Where the United States spends its spine dollars: expenditures on different ambulatory services for the management of back and neck conditions

Are Nonpharmacologic Interventions for Chronic Low Back Pain More Cost Effective Than Usual Care? Proof of Concept Results From a Markov Model

STUDY DESIGN

Markov model.

OBJECTIVE

Examine the 1-year effectiveness and cost-effectiveness (societal and payer perspectives) of adding nonpharmacologic interventions for chronic low back pain (CLBP) to usual care using a decision analytic model-based approach.

SUMMARY OF BACKGROUND DATA

Treatment guidelines now recommend many safe and effective nonpharmacologic interventions for CLBP. However, little is known regarding their effectiveness in subpopulations (e.g., high-impact chronic pain patients), nor about their cost-effectiveness.

METHODS

The model included four health states: high-impact chronic pain (substantial activity limitations); no pain; and two others without activity limitations, but with higher (moderate-impact) or lower (low-impact) pain. We estimated intervention-specific transition probabilities for these health states using individual patient-level data from 10 large randomized trials covering 17 nonpharmacologic therapies. The model was run for nine 6-week cycles to approximate a 1-year time horizon. Quality-adjusted life-year weights were based on six-dimensional health state short form scores; healthcare costs were based on 2003 to 2015 Medical Expenditure Panel Survey data; and lost productivity costs used in the societal perspective were based on reported absenteeism. Results were generated for two target populations: (1) a typical baseline mix of patients with CLBP (25% low-impact, 35% moderate-impact, and 40% high-impact chronic pain) and (2) high-impact chronic pain patients.

RESULTS

From the societal perspective, all but two of the therapies were cost effective (<$50,000/quality-adjusted life-year) for a typical patient mix and most were cost saving. From the payer perspective fewer were cost saving, but the same number was cost-effective. Assuming all patients in the model have high-impact chronic pain increases the effectiveness and cost-effectiveness of most, but not all, therapies indicating that substantial benefits are possible in this subpopulation.

CONCLUSION

Modeling leverages the evidence produced from clinical trials to provide more information than is available in the published studies. We recommend modeling for all existing studies of nonpharmacologic interventions for CLBP.

LEVEL OF EVIDENCE

4.

Analysis of Outcomes and Cost of Inpatient and Ambulatory Anterior Cervical Disk Replacement Using a State-level Database

BACKGROUND

Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures.

OBJECTIVE

The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR.

MATERIALS AND METHODS

Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.

RESULTS

A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001).

CONCLUSIONS

ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.

Changing reimbursement models and private equity ownership in spine surgery

Rising costs of healthcare have been a problem in the United States in the past decade, with unnecessary strain on both providers and patients. The fee-for-service reimbursement model has been proposed as one of the biggest contributors to this phenomenon; as such, newer reimbursement model-including the bundled payments model-have been proposed and are becoming more widely adopted. This review will first discuss the current payment models in practice and then overview private equity ownership as a new avenue in this particular domain.

Future endeavors in ambulatory spine surgery

Due to the high societal and financial burden of spinal disorders, spine surgery is thought to be one of the most impactful targets for healthcare cost reduction. One avenue for cost-reduction that is increasingly being explored not just in spine surgery but across specialties is the performance of surgeries in ambulatory surgery centers (ASCs). Despite potential cost-savings, the utilization of ASCs for spine surgery remains largely limited to high-volume centers in the US, and predominantly for single- or two-level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) procedures. Factors most commonly cited for the lack of wider adoption include the risk of life-threatening complications, paucity of guidelines, and limited accessibility of these procedures to various patient populations. Thus, the future growth and adoption of ambulatory spine surgery depends on addressing these concerns by developing evidence-based guidelines for patient- and procedure selection, creating risk-stratification tools, devising appropriate discharge recommendations, and optimizing care protocols to ensure that safety, efficacy and outcomes are maintained. Other avenues that may allow for more widespread use of ASCs include the use of electronic health tools for post-operative monitoring after discharge from the ASC, increasing accessibility of ambulatory procedures to eligible populations, and identifying systemic inefficiencies and implementing process-improvement measures to optimize patient-selection, scheduling and peri-operative management. The success of ambulatory surgery ultimately depends not only on the surgical procedure, but also on its organization upstream and downstream. It provides an exciting and burgeoning avenue for innovation, cost-reduction and value-creation.

Health Care Costs and Opioid Use Associated With High-impact Chronic Spinal Pain in the United States

STUDY DESIGN

A descriptive analysis of secondary data.

OBJECTIVE

The aim of this study was to estimate health care costs and opioid use for those with high-impact chronic spinal (back and neck) pain.

SUMMARY OF BACKGROUND DATA

The US National Pain Strategy introduced a focus on high-impact chronic pain-that is, chronic pain associated with work, social, and self-care restrictions. Chronic neck and low-back pain are common, costly, and associated with long-term opioid use. Although chronic pain is not homogenous, most estimates of its costs are averages that ignore severity (impact).

METHODS

We used 2003 to 2015 Medical Expenditures Panel Survey (MEPS) data to identify individuals with chronic spinal pain, their health care expenditures, and use of opioids. We developed prediction models to identify those with high- versus moderate- and low-impact chronic spinal pain based on the variables available in MEPS.

RESULTS

We found that overall and spine-related health care costs, and the use and dosage of opioids increased significantly with chronic pain impact levels. Overall and spine-related annual per person health care costs for those with high-impact chronic pain ($14,661 SE: $814; and $5979 SE: $471, respectively) were more than double that of those with low-impact, but still clinically significant, chronic pain ($6371 SE: $557; and $2300 SE: $328). Those with high-impact chronic spinal pain also use spine-related opioids at a rate almost four times that of those with low-impact pain (48.4% vs. 12.4%), and on average use over five times the morphine equivalent daily dose (MEDD) in mg (15.3 SE: 1.4 vs. 2.7 SE: 0.6). Opioid use and dosing increased significantly across years, but the increase in inflation-adjusted health care costs was not statistically significant.

CONCLUSION

Although most studies of chronic spinal pain do not differentiate participants by the impact of their chronic pain, these estimates highlight the importance of identifying chronic pain levels and focusing on those with high-impact chronic pain.

LEVEL OF EVIDENCE

3.

Access to chiropractic care and the cost of spine conditions among older adults

OBJECTIVES

Chiropractic care is a service that operates outside of the conventional medical system and is reimbursed by Medicare. Our objective was to examine the extent to which accessibility of chiropractic care affects spending on medical spine care among Medicare beneficiaries.

STUDY DESIGN

Retrospective cohort study that used beneficiary relocation as a quasi-experiment.

METHODS

We used a combination of national data on provider location and Medicare claims to perform a quasi-experimental study to examine the effect of chiropractic care accessibility on healthcare spending. We identified 84,679 older adults enrolled in Medicare with a spine condition who relocated once between 2010 and 2014. For each year, we measured accessibility using the variable-distance enhanced 2-step floating catchment area method. Using data for the years before and after relocation, we estimated the effect of moving to an area of lower or higher chiropractic accessibility on spine-related spending adjusted for access to medical physicians.

RESULTS

There are approximately 45,000 active chiropractors in the United States, and local accessibility varies considerably. A negative dose-response relationship was observed for spine-related spending on medical evaluation and management as well as diagnostic imaging and testing (mean differences, $20 and $40, respectively, among those exposed to increasingly higher chiropractic accessibility; P <.05 for both). Associations with other types of spine-related spending were not significant.

CONCLUSIONS

Among older adults, access to chiropractic care may reduce medical spending on services for spine conditions.

Exploring the prevalence and construct validity of high-impact chronic pain across chronic low-back pain study samples

BACKGROUND CONTEXT

The US National Pain Strategy focused attention on high-impact chronic pain and its restrictions. Although many interventions have been studied for chronic low-back pain, results are typically reported for heterogeneous samples. To better understand chronic pain and target interventions to those who most need care, more granular classifications recognizing chronic pain's impact are needed.

PURPOSE

To test whether chronic pain impact levels can be identified in chronic low-back pain clinical trial samples, examine the baseline patient mix across studies, and evaluate the construct validity of high-impact chronic pain.

STUDY DESIGN/SETTING

Descriptive analyses using 12 large study datasets.

PATIENT SAMPLES

Chronic low-back pain patients in nonsurgical, nonpharmacologic trials in the US, Canada, and UK.

OUTCOME MEASURES

Preference-based health utilities from the SF-6D and EQ-5D, employment status and absenteeism.

METHODS

We used two logistic regression models to predict whether patients had high-impact chronic pain and whether the remainder had low- or moderate-impact chronic pain. We developed these models using two datasets. Models with the best predictive power were used to impute impact levels for six other datasets. Stratified by these estimated chronic pain impact levels, we characterized the case mix of patients at baseline in each dataset, and summarized their health-utilities and work productivity. This study was funded by a National Center for Complementary and Integrative Medicine grant. The authors have no potential conflicts of interest.

