included studies. The pooled results were verified to be stable by sensitivity analyses. Besides, the grading of recommendations assessment, development, and evaluation level of evidence is low for each outcome.
CONCLUSION
Exercise alone or exercise plus other treatment may be helpful to patients with CR. However, exercise option should be carefully considered for each patient with CR in accordance with their different situations. Large-scale studies using proper methodology are recommended.
Topics: Exercise Therapy; Humans; Pain Measurement; Quality of Life; Radiculopathy; Treatment Outcome; Visual Analog Scale
PubMed: 31702624
DOI: 10.1097/MD.0000000000017733 -
Frontiers in Neurology 2023Painful Diabetic Peripheral Neuropathy (PDPN) is a common complication of diabetes, it severely affects the quality of life of patients. Acupuncture has been shown to be...
BACKGROUND
Painful Diabetic Peripheral Neuropathy (PDPN) is a common complication of diabetes, it severely affects the quality of life of patients. Acupuncture has been shown to be effective in the treatment of PDPN. To evaluate the efficacy and safety of acupuncture for pain relief in patients diagnosed with diabetic peripheral neuropathy, we conducted a systematic review and meta-analysis.
METHOD
We thoroughly searched specific databases, which included PUBMED, EMBASE, Web of Science, the Cochrane Library, the Chinese Biomedical Literature Database, the Chinese National Knowledge Infrastructure, China Science and Technology Journal Database and the Wanfang Data. All randomized controlled trials of acupuncture therapy for PDPN with pain change scales were included. Included studies were assessed for methodological quality according to the risk of bias from the Cochrane handbook. Meta-analyses were carried out to analyze the outcomes, subgroup analyses, sensitivity analyses, and funnel plot analyses were undertaken.
RESULTS
This systematic review evaluated a total of 25 trials of acupuncture therapy in combination with conventional treatment, involving a total of 1,561 patients with PDPN. According to the results, among 16 trials using VAS scores with a total of 1,552 patients, 2 acupoint injection trials (MD -2.38, 95% CI: -2.76 to -2.01, < 0.00001), 12 acupuncture trials (MD -1. 31, 95% CI: -1.60 to -1.02, < 0.00001) and 2 moxibustion trials showed that acupuncture therapy combined with conventional treatment improved pain better than conventional treatment (MD -2.50, 95% CI: -2.76 to -2.24, < 0.00001). In the subgroup analysis of the acupuncture group, the results of the 5 trials in which the location of acupuncture was only in the limbs (MD -1.27, 95% CI: -1.54 to -1.01, < 0.00001) and the 7 trials both in limbs and torso (MD -1.38, 95% CI: -1.81 to -0.95, < 0.00001) also demonstrated that acupuncture was effective in pain improvement.
CONCLUSION
This meta-analysis analyzed the possible efficacy of acupuncture in combination with conventional treatment for pain in diabetic peripheral neuropathy, particularly when acupoints are located in the limbs. However, there are limitations to this meta-analysis and future clinical studies are needed to confirm these findings.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023449447, identifier (CRD42023449447).
PubMed: 38046594
DOI: 10.3389/fneur.2023.1281485 -
European Journal of Physical and... Feb 2022Obstetric brachial plexus palsy (OBPP) is a flaccid paralysis occurring in the upper limb during birth. The OBPP includes mild lesions with complete spontaneous recovery...
INTRODUCTION
Obstetric brachial plexus palsy (OBPP) is a flaccid paralysis occurring in the upper limb during birth. The OBPP includes mild lesions with complete spontaneous recovery and severe injuries with no regain of arm function. Among the most promising rehabilitation treatments aimed at improving upper extremity motor activities in individuals with neurological dysfunctions, there is the modified constraint-induced movement therapy (mCIMT). The aim of this systematic review is to assess and synthesize the critical aspects of the use of mCIMT in children with OBPP.
EVIDENCE ACQUISITION
This systematic review has been carried out according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis). A comprehensive search of the literature was conducted using PubMed, MEDLINE and Evidence Based Medicine Reviews, databases. We enclosed experimental and original articles, case reports and book chapters. Four articles were finally included.
EVIDENCE SYNTHESIS
One case report tested the feasibility of mCIMT to encourage use of the affected arm in a child with Erb-Duchenne palsy and documented the clinical changes observed. A case series had the purpose to determine if mCIMT in combination with botulinum toxin (BTX-A) improved arm function in 2 children with OBPP. A cohort study compared the use of mCIMT in 19 OBPP and 18 unilateral Cerebral Palsy. A prospective single-blind RCT described mCIMT versus conventional therapy in a group of 39 children with OBPP.
