Objective To assess the effects of radiofrequency (RF) denervation for chronic low back pain (LBP) from facet joint, sacroiliac joint, discogenic and non-specific pain.Design Systematic review and meta-analysis.Data sources We searched Medline, Embase, Cochrane Library, CINAHL, PsycINFO, ClinicalTrials.gov and WHO ICTRP up to 18 February 2025 for randomised controlled trials (RCTs).Study selection, data extraction and synthesis Pairs of reviewers independently selected studies, extracted data and assessed risk of bias (Cochrane RoB 2). Meta-analyses with clinically homogeneous studies were performed and certainty of evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation.Results 55 RCTs (n=4394) were included; many outcomes were at some risk of bias. Low to moderate certainty evidence suggested small improvements in pain and function with RF denervation versus sham for facet joint pain, sacroiliac, discogenic and non-specific chronic LBP. None exceeded predefined minimally clinically important between-group differences, suggesting limited clinical relevance.Conclusions RF denervation showed small improvements in pain and function compared with sham, steroid injection or standard care, but the effects did not reach clinically meaningful thresholds and the certainty of evidence was very low to moderate. Additional research is needed to clarify the effects of RF denervation and guide clinical decision-making.PROSPERO registration number CRD42023460743.

RATIONALE:Many therapies exist for the treatment of chronic low back pain (LBP), including spinal manipulative therapy (SMT), which is a worldwide, extensively practised intervention. The effectiveness of SMT for chronic LBP is not without dispute. This Cochrane review is an update of a Cochrane systematic review published in 2011. OBJECTIVES:To evaluate the benefits and harms of SMT compared to (1) sham SMT/placebo intervention, (2) no treatment, and (3) other conservative interventions in people with chronic LBP (18+ years old). SEARCH METHODS:We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, two other databases, and two trial registers up to 18 October 2024, unrestricted by language. We also screened the reference lists of all included studies and relevant systematic reviews, and approached content experts to identify potentially missing studies. ELIGIBILITY CRITERIA:We included randomised controlled trials (RCTs) that examined the effect of spinal manipulation or mobilisation in adults with chronic LBP compared to sham SMT/placebo, no treatment, and other conservative interventions. We placed no restrictions on the setting. We excluded studies that exclusively examined sciatica. OUTCOMES:Our critical outcomes were pain, functional status, and adverse events. The primary time point was one month for pain and functional status. We evaluated adverse events at the end of the intervention. RISK OF BIAS:We assessed bias in the included studies using the original Cochrane risk of bias tool (RoB 1). SYNTHESIS METHODS:Where possible, we synthesised results using meta-analysis with a generic inverse-variance approach and random-effects models; otherwise, we used narrative synthesis. We assessed the certainty of evidence using the GRADE approach. Our main comparisons were SMT versus (1) sham SMT/placebo treatment, (2) no treatment, and (3) other conservative interventions at one month. We converted all pain scales to a 100-point scale. INCLUDED STUDIES:Seventy-six RCTs (11,866 participants) met our inclusion criteria, 50 (66%) of which were not included in the previous version of this review. Seventeen trials (2021 participants) compared SMT to sham SMT/placebo, and four trials (435 participants) compared SMT to no treatment. Most trials (43, including 8291 participants) examined the effect of SMT compared to other conservative interventions. The remaining trials examined other comparisons. Treatment allocation was appropriately conducted in just four sham SMT/placebo-controlled trials (24%), while only six trials 'blinded' participants to the intervention (35%), indicating a high risk of selection and performance bias. Similarly, the no-treatment controlled trials were as susceptible to selection bias (50%) and performance bias (75%). All trials were conducted in high-income (n = 53) or middle-income (n = 23) countries. In most studies, the population was middle-aged and included men and women. SYNTHESIS OF RESULTS:SMT versus sham SMT/placebo We found very low-certainty evidence (downgraded for inconsistency and study limitations) that SMT may result in a small reduction in pain compared to sham SMT/placebo at one month (mean difference (MD) -7.01, 95% confidence interval (CI) -12.48 to -1.53; I2 = 94%; 16 studies, 1570 participants) and very low-certainty evidence (downgraded for study limitations and inconsistency) that SMT may result in a medium improvement in functional status compared to sham SMT/placebo at one month (standardised mean difference (SMD) -0.41, 95% CI -0.69 to -0.13; I2 = 82%; 13 studies, 1416 participants), but the evidence is very uncertain. SMT versus no treatment We found very low-certainty evidence (downgraded for study limitations, inconsistency, and imprecision) that SMT may result in a medium reduction in pain compared to no treatment at one month (MD -13.99, 95% CI -27.33 to -0.66; I2 = 89%; 4 studies, 325 participants), but the evidence is very uncertain. We found low-certainty evidence (downgraded for study limitations and imprecision) that SMT may result in a large improvement in functional status compared to no treatment at one month (SMD -0.84, 95% CI -1.32 to -0.35; I2 = 71%; 4 studies, 312 participants). SMT versus other conservative interventions Low-certainty evidence (downgraded for inconsistency) indicated that SMT may result in little to no difference in pain (MD -4.72, 95% CI -8.26 to -1.17; I2 = 89%; 31 studies, 4109 participants) and may result in a small improvement in functional status (SMD -0.25, 95% CI -0.38 to -0.11; I2 = 73%; 28 studies, 3940 participants) compared to other conservative interventions at one month. These effects, however, should be interpreted with caution due to the substantial statistical heterogeneity for which there is no clear explanation. Less than half of the studies (47%) reported on adverse events, of which 12 studies reported these systematically. Adverse events in the SMT group were limited to muscle soreness, stiffness, and/or transient increase in pain. None of the studies registered any serious complications related to either the experimental or control group treatment. The evidence is very uncertain about the adverse effects of SMT. AUTHORS' CONCLUSIONS:When SMT is compared to sham SMT/placebo, it may result in a small improvement in pain and medium improvement in functional status in adults with chronic low back pain. When compared to no treatment, SMT may result in a medium improvement in pain and a large improvement in functional status. When compared to other conservative interventions, SMT may result in little to no difference in pain and a small improvement in functional status. The evidence is of low to very low certainty, largely due to the fact that the effects of SMT were examined in trials conducted in different settings and populations, with different types of SMT technique, dosage, and frequency of treatment. Continuing to conduct RCTs in the same manner will neither strengthen the evidence nor our confidence in it. FUNDING:This Cochrane review had no dedicated funding, only 'in-kind' support from the Department of General Practice, Erasmus Medical Center, Rotterdam, Netherlands, and the Department of Health Sciences, Faculty of Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Science Research Institute, Netherlands. REGISTRATION:Protocol (2009): DOI: 10.1002/14651858.CD008112 Original review (2011): DOI: 10.1002/14651858.CD000447.pub2.

