Cost-effectiveness of exercise therapy in the treatment of non-specific neck pain and low back pain: a systematic review with meta-analysis

Economic evaluations of musculoskeletal physiotherapy: protocol of a systematic review

INTRODUCTION

Several economic evaluations of musculoskeletal physiotherapy have been published in the literature. We aim to provide an overview of these existing economic evaluations. This overview will be useful for healthcare funders in identifying studies matching their context. In addition, research gaps as well as literature extensive enough to be combined in a meta-analysis will be identified. This will support researchers in planning relevant research projects.

METHODS AND ANALYSES

We will search in PubMed, EconLit and NHS-EED for relevant literature. Full economic evaluations of musculoskeletal physiotherapy interventions will be included, regardless of type, and economic evaluation perspective. Initial searches were performed on 7th October 2021. Study selection, data extraction and the quality evaluation will be conducted initially by two independent researchers. If their agreement is sufficient, one reviewer will proceed with the respected process. From the included studies, we will extract information on the publication year, the country of origin, the type of economical evaluation analyses and the specific musculoskeletal condition. An overview will be provided, concerning the distributions of the included studies regarding the extracted information. Furthermore, an evaluation of the individual study quality will be offered.

ETHICS AND DISSEMINATION

No ethical approval will be required for this systematic review, since no human participants are involved. We aim to distribute the findings of this review in a peer-reviewed journal, on national and international conferences, as well as via social media.

Digital Therapeutic Care Apps With Decision-Support Interventions for People With Low Back Pain in Germany: Cost-Effectiveness Analysis

BACKGROUND

Digital therapeutic care apps provide a new effective and scalable approach for people with nonspecific low back pain (LBP). Digital therapeutic care apps are also driven by personalized decision-support interventions that support the user in self-managing LBP, and may induce prolonged behavior change to reduce the frequency and intensity of pain episodes. However, these therapeutic apps are associated with high attrition rates, and the initial prescription cost is higher than that of face-to-face physiotherapy. In Germany, digital therapeutic care apps are now being reimbursed by statutory health insurance; however, price targets and cost-driving factors for the formation of the reimbursement rate remain unexplored.

OBJECTIVE

The aim of this study was to evaluate the cost-effectiveness of a digital therapeutic care app compared to treatment as usual (TAU) in Germany. We further aimed to explore under which circumstances the reimbursement rate could be modified to consider value-based pricing.

METHODS

We developed a state-transition Markov model based on a best-practice analysis of prior LBP-related decision-analytic models, and evaluated the cost utility of a digital therapeutic care app compared to TAU in Germany. Based on a 3-year time horizon, we simulated the incremental cost and quality-adjusted life years (QALYs) for people with nonacute LBP from the societal perspective. In the deterministic sensitivity and scenario analyses, we focused on diverging attrition rates and app cost to assess our model's robustness and conditions for changing the reimbursement rate. All costs are reported in Euro (€1=US $1.12).

RESULTS

Our base case results indicated that the digital therapeutic care strategy led to an incremental cost of €121.59, but also generated 0.0221 additional QALYs compared to the TAU strategy, with an estimated incremental cost-effectiveness ratio (ICER) of €5486 per QALY. The sensitivity analysis revealed that the reimbursement rate and the capability of digital therapeutic care to prevent reoccurring LBP episodes have a significant impact on the ICER. At the same time, the other parameters remained unaffected and thus supported the robustness of our model. In the scenario analysis, the different model time horizons and attrition rates strongly influenced the economic outcome. Reducing the cost of the app to €99 per 3 months or decreasing the app's attrition rate resulted in digital therapeutic care being significantly less costly with more generated QALYs, and is thus considered to be the dominant strategy over TAU.

CONCLUSIONS

The current reimbursement rate for a digital therapeutic care app in the statutory health insurance can be considered a cost-effective measure compared to TAU. The app's attrition rate and effect on the patient's prolonged behavior change essentially influence the settlement of an appropriate reimbursement rate. Future value-based pricing targets should focus on additional outcome parameters besides pain intensity and functional disability by including attrition rates and the app's long-term effect on quality of life.

The effect of therapeutic exercise and vegan diet on pain and quality of life in young female patients with chronic non-specific neck pain

Background and purpose

In recent years, dietary practices have begun to be used in painful conditions. This study aimed to investigate the effect of a vegan diet and therapeutic exercise in patients with chronic non-specific neck pain.

Materials and methods

A total of 45 young female patients with chronic non-specific neck pain, aged 18–25 years, participated in the study. Body mass index and body fat percentage were measured with bioelectrical impedance analysis. Pain severity was assessed using the Visual Analogue Scale, quality of life with the short form-36 scale, kinesiophobia with the Tampa scale of kinesiophobia and neck disability with the Neck Disability Index.

