Cochrane Database of Systematic Reviews

Recurrent respiratory papillomatosis is a condition characterised by benign papillomatous (wart-like) growths in the upper airway. It can affect both adults and children causing airway-obstruction and voice change. Treatment usually involves repeated surgical debulking of the papillomata, and several agents have been proposed as adjuvants to surgical debulking. These include antivirals, administered systemically or injected into the lesions. To assess the effectiveness of antiviral agents as adjuvant therapy in the management of recurrent respiratory papillomatosis in children and adults. We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2004), MEDLINE (January 1966 to November 2004), and EMBASE (January 1985 to November 2004) in December 2004. We checked reference lists of articles, contacted pharmaceutical companies and contacted leading experts in the field for further studies. All randomised controlled trials. One hundred references were identified from the searches. Twenty-five were appropriate for retrieval and assessed for eligibility by the authors. None met the inclusion criteria. No controlled trials were identified. There was insufficient evidence from controlled trials on which to base reliable conclusions about the effectiveness of antiviral agents as adjuvant therapy in the management of recurrent respiratory papillomatosis. Further research is required before any specific antiviral adjuvant therapy can be recommended.

Although existing trial data indicated some benefit of rivastigmine in VCI, these were derived from studies which had small numbers of patients, and which compared rivastigmine to treatments other than placebo or extrapolated results post hoc from large studies involving patients with Alzheimer's disease and vascular risk factors of unclear significance. They could not be included in this review. Proper randomized placebo-controlled double-blind trials involving patients with VCI are needed before any conclusions regarding the use of rivastigmine in VCI can be drawn.

Background: Pneumonia is an important cause of mortality in intensive care units (ICUs). The incidence of pneumonia in ICU patients ranges between 7% and 40%, and the crude mortality from ventilator-associated pneumonia may exceed 50%. Although not all deaths in patients with this form of pneumonia are directly attributable to pneumonia, it has been shown to contribute to mortality in ICUs independently of other factors that are also strongly associated with such deaths. Objectives: To assess the effects of prophylactic antibiotic regimens, such as selective decontamination of the digestive tract (SDD) for the prevention of respiratory tract infections (RTIs) and overall mortality in adults receiving intensive care. Search strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, issue 1), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register; MEDLINE (January 1966 to March 2009); and EMBASE (January 1990 to March 2009). Selection criteria: Randomised controlled trials (RCTs) of antibiotic prophylaxis for RTIs and deaths among adult ICU patients. Data collection and analysis: At least two review authors independently extracted data and assessed trial quality. Main results: We included 36 trials involving 6914 people. There was variation in the antibiotics used, patient characteristics and risk of RTIs and mortality in the control groups. In trials comparing a combination of topical and systemic antibiotics, there was a significant reduction in both RTIs (number of studies = 16, odds ratio (OR) 0.28, 95% confidence interval (CI) 0.20 to 0.38) and total mortality (number of studies = 17, OR 0.75, 95% CI 0.65 to 0.87) in the treated group. In trials comparing topical antimicrobials alone (or comparing topical plus systemic versus systemic alone) there was a significant reduction in RTIs (number of studies = 17, OR 0.44, 95% CI 0.31 to 0.63) but not in total mortality (number of studies = 19, OR 0.97, 95% CI 0.82 to 1.16) in the treated group. Authors' conclusions: A combination of topical and systemic prophylactic antibiotics reduces RTIs and overall mortality in adult patients receiving intensive care. Treatment based on the use of topical prophylaxis alone reduces respiratory infections but not mortality. The risk of resistance occurring as a negative consequence of antibiotic use was appropriately explored only in one trial which did not show any such effect.

Background: Corticosteroids have been used late in the neonatal period to treat chronic lung disease (CLD) in preterm babies and early to try to prevent it. CLD is likely to be the result of persisting inflammation in the lung and the use of powerful anti-inflammatory drugs like dexamethasone has some rationale. Early use tends to be associated with increased adverse effects so that studies of moderately early treatment (7-14 days postnatal) might have the dual benefits of fewer side effects and onset of action before chronic inflammation is established. Objectives: To determine if moderately early (7-14 days) postnatal corticosteroid treatment vs control (placebo or nothing) is of benefit in the prevention and/or treatment of early chronic lung disease in the preterm infant. Search strategy: Randomised controlled trials of postnatal corticosteroid therapy were sought from the Oxford Database of Perinatal Trials, Cochrane Database of Controlled Trials, Medline, hand searching paediatric and perinatal journals, examining previous review articles and information received from practising neonatologists. Selection criteria: Randomised controlled trials of postnatal corticosteroid treatment from 7-14 days of birth in high risk preterm infants were selected for this review. Data collection and analysis: Data regarding clinical outcomes including mortality up to 28 days and before discharge, failure to extubate, mortality or chronic lung disease at 28 days and 36 weeks, CLD at 28 days and 36 weeks, infection, hyperglycaemia, hypertension, severe retinopathy of prematurity (ROP), pneumothorax, necrotizing enterocolitis (NEC), gastrointestinal bleeding, severe intraventricular haemorrhage (IVH), hypertrophic cardiomyopathy, late rescue with dexamethasone and abnormal neurological examination at follow-up were abstracted and analysed using RevMan 4.1. Main results: Moderately early steroid treatment (vs placebo or nothing) reduced mortality by 28 days, chronic lung disease at 28 days and 36 weeks, and death or chronic lung disease at 28 days or 36 weeks. Earlier extubation was facilitated. There was no significant effect on the rates of pneumothorax, severe ROP, and NEC. Adverse effects included hypertension, hyperglycaemia, gastrointestinal bleeding, hypertrophic cardiomyopathy and infection. Steroid-treated infants were less likely to need late rescue with dexamethasone. There was only one small study of longterm follow-up and it did not show any increase in adverse neurological outcome. Reviewer's conclusions: Moderately early corticosteroid therapy (started at 7-14 days) reduces neonatal mortality and CLD, but at the cost of important short term adverse effects. No reliable evidence concerning long term effects is provided by the trials included in this review. In view of the evidence of an important increase in cerebral palsy and other adverse neurodevelopmental outcomes from trials in which postnatal steroids were begun either earlier or later than 7-14 days, there are reasonable grounds for extending this concern to moderately early initiation of steroid therapy. More research is urgently needed, including long term follow-up of survivors included in previous and any future trials, before the benefits and risks of postnatal steroid treatment, including initiation at 7-14 days, can be reliably assessed (See DART study; ~~ Doyle 2000~~).

