Wetenschappelijke onderzoeken t.a.v. TMS, SOLK en aanverwante onderwerpen
Op deze pagina vindt u wetenschappelijke onderzoeken uit het binnen-en buitenland die het effect van onze methode bewijzen.
Alle wetenschappelijke onderzoeken die we noemen laten stuk voor stuk zien dat vaak niet "fysieke schade" maar stress en onderdrukte emoties de oorzaak zijn van uw pijnklachten.
We hebben een samenvatting van de belangrijkste onderstaande wetenschappelijke artikelen gemaakt en gebundeld in een gratis E-book.
Klik hier om ons gratis E-book "de verborgen oorzaak van chronische pijn" te downloaden.
Door het lezen van ons gratis E-book zult u beter begrijpen waarom uw voorgaande behandelingen niet hebben gewerkt en waardoor u nog steeds pijn heeft.
We hebben deze onderzoeken in categorieën ingedeeld en vervolgens in alfabetische volgorde.
De wetenschappelijke onderzoeken op deze pagina hebben onder andere als doel om te laten zien dat er meer dan voldoende aanwijzingen zijn dat (pijn) klachten door stress, emoties en andere psychologische factoren kunnen komen.
Dr. Sarno noemt dit TMS (Tension Myositus Syndroom) en in Amerika is er ook een andere term voor psycho-physiological disorder (PPD).
In Nederland is de term "SOLK", Somatisch (lichamelijk) onvoldoende verklaarde lichamelijke klachten, de term die er voor gebruikt wordt.
Verder worden er onderzoeken vermeldt die laten zien dat bepaalde afwijkingen die vaak als oorzaak aangewezen worden van langdurige (pijn)klachten de oorzaak niet hoeven of kunnen zijn.
En dat de (pijn)klachten eerder te maken kunnen hebben met stress, TMS en de Nederlandse term SOLK.
De lijst is opgesteld en mede mogelijk gemaakt door onder andere de referenties in de boeken van dr. Schubiner, dr. Sarno, dr. Schechter, dr Alan Gordon, de Psychophysiologic Disorders Association de overkoepelende organisatie in Amerika en Stichting Emovere uit Nederland.
Daar zult u nog veel meer wetenschappelijke artikelen kunnen vinden.
1. Klinische Epidemiologisch onderzoek naar de effectiviteit en kostenreductie van de psychologische behandelmethodieken voor langdurige fysieke symptomen (pijn of anders)
Hieronder staan onderzoeken die bewijs zijn dat psychologische behandeling bij aanhoudende lichamelijke (pijn)klachten, in het bijzonder voor Emotie Bewustwordende & Expressie Therapie, Pain Reprocessing Therapy en Intensive Short Term Dynamic Psychotherapie effectief zijn. Met in kleinere mate cognitieve gedragstherapie, Acceptatie Therapie (met de pijn leren omgaan) en educatieve technieken.
Daarbij te vermelden dat Emotie Bewustwordende & Expressie Therapie, Pain Reprocessing Therapy en Intensive Short Term Dynamic, onderdelen zijn van de meeste TMS programma's of in iedergeval dit op een bepaalde manier toepassen.
1.1 Emotie Bewustwordende & Expressie Therapie en Pain Reprocessing Therapy
10. Burger AJ. (2016) The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: A preliminary, uncontrolled trial. Journal of Psychosomatic Research. Feb;81:1-8.
“This was an initial trial of a newly developed therapy aimed at psychological attribution and emotional awareness and expression. They treated 72 patients and did pre-and post- treatment assessments and a six-month follow-up. Pain was reduced following treatment, and was either maintained or enhanced at the six-month follow-up.”
20. Gordon, A. (2010). Miracles of mindbody medicine. Healthcare Counseling & Psychotherapy Journal, 10(1), 13-18.
This is a very good summary article, appropriate for the general public, that includes some review of the research listed in this bibliography. Also publishes some of Dr. Sarno’s retrospective studies of his patient’s recoveries
Hsu MC, Schubiner H, Lumley MA, et al. Sustained pain reduction through affective self-awareness in fibromyalgia: a randomized controlled trial. J Gen Intern Med. 2010 Oct;25(10):1064-70.
This RCT studied 45 women with fibromyalgia and randomly assigned to Affective Self-Awareness or a waitlist control group. The intervention group had significantly lower pain severity and higher selfreported physical function at 6 months compared to the control group
26. Hsu, M.C. and Schubiner, H. (2010). Recovery from chronic musculoskeletal pain with psychodynamic consultation and brief intervention: A Report ofthree illustrative cases. Pain Medicine, 11(6), 977-980.
“Three retrospective case studies of people with at least four years of chronic pain before treatment. The treatment involves a 90-minute intake session, assigning the reading of Sarno’s Mind-Body Prescription, then three weekly 2-hour group sessions. All three were pain-free at six month follow-up.
Klaver MM. Het effect van stressortherapie door psychosomatische therapeuten bij patiënten met SOLK. Beweegreden 2013;9(4):28-33. Het effect was 80% objectieve verbetering op 4DKL, SF 36 en VAS en 90% subjectieve verbetering.
Klaver MM. Hints naar de psychologische oorzaak van lichamelijke klachten. Beweegreden 2014;10(2):28-31.
Patiënten met SOLK uiten hints die toegang geven tot de psychologische oorzaak van deze klachten. Het herkennen van hints is een aparte competentie en vraagt volle aandacht met gericht luisteren en goed kijken.
Lumley MA, Schubiner H, et al. Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a clusterrandomized controlled trial. Pain 2017;158(12):2354-2363.
Emotional awareness and expression related to psychosocial adversity and conflict was well received, was more effective than a basic educational intervention and had some advantages over CBT on pain.
Lumley MA, Schubiner H. Psychological Therapy for Centralized Pain: An Integrative Assessment and Treatment Model. Psychosom Med. 2019 Feb/Mar;81(2):114-124.
Intensive short-term dynamic psychotherapy (ISTDP) helps patients identify and experience unconscious emotions and then facilitating patients' understanding of the role such emotions and conflicts play in their symptoms, including pain.