CONCLUSIONS
This systematic review on the use of mCIMT in children with OBPP shows that there is unanimous agreement that a program should last 2 weeks at least. However, there is no scientific evidence supporting a single common mCIMT protocol in the management of OBPP because of a considerable heterogeneity. Further high methodological studies regarding the application of mCIMT for OBPP and based on larger patients' sample should have the potential to optimize the appropriateness of care provided to infants with OBPP and, therefore, their quality of life.
Topics: Brachial Plexus; Brachial Plexus Neuropathies; Child; Cohort Studies; Humans; Infant; Paralysis; Prospective Studies; Quality of Life; Single-Blind Method; Treatment Outcome
PubMed: 34747579
DOI: 10.23736/S1973-9087.21.06886-6 -
Biomedicines Aug 2022Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and painful condition in patients who have received chemotherapy. The role of neuromodulation therapy... (Review)
Review
Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating and painful condition in patients who have received chemotherapy. The role of neuromodulation therapy in treating pain and improving neurological function in CIPN remains unclear and warrants evidence appraisal. In compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a systematic review to assess change in pain intensity and neurological function after implementation of any neuromodulation intervention for CIPN. Neuromodulation interventions consisted of dorsal column spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), or peripheral nerve stimulation (PNS). In total, 15 studies utilized SCS (16 participants), 7 studies utilized DRG-S (7 participants), and 1 study utilized PNS (50 participants). Per the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria, there was very low-quality GRADE evidence supporting that dorsal column SCS, DRG-S, and PNS are associated with a reduction in pain severity from CIPN. Results on changes in neurological function remained equivocal due to mixed study findings on thermal sensory thresholds and touch sensation or discrimination. Future prospective, well-powered, and comparative studies assessing neuromodulation for CIPN are warranted.
PubMed: 36009456
DOI: 10.3390/biomedicines10081909 -
BMJ Open Diabetes Research & Care May 2021There is growing evidence of excess peripheral neuropathy in pre-diabetes. We aimed to determine its prevalence, including the impact of diagnostic methodology on... (Review)
Review
There is growing evidence of excess peripheral neuropathy in pre-diabetes. We aimed to determine its prevalence, including the impact of diagnostic methodology on prevalence rates, through a systematic review conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive electronic bibliographic search was performed in MEDLINE, EMBASE, PubMed, Web of Science and the Cochrane Central Register of Controlled Trials from inception to June 1, 2020. Two reviewers independently selected studies, extracted data and assessed risk of bias. An evaluation was undertaken by method of neuropathy assessment. After screening 1784 abstracts and reviewing 84 full-text records, 29 studies (9351 participants) were included. There was a wide range of prevalence estimates (2%-77%, IQR: 6%-34%), but the majority of studies (n=21, 72%) reported a prevalence ≥10%. The three highest prevalence estimates of 77% (95% CI: 54% to 100%), 71% (95% CI: 55% to 88%) and 66% (95% CI: 53% to 78%) were reported using plantar thermography, multimodal quantitative sensory testing and nerve conduction tests, respectively. In general, studies evaluating small nerve fiber parameters yielded a higher prevalence of peripheral neuropathy. Due to a variety of study populations and methods of assessing neuropathy, there was marked heterogeneity in the prevalence estimates. Most studies reported a higher prevalence of peripheral neuropathy in pre-diabetes, primarily of a small nerve fiber origin, than would be expected in the background population. Given the marked rise in pre-diabetes, further consideration of targeting screening in this population is required. Development of risk-stratification tools may facilitate earlier interventions.
Topics: Humans; Peripheral Nervous System Diseases; Prediabetic State; Prevalence; Research Design
PubMed: 34006607
DOI: 10.1136/bmjdrc-2020-002040 -
Diabetes Care Oct 2022Different waveforms of spinal cord stimulation (SCS) have now been evaluated for the management of painful diabetic neuropathy (PDN). However, no direct or indirect... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Different waveforms of spinal cord stimulation (SCS) have now been evaluated for the management of painful diabetic neuropathy (PDN). However, no direct or indirect comparison between SCS waveforms has been performed to date.