Results

The pain severity reduced in the diet group and exercise group after treatment (p = 0.001). After treatment, Neck Disability Index score decreased in the diet group and exercise group (p = 0.001). Tampa scale of kinesiophobia score decreased in the diet group and exercise group (p = 0.001). The eight domains of the short form-36 scale score increased in the diet group and exercise group (p < 0.05). No difference was found in the body mass index and fat percentage in all groups before and after treatment (p˃ 0.05).

Conclusion

A vegan diet and therapeutic exercise are beneficial to patients with chronic non-specific neck pain in terms of pain severity and quality of life.

Neck pain: global epidemiology, trends and risk factors

BACKGROUND

Neck pain is one of the most common musculoskeletal disorders, having an age-standardised prevalence rate of 27.0 per 1000 population in 2019. This literature review describes the global epidemiology and trends associated with neck pain, before exploring the psychological and biological risk factors associated with the initiation and progression of neck pain.

METHODS

The PubMed database and Google Scholar search engine were searched up to May 21, 2021. Studies were included that used human subjects and evaluated the effects of biological or psychological factors on the occurrence or progression of neck pain, or reported its epidemiology.

RESULTS

Psychological risk factors, such as long-term stress, lack of social support, anxiety, and depression are important risk factors for neck pain. In terms of the biological risks, neck pain might occur as a consequence of certain diseases, such as neuromusculoskeletal disorders or autoimmune diseases. There is also evidence that demographic characteristics, such as age and sex, can influence the prevalence and development of neck pain, although further research is needed.

CONCLUSIONS

The findings of the present study provide a comprehensive and informative overview that should be useful for the prevention, diagnosis, and management of neck pain.

Cost-effectiveness analysis of a chronic back pain multidisciplinary biopsychosocial rehabilitation (MBR) compared to standard care for privately insured in Germany

Background

Multidisciplinary biopsychosocial rehabilitation (MBR) is highly recommended for chronic lower back pain (CLBP) treatment, but its economic benefit remains to be clearly demonstrated. The purpose of this study is to analyse the effect of a 12-month MBR programme of behavioural change coaching and device-supported exercise on direct medical costs, sick leave and health-related quality of life (HRQOL) at 24 months.

Methods

An incremental cost-effectiveness analysis was conducted in Germany from a private health insurance perspective using data from a multi-centre, two-arm randomised controlled trial with parallel-group Zelen's randomisation and 24-month follow-up. After removing dissimilarities in characteristics between MBR and usual care (control) via propensity score matching, treatment effects were calculated using a difference-in-difference approach.

Results

Base-case analysis of the MBR (n=112) and usual care group (n=111) showed an incremental cost-effectiveness ratio (ICER) of €8,296 per quality-adjusted life year (QALY) gained, indicating that the intervention was cost-effective. Compared to the controls, MBR reduced economically unaccounted sick leave due to back pain in the last six months by 17.5 days (p = 0.001) and had a positive effect on health-related quality of life (HRQOL) (0.046, p=0.026). Subgroup analysis of participants with major impairment demonstrated that a dominant intervention was possible, as reflected by an ICER of - €7,302 per QALY. Savings were driven by a - €1,824 reduction in back pain-specific costs. Moreover, sick leave was 27 days (p = 0.006) less in the MBR group.

Conclusions

This first cost-effectiveness study with combined data from a private health insurer and a controlled trial in Germany demonstrated that long term MBR for the treatment of CLBP is cost-effective. Subgroups with major impairment from back pain benefitted more from the intervention than those with minor impairment. MBR significantly reduced sick leave in all participants. Hence, it is a profitable intervention from a societal point of view.

Trial registration

The trial of the evaluation study was retrospectively registered in the German Clinical Trials Register under trial number DRKS00015463 retrospectively (dated 4 Sept 2018).

Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Rehabilitation has often been seen as a disability-specific service needed by only few of the population. Despite its individual and societal benefits, rehabilitation has not been prioritised in countries and is under-resourced. We present global, regional, and country data for the number of people who would benefit from rehabilitation at least once during the course of their disabling illness or injury.

METHODS

To estimate the need for rehabilitation, data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 were used to calculate the prevalence and years of life lived with disability (YLDs) of 25 diseases, impairments, or bespoke aggregations of sequelae that were selected as amenable to rehabilitation. All analyses were done at the country level and then aggregated to seven regions: World Bank high-income countries and the six WHO regions (ie, Africa, the Americas, Southeast Asia, Europe, Eastern Mediterranean, and Western Pacific).