33. Lumley, M.A. & Schubiner, H. (2019). Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review. Current Rheumatology Reports (2019) 21:30. https://doi.org/10.1007/s11926-019-0829-6
This article presents the rationale for EAET, describes its principles and techniques, reviews its development and early testing as well as recent clinical trials, and critically analyzes the evidence base
Renna ME, Fresco DM, Mennin DS. Emotion Regulation Therapy and Its Potential Role in the Treatment of Chronic Stress-Related Pathology Across Disorders. Chronic Stress (Thousand Oaks). 2020 Feb13;4
Emotion regulation therapy is a theoretically derived treatment that is based upon affective science. Open and randomized controlled trials have demonstrated considerable preliminary evidence for the utility of emotion regulation therapy and its proposed mechanisms in treating the distress conditions.
Berkel van L, Heuvel van den S, et al. Minder medicijngebruik, minder arbeidsverzuim, minder klachten. Beweegreden 2011 maart;7(1):17-20.
De scores op de 4DKL, SF 36 en VAS zijn significant verbeterd. Het behandeldoel is bij 85% bereikt, de klachten zijn subjectief bij 90% sterk afgenomen. Medicatiegebruik en arbeidsverzuim zijn significant afgenomen
“51 patients diagnosed with PPD were treated and evaluated pre- and post-treatment using selfreport measures. Mean Visual Analog Scale (VAS) scores with the mind-body treatment program decreased 52% for "average" pain (P=.005). Medication usage decreased (P=.0008). Activity levels increased (P=.03). Participants aged >47 years and in pain for >3 years benefited the most.
Key tenets to an ISTDP formulation of MUS include the inadvertent blockage of emotional processing and associated anxiety being channelled into the body, manifesting as somatic distress.
46. Yarns BC, Lumley MA, Cassidy JT et al. (2020). Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than Cognitive Behavioral Therapy in Older Adults with Chronic Musculoskeletal Pain: A Preliminary Randomized Comparison Trial. Pain Medicine, pnaa145, https://doi.org/10.1093/pm/pnaa145
Fifty-three veterans (mean age = 73.5 years, 92.4% male) with chronic musculoskeletal pain. Patients were randomized to EAET or CBT, each delivered as one 90-minute individual session and eight 90-minute group sessions. 42% of EAET patients had >30% pain reduction, one-third had >50%, and 12.5% had >70%. Only one CBT patient achieved at least 30% pain reduction
48. Ziadni MS, Carty JN, Doherty HK, Porcerelli JH, Rapport LJ, Schubiner H, Lumley MA. (2018). A life-stress, emotional awareness and expression interview for primary care patients with medically unexplained symptoms: a randomized controlled trial. Health Psychol 2018;37:282–90.http://dx.doi.org/10.1037/hea0000566
Compared with treatment as usual, the interview led to significantly lower pain severity, pain interference, sleep problems, and global psychological symptom.
1.2 Intensive Short Term Dynamic Psychotherapie
29 consecutively treated outpatients presenting with recurrent unexplained headache, 55% also assessed with comorbid Irritable Bowel Syndrome, direct treatment cost savings were reported from reduced medication usage and indirect savings through patients previously receiving disability payments subsequently returning to work.
“Reviewed 23 studies (13 RCTs and 10 case series with pre/post assessments) of ISTDP. Of these, 21/23 (91.3%), 11/12 (91.6%), 16/19 (76.2%) and 7/9 (77.8%) reported significant or possible effects on physical symptoms, psychological symptoms, social-occupational function and healthcare utilization respectively. Meta-analysis was possible for 14 studies and revealed significant effects on physical symptoms, psychiatric symptoms and social adjustment which were maintained in long-term follow-up.”
Cost savings of treatment of medically unexplained symptoms in a hospital emergency department using ISTDP, found a 69% reduction in repeat emergency visits, amounting to an average cost saving per patient twice the average cost of treatment provided: these effects were greater than a control condition.
Reviews the efficacy and cost-savings data for ISTDP in a study training residents in this model
5. Abbass A, Bernier D, Kisely S, Town J, Johansson R (2015). Sustained reduction in health care costs after adjunctive treatment of graded intensive short-term dynamic psychotherapy in patients with psychotic disorders. Psychiatry Research, 228(3), 538-43.
In the largest naturalistic evaluation of ISTDP, the long-term healthcare costs were assessed in 890 consecutively referred cases of which 61% had Somatoform Disorder: ISTDP treated cases had significantly reduced physician and hospital costs at 1-, 2-, and 3-year post treatment follow-up with a mean savings of over $12,000 by 3 year follow-up. A subsample of this population, consisting of 28 patients with psychogenic non-epileptic seizures who received ISTDP, exhibited similar improvements.
6. Abbass A, Town J, Holmes H et al (2020). Short-Term Psychodynamic Psychotherapy for Functional Somatic Disorders: A Meta-Analysis of Randomized Controlled Trials. Psychotherapy and Psychosomatics, on-line publication DOI: 10.1159/000507738
In meta-analyses of 17 RCTs, STPP significantly outperformed minimal treatment, treatment as usual, or waiting list controls on somatic symptom measures at all time frames, with small to large magnitude effect sizes. Descriptive reviews of 5 RCTs suggest that STPP performed at least as well as other bona fide psychological therapies. Limitations of this meta-analysis include small samples of studies and possible publication bias.
RCT of 36 patients with urinary symptoms without organic lesions with follow-up of 4 years. Of the 13 who received intensive short-term dynamic psychotherapy (14 weekly sessions), 10 had complete relief and 3 had significant improvement. Depression, anxiety and hostility also improved. The 23 controls had traditional urologic care and no significant improvement was found.
