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Physiother Can. 2010 Winter; 62(1): 81–85.
Published online 2010 February 22. doi:  10.3138/physio.62.1.81
PMCID: PMC2841557

Informing Your Practice with Reviews Published by the Cochrane Back Review Group: Conservative Interventions for Neck and Back Pain

In her editorial in the winter 2009 issue of Physiotherapy Canada, Allison Francis outlined a number of online resources that are available to physiotherapists in their quest to find current evidence to inform their practice.1 One of the resources listed as “by subscription only” was The Cochrane Library ( This valuable resource was freely available to all Canadians with Internet access to the end of 2009, as a pilot project organized by the Canadian Cochrane Centre and the Canadian Health Libraries Association. Negotiations for ongoing funding were still in progress at the time of writing; however, abstracts and plain-language summaries continue to be free to all readers. We would like to take this opportunity to give you a brief overview of one the Review Groups that publish and maintain Cochrane Reviews that can help to inform your practice.

The Cochrane Back Review Group (CBRG) is one of 52 Review Groups that produce and maintain systematic reviews on the effects of health care. The goal is to provide the most current information to inform clinical decisions at the individual, institutional, and policy levels. The scope of the CBRG is primary and secondary prevention and treatment of neck and back pain and other spinal disorders, excluding inflammatory diseases and fractures. The CBRG is hosted by the Institute for Work & Health (, an independent, not-for-profit research organization located in Toronto, Ontario, whose mission is to conduct and share research with workers, organized labour, employers, clinicians, and policy makers to promote, protect, and improve the health of working people. The CBRG also receives funding from the Canadian Institutes of Health Research and from the Canadian Agency for Drugs and Technologies in Health.

Our authors, editors, and peer referees are international, multidisciplinary practitioners and researchers in the field of neck and back pain. The editorial team comprises two co-ordinating editors, a managing editor, a librarian, two editorial assistants, an editorial board, and an advisory board that provides peer review. Completed protocols and reviews are published quarterly in The Cochrane Library. Our reviews can be accessed via by browsing ‘by review group,’ or via the CBRG's website ( Access to The Cochrane Library is available by subscription or without charge, depending on the jurisdiction.

The CBRG published 40 reviews and 11 protocols (reviews in progress) in The Cochrane Library 2009, issue 3, released on July 8, 2009. It is the policy of The Cochrane Collaboration to update reviews every two years and to withdraw them if they are out of date. Review teams are currently updating a number of reviews that we expect to be published over the next few months.

The year 2008 was a busy and exciting one. The Cochrane Collaboration released an update of the Handbook for Systematic Reviews of Interventions2 and Review Manager 5, the software used for producing reviews (March 2008), and the CBRG Editorial Board finished their “Updated Methods for Systematic Review in the Cochrane Back Review Group.”3 There are several new features in the handbook, the updated guidelines, and the software that have been developed to make our reviews more transparent and user friendly.

It is recognized that differences in the design and conduct of individual studies can affect the validity (risk of over- or underestimation of the true intervention effect) and rigour of the findings and final conclusion of a systematic review. Assessing the risk of bias (internal validity—the confidence with which we can “believe” the results) of included studies is an integral step in systematic reviews. For over a decade, the CBRG has recommended the use of 11 criteria to assess the risk of bias in primary studies. The new Cochrane Handbook2 recommends one that has not previously been considered, bringing the currently recommended number to 12. The 12 criteria assess sequence generation, allocation concealment, blinding of study participants, completeness and similarity of outcome reporting, similarity of important characteristics at baseline, compliance and co-interventions. Other risks of bias can be added as indicated by the intervention and the outcome.