Background Assessment of activities of daily living (ADL) and cognitive screening are widely used in the care of out-of-hospital cardiac arrest (OHCA) survivors. Evidence linking them to post-discharge outcomes is limited, but could support targeted rehabilitation efforts. Aim To assess whether ADL ability measures and cognitive screening at hospital discharge were associated with post-discharge ADL ability, health-related quality of life (HRQoL) and return to work. Methods This prospective cohort study included 200 OHCA survivors admitted to Aarhus University Hospital. Self-reported ADL ability was measured using the Activities of Daily Living Interview (ADL-I). Observed ADL ability was measured with the Assessment of Motor and Process Skills (AMPS), dichotomised into age-matched or below-ability. Cognitive function was assessed with Montreal Cognitive Assessment (MoCA). Multivariable regressions, with multiple imputation, analysed associations between variables and outcomes, adjusting for age, sex, and comorbidities. Results Adjusted analyses showed significant associations between personal ADL-I (βadjusted = 0.3, 95%CI: 0.2;0.5) and AMPS (βadjusted = -0.6, 95%CI:-1.2;-0.03) at discharge and self-reported ADL ability six months after cardiac arrest. Baseline AMPS was statistically significantly associated with age-matched ADL ability six months after cardiac arrest (ORadjusted 5.5, 95%CI: 1.5;10.0), and personal ADL-I (VAS: βadjusted = 3.00, 95%CI: 1.3;4.6/index score: βadjusted = 0.03, 95%CI 0.01;0.05) and MoCA (index: βadjusted = -0.09, 95%CI: -0.2;-0.02) with HRQoL. The association between MoCA and return to work one-year after cardiac arrest showed an OR of 3.0 (95%CI: 0.5;9.0), although not statistically significant (p = 0.06). Conclusions Decreased ADL ability at hospital discharge was associated with poorer post-discharge outcomes in OHCA survivors, while cognitive screening was also associated with certain aspects of recovery.