21. Guthrie, E., Creed, F., Dawson, D., & Tomenson, B. (1993). A randomised controlled trial of psychotherapy in patients with refractory irritable bowel syndrome. British Journal of Psychiatry, 163, 315–321. http://dx.doi.org/10.1192/bjp.163.3.315
For women, psychotherapy was found to be superior to supportive listening. There was a similar trend for men, but this did not reach significance. Following completion of the trial, patients in the control group were offered psychotherapy; 33 accepted and following treatment experienced a marked improvement in their symptoms. At follow-up 1 yr later, those patients who had received psychotherapy remained well, patients who had dropped out of the trial were unwell with severe symptoms.
30. Laird KT, Tanner-Smith EE, Russell AC, Hollon SD, Walker L. (2016). Short- and Long- Term Efficacy of Psychological Therapies for Irritable Bowel Syndrome: A Systematic Review and Meta-analysis. Clin Gastro Hep Vol 14(7), p 937-947.e4. https://doi.org/10.1016/j.cgh.2015.11.020
Forty-one trials were included in the meta-analysis, comprising data from 2290 individuals. Psychological therapies had a medium effect on GI symptom severity (effect size = 0.69) immediately after treatment. On average, individuals who received psychotherapy had a greater reduction in GI symptoms after treatment than 75% of individuals assigned to a control condition. After short-term follow-up (1–6 months) and long-term follow-up (6–12 months), this effect remained significant and medium in magnitude (0.76 and 0.73, respectively).
40. Russell LA, Abbass A A, Allder SJ, Kisely S, Pohlmann-Eden B, Town JM (2016). A pilot study of reduction in healthcare costs following the application of intensive short-term dynamic psychotherapy for psychogenic nonepileptic seizures. Epilepsy & Behavior : E&B , 63, 17-19. 28 patients with psychogenic non-epileptic seizures who received ISTDP, exhibited improvements which resulted in a total combined healthcare cost reduction of over 80% in each of the three years post treatment compared to the year pre-treatment
1.3 Cognitieve gedragstherapie, Acceptatie Therapie
12. Cherkin DC et al. (2016). Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults with Chronic Low Back Pain. A Randomized Clinical Trial. JAMA. 315(12):1240-1249.
MBSR and CBT were provided to groups for up to two hours weekly for eight weeks. Eighteen weeks after the sessions, clinically meaningful improvement in disability was found in 61% of MBSR and 58% of CBT patients vs only 44% of UC patients. Clinically meaningful improvement in how bothersome the pain felt was found in 44% of MBSR, 45% of CBT but only 27% of UC patients. These are modest benefits. Studies of Pain Reprocessing Therapy and Emotional Awareness and Expression Therapy have documented better outcomes.
23. Hann KEJ, McCracken LM. (2014). A systematic review of randomized controlled trials of acceptance and commitment therapy for adults with chronic pain: outcome domains, design quality, and efficacy. J Contextual Behav Sci 2014;3:217–27.
ACT is efficacious particularly for enhancing general, mostly physical functioning, and for decreasing distress, in comparison to inactive treatment comparisons but pain severity changed little.
28. Kroenke K., Swindle R. (2000) Cognitive-Behavioral Therapy for Somatization and Symptom Syndromes: A Critical Review of Controlled Clinical Trials. Psychother Psychosom 69:205-215. https://doi.org/10.1159/000012395
A total of 31 controlled trials (29 randomized and 2 nonrandomized) was identified. Twenty-five studies targeted a specific syndrome (e.g. chronic fatigue, irritable bowel, pain) while 6 focused on more general somatization or hypochondriasis. Primary outcome assessment included physical symptoms, psychological distress and functional status in 28, 26 and 19 studies, respectively. Physical symptoms appeared the most responsive: CBT-treated patients improved more than control subjects in 71% of the studies and showed possibly greater improvement (i.e., a trend) in another 11% of the studies. A definite or possible advantage of CBT for reducing psychological distress was demonstrated in only 38% and 8% of studies respectively, and for improving functional status in 47% and 26%.
34. Moreley S, Eccleston C, Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 80: 1-13.
A meta-analysis of 25 trials found that when compared with the waiting list control conditions cognitive-behavioural treatments were associated with median effect size across domains = 0.5. Comparison with alternative active treatments revealed that CBT produced significantly greater changes for pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains were not significant: mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophization), and social role functioning.
2.Asymptomatisch, geen (pijn)klachten, maar wel anatomische afwijkingen gevonden in o.a. de rug, nek, schouder, heup, knie.
Hieronder staan onderzoeken die bewijs zijn voor het feit dat MRI scans of Röntgen scans geen goede voorspellers zijn of iemand langdurige of chronische (pijn)klachten heeft en dat psychologische factoren betere voorspellers zijn.
In andere woorden of iemand bijvoorbeeld een hernia, artrose, stenose of scoliose heeft betekent niet dat ze pijn ervaren of dat de ernst van de afwijking de hoeveelheid bepaald. En dat psychologische factoren eerder de aanleiding zijn voor de (pijn)klachten.
Bedson, J. and Croft,P.R. (2008).The discordance between clinical andradiographic knee osteoarthritis: A systematic search and summary of the literature. BMC Musculoskeletal Disorders, 9, pp. 116-127.
“Knee osteoarthritis shown on x-ray is an imprecise guide to the likelihood that knee pain or disability will be present. The results of knee x rays should not be used in isolation when assessing individual patients with knee pain.”
Authors prospectively assessed 3,020 volunteer employees at a Boeing plant for risk factors of filing back injury claims. They followed the subjects for four years, and found that the 279 people who reported back problems had only one physical predictor: previous medical treatment. The most predictive individual factors were (1) job task dissatisfaction and (2) distress as reported on Scale 3 of the MMPI. “This data perhaps explains why the focus on purely physical and injury-related factors has met with little success in dealing with what has become the most expensive orthopedic problem.
Boos, N., Rieder, R., Schade, V., et al. (1995). The Diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine, 20, 2613-25. DOI: 10.1097/00007632-199512150-00002
In an age-, sex-, and risk factor matched group of asymptomatic individuals, disc herniation had a substantially higher prevalence (76%) than previously reported in an unmatched group. Individuals with minor disc herniations (i.e., protrusion, contained discs) are at a very high risk that their magnetic resonance images are not a causal explanation of pain because a high rate of asymptomatic subjects (63%) had comparable morphologic findings. The only highly significant difference between the pain/sciatica group and asymptomatic control group regarding morphologic findings was the criteria of a nerve root compromise. Work perception and psychosocial factors were helpful in discriminating between symptomatic and asymptomatic disc herniations.