RESULTS

The logistic models had excellent predictive power to identify those with high-impact chronic pain. Although studies were all of chronic low-back pain patients, the baseline mix of patients varied widely. Across all datasets, utilities, and productivity were similar for those with high-impact chronic pain and worsened as chronic pain impact increased.

CONCLUSIONS

There is a need to better categorize chronic pain patients to allow the targeting of optimal interventions for those with each level of chronic pain impact.

Does the Day of the Week Affect Length of Stay and Hospital Charges Following Anterior Cervical Discectomy and Fusion?

Background

To reduce the economic impact of excessive costs, risk factors for increased length of stay (LOS) must be identified. Previous literature has demonstrated that surgeries later in the week can affect the LOS and costs following joint arthroplasty. However, few investigations regarding the day of surgery have been performed in the spine literature. The present study attempts to identify the association between day of surgery on LOS and hospital charges following anterior cervical discectomy and fusion (ACDF) procedures.

Methods

A prospectively maintained surgical database of primary, level 1-2 ACDF patients between 2008 and 2015 was retrospectively reviewed. Patients were stratified by surgery day: early week (Tuesday) or late week (Friday) ACDF. Differences in patient demographics and preoperative characteristics were compared between cohorts using chi-square analysis or Student t test for categorical and continuous variables, respectively. Direct hospital costs were obtained using hospital charges for each procedure and subsequent care prior to discharge. Associations between date of surgery and costs were assessed using multivariate linear regression controlled for.

Results

Two hundred and ninety-five patients were included in the analysis. One hundred and fifty-three patients underwent early week ACDF, and 142 underwent late week ACDF. Surgery day cohorts reported similar baseline characteristics. There were no differences in operative characteristics or hospital LOS between cohorts. Additionally, no differences in total or subcategorical hospital costs were identified between surgery day cohorts.

Conclusions

Patients undergoing ACDF later in the week exhibit similar LOS and hospital costs compared to those undergoing ACDF early in the week. These results suggest that outpatient procedures with short postoperative stays are likely not affected by the changes in hospital work efficiency that occur during the transition to the weekend. As such, hospitals should not restrict outpatient procedures to specific days of the week.

Level of Evidence

3.

A 1-Year Cost Analysis of Spinal Surgical Procedures in Spain: Neurosurgeons Versus Orthopedic Surgeons

Objective

To evaluate the direct costs of various spinal surgical procedures within 1 year of follow-up and to compare the profiles of neurosurgeons and orthopedic surgeons.

Methods

All spinal procedures performed within a 10-month period in patients covered by a private insurance company were included. Costs related to the spinal interventions were systematically registered in the company database. Associated costs during the 1-year follow-up were recorded.

Results

In total, 1,862 patients were included, with a total cost of €11,050,970, of whom 34.8% underwent noninstrumented lumbar decompression (€3,473), 27.1% dorsolumbar instrumented fusion (€6,619), 14.6% nucleoplasty (€1,323), 13.5% cervical surgery (€4,463), 3.4% kyphoplasty (€4,200), 2.9% scoliosis (€15,414), 1.2% oncologic surgery (€5,590), 0.5% traumatic compression (€7,844), and 4.7% (€1,343) other minor interventions (mainly rhizotomies). Approximately 42% of patients required reinterventions within the first year, with a global extra cost of €7,280,073; 11% were referred to the pain clinic, with a €114,663 cost; 55.5% were men; and the most common age range of patients who received an intervention was 65–75 years. Neurosurgeons performed 60% of all interventions. Noninstrumented lumbar operations were performed by neurosurgeons twice as often as instrumented operations, and they performed 76% of cervical operations. Orthopedic surgeons performed 2.5 times more instrumented than noninstrumented lumbar operations, and almost all scoliosis and rhizotomy procedures.

Conclusion

The direct costs of spinal surgery in Spain were generally lower than those reported in other European Union countries and the United States. Neurosurgeons and orthopedic surgeons had different spine surgical profiles and costs.

Clinical Scenarios for Which Spinal Mobilization and Manipulation Are Considered by an Expert Panel to be Inappropriate (and Appropriate) for Patients With Chronic Low Back Pain

BACKGROUND

Spinal mobilization and manipulation are 2 therapies found to be generally safe and effective for chronic low back pain (CLBP). However, the question remains whether they are appropriate for all CLBP patients.

RESEARCH DESIGN

An expert panel used a well-validated approach, including an evidence synthesis and clinical acumen, to develop and then rate the appropriateness of the use of spinal mobilization and manipulation across an exhaustive list of clinical scenarios which could present for CLBP. Decision tree analysis (DTA) was used to identify the key patient characteristics that affected the ratings.

RESULTS

Nine hundred clinical scenarios were defined and then rated by a 9-member expert panel as to the appropriateness of spinal mobilization and manipulation. Across clinical scenarios more were rated appropriate than inappropriate. However, the number patients presenting with each scenario is not yet known. Nevertheless, DTA indicates that all clinical scenarios that included major neurological findings, and some others involving imaging findings of central herniated nucleus pulposus, spinal stenosis, or free fragments, were rated as inappropriate for both spinal mobilization and manipulation. DTA also identified the absence of these imaging findings and no previous laminectomy as the most important patient characteristics in predicting ratings of appropriate.

CONCLUSIONS

A well-validated expert panel-based approach was used to develop and then rate the appropriateness of the use of spinal mobilization and manipulation across the clinical scenarios which could present for CLBP. Information on the clinical scenarios for which these therapies are inappropriate should be added to clinical guidelines for CLBP.

Predictive Model for Medical and Surgical Readmissions Following Elective Lumbar Spine Surgery: A National Study of 33,674 Patients

STUDY DESIGN

This study retrospectively analyzes prospectively collected data.

OBJECTIVE

Here we aim to develop predictive models for 3-month medical and surgical readmission after elective lumbar surgery, based on a multi-institutional, national spine registry.

SUMMARY OF BACKGROUND DATA

Unplanned readmissions place considerable stress on payers, hospitals, and patients. Medicare data reveals a 30-day readmission rate of 7.8% for lumbar-decompressions and 13.0% for lumbar-fusions, and hospitals are now being penalized for excessive 30-day readmission rates by virtue of the Hospital Readmissions Reduction Program.

METHODS

The Quality and Outcomes Database (QOD) was queried for patients undergoing elective lumbar surgery for degenerative diseases. The QOD prospectively captures 3-month readmissions through electronic medical record (EMR) review and self-reported outcome questionnaires. Distinct multivariable logistic regression models were fitted for surgery-related and medical readmissions adjusting for patient and surgery-specific variables.

RESULTS

Of the total 33,674 patients included in this study 2079 (6.15%) reported at least one readmission during the 90-day postoperative period. The odds of medical readmission were significantly higher for older patients, males versus females, African Americans versus Caucasion, those with higher American Society of Anesthesiologists (ASA) grade, diabetes, coronary artery disease, higher numbers of involved levels, anterior only or anterior-posterior versus posterior approach; also, for patients who were unemployed compared with employed patients and those with high baseline Oswestry Disability Index (ODI). The odds of surgery-related readmission were significantly greater for patients with a higher body mass index (BMI), a higher ASA grade, female versus male, and African Americans versus Caucasians; also, for patients with severe depression, more involved spinal levels, anterior-only surgical approaches and higher baseline ODI scores.

CONCLUSION

In this study we present internally validated predictive models for medical and surgical readmission after elective lumbar spine surgery. These findings set the stage for targeted interventions with a potential to reduce unnecessary readmissions, and also suggest that medical and surgical readmissions be treated as distinct clinical events.

LEVEL OF EVIDENCE

3.