Most premature infants less than 1500 grams birth weight must be fed initially by tube because of their inablity to suck effectively, or to coordinate sucking, swallowing and breathing. Milk feedings can be given by tube either intermittently, typically over 10-20 minutes every two or three hours, or continuously, using an infusion pump. Although theoretical benefits and risks of each method have been proposed, effects on clinically important outcomes remain uncertain. To examine the evidence from randomized trials regarding the effectiveness of continuous versus intermittent bolus nasogastric milk feeding in premature infants less than 1500 grams. The primary outcomes reviewed included feeding tolerance, days to reach full enteral feeding, somatic growth, days to discharge and incidence of necrotizing enterocolitis (NEC). Searches were performed of MEDLINE, CINAHL, and HealthSTAR, each up to February 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). As well, studies identified from abstracts and conference proceedings and references from relevant publications were retrieved. Randomized and quasi-randomized clinical trials that met the following criteria for relevance: a) Enrollment of infants < 1500 grams birth weight with no major congenital anomalies which might interfere with feeding tolerance b) Comparison of continuous nasogastric versus intermittent bolus tube feedings using breastmilk or formula c) Assessment of relevant outcomes including feeding tolerance, days to full feeds, somatic growth, days to discharge, and complications such as NEC or apnea All articles retrieved from the complete search were assessed independently by the two reviewers for relevance (see selection criteria), and for methodologic quality using the following criteria: blinding of randomization, blinding of intervention, complete follow-up and blinding of outcome measurement. Only those articles judged by both reviewers to be relevant and to have appropriate methodologic quality were included in the analysis. Differences were resolved through discussion and consensus of the reviewers. Infants fed by continuous tube feeding method took longer to reach full enteral feeds (weighted mean difference 3.0 days; 95% CI 0.7, 5.2). Although there was no evidence of a difference in the days to discharge overall, one study suggested a trend toward earlier discharge for infants less than 1000 grams birth weight fed by the continuous tube feeding method (mean difference (MD) -11 days; 95% CI -21.8, -0.2). Overall, there was no evidence of a difference in somatic growth (weight, length, head circumference or skinfold thickness) between the two groups, but subgroup analyses in one study suggested that infants less than 1000 grams and 1000 - 1250 grams birthweight gained weight faster when fed by the continuous tube feeding method (MD 2.0 g/day; 95% CI 0.5, 3.5; MD 2.0 g/day; 95% CI 0.2, 3.8, respectively). There was no evidence of a difference in the incidence of NEC. One study showed a trend toward more apneas during the study period in infants fed by the continuous tube feeding method (MD 14.0 apneas during study period; 95% CI -0.2, 28.2). Infants fed by the continuous tube feeding method took longer to reach full feeds, but there was no significant difference in somatic growth, days to discharge, or the incidence of NEC for infants fed by continuous versus intermittent bolus tube feeds. Small sample sizes, methodologic limitations and conflicting results of the studies to date, together with inconsistencies in controlling variables that may affect outcomes, make it difficult to make universal recommendations regarding the best tube feeding method for premature infants less than 1500 grams. The clinical benefits and risks of continuous versus intermittent nasogastric tube milk feeding cannot be reliably discerned from the limited information available from randomized trials to date.

There is no difference in time to achieve full feedings in low birth weight premature infants fed milk through a tube into the stomach either on a continuous basis or over 10 to 20 minutes every two to three hours. Premature infants born weighing less than 1500 grams are not able to coordinate sucking, swallowing, and breathing. Feeding into the gastrointestinal tract (enteral feeding) helps with gastrointestinal tract development and growth. Therefore, in addition to feeding through a tube into a vein (parenterally), premature infants may be fed milk through a tube placed either up their nose and into the stomach (nasogastric feeding) or through their mouth and into the stomach (orogastric feeding). Usually a set amount of milk is given over 10 to 20 minutes every two to three hours (intermittent bolus gavage feeding). Some clinicians prefer to feed premature infants continuously. Each feeding method has beneficial effects (e.g., achieve full feedings sooner) but can also have harmful effects (destructive inflammation of the gastrointestinal tract or necrotizing enterocolitis. There was no difference in time to achieve full feedings between feeding methods regardless of tube placement. Reports of the incidence of destructive inflammation of the gastrointestinal tract (necrotizing enterocolitis) were similar. However, there is not enough evidence to determine the best feeding method for low birth weight premature infants. More research is required in this area.

Colorectal cancer metastatic to the liver, when technically feasible, is resected with a moderate chance of cure. The most common site of failure after resection is within the remaining liver. With this pattern of clinical failure in mind and in order to enhance survival, chemotherapy has been delivered directly to the liver post resection via the hepatic artery. To assess the effect of post hepatic resection hepatic artery chemotherapy on overall survival. Secondary objectives include adverse events related to the chemotherapy, the risk of intra-hepatic tumour recurrence and tumour free survival. Randomised trials were sought in MEDLINE; the Cochrane Central Register of Controlled Trials; the Cochrane Hepato-Biliary Group Controlled Trials Register; and through contact of trial authors and reference lists using key words: Colorectal, cancer, hepatic metastases, hepatic artery, chemotherapy. Searches were performed in May, 2006. Trials in which patients having resection of colorectal cancer metastatic to the liver were randomised either to hepatic artery chemotherapy or any alternative treatment. Survival data were obtained principally from abstraction from survival curves in published studies using the method of Parmar. A study specific log hazard ratio and then combined effect log hazard ratio were calculated, as well as a combined Kaplan-Meier survival probability curve. Seven randomised trials addressed this issue, encompassing 592 patients. No significant advantage was found in the meta-analysis for hepatic artery chemotherapy measuring overall survival and calculating survival based upon "intention to treat" (lnHR = 0.0848; favouring the control group, 95% confidence interval = -0.1189 to 0.2885, or a Hazard Ratio of 1.089, an 8.9% survival advantage for the control group, 95% CI of the HR = 0.887-1.334). Adverse events related to the hepatic artery therapy were common, including five therapy related deaths. Intra-hepatic recurrence was more frequent in the control group (97 patients versus 43 in the HAI group), though denominators are not reported, and additional outcomes could not be subjected to a combined analysis. Though recurrence in the remaining liver happened less in the hepatic artery chemotherapy group, overall survival was not improved, and even favoured the control group, though not significantly. This added intervention cannot be recommended at this time.