Borenstein D.G., O’Mara, J.W., Boden, S.D., et al. (2001). Lumbar Spine MRI to Predict Low-Back Pain in Asymptomatic Subjects. Jnl Bone Joint Surg, 83-A(9), 1306-11.
“A prospective study of 67 asymptomatic individuals had MRIs in 1989. 31% had an identifiable abnormality in the spine. Seven years later the investigators looked at these subjects to see how they were doing. The findings on magnetic resonance scans were not predictive of the development or duration of low-back pain. Individuals with the longest duration of low-back pain did not have the greatest degree of anatomical abnormality on the original, 1989 scans.”
Brinjikji W et al. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology 36:811–16.
Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age.
*Brown TT, Lee W (2020). The FuturePain study: Validating a questionnaire to predict the probability of having chronic pain 7-10 years into the future. PLOS ONE. https://doi.org/10.1371/journal.pone.0237508
The FUTUREPAIN study developed a questionnaire, based on the biopsychosocial model, to predict the probability of developing or maintaining moderate-to-severe chronic pain 7–10 years into the future. From an initial set of 82 variables, a machine learning algorithm derived an 18- variable model tested on a new cohort with sensitivity of .88 and specificity of .76 for future pain. The five items on the questionnaire with the largest coefficients (listed from largest to smallest) were Psychological Distress (Kessler K6), Fair Health, Lost Home, Parental Abuse and Current Chronic Pain.
*Burns JW, Janssen I, Lillis T et al (2020). The transition from acute to persistent pain: the identification of distinct trajectories among women presenting to an emergency department. PAIN: November 2020 - Volume 161 - Issue 11 - p 2511-2519. doi: 10.1097/j.pain.0000000000001960
Women (N = 375) who presented to an inner-city emergency department (ED) with complaints of acute pain were followed up for 3 months. One group (early recovery; n = 93) had recovered to virtually no pain by the initial visit, whereas a second group (delayed recovery; n = 120) recovered to no pain only after 1 month. A third group (no recovery; n = 162) still reported elevated pain at 3 months after the ED visit. The no recovery group reported significantly greater PTSD symptoms, anger, sleep disturbance, and lower social support at the initial visit than both the early recovery and delayed recovery groups.
Carragee E, Alamin T, et al (2006). Are first-time episodes of serious LBP associated with new MRI findings? Spine, 6(6), 624-635.
“The authors point to the practice of doing MRIs on first time episodes of lower back pain (LBP), and interpreting the abnormal results as causing the pain. They did a prospective study of 200 subjects over five years. MRIs were done at the beginning on people with no LBP. They then compared these baselines with MRIs taken during episodes of LBP and find no significant differences. Most new changes represent progressive age changes not associated with acute events.”
Carragee, E.J., Lincoln, T., et al (2006). A Gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine, 31(18), 2115-2123.
A sophisticated x-ray exam was done to carefully select patients who were most likely to have pain relief from spinal fusion surgery. Even under those strict conditions, in only 27% was the outcome considered highly effective and in 57% it was not even minimally acceptable. In the same study, in a comparison group having spine fusion for a non-pain condition (spondylolisthesis), the corresponding figures were 72% and 9%.
*Carroll LJ, Holm LW, Ferrari R, Ozegovic D and Cassidy JD (2009). Recovery in Whiplash-Associated Disorders: Do You Get What You Expect? Journal of Rheumatology May, 36 (5) 1063-1070; DOI: https://doi.org/10.3899/jrheum.080680
A cohort of 6,015 adults with traffic-related whiplash injuries was assessed. After adjusting for the effect of sociodemographic characteristics, post-crash symptoms and pain, prior health status and collision-related factors, those who expected to get better soon recovered over 3 times as quickly (hazard rate ratio = 3.62, 95% confidence interval 2.55–5.13) as those who expected that they would never get better. Patients’ early expectations for recovery are an important prognostic factor in recovery after whiplash injury and are potentially modifiable by clinicians.
Connor PM et al. (2003) Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: a 5-year follow-up study. American Journal of Sports Medicine Sep-Oct;31(5):724-7
“Eight of 20 (40%) dominant shoulders had findings consistent with partial- or full-thickness tears of the rotator cuff as compared with none (0%) of the nondominant shoulders. Five of 20 (25%) dominant shoulders had magnetic resonance imaging evidence of Bennett's lesions compared with none (0%) of the nondominant shoulders. None of the athletes interviewed 5 years later had any subjective symptoms or had required any evaluation or treatment for shoulder-related problems during the study period.”
*Christensen JO et al. (2012) Work and back pain: a prospective study of psychological, social and mechanical predictors of back pain severity. European Journal of Pain. Jul;16(6):921-33. 21.
“The most consistent predictors of back pain were protective factors including decision control, empowering leadership and fair leadership. Some of the most important predictors included in this study were factors that have previously received little attention in back pain research.”
Culvenor et al (2018). Prevalence of Knee Osteoarthritis Features on Magnetic Resonance Imaging in Asymptomatic Uninjured Adults: A Systematic Review and Meta-Analysis. Br J Sports Med. Oct; 53(20):1268-1278.
We included 63 studies (5397 knees of 4751 adults) of asymptomatic, uninjured adults. The overall pooled prevalence of cartilage defects was 24% and meniscal tears was 10%, with significantly higher prevalence with age.
Elliott J et al (2010) Asymptomatic Spondylolisthesis and Pregnancy. Journal of Orthopaedic & Sports Physical Therapy, Volume:40 Issue:5 Pages:324–324
“The patient was a 32-year-old woman diagnosed with grade III spondylolisthesis at the age of 18. While the patient had not experienced back pain in recent years, she anticipated a recurrence of symptoms during her final trimester of pregnancy. Lumbar magnetic resonance imaging was used to confirm the presence of grade IV spondylolisthesis”
Englund, M., Guermazi, A., Gale, D., et al. (2008) Incidental meniscal findings on knee MRI in middle-aged and elderly persons. NEJM, 359(11), 1108-15.
