Cochrane Back Review Group

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• Cochrane Back Review Group

Prof. Lex Bouter Co-ordinating Editor Victoria
Pennick Co-ordinator Stavanger, Norway August
2nd, 2002
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The Back Review Group
Rome, Oct 1999
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Editorial Base of the Cochrane Back Review Group

• Founding Editor Emeritus
• Alf Nachemson Sweden
• Co-ordinating Editors
• Claire Bombardier Canada
• Lex Bouter The Netherlands
• Editors
• Rob de Bie The Netherlands
• Rick Deyo USA
• Francis Guillemin France
• Paul Shekelle USA
• Gordon Waddell UK
• Jim Weinstein USA
• Co-ordinators
• Victoria Pennick Canada
• Chantelle Garritty (leave) Canada
• Consumer representatives
• Mark Schoene USA
• Andrew King Canada
• Research transfer Associate

Toronto, Canada
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Back Review Group Scope

• randomized controlled trials (RCTs) and
  controlled clinical trials (CCTs) of primary and
  secondary prevention and treatment of neck pain,
  back pain and other spinal disorders, excluding
  inflammatory diseases and fractures

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Back Review Group Scope of Topics

• Spinal disorders
• 1. Cervical spine
• 2. Neck pain
• 3. Thoracic outlet syndrome
• 4. Thoracic spine
• 5. Lumbar spine
• 6. Low back pain
• 7. Spinal deformities
• 8. Spinal infections
• 9. Tumors of the spine

• Interventions
• 1. Pharmacological
• 2. Physical therapy
• 3. Manual therapy
• 4. Psychological therapy
• 5. Exercises
• 6. Multidisciplinary approaches
• 7. Education
• 8. Alternative medicine
• 9. Injections and blocks
• 10. Orthoses and supports
• 11. Surgery

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Back Review Group Funding Sources

• Institute for Work Health
• Canada (1996 present)
• Swedish Council on Technology Assessment in
  Health Care
• Sweden (1996, 1997)

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ORGANIZATION OF THE
BACK REVIEW GROUP
Back
Editorial Team
Co-ordinating Editors
Reviewers
Reviewers
Editors
Group co-ordinator
Cochrane Database of
Systematic Reviews
(online/CD ROM)
Clinicians
Government
Industry
Payers
Patients
Public
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Back Review Group

• 21 reviews
• 7 protocols
• 869 specialized registry
• references

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Assembling Our Specialized Trials Registry

• The AHCPR back panel references
• Hand searching of Spine (1976 - Dec. 2001)
• References of current Cochrane Back Reviews
• Cross-referencing Back Guidelines
• - Paris Task Force
• - WAD Task Force
• - British Back Guidelines
• - Israeli Guidelines
• - New Zealand Guidelines others ongoing
• Quarterly literature searches of electronic
  databases (Medline, Embase, etc.)ongoing

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Number of Reviews Completed

• 16 back reviews
• 5 neck reviews

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16 Back Reviews

• 1. Acupuncture
• 2. Back schools
• 3. Bed rest
• 4. Behavioral treatments (chronic LBP)
• 5. Exercises
• 6. Injections
• 7. Lumbar supports (prevention and treatment)
• 8. Massage
• 9. Multidisciplinary rehabilitation (sub-acute
  LBP)

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16 Back Reviews

• 10. Multidisciplinary teams (chronic LBP)
• 11. NSAIDs
• 12. Stay active (acute or sub-acute LBP)
• 13. TENS (chronic LBP)
• 14. Rehabilitation treatment after lumbar disc
  surgery
• 15. Surgery for degenerative lumbar spondylosis
• 16. Surgery for lumbar disc prolapse

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5 Neck Reviews

• 1. Conservative treatment for WAD
• 2. Multidisciplinary bio-psycho-social
  rehabilitation
• 3. Patient education
• 4. Physical medicine modalities
• 5. Surgery for cervical radiculo-myelopathy

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Reviewers

• 95 active members of BRG
• 71 involved in one or more reviews
• 65 men 35 women
• Multi-national, multi-disciplinary
• Canada, France, Finland, Netherlands, Norway,
  Brazil, USA, Spain, Italy, Switzerland, United
  Kingdom, Sweden, Australia

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Languages of RCTs in reviews

• 273 RCTs
• 255 English
• 10 German
• 6 French
• 1 Polish
• 1 Norwegian

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Quality of RCTs in reviews

• LBP
• 14 SRs on conservative Tx 2 on surgery
• 243 RCTs 34 high quality
• Neck
• 4 SRs on conservative Tx 1 on surgery
• 30 RCTs 30 high quality
• Quality improved over time

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Results acute LBP

• Effective NSAIDs, muscle relaxants, advice to
  stay active
• Not effective Bed rest, specific exercises
• No consistent evidence for acupuncture, lumbar
  supports

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Results chronic LBP

• Effective Exercise therapy, behavioural therapy
  and multidisciplinary pain treatment programs
• Likely to be effective Back schools and massage
• Not effective TENS
• No consistent evidence for acupuncture facet,
  epidural and local injections lumbar supports

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Results Spondylosis Surgery

• No trials comparing surgery with natural history,
  placebo, or conservative tx.
• Instrumented vs. non-instrumented fusion produces
  a higher fusion rate but did not improve clinical
  outcomes.
• The few and heterogeneous trials on
  spondylolisthesis, spinal stenosis and nerve
  compression permitted very limited conclusions.