Youth gangs have long been studied in the United States and interest elsewhere is increasing. Many studies document a robust and consistent relationship between gang membership and elevated delinquency. One theory of gang involvement, drawing on anomie and strain theories, proposes that the gang provides a means of fulfilling the economic needs of youth excluded from legitimate labour markets. Opportunities provision is a gang prevention strategy based on this theory and the principle that providing youth with educational and employment opportunities may reduce gang involvement. Common techniques within opportunities provision include tutoring, remedial education, job training, and job placement. To determine the effectiveness of opportunities provision for preventing youth gang involvement for children and young people aged 7 to 16. Electronic searches were conducted of ASSIA, CINAHL, CJA, Cochrane Library, Dissertations Abstracts, EMBASE, ERIC, IBSS, LILACs, LexisNexis Butterworths, MEDLINE, NCJR Service Abstracts Database, PsycINFO, and Sociological Abstracts, to April 2007. Reviewers contacted relevant organisations, individuals and list-servs and searched pertinent websites and reference lists. All randomised controlled trials or quasi-randomised controlled trials of interventions that have opportunities provision as the majority component, delivered to children and youths aged 7 to 16 not involved in a gang, compared to any other or no intervention. Searches yielded 2,696 unduplicated citations. 2,676 were excluded based on title and abstract. Two were excluded based on personal communication with study authors. Full-text reports for 18 citations were retrieved. 16 were excluded because they were not evaluations, did not address a gang prevention programme, did not include gang-related outcomes, did not include opportunities provision intervention components, or presented preliminary findings for outcomes reported in another citation. The remaining two reports were at least partially relevant to opportunities provision for gang prevention, but methodological flaws excluded both from analysis. No randomised controlled trials or quasi-randomised controlled trials were identified. No evidence from randomised controlled trials or quasi-randomised controlled trials currently exists regarding the effectiveness of opportunities provision for gang prevention. Only two studies addressed opportunities provision as a gang prevention strategy, a case study and a qualitative study, both of which had such substantial methodological limitations that even speculative conclusions as to the impact of opportunities provision were impossible. Rigorous primary evaluations of gang prevention strategies are crucial to develop this research field, justify funding of existing interventions, and guide future gang prevention programmes and policies.

Background: Extensive evidence exists showing analgesic effects of sweet solutions for newborns and infants. It is less certain if the same analgesic effects exist for children one year to 16 years of age. This is an updated version of the original Cochrane review published in Issue 10, 2011 (Harrison 2011) titled Sweet tasting solutions for reduction of needle-related procedural pain in children aged one to 16 years. Objectives: To determine the efficacy of sweet tasting solutions or substances for reducing needle-related procedural pain in children beyond one year of age. Search methods: Searches were run to the end of June 2014. We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects (DARE), Cochrane Methodology Register, Health Technology Assessment, the NHS Economic Evaluation Database, MEDLINE, EMBASE, PsycINFO, and ACP Journal Club (all via OvidSP), and CINAH (via EBSCOhost). We applied no language restrictions. Selection criteria: Published or unpublished randomised controlled trials (RCT) in which children aged one year to 16 years, received a sweet tasting solution or substance for needle-related procedural pain. Control conditions included water, non-sweet tasting substances, pacifier, distraction, positioning/containment, breastfeeding, or no treatment. Data collection and analysis: Outcome measures included crying duration, composite pain scores, physiological or behavioral pain indicators, self-report of pain or parental or healthcare professional-report of the child's pain. We reported mean differences (MD), weighted mean difference (WMD), or standardized mean difference (SMD) with 95% confidence intervals (CI) using fixed-effect or random-effects models as appropriate for continuous outcome measures. We reported risk ratio (RR), risk difference (RD), and the number needed to treat to benefit (NNTB) for dichotomous outcomes. We used the I(2) statistic to assess between-study heterogeneity. Main results: We included one unpublished and seven published studies (total of 808 participants); four more studies and 478 more participants than the 2011 review. Six trials included young children aged one to four years receiving sucrose or candy lollypops for immunisation pain compared with water or no treatment. Usual care included topical anaesthetics, upright parental holding, and distraction. All studies were well designed blinded RCTs, however, five of the six studies had a high risk of bias based on small sample sizes.Two studies included school-aged children receiving sweet or unsweetened chewing gum before, or before and during, immunisation and blood collection. Both studies, conducted by the same author, had a high risk of bias based on small sample sizes.Results for the toddlers/pre-school children were conflicting. Duration of cry, using a random-effects model, was not significantly reduced by sweet taste (six trials, 520 children, WMD -15 seconds, 95% CI -54 to 24, I(2) = 94%).Composite pain score at time of first needle was reported in four studies (n = 121 children). The scores were not significantly different between the sucrose and control group (SMD -0.26, 95% CI -1.27 to 0.75, I(2) = 86%).A Children's Hospital of Eastern Ontario Pain Scale score > 4 was significantly less common in the sucrose group compared to the control group in one study (n = 472, RR 0.55, 95% CI 0.45 to 0.67; RD -0.29, 95% CI -0.37 to -0.20; NNTB 3, 95% CI 3 to 5; tests for heterogeneity not applicable.For school-aged children, chewing sweet gum before needle-related painful procedures (two studies, n = 111 children) or during the procedures (two studies, n = 103 children) did not significantly reduce pain scores. A comparison of the Faces Pain Scale scores in children chewing sweet gum before the procedures compared with scores of children chewing unsweetened gum revealed a WMD of -0.15 (95% CI -0.61 to 0.30). Similar results were found when comparing the chewing of sweet gum with unsweetened gum during the procedure (WMD 0.23, 95% CI -0.28 to 0.74). The Colored Analogue Scale for children chewing sweet gum compared to unsweetened gum before the procedure was not significantly different (WMD 0.24 (-0.69 to 1.18)) nor was it different when children chewed the gum during the procedure (WMD 0.86 (95% CI -0.12 to 1.83)). There was no heterogeneity for any of these analyses in school-aged children (I(2) = 0%). Authors' conclusions: Based on the eight studies included in this systematic review update, two of which were subgroups of small numbers of eligible toddlers from larger studies, and three of which were pilot RCTs with small numbers of participants, there is insufficient evidence of the analgesic effects of sweet tasting solutions or substances during acutely painful procedures in young children between one and four years of age. Further rigorously conducted, adequately powered RCTs are warranted in this population. Based on the two studies by the same author, there was no evidence of analgesic effects of sweet taste in school-aged children. As there are other effective evidence-based strategies available to use in this age group, further trials are not warranted.Despite the addition of four studies in this review, conclusions have not changed since the last version of the review.