Knee MRIs from 991 subjects, ages 50-90 years old. The findings indicated that meniscal tears are common in the general population and increases with age. However, 61% of the subjects who had meniscal tears in their knees had not had any pain, aching, or stiffness during the previous month.”
*Feyer AM et al. (2000) The role of physical and psychological factors in occupational low back pain: a prospective cohort study. Occupational and Environmental Medicine, Feb;57(2):116-20
“Other than a history of LBP, pre-existing psychological distress was the only factor found to have a pre-existing influence on new episodes of LBP.”
Fox, Allan & Lin, Joseph & Pinto, Richard & Kricheff, Irvin. (1975). Myelographic Cervical Nerve Root Deformities 1. Radiology. 116. 355-61. 10.1148/116.2.355.
Myelograms of nerve roots and adjacent subarachnoid space were reviewed to characterize 231 cervical root deformities from both symptomatic and asymptomatic patients. Good correlation between specific features of root deformities and clinical significance could not be demonstrated. Opmerking: de misvormingen betroffen onder andere tumoren. hernia's en botuitsteeksel.
Frank JD, Harris JM et al (2015). Prevalence of Femoroacetabular Impingement Imaging Findings in Asymptomatic Volunteers: A systematic Review. Arthroscopy 31(6): 1199-1204.
26 studies for inclusion, comprising 2,114 asymptomatic hips. The prevalence of an asymptomatic cam deformity was 37%, pincer deformity was 67% and labral injury, which was found on MRI without intra-articular contrast was present in 68% of hips.
Girish G et al (2011). Ultrasound of the Shoulder: Asymptomatic Findings in Men. Am J Roentgenol 197 (4): W713-W719.
Asymptomatic shoulder abnormalities were found in 96% of the 51 subjects (age 40-70). Subacromial-subdeltoid bursal thickening was present in 78%, acromioclavicular joint osteoarthritis in 65%, supraspinatus tendinosis in 39%, subscapularis tendinosis in 25%, partial-thickness tear of the bursal side of the supraspinatus tendon in 22%, and posterior glenoid labral abnormality in 14%.
Jensen, M.C., Brant-Zawadzki, et al. (1994). Magnetic resonance imaging of the lumbar spine in people without back pain. NEJM, 331(2), 69-73.
“A classic study in which MRIs were performed on 98 people with no back pain. They found that only 36% of these people had normal spines, the other 64% had various evidence of disc degeneration. “Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.”
Kaplan LD et al. (2005) Magnetic resonance imaging of the knee in asymptomatic professional basketball players. Arthroscopy, May;21(5):557-61.
“The results of our study show an equal to or higher prevalence of meniscal lesions in male professional basketball players than previously reported in the literature. We found a large number of patella-femoral articular cartilage lesions in our study population of male professional basketball players. These athletes perform at the highest demand level, which indicates that the presence of these lesions did not cause any symptoms.”
Karppinen J. (2001) Severity of symptoms and signs in relation to magnetic resonance imaging findings among sciatic patients. Spine (Philadelphia Pa 1976), Apr 1;26(7):E149-54.
“The degree of disc displacement in magnetic resonance imaging did not correlate with any subjective symptoms, nor did nerve root enhancement or nerve compression.”
*Kendall SA, Elert J et al (2002). Are perceived muscle tension, electromyographic hyperactivity and personality traits correlated in the Fibromyalgia Syndrome? J Rehabil Med 34: 73-79.
Thirt- six women with fibromyalgia performed forward flexion of the shoulder with EMG measurement. Perceived muscle tension did not correlate with EMG hyperactivity but did correlate with anxiety proneness on a personality inventory. EMG hyperactivity did correlate with pain, particularly pain at rest and with a number of personality traits including high impulsiveness, monotony avoidance and inversely with psychasthenia, verbal aggression and irritability.
Kim SJ et al. (2013) Prevalence of disc degeneration in asymptomatic Korean subjects. Part 1: lumbar spine. Journal of Korean Neurosurgical Society, Jan;53(1):31- 8.
“All lumbar disc degenerations are not pathologic, especially in children and adolescents.”
*Kivimäki M et al. (2004) Work stress and incidence of newly diagnosed fibromyalgia: prospective cohort study. Journal of Psychosomatic Research, Nov;57(5):417-22.
"The odds ratio of incident diagnosed fibromyalgia for workplace bullying was 4.1 (95% CI 2.0– 9.6). The corresponding odds ratios for high workload and low decision latitude were 2.1 (1.2–3.9) and 2.1 (1.1–4.0), respectively. Stress seems to be a contributing factor in the development of fibromyalgia, but further research is needed to examine whether stress perceptions are affected by undiagnosed fibromyalgia.
**Lederman E. (2011) The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. Journal of bodywork and movement therapies, Apr;15(2):131-8.
“Can a person's physical shape/posture/structure/biomechanics be the cause of their lower back pain? ”https://cpdo.net/Lederman_The_fall_of_the_postural-structural-biomechanical_model.pdf
*Masselin-Dubois, A., Attal, N.,et al (2013). Are psychological predictors of chronic postsurgical pain dependent on the surgical model? A Comparison of total knee arthroplasty and breast surgery for cancer. Journal of Pain, 14(8), pp. 854-864.
“This prospective study looked at two groups of patients who had surgery: a group of men and women undergoing total knee replacements who had pain pre-surgery, and a group of women with no pre-surgical pain who would have breast surgery for cancer. The predictive value of measures of anxiety, depression and catastrophising were assessed, and it was found that anxiety, level of pain immediately post-surgery, and catastrophising predicted pain at 3 months post-surgery, regardless of which surgery was done.”
Matsumoto M et al. (2013) Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects. European Spine Journal,Apr;22(4):708-13.
