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R Lewis,
N Williams,
H E Matar,
N Din,
D Fitzsimmons,
C Phillips, M Jones,
A Sutton,
K Burton,
S Nafees,
M Hendry,
I Rickard,
R Chakraverty,
C Wilkinson
[show abstract]
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ABSTRACT: Sciatica is a symptom characterised by well-localised leg pain with a sharp, shooting or burning quality that radiates down the back of the leg and normally to the foot or ankle. It is often associated with numbness or altered sensation in the leg.
To determine the clinical effectiveness and cost-effectiveness of different management strategies for sciatica.
Major electronic databases (e.g. MEDLINE, EMBASE and NHS Economic Evaluation Database) and several internet sites including trial registries were searched up to December 2009.
Systematic reviews were undertaken of the clinical effectiveness and cost-effectiveness of different treatment strategies for sciatica. Effectiveness data were synthesised using both conventional meta-analyses and mixed treatment comparison (MTC) methods. An economic model was then developed to estimate costs per quality-adjusted life-year gained for each treatment strategy.
The searches identified 33,590 references, of which 270 studies met the inclusion criteria and 12 included a full economic evaluation. A further 42 ongoing studies and 93 publications that could not be translated were identified. The interventions were grouped into 18 treatment categories. A larger number of studies evaluated invasive interventions and non-opioids than other non-invasive interventions. The proportion of good-quality studies for each treatment category ranged from 0% to 50%. Compared with studies of less invasive interventions, studies of invasive treatments were more likely to confirm disc herniation by imaging, to limit patients included to those with acute sciatica (< 3 months' duration) and to include patients who had received previous treatment. The MTC analyses gave an indication of relative therapeutic effect. The statistically significant odds ratios of global effect compared with inactive control were as follows: disc surgery 2.8, epidural injection 3.1, chemonucleolysis 2.0 and non-opioids 2.6. Disc surgery and epidural injections were associated with more adverse effects than the inactive control. There was some evidence for the effectiveness of biological agents and acupuncture. Opioid medication and activity restriction were found to be less effective than the comparator interventions and opioids were associated with more adverse effects than the inactive control. The full economic evaluations were of reasonable to good quality, but were not able to fully address our research question. Although individual studies raised a number of important issues, it was difficult to draw meaningful conclusions across studies because of their heterogeneity. The economic model demonstrated that stepped-care approaches to patient management were likely to be cost-effective, relative to strategies that involved direct referral to disc surgery.
The limited number of studies for some comparisons, the high level of heterogeneity (within treatment comparisons) and the potential inconsistency (between treatment comparisons) weaken the interpretation of the MTC analyses.
These findings provide support for the effectiveness of currently used therapies for sciatica such as non-opioid medication, epidural corticosteroid injections and disc surgery, but also for chemonucleolysis, which is no longer used in the UK NHS. These findings do not provide support for the effectiveness of opioid analgesia, which is widely used in this patient group, or activity restriction. They also suggest that less frequently used treatments, such as acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be effective. Stepped-care approaches to treatment for patients with sciatica are cost-effective relative to direct referral for surgery. Future research should include randomised controlled trials with concurrent economic evaluation of biological agents and acupuncture compared with placebo or with currently used treatments. Development of alternative economic modelling approaches to assess relative cost-effectiveness of treatment regimes, based on the above trial data, would also be beneficial.
The National Institute for Health Research Health Technology Assessment programme.
Health technology assessment (Winchester, England). 11/2011; 15(39):1-578.
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• R Lewis,
N Williams,
HE Matar,
N Din,
D Fitzsimmons,
C Phillips, M Jones,
A Sutton,
K Burton,
S Nafees,
M Hendry,
I Rickard,
R Chakraverty,
C Wilkinson
[show abstract]
[hide abstract]
ABSTRACT: Research question
To undertake a systematic review of the effectiveness and cost-effectiveness of different management strategies for sciatica
Objective
To undertake a systematic review of the effectiveness and cost-effectiveness of different management strategies for sciatica.
To synthesise the results using meta-analyses and a mixed treatment comparison (MTC) method.
To construct an appropriate probabilistic decision analytic model to estimate costs per quality adjusted life year (QALY) gained for each treatment strategy.
To make recommendations for clinical practice and commissioning in the UK NHS.
Search methodology: Databases used
MEDLINE
MEDLINE in process and other non-indexed citations
EMBASE
CINAHL
PsychINFO
AMED (Allied and Complimentary Database)
HMIC (Health Management Information Consortium)
British Nursing Index
BIOSIS
Cochrane Central Register of Controlled Trials (CENTRAL)
Database of Abstracts of Reviews of Effects (DARE)
Cochrane Database of Systematic Reviews
Health Technology Assessment (HTA) Database
NHS Economic Evaluation database (NHS EED)
Science Citation Index
Social Science Citation Index
Index to Scientific and Technical proceedings (ISTP)
System for Information on Grey Literature (SIGLE)
Inspec
Physiotherapy Evidence Database (PEDro)
Limits (years considered, Publication status, language of publication: None
Selection criteria: Types of studies
For clinical effectiveness:
Randomised and non-randomised controlled trials, as well as controlled observational studies.
For cost effectiveness:
Economic evaluations conducted alongside trials, modelling studies and analyses of administrative databases will be included if they compare two or more treatments and consider both costs and consequences (including cost-effectiveness, cost-utility, cost-benefit and cost-consequences analysis). Cost-analysis undertaken as part of a comparative study, where data on both costs and consequences are reported, but not combined will also be included.