Many studies document a robust and consistent relationship between gang membership and elevated delinquency, with gang members disproportionately involved in crime compared to non-gang peers. Research also indicates that both delinquent youth and youth who join gangs often show a wide range of deficient or distorted social-cognitive processes compared to non-delinquent peers. Cognitive-behavioural interventions are designed to address cognitive deficits in order to reduce maladaptive or dysfunctional behaviour, and studies have documented their positive impact on a number of behavioural and psychological disorders among children and youth. To determine the effectiveness of cognitive-behavioural interventions for preventing youth gang involvement for children and young people (ages 7-16). Electronic searches of ASSIA, CINAHL, CJA, Cochrane Library, Dissertations Abstracts A, EMBASE, ERIC, IBSS, LILACs, LexisNexis Butterworths, MEDLINE, NCJR Service Abstracts Database, PsycINFO, and Sociological Abstracts, to April 2007. Reviewers contacted relevant organisations, individuals, and list-servs and searched pertinent websites and reference lists. All randomised controlled trials or quasi-randomised controlled trials of interventions with a cognitive-behavioural intervention as the majority component, delivered to youth and children aged 7-16 not involved in a gang. Searching yielded 2,284 unduplicated citations, 2,271 of which were excluded as irrelevant based on title and abstract. One was excluded following personal communication with investigators. One citation, of a large randomised prevention trial, awaits assessment; personal communication with study authors yielded unpublished reports addressing gang outcomes, but insufficient detail precluded determining inclusion status. Seven remaining reports were excluded as irrelevant because they were narrative reviews or descriptions of programs without evaluations, did not address a gang prevention programme, or did not address a gang prevention program that included a cognitive-behavioural intervention. The remaining four full-text reports excluded because of study design, leading to 0 included studies. No randomised controlled trials or quasi-randomised controlled trials were identified. No evidence from randomised controlled trials or quasi-randomised controlled trials exists regarding the effectiveness of cognitive-behavioural interventions for gang prevention. Four evaluations of Gang Resistance Education and Training (GREAT) have been conducted, two of which were part of a US national evaluation, but all were excluded based on study design. Reviewers conclude there is an urgent need for rigorous primary evaluations of cognitive-behavioural interventions for gang prevention to develop this research field and guide future gang prevention programmes and policies.

BACKGROUND: Multisystemic Therapy (MST) is an intensive, home-based intervention for families of youth with social, emotional, and behavioral problems. Masters-level therapists engage family members in identifying and changing individual, family, and environmental factors thought to contribute to problem behavior. Intervention may include efforts to improve communication, parenting skills, peer relations, school performance, and social networks. Most MST trials were conducted by program developers in the USA; results of one independent trial are available and others are in progress.

Conduct disorder and delinquency are significant problems for children and adolescents and their families, with the potential to consume much of the resources of the health, social care and juvenile justice systems. A number of family and parenting interventions have been recommended and are used for these conditions. The aim of this review was to determine if these interventions are effective in the management of conduct disorder and delinquency in children and adolescents, aged 10-17. To determine if family and parenting interventions improve the child/adolescent's behaviour; parenting and parental mental health; family functioning and relations; and have an effect on the long term psychosocial outcomes for the child/adolescent. Randomised controlled trials were identified through searching the Cochrane Controlled Trial Register (CCTR), databases (MEDLINE, EMBASE, PsycINFO, CINAHL, Sociofile, ERIC, Healthstar), reference lists of articles and contact with authors. Randomised controlled trials with a major focus on parenting and/or family functioning were eligible for inclusion in the review. Trials needed to include at least one objective outcome measure (e.g. arrest rates) or have used a measure that had been published in peer review publications and validated for the relevant purpose. Studies were required to have a control group, which could be a no intervention group, a wait list group or a usual intervention group (e.g. probation). Trials in children and adolescents aged 10 to 17 years with conduct disorder and/or delinquency and their families were considered. Conduct disorder was defined by a standardised psychological assessment (for example, using a child behaviour checklist), or a psychiatric diagnosis. Delinquency was defined by a referral from a juvenile justice or another legal system for a child/adolescent who has committed a serious crime e.g assault and/or offended on at least two occasions. Two reviewers independently reviewed all eligible studies for inclusion, assessed study quality (allocation concealment, blinding, follow up, clinically important outcomes) and extracted data. Heterogeneity was assessed using the Chi squared test of heterogeneity along with visual inspection of the data. A significance level less than 0.1 was interpreted as evidence of statistically significant heterogeneity. For data where heterogeneity was found the reviewers looked for an explanation. If studies with heterogeneous results were thought to be comparable the statistical synthesis of the results was done using a random effects model. This model takes into account within-study sampling error and between-studies variation in the assessment of uncertainty and will give wider confidence intervals to the effect size and hence a more conservative result. Sensitivity analysis was performed to explore the effects of the varying quality of the studies included on the results. Of the nine hundred and seventy titles initially identified through the search strategy, eight trials met the inclusion criteria. A total of 749 children and their families were randomised to receive a family and parenting intervention or to be in a control group. In seven of these studies the participants were juvenile delinquents and their families and in only one the participants were children/adolescents with conduct disorder who had not yet had contact with the juvenile justice system. At follow up, family and parenting interventions significantly reduced the time spent by juvenile delinquents in institutions (WMD 51.34 days, 95%CI 72.52 to 30.16). There was also a significant reduction in the risk of a juvenile delinquent being re arrested (RR 0.66, 95%CI 0.44 to 0.98) and in their rate of subsequent arrests at 1-3 years (SMD -0.56, 95% CI -1.100 to - 0.03). For both of these outcomes there was substantial heterogeneity in the results suggesting a need for caution in interpretation. At present there is insufficient evidence that family and parenting interventions reduce the risk of being incarcerated (RR=0.50, 95% CI 0.20 to 1.21). No significant difference was found for psychosocial outcomes such as family functioning, and child/adolescent behaviour. The evidence suggests that family and parenting interventions for juvenile delinquents and their families have beneficial effects on reducing time spent in institutions. This has an obvious benefit to the participant and their family and may result in a cost saving for society. These interventions may also reduce rates of subsequent arrest but at present these results need to be interpreted with caution due to the heterogeneity of the results.