OBJECTIVE To assess the healthcare costs of pressure injuries (PIs) among patients with a spinal cord injury (SCI) in a Dutch rehabilitation center and determine if those costs were associated with patients' age or sex. METHODS The direct healthcare costs of PIs were estimated using data from electronic health records of a Dutch rehabilitation center. This dataset contained demographic, clinical, and resource use information of all patients with an SCI or a PI who were treated at the rehabilitation center because of a PI between 2009 and 2022. Standard prices were used to value inpatient rehabilitation, whereas a micro-costing approach was used to value outpatient consultations and material costs. Using ordinary least squares regression analyses, the authors assessed whether the costs were associated with age and sex, after correcting for the patients' length of PI care. RESULTS Between 2009 and 2022, 409 patients with an SCI were treated at the rehabilitation center for a PI. The patients' mean total length of PI care was 883 +/- 1,266 days (median, 137 days; interquartile range, 10-1,620). The mean total rehabilitation cost of PIs among these patients was 15,412 (USD $16,836) per patient with a mean total annual rehabilitation cost of 6,368 (USD $6,956) per patient. Costs were not significantly associated with age and sex. CONCLUSIONS The healthcare costs of PIs among patients with an SCI in a Dutch rehabilitation center represent a significant economic burden. Prevention of PIs seems warranted, not only from a clinical perspective, but also from a health economic perspective.

Objectives Only studying effectiveness of lifestyle interventions for people with severe mental illness (SMI) is insufficient for policy making. As budgets for healthcare are limited, policy makers face the problem of allocating scarce healthcare resources. Cost-effectiveness studies are needed, but currently cost-effectiveness studies of lifestyle interventions for people with SMI delivered in ambulatory care are limited. The aim of this current study was to evaluate the cost-effectiveness of a lifestyle intervention for people with SMI living in the Dutch community in comparison with usual care. Methods and findings An economic evaluation was performed using a societal perspective alongside the Severe Mental Illness Lifestyle Evaluation (SMILE) pragmatic cluster randomized controlled trial. The SMILE lifestyle intervention is a one-year, group-based intervention delivered by trained mental healthcare workers. Costs, body weight change and quality of life were assessed at baseline, 6 and 12 months. Mixed models were used to estimate incremental costs and effects between the treatment group and the usual care group. Overall, the SMILE intervention resulted in lower total costs compared to the usual care group (-€719, 95% CI -7133; 3897). The effect difference between the intervention and usual care groups was -3.76 (95% CI -6.30; -1.23) kilograms for body weight and -0.037 (95% CI -0.083; 0.010) for QALYs. Conclusions Overall, the SMILE intervention resulted in lower total costs compared to the usual care group and was cost-effective for body weight change. However, the SMILE intervention does not seem cost-effective with regards to QALYs. More cost-effectiveness studies in other countries and other settings are needed to gain further insight into the cost-effectiveness of lifestyle interventions for people with SMI.

OBJECTIVES: This study aimed to assess 12-month outcomes on return to work (RTW) and cost-effectiveness in adults on sick leave due to musculoskeletal disorders who were randomized to either usual case management (UC), UC+motivational interviewing (MI) or UC+stratified vocational advice intervention (SVAI). METHODS: The study was conducted in the Norwegian Labor and Welfare Administration (NAV). Workers on sick leave due to musculoskeletal disorders for ≥50% of their contracted work hours for ≥7 consecutive weeks were included. Trained caseworkers delivered MI in two face-to-face sessions, and physiotherapists provided SVAI and identified RTW obstacles. The main outcomes were sick leave days over 12 months and cost-effectiveness, cost-utility and cost-benefit. RESULTS: The trial included 509 workers with a mean age of 48 years. There were statistically significant differences between UC+MI versus UC [-15.6 days, 95% confidence interval (CI) -31.0– -0.2], and UC+SVAI versus UC (-17.6 days, 95% CI -33.0– -2.2). Compared to UC, odds ratios (OR) for receiving wage replacement benefits each month were lower for UC+MI (OR=0.73, 95% CI 0.64–0.84), and UC+SVAI (OR 0.74, 95% CI 0.64–0.84). The probabilities of cost-effectiveness were high for adding either MI or SVAI to UC (ceiling ratio 0.90), and the net benefit for MI was €5225 (95% CI -592–10 985) and for SVAI €7214 ((95% CI 1548–12 851) per person. CONCLUSIONS: Adding MI or SVAI to UC significantly improved RTW outcomes and was cost-effective among people on sickness absence due to musculoskeletal disorders.