“MRI indicated degenerative changes in the lumbar spine in 79 subjects (84 %), with decreased disc signal intensity in 74.5 %, posterior disc protrusion in 78.7 %, Degenerative findings in both the lumbar and cervical spine, suggesting tandem disc degeneration, was common in asymptomatic subjects. These results provide normative data for evaluating patients with degenerative lumbar and cervical disc diseases.”
Nakashima H, Yukawa Y et al (2015). Abnormal Findings on Magnetic Resonance Images of the Cervical Spines in 1211 Asymptomatic Subjects. Spine 40, (6), 392-398.
Most subjects had cervical disc bulging (88%), which significantly increased with age in terms of frequency, severity, and number of levels. Even in their 20s, 75% had bulging discs. In contrast, few asymptomatic subjects were diagnosed with Spinal Cord Compression (5.3%) or increased signal intensity (2.3%).
O’Neil JT et al (2016). Peroneal Tendon Abnormalities on Routine Magnetic Resonance Imaging of the Foot and Ankle. Foot Ankle Int. Jul;37(7): 743-7
The most commonly occurring primary pathology in 294 MRIs of asymptomatic subjects was Achilles tendinosis/tears (29%), followed by posterior tibial tendon dysfunction (15%) with 35% of the peroneal tendons demonstrating some pathology.
*Rajasekaran S et al (2021). The catastrophization effects of an MRI report on the patient and surgeon and the benefits of ‘clinical reporting’: results from an RCT and blinded trials. Eur Spine J. https://doi.org/10.1007/s00586-021-06809-0
Patients with low back pain who were given a full factual explanation of their MRI reports, (compared to a control group who were told their reports reflected age-related changes), failed to get better and were also keen for an intervention to avoid possible deteriorations and future complications. Our study clearly proves that a misinterpretation of the patient’s spinal condition’s status through the MRI report leads to a negative impression of their spine. In a second phase, the authors generated both ‘routine’ and ‘clinical’ reporting for MRIs of 20 chronic LBP patients. Terminologies causing anxiety and fear in Routine Reporting, such as degeneration, tears, fissures, nerve compression, etc., were replaced by alternate terminologies in Clinical Reporting. The effect of Clinical Reporting was significant in orthopaedic surgeons, orthopaedic residents, and physiotherapists as for the same MRI, they perceived lesser severity of the disease, prescribed conservative treatment in more patients, and also assessed lower probability of surgery.
Ultrasound, even in highly skilled hands, has a high rate (54%) of incidental finding of an asymptomatic interdigital nerve enlargement, which can lead to a false diagnosis of a Morton's neuroma.
Simotas AC, Shen T (2005) Neck pain in demolition derby drivers. Arch Phys Med Rehabil, Apr;86(4):693-6.
“40 drivers participated in a mean of 30 career events and had an average of 52 car collisions per event at a mean of 26 mph. Only 2 drivers reported their worst neck pain lasted more than 3 months. 37 drivers reported no chronic neck pain. These data suggest that demolition derby drivers sustain less chronic neck pain after multiple car collision events than might otherwise be expected.”
Silvis ML et al. (2011) High prevalence of pelvic and hip magnetic resonance imaging findings in asymptomatic collegiate and professional hockey players. The Am J Sports Medicine. Apr; 39(4):715-21.
“The study included 21 professional and 18 collegiate hockey players. Self-reported symptoms were measured using a modified Oswestry Disability Questionnaire. Participants underwent 3-T MRI evaluation of the pelvis and hips. Given the high prevalence of MRI findings in asymptomatic hockey players, it is necessary to cautiously interpret the significance of these findings in association with clinical presentation.”
Takatalo J, Karppinen J, Niinimäki J, Taimela S, Näyhä S, Järvelin MR, Kyllönen E, Tervonen O. Prevalence of degenerative imaging findings in lumbar magnetic resonance imaging among young adults. Spine (Phila Pa 1976). 2009 Jul 15;34(16):1716-21. doi: 10.1097/BRS.0b013e3181ac5fec. PMID: 19770614.
Almost half of young Finnish adult aged 21 years had at least one degenerated disc, and a quarter had a bulging disc. Modic changes and disc herniations were, however, relatively rare.
Udby PM, Ohrt-Nissen S, et al. (2020). The Association of MRI Findings and LongTerm Disability in Patients with Chronic Low Back Pain. Global Spine Journal. https://doi.org/10.1177/2192568220921391
In this study of 170 patients with LBP with severe Disc or Facet Joint degeneration, no association was found between baseline MRI findings and 13-year disability. This highlights the limited prognostic value of a single baseline MRI scan on long-term disability. None of the MRI changes suggesting degeneration were associated with a worse outcome at 13-year follow-up.
**Widhe T et al. (2001) Spine: posture, mobility and pain. A longitudinal study from childhood to adolescence”. Eur Spine J. (PMID: 11345632) Apr;10(2):118-23
“A longitudinal study was undertaken to analyse the development of posture and spinal mobility during growth and its relationship to low back pain and sports activities. Occasional low back pain was reported by 38% of the children at the age of 15-16 years, but back pain was not related to posture, spinal mobility or physical activity.”
*Wise, B.L., Niu, J, et al (2010). Psychological factors and their relation to osteoarthritis pain. Osteoarthritis and Cartilage, 18, pp. 883-887.
“The authors demonstrate an association between worsened measures of mental health and osteoarthritis pain and risk of pain flares. They recommend that mental health treatment is a way to prevent pain flares.”
*Young, A.K., Young, B.K, et al. (2014). Assessment of pre-surgical psychological screening in patients undergoing spine surgery: Use and clinical impact. J Spinal Disord Tech, 27:76–79.
“A prospective survey found that only 37% of spinal surgeons used pre-surgical psychological screening (PPS), despite the North American Spine Society guidelines regarding the use of PPS. Depression is associated with longer recuperations, delayed returns to work, more postsurgical complications and failures to comply with medication schedules after patients leave the hospital.”
