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Completed Systematic Reviews




Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. Comparative Effectiveness Review No. 227. [Entered Retrospectively]


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Statistics: 250 Studies, 5 Key Questions, 5 Extraction Forms,
Date Published: Apr 22, 2020 01:41PM
Description: Structured Abstract Objectives. We updated the evidence from our 2018 report assessing persistent improvement in outcomes following completion of therapy for noninvasive nonpharmacological treatment for selected chronic pain conditions. Data sources. Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews), through November 2017 (for priorAHRQreport) and from September 2017 through September 2019 (for this update report), reference lists, ClinicalTrials.gov, and our previous report. Review methods. Using predefined criteria, we selected randomized controlled trials (RCTs) of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that reported results for a at least 1 month postintervention. We analyzed effects and assessed strength of evidence (SOE) at short term (1 to <6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).Results. We included 233 RCTs (31 new to this update). Many were small (N<70), and evidence beyond 12 months after treatment completion was sparse. The most common comparison was with usual care. Evidence on harms was limited, with no evidence suggesting increased risk for serious treatment-related harms for any intervention. Effect sizes were generally small for function and pain. Chronic low back pain: Psychological therapies were associated with small improvements compared with usual care or an attention control for both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). Function improved over short and/or intermediate term for exercise, low-level laser therapy, spinal manipulation, massage, yoga, acupuncture, and multidisciplinary rehabilitation (SOE moderate at short term for exercise, massage, and yoga; low for all others). Improvements in pain at short term were seen for massage, mindfulness-based stress reduction, acupuncture,and multidisciplinary rehabilitation (SOE: moderate), and exercise, low-level laser therapy, and yoga (SOE: low). At intermediate term, spinal manipulation, yoga, multidisciplinary rehabilitation (SOE: moderate) and exercise and mindfulness-based stress reduction (SOE: low) were associated with improved pain. Compared with exercise, multidisciplinary rehabilitation improved both function and pain at short and intermediate terms (small effects, SOE: moderate.) Chronic neck pain: In the short-term, low-level laser therapy (SOE: moderate) and massage (SOE: low) improved function and pain. Exercise in general improved function long term, and combination exercise improved function and pain both short and long term compared with usual care (SOE: low). Acupuncture improved function short and intermediate term, but there was no pain improvement compared with sham acupuncture (SOE: low). Compared with acetaminophen, Pilates improved both function and pain (SOE: low). Osteoarthritis pain: Exercise resulted in small improvements in function and pain at short-term(SOE: moderate) and long-term, and moderate improvement at intermediate-term (SOE: low) followup for knee osteoarthritis versus nonactive comparators. Small improvements in function and pain with exercise were seen for hip osteoarthritis short term (SOE: low). Functional improvement persisted into intermediate term, but pain improvement did not (SOE: low). Fibromyalgia: Functional improvements were seen with exercise, mind-body practices, multidisciplinary rehabilitation (SOE: low) and acupuncture (SOE: moderate) short term compared with usual care, attention control, or sham treatment. At intermediate term, there was functional improvement with exercise and acupuncture (SOE: moderate), cognitive-behavioral therapy (CBT), mindfulness-basdedstress reduction, myofascial release,and multidisciplinary rehabilitation (SOE: low). LLong term, functional improvements persisted for multidisciplinary rehabilitation without improvement in pain (SOE: low). Compared with exercise, tai chiconferred improvement in function short and intermediate term (SOE: low). Pain was improved with exercise (short and intermediate term, SOE moderate), and for CBT (shortterm),mindfulness practices,and multidisciplinary rehabilitation (MDR) (intermediate term)(SOE lowfor these three). Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation resulted in moderate improvement in pain short term. Conclusions. Trials identified subsequent to the earlier report largely support previous findings, —namely that exercise, multidisciplinary rehabilitation, acupuncture, CBT, mindfulness practices, massage,and mind-body practices most consistently improve function and/or pain beyond the course of therapy for specific chronic pain conditions. Additional research, including comparisons with pharmacological and other active controls, on effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain
Contributor(s): Andrea Skelly, Ph.D., M.P.H., Roger Chou, M.D., Joseph Dettori, Ph.D., M.P.H., M.P.T., Judith Turner, Ph.D., Janna Friedly, M.D., Sean Rundell, Ph.D., D.P.T., Rochelle Fu, Ph.D., Erika Brodt, B.S., Ngoc Wasson, M.P.H.,Shelby Kantner, B.A., Aaron Ferguson, B.S.
Funding Source: Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I. AHRQ Publication No. 20-EHC009-EF. Rockville, MD: Agency for Healthcare Research and Quality
Methodology Description: Using predefined criteria, we selected randomized controlled trials of noninvasive, nonpharmacological treatments for five common chronic pain conditions (chronic low back pain, chronic neck pain, osteoarthritis of the knee, hip, or hand, fibromyalgia, and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to < 6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).