BACKGROUND:Pharmacological interventions are the most used treatment for low back pain (LBP). Use of evidence from systematic reviews of the effects of pharmacological interventions for LBP published in the Cochrane Library, is limited by lack of a comprehensive overview. OBJECTIVES:To summarise the evidence from Cochrane Reviews of the efficacy, effectiveness, and safety of systemic pharmacological interventions for adults with non-specific LBP. METHODS:The Cochrane Database of Systematic Reviews was searched from inception to 3 June 2021, to identify reviews of randomised controlled trials (RCTs) that investigated systemic pharmacological interventions for adults with non-specific LBP. Two authors independently assessed eligibility, extracted data, and assessed the quality of the reviews and certainty of the evidence using the AMSTAR 2 and GRADE tools. The review focused on placebo comparisons and the main outcomes were pain intensity, function, and safety. MAIN RESULTS:Seven Cochrane Reviews that included 103 studies (22,238 participants) were included. There is high confidence in the findings of five reviews, moderate confidence in one, and low confidence in the findings of another. The reviews reported data on six medicines or medicine classes: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, benzodiazepines, opioids, and antidepressants. Three reviews included participants with acute or sub-acute LBP and five reviews included participants with chronic LBP. Acute LBP Paracetamol There was high-certainty evidence for no evidence of difference between paracetamol and placebo for reducing pain intensity (MD 0.49 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.99 to 2.97), reducing disability (MD 0.05 on a 0 to 24 scale (higher scores indicate worse disability), 95% CI -0.50 to 0.60), and increasing the risk of adverse events (RR 1.07, 95% CI 0.86 to 1.33). NSAIDs There was moderate-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo at reducing pain intensity (MD -7.29 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.98 to -3.61), high-certainty evidence for a small between-group difference for reducing disability (MD -2.02 on a 0-24 scale (higher scores indicate worse disability), 95% CI -2.89 to -1.15), and very low-certainty evidence for no evidence of an increased risk of adverse events (RR 0.86, 95% CI 0. 63 to 1.18). Muscle relaxants and benzodiazepines There was moderate-certainty evidence for a small between-group difference favouring muscle relaxants compared to placebo for a higher chance of pain relief (RR 0.58, 95% CI 0.45 to 0.76), and higher chance of improving physical function (RR 0.55, 95% CI 0.40 to 0.77), and increased risk of adverse events (RR 1.50, 95% CI 1. 14 to 1.98). Opioids None of the included Cochrane Reviews aimed to identify evidence for acute LBP. Antidepressants No evidence was identified by the included reviews for acute LBP. Chronic LBP Paracetamol No evidence was identified by the included reviews for chronic LBP. NSAIDs There was low-certainty evidence for a small between-group difference favouring NSAIDs compared to placebo for reducing pain intensity (MD -6.97 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -10.74 to -3.19), reducing disability (MD -0.85 on a 0-24 scale (higher scores indicate worse disability), 95% CI -1.30 to -0.40), and no evidence of an increased risk of adverse events (RR 1.04, 95% CI -0.92 to 1.17), all at intermediate-term follow-up (> 3 months and ≤ 12 months postintervention). Muscle relaxants and benzodiazepines There was low-certainty evidence for a small between-group difference favouring benzodiazepines compared to placebo for a higher chance of pain relief (RR 0.71, 95% CI 0.54 to 0.93), and low-certainty evidence for no evidence of difference between muscle relaxants and placebo in the risk of adverse events (RR 1.02, 95% CI 0.67 to 1.57). Opioids There was high-certainty evidence for a small between-group difference favouring tapentadol compared to placebo at reducing pain intensity (MD -8.00 on a 0 to 100 scale (higher scores indicate worse pain), 95% CI -1.22 to -0.38), moderate-certainty evidence for a small between-group difference favouring strong opioids for reducing pain intensity (SMD -0.43, 95% CI -0.52 to -0.33), low-certainty evidence for a medium between-group difference favouring tramadol for reducing pain intensity (SMD -0.55, 95% CI -0.66 to -0.44) and very low-certainty evidence for a small between-group difference favouring buprenorphine for reducing pain intensity (SMD -0.41, 95% CI -0.57 to -0.26). There was moderate-certainty evidence for a small between-group difference favouring strong opioids compared to placebo for reducing disability (SMD -0.26, 95% CI -0.37 to -0.15), moderate-certainty evidence for a small between-group difference favouring tramadol for reducing disability (SMD -0.18, 95% CI -0.29 to -0.07), and low-certainty evidence for a small between-group difference favouring buprenorphine for reducing disability (SMD -0.14, 95% CI -0.53 to -0.25). There was low-certainty evidence for a small between-group difference for an increased risk of adverse events for opioids (all types) compared to placebo; nausea (RD 0.10, 95% CI 0.07 to 0.14), headaches (RD 0.03, 95% CI 0.01 to 0.05), constipation (RD 0.07, 95% CI 0.04 to 0.11), and dizziness (RD 0.08, 95% CI 0.05 to 0.11). Antidepressants There was low-certainty evidence for no evidence of difference for antidepressants (all types) compared to placebo for reducing pain intensity (SMD -0.04, 95% CI -0.25 to 0.17) and reducing disability (SMD -0.06, 95% CI -0.40 to 0.29). AUTHORS' CONCLUSIONS:We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo. For acute LBP, we found moderate-certainty evidence that NSAIDs and muscle relaxants may provide a small effect on pain, and high-certainty evidence for no evidence of difference between paracetamol and placebo. For safety, we found very low- and high-certainty evidence for no evidence of difference with NSAIDs and paracetamol compared to placebo for the risk of adverse events, and moderate-certainty evidence that muscle relaxants may increase the risk of adverse events. For chronic LBP, we found low-certainty evidence that NSAIDs and very low- to high-certainty evidence that opioids may provide a small effect on pain. For safety, we found low-certainty evidence for no evidence of difference between NSAIDs and placebo for the risk of adverse events, and low-certainty evidence that opioids may increase the risk of adverse events.