Because of the high risk of bias and the heterogeneity of important components in many trials in this field, the CBRG used Levels of Evidence to help synthesis the results, first used in the 1994 Guidelines for the Management of Acute Low-Back Pain in Adults.2 Following a new approach introduced in the updated Cochrane Handbook,3 the Updated Method Guidelines now recommend that the overall quality of the evidence for each outcome be assessed using an adapted GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.4 More than 20 other organizations, including the World Health Organization (WHO), the American College of Physicians, and the Canadian Agency for Drugs and Technology in Health (CADTH), have adopted the GRADE approach.5

Five domains are considered in assessing the quality of the evidence: (1) limitations of the study design; (2) inconsistency, (3) indirectness (inability to generalize), and (4) imprecision (insufficient or imprecise data) of results; and (5) publication bias across all studies that measure that particular outcome. The quality starts at “high” when at least 75% of RCTs with a low risk of bias provide consistent, direct, generalizable results for the outcome, and is reduced by one level for each of the domains not met. The CBRG has found that if more than six criteria are met and there are no serious threats to the internal validity of the study (e.g., >50% of participants lost to follow-up), a study can be assessed as having a low risk of bias.6

Cochrane reviews are intended to help people make well-informed decisions about health care research. Drawing conclusions about the practical usefulness of an intervention entails making trade-offs, either implicitly or explicitly, between the estimated benefits, harms, and costs. However, making specific recommendations for an action goes beyond a systematic review and requires additional information and informed judgements, which are typically the domain of clinical practice guideline developers.

The CBRG welcomes both consumers and experienced authors and referees to the group. We invite you to join online ( to receive periodic newsletters that will keep you abreast of initiatives in The Cochrane Collaboration in general and the Cochrane Back Review Group in particular.


Table 1 provides a list of our published reviews that may be of particular interest to Physiotherapy Canada readers. The full list and text of publications can be found in The Cochrane Library or on the CBRG website. Many of the reviews have been incorporated into international guidelines for the management of neck and back pain.

Table 1
Published Reviews of Particular Interest to Physiotherapists

Our editorial office can be reached by e-mail at Please do not hesitate to contact us should you have any questions.

Details of Reviews Highlighted in Table 1 (The Cochrane Library 2009, issue 3)

Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW. et al. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1 Art. No.: CD001351. DOI: 10.1002/14651858 [PubMed]

Trinh KV, Graham N, Gross AR, Goldsmith CH, Wang E, Cameron ID, Kay T. Cervical Overview Group Acupuncture for neck disorders. Cochrane Database of Systematic Reviews 2006, Issue 3 Art. No.: CD004870. DOI: 10.1002/14651858.CD004870.pub3 [PubMed]

Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW. Back schools for non-specific low-back pain. Cochrane Database of Systematic Reviews 2004, Issue 4 Art. No.: CD000261. DOI: 10.1002/14651858 [PubMed]

Verhagen AP, Scholten-Peeters GG, van Wijngaarden S, de Bie RA, Bierma-Zeinstra SM. Conservative treatments for whiplash. Cochrane Database of Systematic Reviews 2007, Issue 2 Art. No.: CD003338. DOI: 10.1002/14651858 [PubMed]

Kroeling P, Gross A, Goldsmith CH, Burnie SJ, Haines T, Graham N, Brant A. Electrotherapy for neck pain. Cochrane Database of Systematic Reviews 2009, Issue 4 Art. No.: CD004251. DOI: 10.1002/14651858.CD004251.pub4 [PubMed]

Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database of Systematic Reviews 2005, Issue 3 Art. No.: CD000335. DOI: 10.1002/14651858 [PubMed]

Kay TM, Gross A, Goldsmith C, Santaguida PL, Hoving J, Bronfort G. Exercises for mechanical neck disorders. Cochrane Database of Systematic Reviews 2005, Issue 3 Art. No.: CD004250. DOI: 10.1002/14651858 [PubMed]

Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database of Systematic Reviews 2008, Issue 1 Art. No.: CD004057. DOI: 10.1002/14651858 [PubMed]

Sahar T, Cohen M, Ne'eman V, Kandel L, Odebiyi D, Lev I. et al. Insoles for prevention and treatment of back pain. Cochrane Database of Systematic Reviews 2007, Issue 4 Art. No.: CD005275. DOI: 10.1002/14651858 [PubMed]