Comparison of STarT Back Screening Tool and Simmonds Physical Performance Based Test Battery in Prediction of Disability Risks Among Patients with Chronic Low-Back Pain

Objectives This study identified disability sub-groups of patients with chronic low back pain (LBP) using the Subgroup for Targeted Treatment (or STarT) Back Screening Tool (SBST) and Simmonds Physical Performance Tests Battery (SPPTB). In addition, the study investigated the divergent validity of SBST, and compared the predictive validity of SBST and SPPTB among the patients with the aim to enhance quick and accurate prediction of disability risks among patients with chronic LBP. Methods This exploratory cross-sectional study involved 70 (52.0% female and 47.1% male) consenting patients with chronic non-specific LBP attending out-patient physiotherapy and Orthopedic Clinics at the Obafemi Awolowo University Teaching Hospitals, Ile-Ife and Ladoke Akintola University of Technology Teaching Hospital, Osogbo, Nigeria. Disability risk subgrouping and prediction were carried out using the SBST and SPPTB (comprising six functional tasks of repeated trunk flexion, sit-to-stand, 360-degree rollover, Sorenson fatigue test, unloaded reach test, and 50 foot walk test). Pain intensity was assessed using the Quadruple Visual Analogue Scale. Data on age, sex, height, weight and BMI were also collected. Descriptive and inferential statistics were used to analyze data at p<0.05 Alpha level. Results The mean age, weight, height and body mass index of the participants were 51.4 ±8.78 years, 1.61 ±0.76 m and 26.6 ±3.18 kg/m2 respectively. The mean pain intensity and duration were 5.37 ±1.37 and 21.2 ±6.68 respectively. The divergent validity of SBST with percentage overall pain intensity was r = 0.732; p = 0.001. Under SBST sub-grouping the majority of participants were rated as having medium disability risk (76%), whilst SPPTB sub-grouped the majority as having high disability risk (71.4%). There was a significant difference in disability risk subgrouping between SBST and SPPTB (χ²=12.334; p=0.015). SBST had no floor and ceiling effects, as less than 15% of the participants reached the lowest (2.9%) or highest (1.4%) possible score. Conversely, SPPBT showed both floor and ceiling effects, as it was unable to detect ‘1’ and ‘9’, the lowest and highest obtainable scores. The ‘Area Under Curve’ for sensitivity (0.83) and specificity (0.23) of the SBST to predict ‘high-disability risk’ was 0.51. The estimated prevalence for ‘high-disability risk’ prediction of SBST was 0.76. The estimate for true positive, false positive, true negative and false negative for prediction of ‘high-disability risk’ for SBST were 0.77, 0.23, 0.31, and 0.69 respectively. Conclusion The Start Back Screening Tool is able to identify the proportion of patients with low back pain with moderate disability risks, while the Simmonds Physical Performance Tests Battery is better able to identify high disability risks. Thus, SBST as a self-report measure may not adequately substitute physical performance assessment based disability risks prediction. However, SBST has good divergent predictive validity with pain intensity. In contrast to SPBBT, SBST exhibited no floor or ceiling effects in our tests, and demonstrated high sensitivity but low specificity in predicting ‘high-disability risk’.

Cost-Utility Analysis of Operative Versus Nonoperative Treatment of Thoracic Adolescent Idiopathic Scoliosis

STUDY DESIGN

Cost-utility analysis OBJECTIVE.: To compare the cost utility of operative versus nonoperative treatment of adolescent idiopathic scoliosis (AIS) and identity factors that influence cost-utility estimates.

SUMMARY OF BACKGROUND DATA

AIS affects 1% to 3% of children aged 10 to 16 years. When the major coronal curve reaches 50°, operative treatment may be considered. The cost utility of operative treatment of AIS is unknown.

METHODS

A decision-analysis model comparing operative versus nonoperative treatment was developed for a hypothetical 15-year-old skeletally mature girl with a 55° right thoracic (Lenke 1) curve. The AIS literature was reviewed to estimate the probability, health utility, and quality-adjusted life years (QALYs) for each event. For the conservative model, we assumed that operative treatment did not result directly in any QALYs gained, and the health utility in AIS patients was the same as the age-matched US population mean. Costs were inflation-adjusted at 3.22% per year to 2015 US dollars. Costs and benefits were discounted at 3%. Probabilistic sensitivity analysis was performed using mixed first-order and second-order Monte Carlo simulations. Incremental cost utility ratio (ICUR) and incremental net monetary benefit were calculated. One-way sensitivity analyses were performed by varying cost, probability, and QALY estimates.

RESULTS

Operative treatment was favored in 98.5% of simulations, with a median ICUR of $20,600/QALY (95% confidence interval, $20,500-$21,900) below the societal willingness-to-pay threshold (WTPT) of $50,000/QALY. The median incremental net monetary benefit associated with operative treatment was $15,100 (95% confidence interval, $14,800-$15,700). Operative treatment produced net monetary benefit across various WTPTs. Factors that most affected the ICUR were net costs associated with uncomplicated operative treatment, undergoing surgery during adulthood, and development of pulmonary complications.

CONCLUSION

Cost-utility analysis suggests that operative treatment of AIS is favored over nonoperative treatment and falls below the $50,000/QALY WTPT for patients with Lenke 1 curves.

LEVEL OF EVIDENCE

2.

Eighteen-Year Trends in the Prevalence of, and Health Care Use for, Noncancer Pain in the United States: Data from the Medical Expenditure Panel Survey

We used data from the nationally representative Medical Expenditure Panel Survey to determine the 18-year trends in the overall rates of noncancer pain prevalence and pain-related interference, as well as in health care use attributable directly to pain management. The proportion of adults reporting painful health condition(s) increased from 32.9% (99.7% confidence interval [CI] = 31.6-34.2%;120 million adults) in 1997/1998 to 41.0% (99.7% CI = 39.2-42.4%; 178 million adults) in 2013/2014 (P_trend < .0001). Among adults with severe pain-related interference associated with their painful health condition(s), the use of strong opioids specifically for pain management more than doubled from 11.5% (99.7% CI = 9.6-13.4%) in 2001/2002 to 24.3% (99.7% CI = 21.3-27.3%) in 2013/2014 (P_trend < .0001). A smaller increase (P_interaction < .0001) in strong opioid use was seen in those with minimal pain-related interference: 1.2% (99.7% CI = 1.0-1.4%) in 2001/2002 to 2.3% (99.7% CI = 1.9-2.7%) in 2013/2014. Small but statistically significant decreases (P_trend < .0001) were seen in 1) the percentage of adults with painful health condition(s) who had ≥1 ambulatory office visit for their pain: 56.1% (99.7% CI = 54.2-58.0%) in 1997/1998 and 53.3% (99.7% CI = 51.4-55.4%) in 2013/2014; 2) the percentage who had ≥1 emergency room visit for their pain; 9.9% (99.7% CI = 8.6-11.2%) to 8.8% (99.7% CI = 7.9-9.7%); and 3) the percentage with ≥1 overnight hospitalization for their pain: 3.2% (99.7% CI = 2.6-4.0%) to 2.3% (99.7% CI = 1.8-2.8%). PERSPECTIVE: Our data illustrate changes in the management of painful health conditions over the last 2 decades in the United States. Strong opioid use remains high, especially in those with severe pain-related interference. Additional education of health care providers and the public concerning the risk/benefit ratio of opioids appears warranted.

Cost-effectiveness of spinal manipulation, exercise, and self-management for spinal pain using an individual participant data meta-analysis approach: a study protocol

Background

Spinal pain is a common and disabling condition with considerable socioeconomic burden. Spine pain management in the United States has gathered increased scrutiny amidst concerns of overutilization of costly and potentially harmful interventions and diagnostic tests. Conservative interventions such as spinal manipulation, exercise and self-management may provide value for the care of spinal pain, but little is known regarding the cost-effectiveness of these interventions in the U.S. Our primary objective for this project is to estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management for spinal pain using an individual patient data meta-analysis approach.

Methods/design

We will estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management using cost and clinical outcome data collected in eight randomized clinical trials performed in the U.S. Cost-effectiveness will be assessed from both societal and healthcare perspectives using QALYs, pain intensity, and disability as effectiveness measures. The eight randomized clinical trials used similar methods and included different combinations of spinal manipulation, exercise therapy, or self-management for spinal pain. They also collected similar clinical outcome, healthcare utilization, and work productivity data. A two-stage approach to individual patient data meta-analysis will be conducted.

Discussion

This project capitalizes on a unique opportunity to combine clinical and economic data collected in a several clinical trials that used similar methods. The findings will provide important information on the value of spinal manipulation, exercise therapy, and self-management for spinal pain management in the U.S.

A longitudinal study of disc height narrowing and facet joint osteoarthritis at the thoracic and lumbar spine, evaluated by computed tomography: the Framingham Study

BACKGROUND CONTEXT

Prevalence and progression of disc height narrowing (DHN) and facet joint osteoarthritis (FJOA) in the thoracic and lumbar regions in non-clinical populations are not well established.

PURPOSE

The present study aimed to use computed tomography (CT) images to determine the prevalence and progression of DHN and FJOA according to age, sex, and spinal region.

STUDY DESIGN

This is a 6-year longitudinal study.

SAMPLE

A total of 1,195 members of the Framingham Study (mean baseline age 61±9 years) were included in the study.

OUTCOME MEASURES

We compared the prevalence and progression (new or worsening) of moderate-to-severe DHN and FJOA by age, sex, and spinal region.

METHODS

A musculoskeletal radiologist evaluated DHN and FJOA from T4/T5 to L4/L5 on baseline and follow-up CT images using a semi-quantitative scale: 0=normal, 1=mild, 2=moderate, and 3=severe.

RESULTS

One-third or more of women and men ages 40-59 years at baseline had imaged-based evidence of prevalent DHN, more than half had prevalent FJOA, and DHN and FJOA prevalence increased approximately two- to fourfold in those age 60-69 and 70-89 years at baseline, respectively (p<.01). Progression of DHN and FJOA occurred more frequently at the lumbar than at the thoracic spine and more in women than in men (DHN: odds ratio [OR]=1.42, 95% confidence interval [CI]=1.07, 1.88; FJOA: OR=1.70, CI=1.33, 2.17).