BACKGROUND CONTEXT: Mechanical Diagnosis and Treatment (MDT) and epidural steroid injections have the potential to reduce pain and disability in sciatica patients and prevent surgery. However, data on their combined influence in reducing the amount of sciatica surgeries is lacking. PURPOSE: To assess if a combination therapy (MDT and TESIs), administered while being on the waiting list for lumbar herniated disc surgery, is effective and cost-effective compared to no intervention (ie, usual care). STUDY DESIGN: Multicentre randomized controlled trial with economic evaluation and 1-year follow-up. PATIENT SAMPLE: Seventy-two adult patients on a waiting list for lumbar herniated disc surgery. OUTCOME MEASURES: Primary outcome was undergoing lumbar disc surgery during followup (yes/no). Secondary outcomes included back and leg pain intensity (NPRS), physical functioning (RMDQ-23), self-perceived recovery (GPE), and health-related quality of life (EQ-5D-5L). Total societal and total healthcare were measured. METHODS: Participants were randomly assigned to combination therapy (intervention group, n=34) or no intervention (control group, n=38). RESULTS: Twenty-nine out of 38 control group patients and 11 out of 34 intervention group patients received surgery. The adjusted odds ratio of receiving surgery in the intervention group compared to the control group was 0.09 (95% CI, 0.02-0.35) and the adjusted risk ratio 0.29 (95% CI, 0.08-0.69). There were no differences in clinical effects between both groups. Surgical, total societal, and total healthcare costs were on average 1,969, 1,754, and 2,363 lower in the intervention group, respectively. The combination therapy's probability of being cost-effective was moderate (<= 0.66) across a range of willingness-to-pay values from 20,000/QALY to 80,000/ QALY, from a societal perspective. CONCLUSION: Patients on the waiting list for lumbar disc surgery and who are open to postpone surgery, may benefit from the combination therapy intervention. (c) 2025 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

BACKGROUND:Out-of-hospital cardiac arrest (OHCA) survivors face important challenges when performing activities of daily living (ADL). The aim was to describe the ADL ability among OHCA survivors at discharge from hospital, characteristics of OHCA survivors with decreased ADL ability, and changes in ADL ability over time. METHODS:In this prospective cohort study, OHCA survivors were recruited and followed for 6 months. Observed ADL ability was evaluated prior to hospital discharge and at 6-month follow-up using the Assessment of Motor and Process Skills (AMPS), and self-reported ADL ability with the ADL Interview (ADL-I). Characteristics were compared between 2 groups: Participants with decreased observed ADL ability below age norms at hospital discharge and those meeting or exceeding age norms. RESULTS:Of the 156 OHCA survivors included, 125 completed the 6-month follow-up. At hospital discharge, 78% had observed ADL motor skills, and 47% ADL process skills below the competence thresholds. In total, 38% of the participants had an observed ADL ability below age norms. These participants were older and had lower cognitive scores at discharge compared to those meeting or exceeding the age norms. At hospital discharge, 89% reported decreased personal ADL ability, particularly in transferring, personal hygiene, body care, and dressing. Over 6 months, most participants improved in both their observed and self-reported ADL ability, although 11% still had an ability below age norm. CONCLUSIONS:Most OHCA survivors experienced decreased observed and self-reported ADL ability at hospital discharge and, despite improvement, decreased ADL ability persisted even after 6 months in some OHCA survivors.