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Blood Pressure Targets in CKD


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Statistics: 3 Studies, 2 Key Questions, 1 Extraction Form,
Date Published: Apr 07, 2020 03:31PM
Description: Background: The optimal blood pressure target in patients with chronic kidney disease (CKD) is unclear. Purpose: To summarize trials comparing lower versus higher blood pressure targets in adult patients with CKD and focus on proteinuria as an effect modifier.
Contributor(s): Upadhyay A, Earley A, Haynes S, Uhlig K.
Funding Source: Kidney Disease: Improving Global Outcomes (KDIGO)
Methodology Description: Data Sources: MEDLINE and the Cochrane Central Register of Controlled Trials (July 2001 through January 2011) were searched for reports from randomized, controlled trials with no language restriction. Study Selection: Authors screened abstracts to identify reports from trials comparing blood pressure targets in adults with CKD that had more than 50 participants per group; at least 1-year follow-up; and outcomes of death, kidney failure, cardiovascular events, change in kidney function, number of antihypertensive agents, and adverse events. Data Extraction: Reviewers extracted data on study design, methods, sample characteristics, interventions, comparators, outcomes, number of medications, and adverse events and rated study quality and quality of analyses for proteinuria subgroups.

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Three types of hypoglycemic agents (DPP- 4Is, GLP-1RAs, SGLT-2Is) for patients with type 2 diabetes: effectiveness and safety evaluation network meta-analysis