There is a high and increasing prevalence of impairments among children and adolescents in the West. Many countries offer personal assistance in the form of individualised support for people living in the community by a paid assistant other than a healthcare professional for at least 20 hours per week. To assess the effectiveness of personal assistance for children and adolescents with both physical and intellectual impairments, and the impacts of personal assistance on others, compared to other interventions. Electronic databases including CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Dissertation Abstracts International and a variety of specialist Swedish databases were searched from 1980 to June 2005; reference lists were checked; 345 experts, organisations, government bodies and charities were contacted in an attempt to locate relevant research. Children and adolescents with both physical and intellectual impairments (0-18 years) living in the community who require assistance to perform tasks of daily living (e.g., bathing and eating) and participate in normal activities due to permanent impairments. Controlled studies of personal assistance in which participants were prospectively assigned to study groups and in which control group outcomes were measured concurrently with intervention group outcomes were included. Titles and abstracts were examined by two reviewers. 130 full papers were examined. None met the inclusion criteria. No eligible studies were found. Research in this field is limited, though one related review provides some evidence of the effectiveness of personal assistance for children and adolescents with intellectual impairments. When implementing new programmes, recipients could be randomly assigned to different forms of assistance. While advocates may support personal assistance for myriad reasons, this review demonstrates that further studies are required to determine which models of personal assistance are most effective and efficient for particular people.

Background: A significant proportion of children have caries requiring restorations or extractions, and some of these children will not accept this treatment under local anaesthetic. Historically this has been managed in children by the use of a general anaesthetic, however use of sedation may lead to reduced morbidity and cost. The aim of this review is to compare the efficiency of sedation versus general anaesthesia for the provision of dental treatment for children and adolescents aged under 18 years.This review was originally published in 2009 and updated in 2012. Objectives: We evaluated the intra- and postoperative morbidity, effectiveness and cost effectiveness of sedation versus general anaesthesia for the provision of dental treatment for under 18 year olds. Search methods: In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); MEDLINE (Ovid) (1950 to July 2012); EMBASE (Ovid) (1974 to July 2012); System for information on Grey Literature in Europe (SIGLE) (1980 to October 2008), Latin American & Caribbean Health Sciences Literature (LILACS) (1982 to July 2012), and ISI Web of Science (1945 to October 2008). The searches were updated to July 2012. The original search was performed in October 2008.We also carried out handsearching of relevant journals to July 2012. We imposed no language restriction. Selection criteria: We planned to include randomized controlled clinical trials of sedative agents compared to general anaesthesia in children and adolescents aged up to 18 years having dental treatment. We excluded complex surgical procedures and pseudo-randomized trials. Data collection and analysis: Two authors assessed titles and abstracts for inclusion in the review. We recorded information relevant to the objectives and outcome measures in a specially designed 'data extraction form'. Main results: We identified 15 studies for potential inclusion after searching the available databases and screening the titles and abstracts. We identified a further study through personal contacts. Following full text retrieval of the studies, we found none to be eligible for inclusion in this review. Authors' conclusions: Randomized controlled studies are required comparing the use of dental general anaesthesia with sedation to quantify differences such as morbidity and cost.

The World Health Organization estimates that 1.9 million deaths worldwide are attributable to physical inactivity. Chronic diseases associated with physical inactivity include cancer, diabetes and coronary heart disease. The purpose of this systematic review is to summarize the evidence of the effectiveness of school-based interventions in promoting physical activity and fitness in children and adolescents. The search strategy included searching several databases. In addition, reference lists of included articles and background papers were reviewed for potentially relevant studies, as well as references from relevant Cochrane reviews. Primary authors of included studies were contacted as needed for additional information. To be included, the intervention had to be relevant to public health practice, implemented, facilitated, or promoted by staff in local public health units, implemented in a school setting and aimed at increasing physical activity, report on outcomes for children and adolescents (aged 6 to 18 years), and use a prospective design with a control group. Standardized tools were used by two independent reviewers to rate each study's methodological quality and for data extraction. Where discrepancies existed discussion occurred until consensus was reached. The results were summarized narratively due to wide variations in the populations, interventions evaluated and outcomes measured. 13,841 titles were identified and screened and 482 articles were retrieved. Multiple publications on the same project were combined and counted as one project, resulting in 395 distinct project accounts (studies). Of the 395 studies 104 were deemed relevant and of those, four were assessed as having strong methodological quality, 22 were of moderate quality and 78 were considered weak. In total 26 studies were included in the review. There is good evidence that school-based physical activity interventions have a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, and blood cholesterol. Generally school-based interventions had no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity result in positive effects. Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time.

Attention Deficit Hyperactivity Disorder (ADHD) in children is associated with hyperactivity and impulsitivity, attention problems, and difficulties with social interactions. Pharmacological treatment may alleviate symptoms of ADHD but seldom solves difficulties with social interactions. Social skills training may benefit ADHD children in their social interactions. We examined the effects of social skills training on children's social competences, general behaviour, ADHD symptoms, and performance in school. To assess the effects of social skills training in children and adolescents with ADHD. We searched the following electronic databases: CENTRAL (2011, Issue1), MEDLINE (1948 to March 2011), EMBASE (1980 to March 2011), ERIC (1966 to March 2011 ), AMED (1985 to June 2011), PsycINFO (1806 to March 2011), CINAHL (1980 to March 2011), and Sociological Abstracts (1952 to March 2011). We also searched the metaRegister of Controlled Trials on 15 October 2010. We did not apply any language or date restrictions to the searches. We searched online conference abstracts and contacted 176 experts in the field for possible information about unpublished or ongoing RCTs. Randomised trials investigating social skills training for children with ADHD as a stand alone treatment or as an adjunct to pharmacological treatment. We conducted the review according to the Cochrane Handbook for Systematic Reviews of Intervention. Two authors (OJS, MS) extracted data independently using an appropriate data collection form. We performed the analyses using Review Manager 5 software. We included 11 randomised trials described in 26 records (all full text articles) in the review. The trials included a total of 747 participants. All participants were between five and 12 years of age. No trials assessed adolescents. In 10 of the trials the participants suffered from different comorbidities.The duration of the interventions ranged from eight to 10 weeks (eight trials) up to two years. The types of social skills interventions were named social skills training, cognitive behavioural intervention, multimodal behavioural/psychosocial therapy, behavioural therapy/treatment, behavioural and social skills treatment, and psychosocial treatment. The content of the social skills interventions were comparable and based on a cognitive behavioural model. Most of the trials compared child social skills training and parent training plus medication versus medication alone. Some of the experimental interventions also included teacher consultations.More than half of the trials were at high risk of bias regarding generation of the allocation sequence and allocation concealment. No trial reported blinding of participants and personnel and most of the trials had no reports regarding differences between groups in collateral medication for comorbid disorders. Overall, the trials had high risk of bias due to systematic errors. Even so, as recommended by the Cochrane Handbook of Systematic Reviews of Interventions, we used all eligible trials in the meta-analysis, but the results are downgraded to low quality evidence.There were no statistically significant treatment effects either on social skills competences (positive value = better for the intervention group) (SMD 0.16; 95% CI -0.04 to 0.36; 5 trials, n = 392), on the teacher-rated general behaviour (negative value = better for the intervention group) (SMD 0.00; 95% CI -0.21 to 0.21; 3 trials, n = 358), or on the ADHD symptoms (negative value = better for the intervention group) (SMD -0.02; 95% CI -0.19 to 0.16; 6 trials, n = 515).No serious or non-serious adverse events were reported. The review suggests that there is little evidence to support or refute social skills training for adolescents with ADHD. There is need for more trials, with low risk of bias and with a sufficient number of participants, investigating the efficacy of social skills training versus no training for both children and adolescents.