To determine benefits and adverse effects (AE) of oral muscle-relaxants (MR) (non-benzodiazepines) for acute (< 6 weeks) and chronic (> 12 weeks) primary LBP, administered alone or combined with analgesics/NSAIDs. CENTRAL, MEDLINE, EMBASE, CINAHL were searched for pertinent randomized controlled trials. Primary outcomes comprised lack of pain relief, global efficacy and AE at 5–7 days follow-up assessed dichotomously (risk ratio, RR). Fifty studies (7531 participants) were included, with data from 4775 pooled in meta-analyses. For acute LBP, non-benzodiazepine MR were associated with increased likelihood of pain relief (moderate certainty; RR: 0.53, p < 0.0001), global efficacy (RR: 0.49, p = 0.0001), muscle spasm (RR: 0.62, p < 0.00001), and physical outcomes (RR: 0.60, p < 0.00001) compared to placebo. AE were more frequent with non-benzodiazepine MR compared to placebo (low-to-moderate certainty; RR: 1.56; p = 0.003), and at central nervous system (CNS; RR: 2.40; p < 0.00001), but not at gastrointestinal (GI) level (RR: 0.77; p = 0.62). Combined non-benzodiazepines + analgesics/non-steroidal anti-inflammatory drugs (NSAIDs) provide a larger and clinically meaningful benefit compared to placebo + analgesics/NSAIDs for global efficacy at 5–7 days (low-certainty; RR: 0.62; p = 0.01). Combined therapy did not result in significant between-group differences for total AE (moderate-certainty; RR: 1.15; p = 0.50) and GI AE (RR: 0.63; p = 0.08), despite responsible for more CNS AE (low-certainty; RR: 1.91; p = 0.002). When comparing non-benzodiazepine MR versus placebo for chronic LBP, only data on total AE could be pooled, without between-group difference (RR: 0.93; p = 0.69). Non-benzodiazepine MR for acute LBP were associated with increased likelihood of pain relief and global efficacy compared to placebo. Combined therapy with analgesics/NSAIDs proved superior for global efficacy. Studies are needed to evaluate if non-benzodiazepine MR are of larger benefit than analgesics/NSAIDs, and if stand-alone administration provides more benefit than combined treatment. The observed AE warrant caution.

BackgroundNeck pain is a common musculoskeletal disorder. Although surgery reduces symptoms, some patients still report significant pain and disabilities postoperatively. A deeper understanding of patients' experiences is needed to plan coherent rehabilitation.ObjectiveTo explore how patients undergoing cervical spine surgery experience their everyday life pre- and post-operatively.MethodsA qualitative study with a descriptive approach. Nine patients who had recently undergone cervical spine surgery were interviewed. Systematic text condensation was used in the analysis.ResultsFive themes emerged: "Neck pain has an extensive impact", "Surgery gives expectations of a life again", "Handling the situation", "After surgery, it´s in the back of your mind" and "Uncertainty abounds". Patients living with neck pain experience a high impact on physical, mental and social aspects. Acceptance, support and planning are important to deal with the situation. Postoperatively, patients experience a fear of doing something wrong making them refrain from activities.ConclusionLiving with neck pain seems to have an extensive impact on physical, mental and social aspects of everyday life. Although patients have positive expectations, uncertainty concerning physical abilities is a mental challenge. This indicates that the rehabilitation process should target efficient utilization of mental, social and physical resources.

IntroductionSocietal costs of out-of-hospital cardiac arrest (OHCA) survivors may be extensive due to high health care utilization and sick leave. Knowledge of the costs of OHCA survivors may guide decision-makers to prioritize health resources.AimThe aims of the study were to evaluate the costs of OHCA survivors from a societal perspective, and to compare these costs to the costs of individuals with non-cardiac arrest myocardial infarction (MI) and individuals with no cardiac disease (non-CD).MethodsFrom the Danish OHCA Registers, survivors, with a cardiac arrest between 2005-2018 were identified. Each case was assigned one MI control and one non-CD control, matched on gender and age. Based on register data, costs of healthcare utilization, sick leave, vocational rehabilitation, disability pension and other social benefits one year before event and five years after, were estimated.ResultsIn total 5,646 OHCA survivors were identified with associated control groups. The mean costs for OHCA survivors during the 6-year period were €119,106 (95%CI: 116,297-121,916), with €83,472 (95%CI: 81,392-85,552) being healthcare costs. Mean costs of OHCA survivors were €49,132 higher than the MI-control group and €100,583 higher than the non-CD control group.ConclusionsTotal costs of OHCA survivors were considerably higher than costs of MI- and non-CD controls. Hospital costs were highest during the first year after event, and work inability during the second to fifth year with sick leave and later disability pension as main burdens.

IntroductionChronic non-specific low back pain (CNLBP) is a major cause of disability resulting in high healthcare and lost productivity costs worldwide. Exercise therapy is the most prescribed treatment for CNLBP worldwide. Despite the benefits of exercise therapy, systematic reviews have highlighted the need for further high-quality evidence regarding their (cost-)effectiveness related to alternative treatments such as Pilates. Therefore, the aim was to investigate the cost-effectiveness of Pilates compared with home-based exercises for CNLBP.

