Top POEMs of 2012: Musculoskeletal Disease and Exercise

Exercise Decreases Depressive Symptoms of Chronic Illness

Clinical question: In patients with chronic illness complicated by depressive symptoms, is exercise effective in decreasing these symptoms?

Bottom line: Getting chronically ill patients up on their feet and into exercise programs will decrease their depressive symptoms. The response is greater in patients with higher depression scores and in patients who exercise regularly. These results apply to patients with depressive symptoms in general, not just to patients with major depressive disorder. (LOE = 1a)

Reference: Herring MP, Puetz TW, O'Connor PJ, Dishman RK. Effect of exercise training on depressive symptoms among patients with a chronic illness. A systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2012;172(2):101-111.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis: The authors included English language studies of sedentary patients with a chronic illness -- cardiovascular disease, cancer, fibromyalgia, multiple sclerosis, and others -- with depression who were randomly assigned to exercise or a nonexercise treatment. The authors searched several databases, but not the Cochrane Library or any other evidence-based resource. Two authors independently assessed the studies for quality. There was heterogeneity among the studies, perhaps due to the type of patients enrolled. There was no evidence of publication bias. Surprisingly, the authors identified 90 articles evaluating 10,534 patients. They were able to find this many studies because depressive symptoms were often secondary outcomes in other studies. They were not looking for studies of chronically ill patients with major depressive disorder, though some patients undoubtedly could have met this diagnosis. Overall, exercise had a moderate effect on depressive symptoms, with greater effects seen in patients with higher baseline depression scores and in patients who did the exercises regularly.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Lifestyle Change Greatly Reduces Disability, Increases Mobility in Obese Patients

Clinical question: Can a lifestyle intervention improve mobility and reduce the likelihood of disability among obese adults with type 2 diabetes mellitus?

Bottom line: A fairly intensive lifestyle intervention had impressive results, with a significant reduction in disability and loss of mobility. The benefit was associated with both the weight loss and the improved physical fitness. Mortality and morbidity data are not reported by the authors. (LOE = 1b)

Reference: Rejeski WJ, Ip EH, Bertoni AG, et al, for the Look AHEAD Research Group. Lifestyle change and mobility in obese adults with type 2 diabetes. N Engl J Med 2012;366(13):1209-1217.

Study design: Randomized controlled trial (single-blinded)

Funding source: Government

Allocation: Uncertain

Setting: Outpatient (any)

Synopsis: The researchers recruited 5145 overweight or obese adults between the ages of 45 and 74 years with type 2 diabetes. The mean age of participants was 59 years, 60% were women, 13% were Hispanic, and 16% were African American. They were randomized to receive diabetes support and education (the control group) or a lifestyle intervention. The latter consisted of a weight-loss program based on portion control and encouragement of physical activity, with a goal of a 7% weight loss and at least 175 minutes per week of physical activity. Participants had weekly meetings (largely in groups) during the first 6 months, then they met every other week for the next 6 months. For the rest of the study, participants had at least 1 in-person visit per month and 1 other contact via phone, email, postal mail, or voicemail. The lifestyle intervention group ultimately achieved a 6.1% weight loss compared with 0.9% in the control group (P < .001). They also had greater increase in energy expenditure per week in year 1 (881 vs 99 calories; P < .001) and in year 4 (358 vs 96 calories; P < .001). They used a sophisticated analysis that looked at the effect of weight loss and/or fitness on mobility; the latter was determined using elements of the validated Medical Outcomes Study Short Form health survey that included vigorous activity; moderate activity; walking more than a block; climbing 1 flight of stairs; and bending, kneeling, or stooping. Patients were classified in 1 of 4 mobility states based on their performance on these measures at each annual visit. At the end of the 4-year study, more patients in the lifestyle intervention group had good mobility (26.2% vs 20.6%; number needed to treat [NNT] = 18) and fewer had severe disability (31.9% vs 38.5%; NNT = 16). The improvement in mobility was associated with both weight loss and improved fitness.

Mark H. Ebell, MD, MS
Associate Professor
University of Georgia
Athens, GA

Prognosis of Acute and Persistent Low Back Pain

Clinical question: What is the usual course of acute low back pain and of persistent low back pain?

Bottom line: Most patients with acute low back pain have significant improvement at 6 weeks, although some will still have significant pain at 1 year after presentation. (LOE = 1a-)

Reference: Menezes Costa L da C, Maher CG, McAuley JH, et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ 2012;184(11):e613-624.

Study design: Meta-analysis (other)

Funding source: Self-funded or unfunded

Setting: Various (meta-analysis)

Synopsis: Prognosis is important; it gives our patients realistic expectations, which may help avoid frustration, overtesting, and overtreatment. The authors of this systematic review did a careful search for any inception cohort studies; that is, studies that assembled a group of patients with back pain and followed them forward in time. The authors did not include randomized trials or even the untreated arms of randomized trials, arguing that these studies often have fairly narrow inclusion criteria that hurt generalizability. They identified 2 groups of cohort studies, one of patients with acute and subacute low back pain (less than 12 weeks duration) and one of patients with persistent back pain (12 weeks to 12 months). Studies were of reasonable quality, with approximately three fourths having less than 20% lost to follow-up. Of 21 cohort studies reporting pain as an outcome, 15 included patients with acute low back pain and 6 patients with persistent low back pain. The authors adjusted the duration of symptoms based on the mean or median duration of symptoms prior to entry into the study. For patients with acute low back pain, pain on a 100-point scale decreased from 69 at baseline to 28 at 6 weeks, 12 at 26 weeks, and 4 at 1 year. For patients with persistent low back pain, the pain score was 55 at 6 weeks, 29 at 26 weeks, and 17 at 1 year. Disability scores followed a similar pattern for those with persistent low back pain: the score was 51 at baseline, 28 at 6 weeks, 19 at 26 weeks, and 15 at 1 year. For acute low back pain, diability scores were 57 at baseline, 28 at 6 weeks, 17 at 26 weeks, and 11 at 1 year.

Mark H. Ebell, MD, MS
Associate Professor
University of Georgia
Athens, GA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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