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Statistics: 9 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Apr 06, 2020 02:51PM
Description: Objective: In view of the development of hypoglycemic agents in recent years and the growth in the number of people with type 2 diabetes mellitus(T2DM), latest information is needed for clinicians and patients to make more reliable decisions. The objective of this systematic review database is to summarize and compare the effectiveness and possible safeties of the current three new types of hypoglycemic agents: dipeptidyl peptidase-4 inhibitors[DPP- 4Is], glucagon-like peptide-1 receptor agonists[GLP-1RAs] and sodium-dependent glucose transporters 2 inhibitors[SGLT-2Is]. Data Sources: We searched the MEDLINE, Embase and Cochrane Library databases for original English-language articles, and collected unpublished studies’ data from clinicaltrial.org and other sources. We included all randomized controlled trials (RCTs) that use any of these three types of hypoglycemic agents as interventions in comparison groups, and the searching process is now updated to March 2019. Results: This systematic review database contains three types of hypoglycemic agents: DDP-4Is, GLP-1RAs and SGLT-2Is, which involved in 441,338 and 573 RCTs respectively. We recorded the baseline characteristics of patients and outcome indicators, which include gender, age, duration of type 2 diabetes, and the level of HbA1c, FPG, PPG, LDL, HDL, TC, body weight, BMI, blood pressure, heart rate, etc. Additionally, we included almost all adverse events that were observed in studies to obtain comprehensive information, for instance: digestive system disorders(e.g. nausea, diarrhea, decreased appetite, hyperchlorhydria); cardiovascular system dysfunctions(e.g. stroke, angina pectoris, arrhythmia, myocardial infarction); liver and renal impairments(e.g. renal stone, acute renal failure, hepatic encephalopathy, hepatic steatosis); musculoskeletal disorders(e.g. arthtitis, fracture, muscular weakness); various types of infections and neural disorders, etc. The data extraction and quality evaluation process now is partly done, and we have been keeping the database updated. Next, we will select the appropriate information from this database for deeper statistical analysis, and complete systematic reviews and meta-analysis. Conclusions: Till today, the existing results of original researches on the effectiveness and safety of three type of hypoglycemic drugs are diverse, and related systematic reviews are still incomplete. For example, study had shown that SGLT-2Is improve cardiovascular function in T2DM patients with coronary artery disease or chronic kidney dysfunction compared to DPP-4Is; DPP-4Is(sitagliptin)may exert a less potent effect on HbA1C, FPG, PPG, and weight reduction than GLP-1 receptor agonists in obese or overweight patients; There are also differences between different drugs in one single type. Observing the effects of hypoglycemic drugs requires studies with large samples and long term observation. Therefore, better evidences are needed to provide a compelling reason for their use in different situations and different population subgroups. All of comprehensive information was included in this database, which is essential for further statistical analysis. Studies that focus on a single outcome have certain limitations. So in the future, we will use this database to explore the benefit-risk of these drugs with multiple outcomes. The models we are interested in are multi-criteria decision analysis (MCDA) model and its derivative model stochastic multicriteria acceptability analysis (SMAA). When we conduct benefit/risk analysis, we will make good use of indirect comparative studies through network meta-analysis. Through the comparison within or between three types of hypoglycemic agents, we may hopefully provide more reliable conclusions for clinicians and patients to develop personalized treatment plans and gain the greatest health benefit for patients.
Contributor(s): Sun feng; Liu fengqi; Yu shuqing; Gao le; Yang zhirong; Wu shanshan; Zhang yuan; Chai sanbao; Ji linong; Zhan siyan.
DOI: DOI pending.
Funding Source: The National Natural Science Foundation of China(Project number:71673003)
Methodology Description: We searched the following databases for primary studies for the periods in parentheses: MEDLINE(1966 to March 2019), Embase(1974 to March 2019), and Cochrane Library(1995 to March 2019). We developed a search strategy based on the purposes of this research and the analysis of MeSH terms. The articles which were selected out from above mentioned databases were exported and gathered into an EndNote library(EndNote version X9). We used the duplication check feature in EndNote to scan for duplicate articles, and deleted duplicates more precisely by two reviewers during screening. Two reviewers screened these articles by their titles and abstracts independently, classified those which meet the criterion, and excluded those which do not. Then detailed data, including study design, treatments for the comparison groups, baseline characteristics, outcome indicators and adverse events, was extracted from each article by using standardized protocols and pooled into ADDIS(Aggregate Data Drug Information System), and the evaluation of the studies’ qualities was summarized into a table in Excel(Microsoft Office 2016). Data analysis were performed by using WinBUGS(version 1.4), STATA(version 13.0), etc.

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Skin Substitutes for Treating Chronic Wounds


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Statistics: 22 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Apr 02, 2020 01:03PM
Description: Systematic review to describe skin substitute products commercially available in the United States used to treat chronic wounds, examine systems used to classify skin substitutes, identify and assess randomized controlled trials (RCTs), and suggest best practices for future studies.
Contributor(s): David L Snyder, Nancy Sullivan, Karen Schoelles
DOI: DOI pending.
Funding Source: Agency for Healthcare Research and Quality
Methodology Description: Systematic review

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Opioid Treatments for Chronic Pain


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Statistics: 175 Studies, 4 Key Questions, 1 Extraction Form,
Date Published: Mar 16, 2020 01:17PM
Description: To assess the effectiveness and harms of opioid therapy for chronic noncancer pain; alternative opioid dosing strategies; and risk mitigation strategies
Contributor(s): Roger Chou, MD Daniel Hartung, PharmD Judith Turner, PhD Ian Blazina, MPH Brian Chan, MD Ximena Levander, MD Marian McDonagh, PharmD Shelley Selph, MD, MPH Miranda Pappas, MA
DOI: DOI pending.
Funding Source: AHRQ Contract No. HHSA-290201500009I
Methodology Description: Predefined criteria were used to select studies of patients with chronic pain prescribed opioids that addressed effectiveness or harms versus placebo, no opioid use, or nonopioid pharmacological therapies; different opioid dosing methods; or risk mitigation strategies. Effects were analyzed at short term (1 to <6 months), intermediate term (≥6 to <12 months), and long term (≥12 months) followup. Studies on the accuracy of risk prediction instruments for predicting opioid use disorder or misuse were also included. Random effects meta-analysis was conducted on short-term trials of opioids versus placebo, opioids versus nonopioids, and opioids plus nonopioids versus an opioid or nonopioid alone. Magnitude of effects was classified as small, moderate, or large using predefined criteria and strength of evidence was assessed.

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