FINDINGS

Globally, in 2019, 2·41 billion (95% uncertainty interval 2·34-2·50) individuals had conditions that would benefit from rehabilitation, contributing to 310 million [235-392] YLDs. This number had increased by 63% from 1990 to 2019. Regionally, the Western Pacific had the highest need of rehabilitation services (610 million people [588-636] and 83 million YLDs [62-106]). The disease area that contributed most to prevalence was musculoskeletal disorders (1·71 billion people [1·68-1·80]), with low back pain being the most prevalent condition in 134 of the 204 countries analysed.

INTERPRETATION

To our knowledge, this is the first study to produce a global estimate of the need for rehabilitation services and to show that at least one in every three people in the world needs rehabilitation at some point in the course of their illness or injury. This number counters the common view of rehabilitation as a service required by only few people. We argue that rehabilitation needs to be brought close to communities as an integral part of primary health care to reach more people in need.

FUNDING

Bill & Melinda Gates Foundation.

Prevalence of non-specific chronic low-back pain and risk factors among male soldiers in Saudi Arabia

Background

Non-specific chronic low back pain (NSCLBP) is the most common musculoskeletal disorder affecting health and work among the military population. NSCLBP is a complex disorder with several risk factors contributing to its occurrence. Therefore, the objective of our study was to estimate the prevalence and contribution of risk factors towards NSCLBP among male soldiers in Saudi Arabia.

Methods

A cross-sectional study was conducted from March 2020 to January 2021 among the military personnel at Hafar Al-Batin military base, Saudi Arabia. The entire population (n = 62, 000) at the military base were invited to participate in the study. The participants were invited to participate in the study either through direct referral from in-patient and out-patient departments of the military hospital or by invitation through pamphlets, email, and advertisement across the offices and residential areas. Soldiers reporting lower back pain for at least 12 weeks were screened for inclusion criteria at the physical therapy department of the military hospital. Inclusion criteria included pain or discomfort originating from the lower back without any known spinal diseases. Participants with a systemic inflammatory disorder, trauma, neurological symptoms, and recent spinal surgery were excluded. All eligible participants were assessed for demographic variables and risk factors and complete the Rolland Morris Disability Questionnaire and WHO-Five Well-Being Index.

Results

This study identified a 46.3% prevalence of pain originating from the spine with a 2.7% prevalence of NSCLBP. Spearman's rho correlation between the severity of disability due to NSCLBP was strongly associated with age (r_s = 0.834, p < 0.01), quality of sleep (r_s = 0.790, p < 0.01), body mass index (BMI) (r_s = 0.617, p < 0.01), smoking (r_s = 0.520, p < 0.01), co-morbidity (r_s = 0.357, p < 0.01), but not with the level of physical activity (r_s = 0.044, p = 0.07).

Conclusion

There was a high prevalence of pain originating from the spine among male Saudi soldiers with a relatively low prevalence of NSCLBP. However, the prevalence of disability due to NSCLBP was strongly associated with age, sleep quality, BMI, smoking habit, and co-morbidity.

Cost-effectiveness of direct discharge from the emergency department of patients with simple stable injuries in the Netherlands

Background

Approximately one-third of musculoskeletal injuries are simple stable injuries (SSIs). Direct discharge (DD) from the emergency department (ED) of patients with SSIs reduces healthcare utilization, without compromising patient outcome and experience, when compared with "traditional" care with routine follow-up. This study aimed to determine the cost-effectiveness of DD compared with traditional care from a societal perspective.

Methods

Societal costs, including healthcare, work absenteeism, and travel costs, were calculated for patients with an SSI, 6 months before (pre-DD cohort) and after implementation of DD (DD cohort). The pre-DD cohort was treated according to local protocols. The DD cohort was treated using orthoses, discharge leaflet, smartphone application, and telephone helpline, without scheduling routine follow-up. Effect measures included generic health-related quality of life (HR-QoL; EuroQol Five-Dimensional Questionnaire); disease-specific HR-QoL (functional outcome, different validated questionnaires, converted to 0-100 scale); treatment satisfaction (Visual Analog Scale (VAS), 1-10); and pain (VAS, 1-10). All data were assessed using a 3-month postinjury survey and electronic patient records. Incremental cost-effectiveness ratios were calculated and uncertainty was assessed using bootstrapping techniques.