CONCLUSIONS

Prevalence and progression of moderate-to-severe DHN and FJOA are common in non-clinical populations of older adults. The high frequency of spinal degeneration observed on CTs in this community-based study may contribute to challenges in interpreting the clinical significance of imaging evidence of DHN and FJOA. Future studies investigating the association of CT-based spinal degenerative features with pain and functional impairments in population-based samples are needed to help determine the clinical significance of imaged-based findings of DHN and FJOA.

A Comparison of Narcotic Consumption Between Hospital and Ambulatory-Based Surgery Centers Following Anterior Cervical Discectomy and Fusion

Background

Several studies have compared outcomes between hospital-based (HBCs) and ambulatory surgery centers (ASCs) following anterior cervical discectomy and fusion (ACDF). However, the association between narcotic consumption and pain in the early postoperative period has not been well characterized. As such, the purpose of this study is to compare pain, narcotic consumption, and length of stay (LOS) between HBC and ASC patients undergoing same-day-discharge following ACDF.

Methods

A surgical registry of patients who underwent a primary, 1- or 2-level ACDF during 2013-2015 was reviewed. Patients were stratified by operative location. Differences in demographics were assessed using independent-sample t tests and chi-square analysis. The presence of an association between operative location and outcomes was analyzed using Poisson regression with robust error variance or linear regression adjusted for preoperative characteristics.

Results

A total of 76 patients were identified, of which 42 and 34 underwent surgery at an HBC or ASC, respectively. The HBC cohort had greater total (P < .001) and hourly (P = .034) narcotic consumption and prolonged LOS (P < .001). Over 90% of ASC patients consumed less than or equal to the 30th percentile (32.0 mg) of oral morphine equivalents (OME), whereas over 57% of HBC patients consumed greater than 32.0 mg OME. The HBC cohort consumed greater average doses of fentanyl and oxycodone (P < .001 for each).

Conclusions

This study demonstrates that patients undergoing same-day surgery for primary 1- or 2-level ACDF received more narcotics at HBCs compared to at ASCs. The increased narcotic consumption at HBCs may have resulted in longer LOS; however, this did not impact long-term pain, complications, or clinical outcomes.

Clinical Relevance

Patients scheduled to be discharged on postoperative day 0 following ACDF at HBCs may be able to receive fewer narcotics and be discharged sooner without compromising pain control or increasing their risk for complications.

View of U.S. spine surgeons regarding cost reduction measures

Background

This is a cross-sectional study. Our objective is to survey spine surgeons' views of responsibility to reduce healthcare costs, enthusiasm for cost reduction strategies, and agreement regarding roles in cost containment. The rising cost of healthcare has spurred debate about reducing expenditures. Previous studies have found that attitudes of anesthesiologists are predominantly in alignment with those of American physicians, but less is known about the views of spine surgeons.

Methods

After obtaining institutional approval, an electronic survey was disseminated to active members of AO Spine North America (AOSNA) via email. Respondents were asked eight questions about their age, gender, years in practice, practice facility, political views and opinions regarding management of healthcare costs.

Results

From 91 respondents, most were under the age of 60 years (87%), male (96%), and in practice for less than 30 years (91%), practiced at university hospitals (47%) and held politically conservative views (47%). Most responsibility was allocated to hospital and health systems, health insurance companies, pharmaceutical companies, and device manufacturers. Respondents were most enthusiastic about rooting out fraud and abuse and aware of their role in managing the cost of healthcare. Spine surgeons who were in practice for longer were more enthusiastic about reducing cost by reducing overall physician reimbursement via bundled payments, Medicare payment reduction, ending fee-for-service, penalizing surgeons for patient readmissions, and lowering compensation to individual spine surgeons.

Conclusions

Spine surgeons allocated responsibility to reduce healthcare costs to healthcare systems, were most enthusiastic about eliminating wasteful spending, and were in agreement regarding their responsibility to control the costs of healthcare. Compared to US physicians of various specialties and anesthesiologists, spine surgeons assigned less responsibility to trials lawyers and expressed markedly less enthusiasm for limiting access to expensive treatments.

Does the Addition of Either a Lateral or Posterior Interbody Device to Posterior Instrumented Lumbar Fusion Decrease Cost Over a 6-Year Period?

STUDY DESIGN

Retrospective case-control study.

OBJECTIVES

Few studies have compared the costs of single-level (1) posterior instrumented fusion alone (PSF), (2) posterior interbody fusion with PSF (PLIF), and (3) lateral interbody fusion with PSF (circumferential LLIF). The purpose of this study was to compare costs associated with these procedures.

METHODS

Charts were reviewed and patients followed-up with a telephone questionnaire. Medicare reimbursement data was used for cost estimation from the payer's perspective. Multivariate survival analysis was performed to assess time to elevated resource use (greater than 90% of study patients or $68 672).

RESULTS

A total of 337 patients (PSF, 45; PLIF, 222; circumferential LLIF, 70) were included (63% follow-up at 6 years). PSF and circumferential LLIF patients were 3 times more likely to reach the cutoff value compared with PLIF patients (P = .017).

CONCLUSIONS

Circumferential LLIF and PSF patients were more likely to have higher resource use than PLIF patients and thus incur greater costs at 6-year follow-up.

Causes and Timing of Unplanned 90-day Readmissions Following Spine Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to evaluate the causes, timing, and factors associated with unplanned 90-day readmissions following elective spine surgery.

SUMMARY OF BACKGROUND DATA

Unplanned readmissions after spine surgery are costly and an important determinant of the value of care. Several studies using database information have reported on rates and causes of readmission. However, these often lack the clinical detail and actionable data necessary to guide early postdischarge interventions.

METHODS

Patients undergoing elective spine surgery for degenerative disease at a major medical center were enrolled in a prospective longitudinal registry. Patient and surgery-specific characteristics, baseline, and 3-month patient-reported outcomes were prospectively recorded. Readmissions were reviewed retrospectively to establish the reason and time to readmission. A multivariable Cox proportional hazard model was created to analyze the independent effects of several factors on readmission.

RESULTS

Of 2761 patients with complete 3-month follow-up, 156 had unplanned 90-day readmissions (5.6%). The most common reason was surgery-related (52%), followed by medical complications (38%) and pain (10%). Pain readmissions presented with a median time of 6 days. Medical readmissions presented at 12 days. Surgical complications presented at various times with wound complications at 6 days, cerebrospinal fluid leaks at 12 days, surgical site infections at 23 days, and surgical failure at 38 days. A history of myocardial infarction, osteoporosis, higher baseline leg and arm pain scores, longer operative duration, and lumbar surgery were associated with readmission.

CONCLUSION

Nearly half of all unplanned 90-day readmissions were because of pain and medical complications and occurred with a median time of 6 and 12 days, respectively. The remaining 52% of readmissions were directly related to surgery and occurred at various times depending on the specific reason. This timeline for pain and medical readmissions represents an opportunity for targeted postdischarge interventions to prevent unplanned readmissions following spine surgery.

LEVEL OF EVIDENCE

3.

Associations of Race and Ethnicity With Patient-Reported Outcomes and Health Care Utilization Among Older Adults Initiating a New Episode of Care for Back Pain

STUDY DESIGN

Secondary analysis of the Back Pain Outcomes using Longitudinal Data (BOLD) cohort study.

OBJECTIVE

To characterize associations of self-reported race/ethnicity with back pain (BP) patient-reported outcomes (PROs) and health care utilization among older adults with a new episode of care for BP.

SUMMARY OF BACKGROUND DATA

No prior longitudinal studies have characterized associations between multiple race/ethnicity groups, and BP-related PROs and health care utilization in the United States.

METHODS

This study included 5117 participants ≥65 years from three US health care systems. The primary BP-related PROs were BP intensity and back-related functional limitations over 24 months. Health care utilization measures included common diagnostic tests and treatments related to BP (spine imaging, spine-related relative value units [RVUs], and total RVUs) over 24 months. Analyses were adjusted for multiple potential confounders including sociodemographics, clinical characteristics, and study site.

RESULTS

Baseline BP ratings were significantly higher for blacks vs. whites (5.8 vs. 5.0; P < 0.001). Participants in all race/ethnicity groups showed statistically significant, but modest improvements in BP over 24 months. Blacks and Hispanics did not have statistically significant improvement in BP-related functional limitations over time, unlike whites, Asians, and non-Hispanics; however, the magnitude of differences in improvement between groups was small. Blacks had less spine-related health care utilization over 24 months than whites (spine-related RVU ratio of means 0.66, 95% confidence interval [CI] 0.51-0.86). Hispanics had less spine-related health care utilization than non-Hispanics (spine-related RVU ratio of means 0.60; 95% CI 0.40-0.90).

CONCLUSION

Blacks and Hispanics had slightly less improvement in BP-related functional limitations over time, and less spine-related health care utilization, as compared to whites and non-Hispanics, respectively. Residual confounding may explain some of the association between race/ethnicity and health outcomes. Further studies are needed to understand the factors underlying these differences and which differences reflect disparities.