Background: Attention Deficit Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder characterised by high levels of inattention, hyperactivity and impulsivity that are present before the age of seven years, seen in a range of situations, inconsistent with the child's developmental level and causing social or academic impairment. Parent training programmes are psychosocial interventions aimed at training parents in techniques to enable them to manage their children's challenging behaviour. Objectives: To determine whether parent training interventions are effective in reducing ADHD symptoms and associated problems in children aged between five and eigtheen years with a diagnosis of ADHD, compared to controls with no parent training intervention. Search methods: We searched the following electronic databases (for all available years until September 2010): CENTRAL (2010, Issue 3), MEDLINE (1950 to 10 September 2010), EMBASE (1980 to 2010 Week 36), CINAHL (1937 to 13 September 2010), PsycINFO (1806 to September Week 1 2010), Dissertation Abstracts International (14 September 2010) and the metaRegister of Controlled Trials (14 September 2010). We contacted experts in the field to ask for details of unpublished or ongoing research. Selection criteria: Randomised (including quasi-randomised) studies comparing parent training with no treatment, a waiting list or treatment as usual (adjunctive or otherwise). We included studies if ADHD was the main focus of the trial and participants were over five years old and had a clinical diagnosis of ADHD or hyperkinetic disorder that was made by a specialist using the operationalised diagnostic criteria of the DSM-III/DSM-IV or ICD-10. We only included trials that reported at least one child outcome. Data collection and analysis: Four authors were involved in screening abstracts and at least 2 authors looked independently at each one. We reviewed a total of 12,691 studies and assessed five as eligible for inclusion. We extracted data and assessed the risk of bias in the five included trials. Opportunities for meta-analysis were limited and most data that we have reported are based on single studies. Main results: We found five studies including 284 participants that met the inclusion criteria, all of which compared parent training with de facto treatment as usual (TAU). One study included a nondirective parent support group as a second control arm. Four studies targeted children's behaviour problems and one assessed changes in parenting skills. Of the four studies targeting children's behaviour, two focused on behaviour at home and two focused on behaviour at school. The two studies focusing on behaviour at home had different findings: one found no difference between parent training and treatment as usual, whilst the other reported statistically significant results for parent training versus control. The two studies of behaviour at school also had different findings: one study found no difference between groups, whilst the other reported positive results for parent training when ADHD was not comorbid with oppositional defiant disorder. In this latter study, outcomes were better for girls and for children on medication.We assessed the risk of bias in most of the studies as unclear at best and often as high. Information on randomisation and allocation concealment did not appear in any study report. Inevitably, blinding of participants or personnel was impossible for this intervention; likewise, blinding of outcome assessors (who were most often the parents who had delivered the intervention) was impossible.We were only able to conduct meta-analysis for two outcomes: child 'externalising' behaviour (a measure of rulebreaking, oppositional behaviour or aggression) and child 'internalising' behaviour (for example, withdrawal and anxiety). Meta-analysis of three studies (n = 190) providing data on externalising behaviour produced results that fell short of statistical significance (SMD -0.32; 95% CI -0.83 to 0.18, I(2) = 60%). A meta-analysis of two studies (n = 142) for internalising behaviour gave significant results in the parent training groups (SMD -0.48; 95% CI -0.84 to -0.13, I(2) = 9%). Data from a third study likely to have contributed to this outcome were missing, and we have some concerns about selective outcome reporting bias.Individual study results for child behaviour outcomes were mixed. Positive results on an inventory of child behaviour problems were reported for one small study (n = 24) with the caveat that results were only positive when parent training was delivered to individuals and not groups. In another study (n = 62), positive effects (once results were adjusted for demographic and baseline data) were reported for the intervention group on a social skills measure.The study (n = 48) that assessed parenting skill changes compared parent training with a nondirective parent support group. Statistically significant improvements were reported for the parent training group. Two studies (n = 142) provided data on parent stress indices that were suitable for combining in a meta-analysis. The results were significant for the 'child' domain (MD -10.52; 95% CI -20.55 to -0.48) but not the 'parent' domain (MD -7.54; 95% CI -24.38 to 9.30). Results for this outcome from a small study (n = 24) suggested a long-term benefit for mothers who received the intervention at an individual level; in contrast, fathers benefited from short-term group treatment. A fourth study reported change data for within group measures of parental stress and found significant benefits in only one of the two active parent training group arms (P ≤ 0.01).No study reported data for academic achievement, adverse events or parental understanding of ADHD. Authors' conclusions: Parent training may have a positive effect on the behaviour of children with ADHD. It may also reduce parental stress and enhance parental confidence. However, the poor methodological quality of the included studies increases the risk of bias in the results. Data concerning ADHD-specific behaviour are ambiguous. For many important outcomes, including school achievement and adverse effects, data are lacking.Evidence from this review is not strong enough to form a basis for clinical practice guidelines. Future research should ensure better reporting of the study procedures and results.