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Results Disc Prolapse Surgery

• Surgical discectomy produced better clinical
  outcomes than chemonucleolysis with chymopapain
• Chemonucleolysis produced better clinical
  outcomes than percutaneous discectomy and placebo
• No difference between micro- and standard
  discectomy

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Results Whiplash

• Rest and immobilization using collars are not
  recommended
• Active interventions, such as advice to 'maintain
  usual activities' might be effective
• Only one RCT on chronic whiplash

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Results Neck Pain

• Patient education using individualised or group
  strategies are not beneficial in reducing pain
• Effective Electromagnetic therapy
• Not effective laser therapy
• No sufficient evidence on exercise, traction,
  acupuncture, heat / cold applications,
  electrotherapies, cervical orthoses and
  behavioural treatment

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Results neck surgery

• 2 small trials
• One trial (n81) better short-term effects with
  surgical decompression vs. either physiotherapy
  or cervical collar for radiculopathy, no long
  term effects
• One trial (n49) no differences between surgery
  and conservative treatment for myelopathy
• Conclusions no reliable evidence

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Protocols

• Low back pain
• Antidepressants
• Neuro-reflexotherapy
• Spinal manipulation
• Traction

• Neck and LBP
• Work hardening, work conditioning and functional
  restoration
• Mechanical neck disorders
• Drug therapy
• Manual therapy

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Summary BRG reviews

• Active group, many protocols reviews
• Multidisciplinary, multinational group
• Mainly English language trials included
• Only 34 of RCTs high quality
• Strong evidence for some interventions
• Reviews used as basis for guidelines

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CHALLENGES

• Slow Process
• Potential for Conflicting Reviews
• Lack of Funding
• Dissemination Issues Press release

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Slow Process What takes so long?

• The review is developed into two phases Protocol
  Review
• Each phase undergoes the editorial review process
• Often a time lag exists between editorial
  approval publication in the Cochrane Library
• Deadlines are difficult to enforce

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Potential for Conflicting Reviews

• Across Back Reviews there may be different
  perspectives taken of the same problem. This
  leads to
• Variations in interventions included
• Variations in subgroup of populations included
• Diagnosis
• Duration
• Variations in outcomes included

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Lack of funding

• For reviewers conducting the reviews
• For reviewer training workshops one-on-one
  guidance from individual review groups
• For maintenance of a Trials Registry

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Press Releases(A Positive Challenge)

• Increase the profile of
• Back Review Group
• Individual reviewers
• Cochrane Collaboration
• Supporting/hosting institution
• While educating the public and clinicians at the
  same time.
• Press coverage provides...
• An avenue of disseminating Cochrane findings
• A source of motivation for reviewers

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BRG Press Releases

• The Back Group began the press release process in
  November 2000.
• 6 releases have been developed and circulated
• Tracking services indicate they have been picked
  up by various media sources

Front page headline, November 16, 2000 National
Post (Canada) Bed rest is a bad way to treat
back pain, vast study concludes Finding defies
a centurys worth of conventional wisdom. Hagen
KB, Hilde G, Jamtvedt G, Winnem M. The Cochrane
Review of Bed Rest for Acute Low Back Pain and
Sciatica. Spine. 2000252932-2939
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Additional BRG Activities

• Updating the BRG methods guidelines
• Are guidelines useful to reviewers?
• How to improve consistency among reviews?
• How to improve use of guidelines?

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Additional BRG Activities

• Updating the BRG methods guidelines
• Guidelines published in 1997
• Minimum criteria/further guidance
• Criteria for authors
• Minimum number of RCTs
• Inclusion of non-randomized evidence
• Length of text and tables

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Additional BRG Activities

• Formulating a policy document
• Conflicts of interest
• Enforcement of deadlines
• Funding of editorial office
• Identification of gaps

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Additional BRG Activities

• Formulating a policy document
• Identification of new eligible RCTs
• Register of guidelines
• Register of diagnostic, prognostic and etiologic
  reviews
• Promotion of methodological research

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WHAT CAN I DO
þ
Join a Review Group, Field, Methods Group or
Consumer network
þ
Hand search a journal
þ
Provide details of previous/ongoing trials
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Translating articles
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Be an external peer reviewer
þ
Raise funds
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Disseminate information
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For more information

• Victoria Pennick
• vpennick_at_iwh.on.ca

• Cochrane Back Review Group
• http//www.cochrane.iwh.on.ca
• Cochrane Collaboration
• http//www.cochrane.org

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