LEVEL OF EVIDENCE

3.

Does Day of Surgery Affect Hospital Length of Stay and Charges Following Minimally Invasive Transforaminal Lumbar Interbody Fusion?

STUDY DESIGN

Retrospective Cohort.

OBJECTIVE

To determine if an association exists between surgery day and length of stay or hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARYOF BACKGROUND DATA

Length of inpatient stay after orthopedic procedures has been identified as a primary cost driver, and previous research has focused on determining risk factors for prolonged length of stay. In the arthroplasty literature, surgery performed later in the week has been identified as a predictor of increased length of stay. However, no such investigation has been performed for MIS TLIF.

MATERIALS AND METHODS

A surgical registry of patients undergoing MIS TLIF between 2008 and 2016 was retrospectively reviewed. Patients were grouped based on day of surgery, with groups including early surgery and late surgery. Day of surgery group was tested for an association with demographics and perioperative variables using the student t test or χ analysis. Day of surgery group was then tested for an association with direct hospital costs using multivariate linear regression.

RESULTS

In total, 438 patients were analyzed. In total, 51.8% were in the early surgery group, and 48.2% were in the late surgery group. There were no differences in demographics between groups. There were no differences between groups with regard to operative time, intraoperative blood loss, length of stay, or discharge day. Finally, there were no differences in total hospital charges between early and late surgery groups (P=0.247).

CONCLUSIONS

The specific day on which a MIS TLIF procedure occurs is not associated with differences in length of inpatient stay or total hospital costs. This suggests that the postoperative course after MIS TLIF procedures is not affected by the differences in hospital staffing that occurs on the weekend compared with weekdays.

Facteurs influençant la multiplication de traitements en physiothérapie : une analyse thématique de la jurisprudence québécoise

La physiothérapie est touchée par un problème de multiplication de traitements; la fréquence des traitements ou leur durée peuvent être inappropriées ou disproportionnées face aux besoins du patient. La multiplication de traitements peut avoir des conséquences financières, physiques, psychologiques et sociales. Pour explorer les facteurs influençant la fréquence et la durée des traitements dans les situations de multiplication de traitements, une analyse thématique de la jurisprudence a été réalisée. Certains facteurs cliniques et non cliniques influençant la fréquence et la durée des traitements ont pu être identifiés par cette analyse thématique de la jurisprudence. Les facteurs cliniques impliquent que l’allocation des ressources soit guidée par la condition et l’évolution du patient. Les facteurs non cliniques peuvent inclure la pression des employeurs, les demandes des autres professionnels de la santé ou les conflits d’intérêts de type financier. Cette analyse thématique de la jurisprudence est une première étape pour comprendre ce qui motive les décisions cliniques d’allocation des ressources des professionnels de la physiothérapie. Cette démarche est essentielle pour mettre en place des politiques et des normes de pratique soucieuses du contexte de pratique et des normes éthiques, déontologiques et légales qui animent la profession.

Biomechanical evaluation of exoskeleton use on loading of the lumbar spine

The objective of this study was to investigate biomechanical loading to the low back as a result of wearing an exoskeletal intervention designed to assist in occupational work. Twelve subjects simulated the use of two powered hand tools with and without the use of a Steadicam vest with an articulation tool support arm in a laboratory environment. Dependent measures of peak and mean muscle forces in ten trunk muscles and peak and mean spinal loads were examined utilizing a dynamic electromyography-assisted spine model. The exoskeletal device increased both peak and mean muscle forces in the torso extensor muscles (p < 0.001). Peak and mean compressive spinal loads were also increased up to 52.5% and 56.8%, respectively, for the exoskeleton condition relative to the control condition (p < 0.001). The results of this study highlight the need to design exoskeletal interventions while anticipating how mechanical loads might be shifted or transferred with their use.

Variation in perceived providers of ambulatory physical therapy in the United States, 2009-2012: An analysis using data from the Medical Expenditure Panel Survey

Introduction: Little is known about public perception of physical therapy (PT) delivery by type of provider in the United States (US). Purpose: This study aimed to describe differences in ambulatory PT visits and expenditures according to perceived provider type, and to determine if visits and expenditures varied by provider type. Methods: This study employed the Medical Expenditure Panel Survey (MEPS), which is a nationally representative survey of US households that used a complex, stratified, cluster sample design. Data from cross-sectional samples over 4 years of the MEPS Household Component were used to study adults with musculoskeletal conditions who reported receiving ambulatory PT. National-level, average annual estimates of numbers of visits, and reported total expenditures by perceived provider type were computed. Associations between perceived provider type and visits and expenditures were determined by linear regression, accounting for the sample design, and adjusting for demographic and clinical covariates. Results: Estimated annual perceived PT visits were 60.00 million with physical therapists, 39.66 million with non-physical therapist providers, and 20.66 million with multiple providers. Estimated annual expenditures for PT were $9.37 billion with physical therapists, $4.62 billion with non-physical therapist providers, and $3.09 billion with multiple providers. Compared with non-physical therapist providers, physical therapist provider status and multiple provider status were associated with higher numbers of visits and expenditures. Conclusion: Non-physical therapist providers are responsible for a substantial amount of PT delivery in the US. Numbers of visits and total expenditures varied by the type of provider delivering PT.

The Influence of Patient Choice of First Provider on Costs and Outcomes: Analysis From a Physical Therapy Patient Registry

Study Design Retrospective study. Background Alternative models of care that allow patients to choose direct access to physical therapy have shown promise in terms of cost reduction for neck and back pain. However, real-world exploration within the US health care system is notably limited. Objectives To compare total claims paid and patient outcomes for patients with neck and back pain who received physical therapy intervention via direct access versus medical referral. Methods Data were accessed for patients seeking care for neck or back pain (n = 603) between 2012 and 2014, who chose to begin care either through traditional medical referral or direct access to a physical therapy- led spine management program. All patients received a standardized, pragmatic physical therapy approach, with patient-reported measures of pain and disability assessed before and after treatment. Patient demographics and outcomes data were obtained from the medical center patient registry and combined with total claims paid calculated for the year after the index claim. Linear mixed-effects modeling was used to analyze group differences in pain and disability, visits/time, and annualized costs. Results Patients who chose to enter care via the direct-access physical therapy-led spine management program displayed significantly lower total costs (mean difference, $1543; 95% confidence interval: $51, $3028; P = .04) than those who chose traditional medical referral. Patients in both groups showed clinically important improvements in pain and disability, which were similar between groups (P>.05). Conclusion The initial patient choice to begin care with a physical therapist for back or neck pain resulted in lower cost of care over the next year, while resulting in similar improvements in patient outcomes at discharge from physical therapy. These findings add to the emerging literature suggesting that patients' choice to access physical therapy through direct access may be associated with lower health care expenditures for patients with neck and back pain. Level of Evidence Economic and decision analyses, level 4. J Orthop Sports Phys Ther 2018;48(2):63-71. Epub 26 Oct 2017. doi:10.2519/jospt.2018.7423.

Measurement properties of instruments assessing permanent functional impairment of the spine: a systematic review protocol

INTRODUCTION

Permanent functional impairment (PFI) of the spine is a rating system used by compensation authorities, such as workers compensation boards, to establish an appropriate level of financial compensation for persistent loss of function. Determination of PFI of the spine is commonly based on the assessment of spinal movement combined with other measures of physical and functional impairments; however, the reliability and validity of the measurement instruments used for these evaluations have yet to be established. The aim of this study is to systematically review and synthesise the literature concerning measurement properties of the various and different instruments used for assessing PFI of the spine.

METHODS

Three conceptual groups of terms (1) PFI, (2) spinal disorder and (3) measurement properties will be combined to search Medline, EMBASE, CINAHL, Web of Science, Scopus, PEDro, OTSeeker and Health and Safety Science Abstracts. We will examine peer-reviewed, full-text articles over the full available date range. Two reviewers will independently screen citations (title, abstract and full text) and perform data extraction. Included studies will be appraised as to their methodological quality using the COnsensus-based Standards for the selection of health Measurement INstruments criteria. Findings will be summarised and presented descriptively, with meta-analysis pursued as appropriate.

ETHICS AND DISSEMINATION

This review will summarise the current level of evidence of measurement properties of instruments used for assessing PFI of the spine. Findings of this review may be applicable to clinicians, policy-makers, workers' compensation boards, other insurers and health and safety organisations. The findings will likely provide a foundation and direction for future research priorities for assessing spinal PFI.

PROSPERO REGISTRATION NUMBER

CRD42017060390.

Best Practices for Outpatient Anterior Cervical Surgery: Results From a Delphi Panel

STUDY DESIGN

Delphi Panel expert panel consensus and narrative literature review.

OBJECTIVE

To obtain expert consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (anterior cervical disc fusion (ACDF) and cervical total disc replacement (CTDR)).