*Young, Casey C et al. (2008) Transition from acute to chronic pain and disability: a model including cognitive, affective, and trauma factors. Pain. Jan;134(1-2):69-79.
“Early detection of elevated depressive symptoms and high trauma exposure may identify individuals at greater risk for developing chronic pain syndromes who may benefit from early multidisciplinary intervention.”
3.Ineffectieve behandelingen tegen langdurige of chronische (pijn)klachten
Hieronder staan onderzoeken die bewijs zijn dat invasieve behandeling (o.a. operaties), niet-invasieve (o.a. fysiotherapie)-, niet-psychologische behandeling en opioïden (medicatie) niet effectief zijn voor chronische of langdurige (pijn)klachten.
Anheyer, D, Haller H, Barth J et al (2017). Mindfulness-Based Stress Reduction for Treating Low Back Pain. Ann Intern Med. 166:799-807.
In seven RCTs involving 864 patients with low back pain, MBSR compared to usual care led to short term improvements in pain intensity and physical functioning that were not sustained in the long term. Disability, mental health, pain acceptance and mindfulness also were not significantly different in the short or long term.
Berthelot JM. (2015) Strong opioids for noncancer pain due to musculoskeletal diseases: Not more effective than acetaminophen or NSAIDs. Joint Bone Spine. Dec;82(6):397-401.
“In patients with chronic noncancer low back pain, morphine and other strong opioids in dosages of up to 100mg/day were only slightly more effective than their placebos, no more effective than acetaminophen, and somewhat less effective than nonsteroidal anti-inflammatory drugs (NSAIDs).”
Buchbinder R, Osborne RH, Kallmes D. (2009) Vertebroplasty appears no better than placebo for painful osteoporotic spinal fractures, and has potential to causeharm. Med J Aust. Nov 2;191(9):476-7.
“Two randomised placebo-controlled trials show Vertebroplasty appears no better than placebo for painful osteoporotic spinal fractures, and has potential to causeharm. Shows the importance of establishing the efficacy of procedures before adopting them into clinical practice.”
Carragee, E.J., Lincoln, T., et al (2006). A Gold standard evaluation of the “discogenic pain” diagnosis as determined by provocative discography. Spine, 31(18), 2115-2123.
A sophisticated x-ray exam was done to carefully select patients who were most likely to have pain relief from spinal fusion surgery. Even under those strict conditions, in only 27% was the outcome considered highly effective and in 57% it was not even minimally acceptable. In the same study, in a comparison group having spine fusion for a non-pain condition (spondylolisthesis), the corresponding figures were 72% and 9%.
Carreon, L.Y., Glassman, S.D., et al (2010). Clinical outcomes after posterolateral lumbar fusion in workers’ compensation patients. Spine 35(19), 1812–1817.
“Compared outcomes post-surgery between people on workers compensation and matched subject not on workers compensation. Only 16-19% of workers compensation patients showed improvement, while 36-40% of patients not on workers compensation showed improvement.”
Chaparro LE. (2014) Opioids compared with placebo or other treatments for chronic low back pain: an update of the Cochrane Review. Spine Apr 1;39(7):556- 63.
“The effectiveness and safety of long-term opioid therapy for treatment of CLBP remains unproven.”
Chou R, Baisden, J, et al. (2009). Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine, 34(10), 1094-109.
“Reviewed online databases of RCTs and systematic reviews. Surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up in some trials. For non-radicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation, but associated with small to moderate benefits compared to standard nonsurgical therapy.”
Chou R. (2015) Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. Sep 1;163(5):373- 81.
“Epidural corticosteroid injections for radiculopathy were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.”
Deyo RA, Mirza SK, Turner JA, Martin BI. (2009). Overtreating chronic back pain: time to back off? J Am Board Fam Med. 22:62–8.
Recent studies document a 629% increase in Medicare expenditures for epidural steroid injections; a 423% increase in expenditures for opioids for back pain; a 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries; and a 220% increase in spinal fusion surgery rates. The limited studies available suggest that these increases have not been accompanied by population-level improvements in patient outcomes or disability rates.
Franklin GM, Haug, et al (1994). Outcome of lumbar fusion in Washington State workers' compensation. Spine, 19(17):1897-1903.
“This study looked at patients from the workers compensation program who had had lumbar surgery to look for predictive factors for disability and reoperation. Most patients reported that back pain (67.7%) was worse and overall quality of life (55.8%) was no better or worse than before surgery.”
Fritzell, P., Hagg, O. et al (2001) Lumbar fusion versus nonsurgical treatment for chronic low back pain. Spine, 26, (23), 2521–2534.
“This is a RCT multi-site study with 2-year follow-up with independent observer comparing pain and disability outcomes between surgery and non-surgery for lower back pain. The non-surgical group had physical therapy, and the surgical group had fusion surgery. Surgical group’s pain was reduced by 33% and the non-surgical group by 7%. Pain improved most in the first six months, and then gradually got worse.”
Geiss A. (2005) Predicting the failure of disc surgery by a hypofunctional HPA axis: evidence from a prospective study on patients undergoing disc surgery. Pain, Mar;114(1-2):104-17.
“Patients with postoperative ongoing sciatic pain have been shown to exhibit reduced cortisol levels along with enhanced IL-6 levels. The aim of the present study was to clarify the relationship between a reduced cortisol secretion and enhanced cytokine levels by performing a prospective study on patients with disc herniation. These findings suggest that chronically stressed patients are at a higher risk for a poor surgical outcome as their reduced cortisol secretion promotes the postoperative ongoing synthesis of proinflammatory cytokines.”
Hadler, N.M. (2003). MRI for regional back pain: Need for less imaging, better understanding. JAMA, 289(21), 2863-2865.
“This is an editorial commenting on a study in the same issue that showed that substituting rapid MRI neither saved money nor led to improved clinical outcomes. Rather, the data suggested that substituting rapid MRI increases cost in part because it predisposes patients to undergo surgical intervention. The author makes the point that there has yet to be any evidence that a structural issue causes back pain. Therefore, “Imaging only serves to bolster the notion that back pain is nothing more than the symptom of an underlying disease. This is a social construct that nurtures an enormous treating enterprise far more than it helps the patient.”