Background: Asthma is the most common chronic medical condition in children and a common reason for hospitalisation. Observational studies have suggested that swimming, in particular, is an ideal form of physical activity to improve fitness and decrease the burden of disease in asthma. Objectives: To determine the effectiveness and safety of swimming training as an intervention for asthma in children and adolescents aged 18 years and under. Search methods: We searched the Cochrane Airways Group's Specialised Register of trials (CENTRAL), MEDLINE , EMBASE, CINAHL, in November 2011, and repeated the search of CENTRAL in July 2012. We also handsearched ongoing Clinical Trials Registers. Selection criteria: We included all randomised controlled trials (RCTs) and quasi-RCTs of children and adolescents comparing swimming training with usual care, a non-physical activity, or physical activity other than swimming. Data collection and analysis: We used standard methods specified in the Cochrane Handbook for Systematic reviews of Interventions. Two review authors used a standard template to independently assess trials for inclusion and extract data on study characteristics, risk of bias elements and outcomes. We contacted trial authors to request data if not published fully. When required, we calculated correlation coefficients from studies with full outcome data to impute standard deviation of changes from baseline. Main results: Eight studies involving 262 participants were included in the review. Participants had stable asthma, with severity ranging from mild to severe. All studies were randomised trials, three studies had high withdrawal rates. Participants were between five to 18 years of age, and in seven studies swimming training varied from 30 to 90 minutes, two to three times a week, over six to 12 weeks. The programme in one study gave 30 minutes training six times per week. The comparison was usual care in seven studies and golf in one study. Chlorination status of swimming pool was unknown for four studies. Two studies used non-chlorinated pools, one study used an indoor chlorinated pool and one study used a chlorinated but well-ventilated pool.No statistically significant effects were seen in studies comparing swimming training with usual care or another physical activity for the primary outcomes; quality of life, asthma control, asthma exacerbations or use of corticosteroids for asthma. Swimming training had a clinically meaningful effect on exercise capacity compared with usual care, measured as maximal oxygen consumption during a maximum effort exercise test (VO2 max) (two studies, n = 32), with a mean increase of 9.67 mL/kg/min; 95% confidence interval (CI) 5.84 to 13.51. A difference of equivalent magnitude was found when other measures of exercise capacity were also pooled (four studies, n = 74), giving a standardised mean difference (SMD) 1.34; 95% CI 0.82 to 1.86. Swimming training was associated with small increases in resting lung function parameters of varying statistical significance; mean difference (MD) for FEV1 % predicted 8.07; 95% CI 3.59 to 12.54. In sensitivity analyses, by risk of attrition bias or use of imputed standard deviations, there were no important changes on effect sizes. Unknown chlorination status of pools limited subgroup analyses.Based on limited data, there were no adverse effects on asthma control or occurrence of exacerbations. Authors' conclusions: This review indicates that swimming training is well-tolerated in children and adolescents with stable asthma, and increases lung function (moderate strength evidence) and cardio-pulmonary fitness (high strength evidence). There was no evidence that swimming training caused adverse effects on asthma control in young people 18 years and under with stable asthma of any severity. However whether swimming is better than other forms of physical activity cannot be determined from this review. Further adequately powered trials with longer follow-up periods are needed to better assess the long-term benefits of swimming.

There is a high and increasing prevalence of impairments among children and adolescents in the West. Many countries offer personal assistance in the form of individualised support for people living in the community by a paid assistant other than a healthcare professional for at least 20 hours per week. To assess the effectiveness of personal assistance for children and adolescents with physical impairments, and the impacts of personal assistance on others, compared to other interventions. Electronic databases including CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Dissertation Abstracts International and a variety of specialist Swedish databases were searched from 1980 to June 2005; reference lists were checked; 345 experts, organisations, government bodies and charities were contacted in an attempt to locate relevant research. Children and adolescents with physical impairments (0-18 years) living in the community who require assistance to perform tasks of daily living (e.g., bathing and eating) and participate in normal activities due to permanent impairments. Controlled studies of personal assistance in which participants were prospectively assigned to study groups and in which control group outcomes were measured concurrently with intervention group outcomes were included. Titles and abstracts were examined by two reviewers. 130 full papers were examined. None met the inclusion criteria. No eligible studies were found. Research in this field is limited. When implementing new programmes, recipients could be randomly assigned to different forms of assistance. While advocates may support personal assistance for myriad reasons, this review demonstrates that further studies are required to determine which models of personal assistance are most effective and efficient for particular people.

There is a high and increasing prevalence of intellectual impairments among children and adolescents in the West. Many countries offer personal assistance in the form of individualised support for people living in the community by a paid assistant other than a healthcare professional for at least 20 hours per week. To assess the effectiveness of personal assistance for children and adolescents with intellectual impairments, and the impacts of personal assistance on others, compared to other interventions. Electronic databases including CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Dissertation Abstracts International and a variety of specialist Swedish databases were searched from 1980 to June 2005; reference lists were checked; 345 experts, organisations, government bodies and charities were contacted in an attempt to locate relevant research. Children and adolescents with intellectual impairments (0-18 years) living in the community who require assistance to perform tasks of daily living (e.g., bathing and eating) and participate in normal activities due to permanent impairments. Controlled studies of personal assistance in which participants were prospectively assigned to study groups and in which control group outcomes were measured concurrently with intervention group outcomes were included. Titles and abstracts were examined by two reviewers. Outcome data were extracted. Studies were assessed for the possibility of bias. Results and potential sources of bias are presented for included studies. One included study randomised 1002 participants to personal assistance or usual care. Whilst personal assistance was generally preferred over other services, some people prefer other models of care. This review indicates that personal assistance may have some benefits for some recipients and may benefit caregivers. However, near complete dependence on proxy respondents raises concerns about the validity of these results. Paid assistance probably substitutes for informal care and may cost government more than alternatives; however, the total costs to recipients and society are currently unknown. Research in this field is limited. When implementing new programmes, recipients could be randomly assigned to different forms of assistance. While advocates may support personal assistance for myriad reasons, this review demonstrates that further studies are required to determine which models of personal assistance are most effective and efficient for particular people.

Not enough evidence that induced hypothermia (cooling) of newborn babies who may have suffered from a lack of oxygen at birth reduces death or disability A lack of oxygen before and during birth can destroy cells in a newborn baby's brain, and this damage continues for some time afterwards. One way to try and stop this damage is to induce hypothermia - cooling the baby or just the baby's head for some hours to days. This may reduce the amount of damage to brain cells. This review found that there is not enough evidence from trials to show whether or not induced hypothermia helps newborn babies at risk of brain damage. More research is needed.