SUMMARY OF BACKGROUND DATA

Spine surgery in ambulatory settings is becoming a preferred option for both patients and providers. The transition from traditional inpatient environments has been enabled by innovation in anesthesia protocols and surgical technique, as well as favorable economics. Studies have demonstrated that anterior cervical surgery (ACDF and CTDR) can be performed safely on an outpatient basis. However, practice guidelines and evidence-based protocols to inform best practices for the safe and efficient performance of these procedures in same-day, ambulatory settings are lacking.

METHODS

A panel of five neurosurgeons, three anesthesiologists, one orthopedic spine surgeon, and a registered nurse was convened to comprise a multidisciplinary expert panel. A three-round modified-Delphi method was used to generate best-practice statements. Predetermined consensus was set at 70% for each best-practice statement.

RESULTS

A total of 94 consensus statements were reviewed by the panel. After three rounds of review, there was consensus for 83 best-practice statements, while 11 statements failed to achieve consensus. All statements within several perioperative categories (and subcategories) achieved consensus, including preoperative assessment (n = 8), home-care/follow-up (n = 2), second-stage recovery (n = 18), provider economics (n = 8), patient education (n = 14), discharge criteria (n = 4), and hypothermia prevention (n = 6).

CONCLUSION

This study obtained expert-panel consensus on best practices for patient selection and perioperative decision making for outpatient anterior cervical surgery (ACDF/CTDR). Given a paucity of guidelines and a lack of established care pathways for ACDF/CTDR in same-day, ambulatory settings, results from this study can supplement available evidence in support of local protocol development for providers considering a transition to the outpatient environment.

LEVEL OF EVIDENCE

4.

Correlation of Body Composition and Low Back Pain Severity in a Cross-Section of US Veterans

OBJECTIVE

Back pain is more prevalent in the obese, but whether back pain severity is directly correlated to obesity in veterans is unknown. We sought to determine if there was a correlation between body composition and low back pain severity in a sample of veterans. The hypothesis was that veterans with higher body mass index values would report higher low back pain severity scores.

METHODS

This study was a retrospective chart review of 1768 veterans presenting to a Veterans Affairs chiropractic clinic with a chief complaint of low back pain between January 1, 2009 and December 31, 2014. Spearman's rho was used to test for correlation between body composition as measured by body mass index and low back pain severity as measured by the Back Bournemouth Questionnaire.

RESULTS

On average, the sample was predominantly male (91%), older than 50, and overweight (36.5%) or obese (48.9%). There was no correlation between body mass index and Back Bournemouth Questionnaire scores, r = .088, p < .001.

CONCLUSIONS

The majority of veterans with low back pain in this sample were either overweight or obese. There was no correlation between body composition and low back pain severity in this sample of veterans.

Outpatient vs Inpatient Anterior Cervical Discectomy and Fusion: A Population-Level Analysis of Outcomes and Cost

BACKGROUND

Outpatient anterior cervical discectomy and fusion (ACDF) is a promising candidate for US healthcare cost reduction as several studies have demonstrated that overall complications are relatively low and early discharge can preserve high patient satisfaction, low morbidity, and minimal readmission.

OBJECTIVE

To compare clinical outcomes and associated costs between inpatient and ambulatory setting ACDF.

METHODS

Demographics, comorbidities, emergency department (ED) visits, readmissions, reoperation rates, and 90-d charges were retrospectively analyzed for patients undergoing elective ACDF in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases.

RESULTS

A total of 3135 ambulatory and 46 996 inpatient ACDFs were performed. Mean Charlson comorbidity index, length of stay, and mortality were 0.2, 0.4 d, and 0% in the ambulatory cohort and 0.4, 1.8 d, and 0.04% for inpatients (P &lt; .0001). Ambulatory patients were younger (48.0 vs 53.1) and more likely to be Caucasian. One hundred sixty-eight ambulatory patients (5.4%) presented to the ED within 30 d (mean 11.3 d), 51 (1.6%) were readmitted, and 5 (0.2%) underwent reoperation. Among inpatient surgeries, 2607 patients (5.5%) presented to the ED within 30 d (mean 9.7 d), 1778 (3.8%) were readmitted (mean 6.3 d), and 200 (0.4%) underwent reoperation. Higher Charlson comorbidity index increased rate of ED visits (ambulatory operating room [OR] 1.285, P &lt; .05; inpatient OR 1.289, P &lt; .0001) and readmission (ambulatory OR 1.746, P &lt; .0001; inpatient OR 1.685, P &lt; .0001). Overall charges were significantly lower for ambulatory ACDFs ($33 362.51 vs $74 667.04; P &lt; .0001).

CONCLUSION

ACDF can be performed in an ambulatory setting with comparable morbidity and readmission rates, and lower costs, to those performed in an inpatient setting.

Clinical Specialization and Adherence to Evidence-Based Practice Guidelines for Low Back Pain Management: A Survey of US Physical Therapists

Study Design Electronic cross-sectional survey. Background The American Physical Therapy Association (APTA) evidence-based practice guideline for low back pain (LBP) elaborated on strategies to manage nonspecific LBP in routine physical therapy practice. This guideline described LBP associated with mobility deficit, leg pain and a directional preference, coordination impairment (lumbar instability), and fear-avoidance behavior. Objectives To assess American physical therapists' adherence to the clinical practice guidelines (CPGs) for LBP of the Orthopaedic Section of the APTA, and to compare adherence among physical therapists with different qualifications. Methods The investigators contacted 1861 members of the Orthopaedic Section of the APTA and 1000 members of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). Participants made treatment choices for 4 clinical vignettes: LBP with mobility deficit, coordination impairment, leg pain (directional preference), or fear-avoidance behavior. The investigator used logistic regression analyses to compare guideline adherence among physical therapists with the following qualifications: orthopaedic clinical specialists (PTOs), Fellows of the AAOMPT (PTFs), PTOs and PTFs (PTFOs), and physical therapists without clinical specialization but with a musculoskeletal interest (PTMSs). Results A total of 410 physical therapists completed all sections of the survey (142 PTOs, 110 PTFOs, 74 PTFs, and 84 PTMSs). Adherence to the APTA's CPG was highest for LBP associated with leg pain and a directional preference (72.2%), followed by LBP with mobility deficit (57.1%), LBP with coordination impairment (46.1%), and fear-avoidance behavior (29.5%). Physical therapists who were PTFOs adhered better to the CPG for LBP than did PTMSs for all 4 patient vignettes. Orthopaedic clinical specialists adhered better to the CPG for LBP for the vignettes of mobility deficit and of LBP with fear-avoidance behavior than did PTMSs. Conclusion Physical therapists who were PTFOs and PTOs adhered better to the CPG than did PTMSs. Based on our preliminary results, further education on the CPG for LBP management is needed, particularly for managing LBP with coordination impairment and with fear-avoidance behavior. J Orthop Sports Phys Ther 2017;47(5):347-358. Epub 3 Mar 2017. doi:10.2519/jospt.2017.6561.

A treatise for a new philosophy of chiropractic medicine

BACKGROUND

The philosophy of chiropractic has been a much debated entity throughout the existence of the chiropractic profession. Much criticism has been passed upon the historical philosophy of chiropractic and propagated by contemporary adherents. To date, a new philosophy has not been detailed nor presented that demonstrates principles by which to follow.

AIM

The purpose of this paper is to expand upon the work of Russell Kirk (b.1918, d. 1994), an American political theorist, as a basis for principles to guide the formation of a philosophy of chiropractic medicine (PCM). Each of Kirk's principles will be explained and expounded upon as applicable to a PCM. The addition of the term "medicine" to chiropractic is indicative of a new direction for the profession.

DISCUSSION

The ten principles that provide a foundation for a PCM include: (a) moral order, (b) custom, convention and continuity, (c) prescription, (d) prudence, (e) variety, (f) imperfectability, (g) freedom and property linkage, (h) voluntary community and involuntary collectivism, (i) prudent restraints upon power and human passions, and (j) permanence and change. Each of these principles offers not a dogmatic approach but provides insight into the application of chiropractic medicine to the entire station of the patient and society at large especially that of the economic, social and political. These principles provide direction in not only the approach to the doctor-patient encounter but can be used to visualize the wider world and its potential impact. Instead, these principles examine many tangential issues worthy of discussion that may impact health, social, political, and economic policy and how the chiropractic profession can approach these issues.

CONCLUSION

This paper provides the initial steps in formulating a PCM using principles from a sociological, political and economic standpoint which may impact on how chiropractic medicine approaches the patient and society in totality. In addition, these principles provide the necessary first steps in the arena of the social, political and economic aspects and how chiropractic medicine can advance.

Cost-Effectiveness of Primary Care Management With or Without Early Physical Therapy for Acute Low Back Pain: Economic Evaluation of a Randomized Clinical Trial

STUDY DESIGN

Economic evaluation of a randomized clinical trial.