Objective To investigate the effectiveness of a Pilates exercise program compared with home-based exercises in individuals with chronic non-specific low back pain. Design A randomised controlled trial with a six-month follow-up. Setting Rehabilitation clinic. Participants One hundred and forty-five individuals (18–50 years of age) with low back pain for ≥ 12 consecutive weeks were enrolled and randomly allocated to either Pilates ( n = 72) or home-based exercise groups ( n = 73). Interventions Method Pilates (Mat Pilates exercises using accessories) versus home-based exercise (postural exercises, muscle stretching and strengthening, and spine stabilisation/mobilisation), twice a week, for 6 weeks. Main measures Assessments were performed at baseline, post-intervention, and six months follow-up. Outcomes were pain intensity, disability, and health-related quality of life. Results At post-intervention, the Pilates group had significantly lower pain intensity (mean difference = −1.14; 95% CI −2.05; −0.23), less disability (mean difference = −6.7; 95% CI −11.3; −2.0), and higher health-related quality of life (mean difference = 0.102; 95% CI 0.054; 0151) compared to the home-based exercise group. At follow-up, the Pilates group had a significantly higher health-related quality of life (mean difference = 0.055; 95% CI 0.003; 0.106) compared with the home-based exercise group but there were no significant differences in pain and disability. A significant overall effect of Pilates compared to home-based exercise was found for disability (mean difference = −4.4; 95% CI −7.6; −1.1), and health-related quality of life (mean difference = 0.049; 95% CI 0.022; 0.076), but not for pain. Conclusion Although Pilates was significantly superior to home exercise for pain and disability, the differences were not considered clinically relevant. However, Pilates did provide significant and clinically relevant differences in utility.

ObjectiveTo assess the effectiveness of exercise for acute non-specific low back pain (LBP) versus our main comparisons: 1) sham treatment, and 2) no treatment at short-term (main follow-up time).Data Sources and Study SelectionA comprehensive search up till November 2021 was conducted in numerous databases for randomised controlled trials (RCTs) on the effectiveness of exercise in adults with acute LBP (< 6 weeks). Studies examining LBP with a specific aetiology were excluded. The primary outcomes were back pain, back-specific functional status and recovery.Data ExtractionTwo review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the certainty of the evidence.Data SynthesisWe identified 23 RCTs (2674 participants). There is very low-certainty evidence that exercise therapy compared with sham/placebo treatment has no clinically relevant effect on pain (mean difference (MD) −0.80, 95% confidence interval (CI) −5.79 to 4.19; 1 study, 299 participants) and on functional status (MD 2.00, 95% CI −2.20 to 6.20; 1 study, 299 participants) in the short term. There is very low-quality evidence which suggests no difference in effect on pain and functional status for exercise vs. no treatment (2 studies; n=157, not pooled due to heterogeneity) at short-term follow-up. Similar results were found for the other follow-up moments. The certainty of the evidence was downgraded because many RCTs had a high risk of bias, were small in size and/or there was substantial heterogeneity.ConclusionExercise therapy compared to sham/placebo and no treatment may have no clinically relevant effect on pain or functional status in the short term in people with acute non-specific LBP, but the evidence is very uncertain. Owing to insufficient reporting of adverse events, we were unable to reach any conclusions on the safety or harms related to exercise therapy.

Objective A comparison of cryoneurolysis or radio frequency (RF) with placebo in patients with facetogenic chronic low back pain (LBP) for patient global impression of change (PGIC), pain intensity, function and quality of life, with 1-year follow-up.Design Single-centre, single-blinded placebo-controlled randomised controlled trial.Setting Single-centre study.Participants Inclusion from March 2020 to September 2022: consenting adults over 18 years of age, LBP>3 months, average Numeric Rating Scale LBP≥4 average last 14 days and a positive response to a diagnostic medial branch block (>50% pain reduction after 60 min).Interventions 120 patients were block randomised 1:1:1 to cryoneurolysis, RF or placebo of the medial branch nerves. Physical therapy was added after 4 weeks for all groups.Main outcome measures Primary outcome was PGIC 4 weeks after the intervention. Secondary outcomes included pain intensity (Numeric Rating Scale, NRS), quality of life (Short Form 36, EQ-5D-5L), disability (Oswestry Disability Index), depression (Major Depression Inventory) and catastrophising (Pain Catastrophising Scale). Outcomes were measured at 4 weeks, 3, 6 and 12 months.Results There was no statistically significant difference in PGIC at 4 weeks between cryoneurolysis and placebo (risk ratio (RR) 2; 95% CI 0.75 to 5.33, p=0.17) and RF and placebo (RR 1.6; 95% CI 0.57 to 4.49, p=0.37), except PGIC for cryoneurolysis at 6-month follow-up (RR 5.1; 95% CI 1.20 to 22.03, p=0.03). No statistically significant differences were found in secondary follow-up endpoints.Conclusions Denervation of the medial branch nerve by either cryoneurolysis or RF compared with placebo did not demonstrate significant improvement in PGIC, pain intensity, function and quality of life in patients with facetogenic chronic LBP at short-term or long-term follow-up.Trial registration number NCT04786145.