Types of participants
Adults with sciatica or lumbar nerve root pain diagnosed clinically or confirmed by imaging. The essential clinical criterion is leg pain worse than back pain. Other clinical criteria which support the diagnosis include: unilateral leg pain; pain radiation below the knee; aggravated by cough/sneeze; segmental distribution; provocation tests (eg impaired SLR); reduced power, sensation or reflexes in one nerve root. Studies that include participants with low back pain will be included if the findings for patients with sciatica are reported
separately; studies where the results are not reported separately for sciatica will be excluded. Studies of specific conditions such as spinal stenosis or discogenic pain will only be included if it is documented that leg pain is worse than back pain. If imaging has been used it must demonstrate evidence of nerve root irritation.
Outcome measure description
Any relevant patient based outcome measure such as pain, disability, functional status, adverse effects, health status, quality of life, analgesic use, operation rates, health utility, return to work, health service use and costs. Biochemical outcomes and biomechanical measurements (e.g. change in disk space) will be excluded.
HTA Monograph in press. 01/2011;
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ABSTRACT: To compare survival and adverse outcome of patients with non-valvar atrial fibrillation (NVAF) treated with or without warfarin.
Record linkage method to identify patients with a previous hospital diagnosis of atrial fibrillation and to link these patients to international normalised ratio (INR) test results and mortality data.
Cardiff and the Vale of Glamorgan, Wales.
Mortality, specifically from ischaemic and thromboembolic events.
6108 patients were identified with NVAF, of whom 36.4% received warfarin. Mean survival in the warfarin and non-warfarin groups was 52.0 months and 38.2 months, respectively (p < 0.001), and 14.4 months (p < 0.001) after adjustment for confounding factors. Warfarin treated patients in the upper quartile of INR control had significantly longer survival (57.5 months) than did those in the lowest quartile of control (38.1 months, p < 0.001). The risk of stroke in the warfarin group when treated was lower than that in the non-warfarin group (relative rate (RR) 0.74, p < 0.001). The risk of death from ischaemic stroke was lower in the warfarin group (RR 0.43, p < 0.001). The risk of all ischaemic and embolic events in the warfarin group was lower when they were taking warfarin (RR 0.74, p < 0.001). The risk of bleeding in the warfarin group when treated was greater (RR 1.78, p = 0.001).
Patients with NVAF within the recommended target INR range of 2.0-3.0 survive longer and have reduced morbidity. Probably too few people are anticoagulated with warfarin in NVAF.
Heart (British Cardiac Society) 03/2006; 92(2):196-200. · 4.22 Impact Factor
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ABSTRACT: To evaluate how well patients with non-valvar atrial fibrillation (NVAF) were maintained within the recommended international normalised ratio (INR) target of 2.0-3.0 and to explore the relation between achieved INR control and clinical outcomes.
Record linkage study of routine activity records and INR measurements.
Cardiff and the Vale of Glamorgan, South Wales, UK.
2223 patients with NVAF, no history of heart valve replacement, and with at least five INR measurements.
Mortality, ischaemic stroke, all thromboembolic events, bleeding events, hospitalisation, and patterns of INR monitoring.
Patients treated with warfarin were outside the INR target range 32.1% of the time, with 15.4% INR values > 3.0 and 16.7% INR values < 2.0. However, the quartile with worst control spent 71.6% of their time out of target range compared with only 16.3% out of range in the best controlled quartile. The median period between INR tests was 16 days. Time spent outside the target range decreased as the duration of INR monitoring increased, from 52% in the first three months of monitoring to 30% after two years. A multivariate logistic regression model showed that a 10% increase in time out of range was associated with an increased risk of mortality (odds ratio (OR) 1.29, p < 0.001) and of an ischaemic stroke (OR 1.10, p = 0.006) and other thromboembolic events (OR 1.12, p < 0.001). The rate of hospitalisation was higher when INR was outside the target range.
Suboptimal anticoagulation was associated with poor clinical outcomes, even in a well controlled population. However, good control was difficult to achieve and maintain. New measures are needed to improve maintenance anticoagulation in patients with NVAF.
Heart (British Cardiac Society) 05/2005; 91(4):472-7. · 4.22 Impact Factor
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ABSTRACT: Optical ellipsometry studies of single, skinned muscle fibers conducted on the diffraction orders have yielded spectra that are sensitive to the state of the fiber. The linearly polarized light field vector becomes elliptically polarized as it passes through the fiber and may be collected at the diffraction orders. Fibers that have been subjected to extraction of myosin (0.6 M KCl) retain a weak diffraction pattern and exhibit a substantially decreased depolarization of incident linearly polarized light. A significant decrease in polarization is seen in skinned fibers that are subject to an increase in pH from 7.0 to 8.0. This increase in pH results in a decrease of approximately 30% in the depolarization angle of single fibers. The major decrease in depolarization angle that we observe at pH 8.0 is consistent with the notion that as cross-bridges move out from the shaft of the thick filament, their ability to cause depolarization of the incident linearly polarized light decreases. This interpretation is also consistent with the work of Ueno and Harrington where the decrease in the ability to cross-link S-1 and S-2 to the thick filament at pH 8.2 suggests cross-bridge movement away from the thick filament. A large decrease in birefringence, seen after treatment of skinned fibers with alpha-chymotrypsin, appears to be related to the breakdown of myosin into rod, S-1, heavy meromyosin, and light meromyosin.
Biophysical Journal 08/1986; 50(1):63-74. · 3.65 Impact Factor