There is a high incidence of impairments among working age adults. Many countries offer personal assistance in the form of individualised support for people living in the community by a paid assistant other than a healthcare professional for at least 20 hours per week. To assess the effectiveness of personal assistance for adults with physical impairments, and the impacts of personal assistance on others, compared to other interventions. Electronic databases including CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Dissertation Abstracts International and a variety of specialist Swedish databases were searched from 1980 to June 2005; reference lists were checked; 345 experts, organisations, government bodies and charities were contacted in an attempt to locate relevant research. Adults (19-64) with physical impairments living in the community who require assistance to perform tasks of daily living (e.g., bathing and eating) and participate in normal activities due to permanent impairments. Controlled studies of personal assistance in which participants were prospectively assigned to study groups and in which control group outcomes were measured concurrently with intervention group outcomes were included. Titles and abstracts were examined by two reviewers. Outcome data were extracted. Studies were assessed for the possibility of bias. Results and potential sources of bias are presented for included studies. One randomised controlled trial involving 817 participants compared personal assistance versus usual care was identified. Whilst personal assistance was generally preferred over other services, some people prefer other models of care. This review indicates that personal assistance may have some benefits for some recipients and may benefit caregivers. Whilst paid assistance probably substitutes for informal care and may cost government more than alternatives, the total costs to recipients and society are currently unknown. Research in this field is limited. When implementing new programmes, recipients could be randomly assigned to different forms of assistance. While advocates may support personal assistance for myriad reasons, this review demonstrates that further studies are required to determine which models of personal assistance are most effective and efficient for particular people.

There is a high incidence of impairments among working age adults, and their prevalence is increasing in the West. Many countries offer personal assistance in the form of individualised support for people living in the community by a paid assistant other than a healthcare professional for at least 20 hours per week. To assess the effectiveness of personal assistance for adults with physical and intellectual impairments, and the impacts of personal assistance on others, compared to other interventions. Electronic databases including CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Dissertation Abstracts International and a variety of specialist Swedish databases were searched from 1980 to June 2005; reference lists were checked; 345 experts, organisations, government bodies and charities were contacted in an attempt to locate relevant research. Adults (19-64) with permanent physical and intellectual impairments living in the community who require assistance to perform tasks of daily living (e.g., bathing and eating) and participate in normal activities. Controlled studies of personal assistance in which participants were prospectively assigned to study groups and in which control group outcomes were measured concurrently with intervention group outcomes were included. Titles and abstracts were examined by two reviewers. Outcome data were extracted. Because no two studies made the same comparison, studies were not combined for meta-analyses. Studies were assessed for bias. Results and potential sources of bias are presented for included studies. Two studies involving 1002 participants compared personal assistance versus usual care. Whilst personal assistance was generally preferred over other services, some people prefer other services. Personal assistance may have some benefits for some recipients and may benefit caregivers. Paid assistance probably substitutes for informal care and may cost government more than alternatives; however, some evidence suggests it may reduce costs. The total costs to recipients and society are unknown. Research in this field is limited. Personal assistance is expensive and difficult to organise, especially in places that do not already have services in place, but its total cost relative to other services is unknown. When implementing new programmes, recipients could be randomly assigned to different forms of assistance (e.g. organised by individual users versus organised through a cooperative). While advocates may support personal assistance for myriad reasons, this review demonstrates that further studies are required to determine which models of assistance are most effective and efficient for particular people.

Transcutaneous electrical nerve stimulation (TENS), originally based on the gate-control theory of pain, is widely used for the treatment of chronic low back pain. Despite its wide use and theoretical rationale, there appears at first glance little scientific evidence to support its use. This Cochrane review examines the available evidence on TENS for the treatment of chronic back pain through an exhaustive search of the literature. Transcutaneous electrical nerve stimulation (TENS) and acupuncture-like transcutaneous electrical nerve stimulation (ALTENS) for chronic low back pain management have experienced a tremendous growth over the past 25 years. The objective of this review was to assess the effects of TENS and ALTENS for reducing pain and improving function in patients with chronic back pain. We searched MEDLINE up to November 1997, EMBASE from 1985 to September 1995, Amed and Ciscom to January 1995, reference lists of the retrieved articles, proceedings of conferences and contacted investigators in the field. Randomised trials comparing TENS or ALTENS therapy to placebo in patients with chronic low back pain. Two reviewers independently assessed trial quality and extracted data on pain reduction, range of movement, functional and work status. Six trials were included. The trials included 288 participants with an average age range of 45 to 50 years and approximately equal numbers of women and men. The overall odds ratio for improvement in pain for each comparison was: TENS/ALTENS versus placebo 2.11 (95% confidence interval 1.32 to 3. 38), ALTENS versus placebo 7.22 (95% confidence interval 2.60 to 20.01) and TENS versus placebo 1.52 (95% confidence interval 0.90 to 2.58). The odds ration for improvement in range of motion on ALTENS versus placebo was 6.61 (95% confidence interval 2.36 to 18.55). There is evidence from the limited data available that TENS/ALTENS reduces pain and improves range of motion in chronic back pain patients, at least in the short term. A large trial of ALTENS and TENS is needed to confirm these findings.

Face-to-face interventions for promoting physical activity (PA) are continuing to be popular as remote and web 2.0 approaches rapidly emerge, but we are unsure which approach is more effective at achieving long term sustained change. To compare the effectiveness of face-to-face versus remote and web 2.0 interventions for PA promotion in community dwelling adults (aged 16 years and above). We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and some other databases (from earliest dates available to October 2012). Reference lists of relevant articles were checked. No language restrictions were applied. Randomised trials that compared face-to-face versus remote and web 2.0 PA interventions for community dwelling adults. We included studies if they compared an intervention that was principally delivered face-to-face to an intervention that had principally remote and web 2.0 methods. To assess behavioural change over time, the included studies had a minimum of 12 months follow-up from the start of the intervention to the final results. We excluded studies that had more than a 20% loss to follow-up if they did not apply an intention-to-treat analysis. At least two review authors independently assessed the quality of each study and extracted the data. Non-English language papers were reviewed with the assistance of an interpreter who was an epidemiologist. Study authors were contacted for additional information where necessary. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for continuous measures of cardio-respiratory fitness. One study recruiting 225 apparently healthy adults met the inclusion criteria. This study took place in a high-income country. From 27,299 hits, the full texts of 193 papers were retrieved for examination against the inclusion criteria. However, there was only one paper that met the inclusion criteria. This study reported the effect of a PA intervention on cardio-respiratory fitness. There were no reported data for PA, quality of life, or cost effectiveness. The difference between the remote and web 2.0 versus face-to-face arms was not significant (SMD -0.02; 95% CI -0.30 to 0.26; high quality evidence). The risk of bias in the included study was assessed as low, and there was no evidence of an increased risk of adverse events. There is insufficient evidence to assess whether face-to-face interventions or remote and web 2.0 approaches are more effective at promoting PA.