Introduction Femoroacetabular impingement syndrome (FAIS) is a motion-related and position-related clinical condition of the hip associated with pain, reduced physical function and hip-related quality of life (QoL). Interestingly, higher maximal muscle strength is associated with less pain, better physical function and improved QoL in people with FAIS. Furthermore, preliminary evidence suggests that a proportion of patients with FAIS respond positively to strength exercise as first-line treatment. Nonetheless, there is little evidence supporting a specific exercise intervention offered as a first-line treatment. We will conduct a randomised controlled trial investigating the clinical effectiveness and cost-effectiveness of a 6-month strength exercise intervention compared with usual care as first-line treatment in patients with FAIS.Methods and analysis This is a multicentre randomised controlled trial that will be conducted at hospitals and physiotherapy clinics across Denmark and Australia. A total of 120 patients with FAIS will be randomised (1:1) to 6 months of supervised strength exercise or usual care. The primary outcome is the change in hip-related QoL measured using the International Hip and Outcome Tool 33 (iHOT-33) from baseline to the end of intervention. A health economic evaluation will be conducted from a societal and healthcare perspective based on the data collection over a 12-month period starting at baseline. The analysis will calculate incremental cost-effectiveness ratios using quality-adjusted life-years and iHOT-33 scores while estimating costs using microcosting and cost questionnaires. Secondary outcomes include objectively measured physical function at baseline and after 6 months and patient-reported outcomes measured at baseline, 3-month, 6-month and 12-month follow-up.Ethics and dissemination The trial has been approved by the Committee on Health Research Ethics in the Central Denmark Region (journal no 1-10-72-45-23) and La Trobe University Human Ethics Committee (HEC24042) and is registered at the Central Denmark Region List of Research Projects (journal no 1-16-02-115-23). Informed consent will be obtained from each participant before randomisation. Results will be published in international peer-reviewed scientific journals.Trial registration number NCT05927935.

Abstract Objectives This study evaluates the six-month cost-effectiveness and cost-benefits of motivational interviewing (MI) or a stratified vocational advice intervention (SVAI) added to usual case management (UC) for workers on sick leave due to musculoskeletal disorders. Methods This study was conducted alongside a three-arm RCT including 514 employed workers on sick leave for at least 50% for ≥ 7 weeks. All participants received UC. The UC + MI group received two MI sessions, and the UC + SVAI group received 1–4 SVAI sessions. Sickness absence days, quality-adjusted life-years (QALYs), and societal costs were measured between baseline and six months. Results Adding MI to UC, resulted in incremental cost-reduction of -2580EUR (95%CI -5687;612), and a reduction in QALYs of -0.001 (95%CI -0.02;0.01). Secondly, adding MI to UC resulted in an incremental cost-reduction of -538EUR (95%CI -1358;352), and reduction of 5.08 (95%CI -3.3;13.5) sickness-absence days. Financial return estimates were positive, but not statistically significant. Adding SVAI to UC, resulted in an incremental cost-reduction of -2899 EUR (95% CI -5840;18), and a reduction in QALYs of 0.002 (95% CI -0.02;0.01). Secondly, adding SVAI to UC resulted in an statistically significant incremental cost-reduction of -695 EUR (95% CI -1459;-3), and a reduction of 7.9 (95% CI -0.04;15.9) sickness absence days. Financial return estimates were positive and statistically significant. The probabilities of cost-effectiveness for QALYs were high for adding MI or SVAI (ceiling ratio 0.90). Conclusions In comparison to UC only, adding MI to UC tends to be cost-effective. Adding SVAI to UC is cost-effective for workers on sick leave due to musculoskeletal disorders. Trial registration ClinicalTrials.gov (identifier: NCT03871712).

Measurement instruments are important in clinical practice and research for assessing physical function in critically ill patients in the intensive care unit (ICU). To investigate inter-rater reliability and responsiveness of the Danish version of the CPAx (CPAx-D). Critically ill patients from three Danish ICUs were included. Patients were assessed with CPAx-D by two blinded testers during a regular physiotherapy session. Follow-up tests were performed in patients who stayed in the ICU for more than 24 hours, were not transferred to another hospital or received palliative care. Floor and ceiling effects were examined in all assessments.Results For the reliability analysis 66 patients were included. Results Showed no significant difference between raters. For the total score, intra class correlation coefficient (ICC) was 0.996 (95% CI: 0.993; 0.997), standard error of measurement was 0.72 point and minimal detectable change 2.0 points. Bland-Altman plot revealed no heteroscedacity. The responsiveness results of 24 patients showed that the effect size was 1.2 and the standardized response mean 1.1, which was in accordance with the hypothesis. No ceiling or floor effect was revealed. The CPAx-D showed excellent inter-rater reliability and responsiveness.