OBJECTIVE

Compare costs and cost-effectiveness of usual primary care management for patients with acute low back pain (LBP) with or without the addition of early physical therapy.

SUMMARY OF BACKGROUND DATA

Low back pain is among the most common and costly conditions encountered in primary care. Early physical therapy after a new primary care consultation for acute LBP results in small clinical improvement but cost-effectiveness of a strategy of early physical therapy is unknown.

METHODS

Economic evaluation was conducted alongside a randomized clinical trial of patients with acute, nonspecific LBP consulting a primary care provider. All patients received usual primary care management and education, and were randomly assigned to receive four sessions of physical therapy or usual care of delaying referral consideration to permit spontaneous recovery. Data were collected in a randomized trial involving 220 participants age 18 to 60 with LBP <16 days duration without red flags or signs of nerve root compression. The EuroQoL EQ-5D health states were collected at baseline and after 1-year and used to compute the quality adjusted life year (QALY) gained. Direct (health care utilization) and indirect (work absence or reduced productivity) costs related to LBP were collected monthly and valued using standard costs. The incremental cost-effectiveness ratio was computed as incremental total costs divided by incremental QALYs.

RESULTS

Early physical therapy resulted in higher total 1-year costs (mean difference in adjusted total costs = $580, 95% CI: $175, $984, P = 0.005) and better quality of life (mean difference in QALYs = 0.02, 95% CI: 0.005, 0.35, P = 0.008) after 1-year. The incremental cost-effectiveness ratio was $32,058 (95% CI: $10,629, $151,161) per QALY.

CONCLUSION

Our results support early physical therapy as cost-effective relative to usual primary care after 1 year for patients with acute, nonspecific LBP.

LEVEL OF EVIDENCE

2.

Trends in the use of patient-reported outcome instruments in neurosurgical adult thoracolumbar deformity and degenerative disease literature

Objective:

Shifting national healthcare trends place increased emphasis on patient-centered care and value-based outcomes, and thus, patient-reported outcome instruments (PROIs) are often used. We sought to characterize the trends in PROI use over the past decade with regard to thoracolumbar degenerative spine disease and spinal deformity in major neurosurgical journals.

Methods:

Articles were screened for PROI use through a PubMed search among five major neurosurgical journals from 2006 to 2016. Articles focusing on adult thoracolumbar deformity and degenerative disease were selected with stringent criteria to further characterize PROI use.

Results:

A total of 29 different PROIs were used among 102 articles identified from 2006 to 2016 using our search strategy. Journal of Neurosurgery: Spine contained the most articles utilizing PROIs with 35.3% of all articles meeting search criteria. The most frequently used PROIs were Oswestry Disability Index, visual analog scale, and the European Quality of Life Five-dimension questionnaire used in 79.4%, 59.8%, and 29.4% of articles, respectively. Linear regression identified a significant increase in the number of articles employing PROIs from 2006 to 2016 (Y = 1.85, R²= 0.77, P < 0.01). The total number of PROIs per article was relatively stagnant over time and did not significantly change (Y = 0.03, R²= 0.05, P = 0.51).

Conclusions:

PROI use as an outcome tool in the adult thoracolumbar disease literature has increased during the past decade, which may be an indicative of PROI use to define patient expectations. This may also represent a trend toward PROI use as a surrogate measure of value-based care.

Local, national, and service component cost variations in the management of low back pain: Considerations for the clinician

In the past two decades, the cost associated with managing low back pain has increased significantly. Improved consciousness of how clinicians utilize resources when managing low back pain is necessary in the current economic climate. The goal of this review is to examine the component costs associated with managing low back pain and provide practical solutions for reducing healthcare costs. This is accomplished by utilizing examples from a major metropolitan area with several major academic institutions and private health care centers. It is clear that there is considerable local and national variation in the component costs of managing low back pain, including physician visits, imaging studies, medications, and therapy services. By being well informed about these variations in one's environment, clinicians and patients alike can make strides towards reducing the financial impact of low back pain. Investigation of the cost discrepancies for services within one's community of practice is important. Improved public access to both cost and outcomes data is needed.

Cost-effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain

BACKGROUND CONTEXT

Chronic neck pain is a prevalent and disabling condition among older adults. Despite the large burden of neck pain, little is known regarding the cost-effectiveness of commonly used treatments.

PURPOSE

This study aimed to estimate the cost-effectiveness of home exercise and advice (HEA), spinal manipulative therapy (SMT) plus HEA, and supervised rehabilitative exercise (SRE) plus HEA.

STUDY DESIGN/SETTING

Cost-effectiveness analysis conducted alongside a randomized clinical trial (RCT) was performed.

PATIENT SAMPLE

A total of 241 older adults (≥65 years) with chronic mechanical neck pain comprised the patient sample.

OUTCOME MEASURES

The outcome measures were direct and indirect costs, neck pain, neck disability, SF-6D-derived quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) over a 1-year time horizon.

METHODS

This work was supported by grants from the National Center for Complementary and Integrative Health (#F32AT007507), National Institute of Arthritis and Musculoskeletal and Skin Diseases (#P60AR062799), and Health Resources and Services Administration (#R18HP01425). The RCT is registered at ClinicalTrials.gov (#NCT00269308). A societal perspective was adopted for the primary analysis. A healthcare perspective was adopted as a sensitivity analysis. Cost-effectivenesswas a secondary aim of the RCT which was not powered for differences in costs or QALYs. Differences in costs and clinical outcomes were estimated using generalized estimating equations and linear mixed models, respectively. Cost-effectiveness acceptability curves were calculated to assess the uncertainty surrounding cost-effectiveness estimates.

RESULTS

Total costs for SMT+HEA were 5% lower than HEA (mean difference: -$111; 95% confidence interval [CI] -$1,354 to $899) and 47% lower than SRE+HEA (mean difference: -$1,932; 95% CI -$2,796 to -$1,097). SMT+HEA also resulted in a greater reduction of neck pain over the year relative to HEA (0.57; 95% CI 0.23 to 0.92) and SRE+HEA (0.41; 95% CI 0.05 to 0.76). Differences in disability and QALYs favored SMT+HEA. The probability that adding SMT to HEA is cost-effective at willingness to pay thresholds of $50,000 to $200,000 per QALY gained ranges from 0.75 to 0.81. If adopting a health-care perspective, costs for SMT+HEA were 66% higher than HEA (mean difference: $515; 95% CI $225 to $1,094), resulting in an ICER of $55,975 per QALY gained.

CONCLUSION

On average, SMT+HEA resulted in better clinical outcomes and lower total societal costs relative to SRE+HEA and HEA alone, with a 0.75 to 0.81 probability of cost-effectiveness for willingness to pay thresholds of $50,000 to $200,000 per QALY.

Understanding the Extent and Drivers of Interphysician Cost Variation for Spine Procedures

STUDY DESIGN

Retrospective analysis of billing data, medical records, and hospital cost data.

OBJECTIVE

To quantify intersurgeon variation for hospital costs of four spine procedures while adjusting for patient comorbidities and demographic factors.

SUMMARY OF BACKGROUND DATA

Spine care accounts for $90 billion in health care expenditures in the United States. Past findings demonstrate regional variation in surgery rates and high intersurgeon variation for anterior cervical discectomies/fusions. However, less has been done to examine intersurgeon variation in resource use across multiple procedures while adjusting for patient characteristics outside of a surgeon's control.

METHODS

We examined intersurgeon variation for 1241 elective spine procedures at one facility for 3 years. The procedures included 1 to 2 level cases of anterior cervical discectomies/fusions, posterior lumbar decompressions/fusions, posterior laminectomies, and lumbar discectomies. We isolated mean and median costs by surgeon and adjusted for patient demographics, comorbidities, and procedure types. Finally, we examined variation in subcategories such as instrumentation and inpatient stay costs to determine which contribute to total cost variation.

RESULTS

Unadjusted costs per surgeon varied by a factor of 1.32 to 1.81 between lowest and highest cost surgeon depending on procedure. After adjusting for patient features and procedure, variation was reduced to 1.31x. Of the seven surgeons who had sufficient patient volume, one was significantly less costly (-$1,462 per procedure) whereas three were significantly more costly than mean (+$685, +$839, +$702 per procedure). Intersurgeon differences in supply and operating room costs largely accounted for total variation, though actual drivers of variation were surgeon-specific.

CONCLUSION

Surgeons vary in average cost for spine procedures, though variation is more modest once adjusted for patient characteristics. Data on procedure-level variation should be discussed with individual surgeons to shift practice patterns. Finally, the comparison methodology can be applied to other procedures and specialties.

LEVEL OF EVIDENCE

4.

Chiropractic Distraction Spinal Manipulation on Postsurgical Continued Low Back and Radicular Pain Patients: A Retrospective Case Series

PURPOSE

The purpose of this case series is to report on changes in pain levels experienced by 69 postsurgical continued pain patients who received Cox Technic Flexion Distraction (CTFD).