Yousefi-Nooraie R, Schonstein E, Heidari K, Rashidian A, Pennick V, Akbari-Kamrani M. et al. Low level laser therapy for nonspecific low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 2 Art. No.: CD005107. DOI: 10.1002/14651858 [PubMed]

van Duijvenbode ICD, Jellema P, Van Poppel MNM, van Tulder MW. Lumbar supports for prevention and treatment of low back pain. Cochrane Database of Systematic Reviews 2008, Issue 2 Art. No.: CD00182. DOI: 10.1002/14651858

Martimo KP, Verbeek J, Karppinen J, Furlan AD, Kuijer PP, Viikari-Juntura E. et al. Manual material handling advice and assistive devices for preventing and treating back pain in workers. Cochrane Database of Systematic Reviews 2007, Issue 3 Art. No.: CD005958. DOI: 10.1002/14651858 [PubMed]

Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 4 Art. No.: CD001929. DOI: 10.1002/14651858 [PubMed]

Haraldsson BG, Gross AR, Myers CD, Ezzo JM, Morien A, Goldsmith C. et al. Massage for mechanical neck disorders. Cochrane Database of Systematic Reviews 2006, Issue 3 Art. No.: CD004871. DOI: 10.1002/14651858 [PubMed]

Graham N, Gross A, Goldsmith CH, Klaber MJ, Haines T, Burnie SJ. et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database of Systematic Reviews 2008, Issue 3 Art. No.: CD006408. DOI: 10.1002/14651858 [PubMed]

Haines T, Gross A, Burnie SJ, Goldsmith CH, Perry L. Patient education for neck pain with or without radiculopathy. Cochrane Database of Systematic Reviews 2009, Issue 1 Art. No.: CD005106. DOI: 10.1002/14651858.CD005106.pub3 [PubMed]

Ostelo RW, Costa LO, Maher CG, de Vet HC, van Tulder MW. Rehabilitation after lumbar disc surgery. Cochrane Database of Systematic Reviews 2008, Issue 4 Art. No.: CD003007. DOI: 10.1002/14651858 [PubMed]

French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database of Systematic Reviews 2006, Issue 1 Art. No.: CD004750. DOI: 10.1002/14651858 [PubMed]

Clarke JA, van Tulder MW, Blomberg SE, de Vet HC, van der Heijden GJ, Bronfort G. et al. Traction for low-back pain with or without sciatica. Cochrane Database of Systematic Reviews 2007, Issue 2 Art. No.: CD003010. DOI: 10.1002/14651858 [PubMed]

Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. Transcutaneous electrical nerve stimulation (TENS) versus placebo for chronic low-back pain. Cochrane Database of Systematic Reviews 2008, Issue 4 Art. No.: CD003008. DOI: 10.1002/14651858 [PubMed]


1. Francis AP. Evidence-based practice in women's health: making evidence come to you! Physiother Can. 2009;61:1–2. [PMC free article] [PubMed]
2. Bigos S, Braen G, Deyo R, Hart J, Keller R, Liang M, et al. Clinical Practice Guideline number 14: Acute low back problems in adults. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1994.
3. Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions version 5.0.1. 2008. [updated 2008 Sep; cited 2009 Jul 7]. The Cochrane Collaboration, Available from:
4. Furlan AD, Pennick V, Bombardier C, van Tulder M. Cochrane Back Review Group. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine. 2009;34:1929–41. [PubMed]
5. Grading the quality of evidence and the strength of recommendations. GRADE Working Group [homepage on the Internet] [cited 2009 Jul 7]. Available from:
6. van Tulder MW, Suttorp M, Morton S, Bouter LM, Shekelle PG. Empirical evidence of an association between internal validity and effect size in randomized controlled trials. Spine. 2009;34:1685–92. [PubMed]

Articles from Physiotherapy Canada are provided here courtesy of University of Toronto Press and the Canadian Physiotherapy Association