PURPOSE
To conduct a systematic review and network meta-analysis to evaluate the effectiveness of SCS for PDN.
DATA SOURCES
MEDLINE, CENTRAL, Embase, and WikiStim were searched from inception until December 2021.
STUDY SELECTION
Randomized controlled trials (RCTs) of SCS for PDN were included.
DATA EXTRACTION
Pain intensity, proportion of patients achieving at least a 50% reduction in pain intensity, and health-related quality of life (HRQoL) data were extracted.
DATA SYNTHESIS
Significant reductions in pain intensity were observed for low-frequency SCS (LF-SCS) (mean difference [MD] -3.13 [95% CI -4.19 to -2.08], moderate certainty) and high-frequency SCS (HF-SCS) (MD -5.20 [95% CI -5.77 to -4.63], moderate certainty) compared with conventional medical management (CMM) alone. There was a significantly greater reduction in pain intensity on HF-SCS compared with LF-SCS (MD -2.07 [95% CI -3.26 to -0.87], moderate certainty). Significant differences were observed for LF-SCS and HF-SCS compared with CMM for the outcomes proportion of patients with at least 50% pain reduction and HRQoL (very low to moderate certainty). No significant differences were observed between LF-SCS and HF-SCS (very low to moderate certainty).
LIMITATIONS
Limited number of RCTs and no head-to-head RCTs conducted.
CONCLUSIONS
Our findings confirm the pain relief and HRQoL benefits of the addition of SCS to CMM for patients with PDN. However, in the absence of head-to-head RCT evidence, the relative benefits of HF-SCS compared with LF-SCS for patients with PDN remain uncertain.
Topics: Diabetes Mellitus; Diabetic Neuropathies; Humans; Network Meta-Analysis; Pain; Pain Measurement; Spinal Cord Stimulation
PubMed: 36150057
DOI: 10.2337/dc22-0932 -
Pain Physician Oct 2022Epidural injections are among the most commonly performed procedures for managing low back and lower extremity pain. Pinto et al and Chou et al previously performed... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Epidural injections are among the most commonly performed procedures for managing low back and lower extremity pain. Pinto et al and Chou et al previously performed systematic reviews and meta-analyses, which, along with a recent update from Oliveira et al showing the lack of effectiveness of epidural steroid injections in managing lumbar disc herniation, spinal stenosis, and radiculopathy. In contrast to these papers, multiple other systematic reviews and meta-analyses have supported the effectiveness and use of epidural injections utilizing fluoroscopically guided techniques. A major flaw in the review can be related to attributing active-controlled trials to placebo-controlled trials. The assumption that local anesthetics do not provide sustained benefit, despite extensive evidence that local anesthetics provide long-term relief, similar to a combination of local anesthetic with steroids is flawed.
STUDY DESIGN
The Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy were reanalyzed using systematic methodology and meta-analysis.
OBJECTIVES
To re-evaluate Cochrane data on RCTs of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy utilizing qualitative and quantitative techniques with dual-arm and single-arm analysis.
METHODS
In this systematic review, we have used the same RCTs from the Cochrane Review of a minimum of 20% change in pain scale or significant pain relief of >= 50%. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Our review was performed utilizing the Cochrane Review methodologic quality assessment and the Interventional Pain Management Techniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing the principles of best evidence synthesis and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Clinical relevance of the pragmatic nature of each study was assessed.
RESULTS
In evaluating the RCTs in the Cochrane Review, 10 trials were performed with fluoroscopic guidance. Utilizing conventional dual-arm and single-arm meta-analysis, the evidence is vastly different from the interpretation of the data within the Cochrane Review. The overall combined evidence is Level I, or strong evidence, at one and 3 months, and Level II, or moderate evidence, at 6 and 12 months.
LIMITATIONS
The limitation of this study is that only data contained in the Cochrane Review were analyzed.
CONCLUSION
A comparative systematic review and meta-analysis of the Cochrane Review of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy yielded different results. This review, based on the evidence derived from placebo-controlled trials and active-controlled trials showed Level I, or strong evidence, at one and 3 months and Level II at 6 and 12 months. This review once again emphasizes the importance of the allocation of studies to placebo-control and active-control groups, utilizing standards of practice with inclusion of only the studies performed under fluoroscopic guidance.
Topics: Humans; Radiculopathy; Anesthetics, Local; Sciatica; Low Back Pain; Injections, Epidural; Steroids
PubMed: 36288577
DOI: No ID Found