METHODS

Fifteen doctors of chiropractic collected retrospective data from the records of the postsurgical continued pain patients seen in their clinic from February to July 2012 who were treated with CTFD, which is a type of chiropractic distraction spinal manipulation. Informed consent was obtained from all patients who met the inclusion criteria for this study. Data recorded included subjective patient pain levels at the end of the treatments provided and at 24 months following the last treatment.

RESULTS

Fifty-four (81%) of the patients showed greater than 50% reduction in pain levels at the end of the last treatment, and 13 (19%) showed less than 50% improvement of pain levels at the end of active care (mean, 49 days and 11 treatments). At 24-month follow-up, of 56 patients available, 44 (78.6%) had continued pain relief of greater than 50% and 10 (18%) reported 50% or less relief. The mean percentage of relief at the end of active care was 71.6 (SD, 23.2) and at 24 months was 70 (SD, 25). At 24 months after active care, 24 patients (43%) had not sought further care, and 32 required further treatment consisting of chiropractic manipulation for 17 (53%), physical therapy, exercise, injections, and medication for 9 (28%), and further surgery for 5 (16%).

CONCLUSION

Greater than 50% pain relief following CTFD chiropractic distraction spinal manipulation was seen in 81% of postsurgical patients receiving a mean of 11 visits over a 49-day period of active care.

Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis

OBJECTIVES

The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by provider patterns of care for the treatment of neck pain in North Carolina.

METHODS

This was an analysis of neck-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees (NCSHP) from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the NCSHP using ICD-9 diagnostic codes for uncomplicated neck pain (UNP) and complicated neck pain (CNP).

RESULTS

Care patterns with single-provider types and no referrals incurred the least average charges for both UNP and CNP. When care did not include referral providers or services, for either UNP or CNP, MD care with PT was generally less expensive than MD care with DC care. However, when care involved referral providers or services, MD and PT care was on average more expensive than MD and DC care for either UNP or CNP. Risk-adjusted charges for patients in the middle quintile of risk (available 2006-2009) were lower for chiropractic patients with or without medical care or referral care to other providers.

CONCLUSIONS

Chiropractic care alone or DC with MD care incurred appreciably fewer charges for UNP or CNP compared to MD care with or without PT care, when care included referral providers or services. This finding was reversed when care did not include referral providers or services. Risk-adjusted charges for UNP and CNP patients were lower for DC care patterns.

Importance of the type of provider seen to begin health care for a new episode low back pain: associations with future utilization and costs

RATIONALE, AIMS AND OBJECTIVE

Low back pain (LBP) care can involve many providers. The provider chosen for entry into care may predict future health care utilization and costs. The objective of this study was to explore associations between entry settings and future LBP-related utilization and costs.

METHODS

A retrospective review of claims data identified new entries into health care for LBP. We examined the year after entry to identify utilization outcomes (imaging, surgeon or emergency visits, injections, surgery) and total LBP-related costs. Multivariate models with inverse probability weighting on propensity scores were used to evaluate relationships between utilization and cost outcomes with entry setting.

RESULTS

747 patients were identified (mean age = 38.2 (± 10.7) years, 61.2% female). Entry setting was primary care (n = 409, 54.8%), chiropractic (n = 207, 27.7%), physiatry (n = 83, 11.1%) and physical therapy (n = 48, 6.4%). Relative to primary care, entry in physiatry increased risk for radiographs (OR = 3.46, P = 0.001), advanced imaging (OR = 3.38, P < 0.001), injections (OR = 4.91, P < 0.001), surgery (OR = 4.76, P = 0.012) and LBP-related costs (standardized Β = 0.67, P < 0.001). Entry in chiropractic was associated with decreased risk for advanced imaging (OR = 0.21, P = 0.001) or a surgeon visit (OR = 0.13, P = 0.005) and increased episode of care duration (standardized Β = 0.51, P < 0.001). Entry in physical therapy decreased risk of radiographs (OR = 0.39, P = 0.017) and no patient entering in physical therapy had surgery.

CONCLUSIONS

Entry setting for LBP was associated with future health care utilization and costs. Consideration of where patients chose to enter care may be a strategy to improve outcomes and reduce costs.

A Survey of Innovative Reimbursement Models in Spine Care

STUDY DESIGN

Structured key informant interviews with follow-up.

OBJECTIVE

The aim of the study was to describe innovative reimbursement models in spine care and gather perspectives on the future of spine care reimbursement.

SUMMARY OF BACKGROUND DATA

The United States spends $90 billion annually on medical expenses for low back pain. One approach to promoting high-quality, cost-effective care is through bundled payments and other reimbursement models wherein physicians are held accountable for costs and utilization. Little data exist on innovative payment models in spine care.

METHODS

Through literature review and discussions with leaders in the field, we identified organizations that were engaged in bundled payment initiatives for spine care and surgery. These included healthcare systems, physician groups, organizations helping to set up bundles, and a large employer. We conducted interviews to understand the background and specific features of each initiative, generalizable success factors and challenges, and perspectives on the future of spine reimbursement.

RESULTS

We interviewed 24 stakeholders across 18 organizations that collectively perform approximately 12,000 inpatient spine surgeries annually. Fee-for-service reimbursement accounts for a majority of revenue, but several organizations expect 30% to 45% of their spine volume to be covered under bundled payments within 3 years and cite new patient volume, increased surgical yield, and financial benefits from efficiency improvements as reasons for adopting bundled payments. Current initiatives are heterogeneous, but share similar success factors and challenges. Institutions are more hesitant to adopt risk-based payment models for chronic back care, citing difficulty modeling risk, patient heterogeneity, and difficulty aligning incentives.

CONCLUSION

Payment models outside of the traditional fee-for-service paradigm are emerging in spine care. Providers that preemptively adopt bundled payments can increase patient volumes from payers seeking cost-effective care. Going forward, organizations should begin considering reimbursement models that focus on noninterventional spine care. Finally, developments in spine reimbursement may apply to other procedure-based specialties, including orthopedics and cardiology.

LEVEL OF EVIDENCE

5.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment

BACKGROUND

Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010.

OBJECTIVES

To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.

SEARCH METHODS

Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).

MAIN RESULTS

We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).

AUTHORS' CONCLUSIONS

Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

A Preliminary Risk Stratification Model for Individuals with Neck Pain

INTRODUCTION

The aim of the present study was to identify predictive characteristics related to patients with neck impairments who have a high risk of a poor prognosis (lowest functional recovery compared to visit utilization) as well as those who are at low risk of a poor prognosis (highest functional recovery compared to visit utilization).

METHODS

A retrospective cohort of 3,137 patients with neck pain who were seen for physiotherapy care was included in the study. All patients were seen at physiotherapy clinics in the United States and were provided with care in a manner in which the physiotherapists felt was appropriate and necessary. Univariate and multivariate multinomial regression analyses were used to identify significant patient characteristics predictive of treatment response.

RESULTS

Statistically significant predictors of high-risk categorization included longer duration of symptoms, surgical history and lower comparative levels of disability at baseline. Statistically significant predictors of low-risk categorization were younger age, shorter duration of symptoms, no surgical history, fewer comorbidities and higher comparative disability levels of function at baseline.

DISCUSSION

Few studies have analysed risk stratification models for neck pain, and the findings of the present study suggest that predictors of poor success are similar to those in most musculoskeletal prognostic models. Limitations of the study included those inherent in secondary analysis and the inability to identify the diagnoses of the patients.

CONCLUSIONS

Future research should continue to examine the variables predictive of treatment response in patients with neck pain. Copyright © 2015 John Wiley & Sons, Ltd.

Cervical Spine Disc Deformation During In Vivo Three-Dimensional Head Movements

Although substantial research demonstrates that intervertebral disc cells respond to mechanical signals, little research has been done to characterize the in vivo mechanical environment in the disc tissue. The objective of this study was to estimate cervical disc strain during three-dimensional head movements. Twenty-nine young healthy adults performed full range of motion flexion/extension, lateral bending, and axial rotation of the head within a biplane radiography system. Three-dimensional vertebral kinematics were determined using a validated model-based tracking technique. A computational model used these kinematics to estimate subject-specific intervertebral disc deformation (C3-4 to C6-7). Peak compression, distraction and shear strains were calculated for each movement, disc level, and disc region. Peak compression strain and peak shear strain were highest during flexion/extension (mean ± 95% confidence interval) (32 ± 3 and 86 ± 8%, respectively), while peak distraction strain was highest during lateral bending (57 ± 5%). Peak compression strain occurred at C4-5 (33 ± 4%), while peak distraction and shear strain occurred at C3-4 (54 ± 8 and 83 ± 11%, respectively). Peak compression, distraction, and shear strains all occurred in the posterior-lateral annulus (48 ± 4, 80 ± 8, and 109 ± 12%, respectively). These peak strain values may serve as boundary conditions for in vitro loading paradigms that aim to assess the biologic response to physiologic disc deformations.