Jonas WB, Crawford C et al (2019). Are Invasive Procedures Effective for Chronic Pain? A Systematic Review. Pain Medicine, 20(7), 2019, 1281–1293 doi: 10.1093/pm/pny154
Twenty-five trials (2,000 participants) were included in the review assessing the effect of invasive procedures over sham. Conditions included low back (N.7 trials), arthritis (4), angina (4), abdominal pain (3), endometriosis (3), biliary colic (2), and migraine (2). The risk of any adverse event was significantly higher for invasive procedures (12%) than sham procedures (4%). In the two metaanalysis subsets, the standardized mean difference for reduction of low back pain in seven studies (N.445) was 0.18, and for knee pain in three studies (N.496) it was 0.04. The relative contribution of within-group improvement in sham treatments accounted for 87% of the effect compared with active treatment across all conditions. Conclusions: There is little evidence for the specific efficacy beyond sham for invasive procedures in chronic pain. A moderate amount of evidence does not support the use of invasive procedures as compared with sham procedures for patients with chronic back or knee pain. Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain.
Kallmes DF et al (2009) A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med, Aug 6;361(6):569- 79
“We randomly assigned 131 patients who had one to three painful osteoporotic vertebral compression fractures to undergo either vertebroplasty or a simulated procedure without cement (control group). Improvements in pain and pain-related disability associated with osteoporotic compression fractures in patients treated with vertebroplasty were similar to the improvements in the simulated procedure (control) group.”
Keller A et al. (2007) Effect sizes of non-surgical treatments of non-specific low-back pain. European spine journal, Nov;16(11):1776-88.
“As a conclusion, the effect of non-surgical treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.”
Khan, M., Evaniew, N., et al (2014). Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ, 186(14), pp. 1057-1064.
“Included seven RCTs in this review and found moderate evidence to suggest that there is no benefit to arthroscopic surgery in comparison with non-operative or sham treatments in middleaged patients with mild or no concomitant osteoarthritis. The authors recommend a trial of nonoperative management as the first-line treatment for such patients.”
Kirkley A, Birmingham TB, Litchfield RB, et al. (2008). A Randomized trial of arthroscopic surgery for osteoarthritis of the knee. NEJM, 359(11), 1097-1107.
“RCT comparing 86 patients who had surgery for osteoarthritis of the knee with 86 who underwent physical and medical therapy. There was no difference in outcome between the two groups.”
Lian, J., Mohamadi, A et al (2018). Comparative efficacy and safety of nonsurgical treatment options for enthesopathy of the extensor carpi radialis brevis:A Systematic review and meta-analysis of randomized placebo-controlled trials. American Journal of Sports Medicine, published online October 31.
“This meta-analysis of tennis elbow found that in 36 RCTs with placebo controls, most patients experienced pain resolution after receiving placebo within 4 weeks of follow-up. At best, all treatments provided only small pain relief while increasing the odds of adverse events.”
Mirza, S.K. and Deyo, R.A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine,32:816-23.
“Examined five RCT studies comparing surgery to non-surgical approaches to chronic back pain. Found methodological problems in all five studies. However, concluded that surgery is better than unstructured nonsurgical care, but structured therapy was better than surgery.”
Nguyen TH. (2011) Long-term outcomes of lumbar fusion among workers' compensation subjects: a historical cohort study. Spine, Feb15;36(4):320-31.
“Compared return-to-work (RTW) data, permanent disability, postsurgical complications, opiate utilization, and reoperation status for chronic low back pain subjects who had lumbar fusion surgery with nonsurgical controls. They concluded that lumbar fusion surgery for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a Workers Compensation setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor Return-To-Work status. In addition, in the surgical group, 36% had complications, 27% needed reoperation.”
Pape E, Hagen KB et al (2012). Early multidisciplinary evaluation and advice was ineffective for whiplash-associated disorders. European Journal of Pain. Volume 13, Issue 10, November 2009, Pages 1068-1075.
Assessed the effect of early multidisciplinary evaluation and advice on the frequency of chronic neck pain three years post-injury in persons with minor or moderate traffic injuries. The advice actually increased the risk of having chronic neck pain three years later. Literally, the intervention may therefore have done more harm than good.
Staal JB. (2009) Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine, Jan 1;34(1):49-59.
“The effectiveness of injection therapy for low back pain is still debatable. Heterogeneity of target tissue, pharmacological agent, and dosage, generally found in RCTs, point to theneed for clinically valid comparisons in a literature synthesis.”
Thordarson, D., Ebramzadeh, E. et al (2005). Correlation of Hallux Valgus Surgical Outcome With AOFAS Forefoot Score and Radiological Parameters. Foot and Ankle International, 26 (2), pp, 122-127.
“This prospective study looked at people who had undergone three different surgical procedures for bunions. The authors note their surprise that neither the degree of deformity pre-surgery, nor the degree of residual deformity post-surgery significantly affected the improvement that patients experienced, including pain scores. This suggests that the degree of deformity is not a good predictor of pain nor of success of surgery.”
Traeger AC, Lee H, Hubscher M, Skinner IW, Moseley GL et al. (2019). Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain. A Randomized Clinical Trial. JAMA Neurol. 2019;76(2):161- 169. doi:10.1001/jamaneurol.2018.3376
In this randomized clinical trial of 202 adults with acute low back pain from Sydney, Australia, adding intensive patient education to first-line care of patients was no better at improving pain outcomes than a placebo intervention.
**Verbeek JH. (2012) Proper manual handling techniques to prevent low backpain, a Cochrane systematic review. Work: a journal of prevention, assessment, and rehabilitation; 41 Suppl 1:2299-301.
“Training and provision of assistive devices are considered major interventions to prevent and treat low back pain (LBP) among workers exposed to manual material handling (MMH). None of the included RCTs and CCTs provided evidence that training and provision of assistive devices prevented LBP when compared to no intervention or another intervention.”