Results

Before DD, 144 of 348 participants completed the survey versus 153 of 371 patients thereafter. There were no statistically significant differences between the pre-DD cohort and the DD cohort for generic HR-QoL (0.03; 95% CI -0.01 to 0.08), disease-specific HR-QoL (4.4; 95% CI -1.1 to 9.9), pain (0.08; 95% CI -0.37 to 0.52) and treatment satisfaction (-0.16; 95% CI -0.53 to 0.21). Total societal costs were lowest in the DD cohort (-€822; 95% CI -€1719 to -€67), including healthcare costs (-€168; 95% CI -€205 to -€131) and absenteeism costs (-€645; 95% CI -€1535 to €100). The probability of DD being cost-effective was 0.98 at a willingness-to-pay of €0 for all effect measures, remaining high with increasing willingness-to-pay for generic HR-QoL, disease-specific HR-QoL, and pain, and decreasing with increasing willingness-to-pay for treatment satisfaction.

Discussion

DD from the ED of patients with SSI seems cost-effective from a societal perspective. Future studies should test generalizability in other healthcare systems and strengthen findings in larger injury-specific cohorts.

Level of evidence

II.

Making exercise count: Considerations for the role of exercise in back pain treatment

INTRODUCTION

Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP.

AIM

This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals.

METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP.

RESULTS/DISCUSSION

Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain.

CONCLUSION

To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

Exercise therapy for chronic low back pain

BACKGROUND

Low back pain has been the leading cause of disability globally for at least the past three decades and results in enormous direct healthcare and lost productivity costs.

OBJECTIVES

The primary objective of this systematic review is to assess the impact of exercise treatment on pain and functional limitations in adults with chronic non-specific low back pain compared to no treatment, usual care, placebo and other conservative treatments.

SEARCH METHODS

We searched CENTRAL (which includes the Cochrane Back and Neck trials register), MEDLINE, Embase, CINAHL, PsycINFO, PEDro, SPORTDiscus, and trials registries (ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform), and conducted citation searching of relevant systematic reviews to identify additional studies. The review includes data for trials identified in searches up to 27 April 2018. All eligible trials have been identified through searches to 7 December 2020, but have not yet been extracted; these trials will be integrated in the next update.

SELECTION CRITERIA

We included randomised controlled trials that assessed exercise treatment compared to no treatment, usual care, placebo or other conservative treatment on the outcomes of pain or functional limitations for a population of adult participants with chronic non-specific low back pain of more than 12 weeks' duration.

DATA COLLECTION AND ANALYSIS

Two authors screened and assessed studies independently, with consensus. We extracted outcome data using electronic databases; pain and functional limitations outcomes were re-scaled to 0 to 100 points for meta-analyses where 0 is no pain or functional limitations. We assessed risk of bias using the Cochrane risk of bias (RoB) tool and used GRADE to evaluate the overall certainty of the evidence. When required, we contacted study authors to obtain missing data. To interpret meta-analysis results, we considered a 15-point difference in pain and a 10-point difference in functional limitations outcomes to be clinically important for the primary comparison of exercise versus no treatment, usual care or placebo.

MAIN RESULTS

We included 249 trials of exercise treatment, including studies conducted in Europe (122 studies), Asia (38 studies), North America (33 studies), and the Middle East (24 studies). Sixty-one per cent of studies (151 trials) examined the effectiveness of two or more different types of exercise treatment, and 57% (142 trials) compared exercise treatment to a non-exercise comparison treatment. Study participants had a mean age of 43.7 years and, on average, 59% of study populations were female. Most of the trials were judged to be at risk of bias, including 79% at risk of performance bias due to difficulty blinding exercise treatments. We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clinically important difference. Certainty of evidence was downgraded mainly due to heterogeneity. For the same comparison, there was moderate-certainty evidence for functional limitations outcomes (MD -6.8 (95% CI -8.3 to -5.3); this finding did not meet our prespecified threshold for minimal clinically important difference. Certainty of evidence was downgraded mainly due to some evidence of publication bias.  Compared to all other investigated conservative treatments, exercise treatment was found to have improved pain (MD -9.1, 95% CI -12.6 to -5.6) and functional limitations outcomes (MD -4.1, 95% CI -6.0 to -2.2). These effects did not meet our prespecified threshold for clinically important difference. Subgroup analysis of pain outcomes suggested that exercise treatment is probably more effective than education alone (MD -12.2, 95% CI -19.4 to -5.0) or non-exercise physical therapy (MD -10.4, 95% CI -15.2 to -5.6), but with no differences observed for manual therapy (MD 1.0, 95% CI -3.1 to 5.1). In studies that reported adverse effects (86 studies), one or more adverse effects were reported in 37 of 112 exercise groups (33%) and 12 of 42 comparison groups (29%). Twelve included studies reported measuring adverse effects in a systematic way, with a median of 0.14 (IQR 0.01 to 0.57) per participant in the exercise groups (mostly minor harms, e.g. muscle soreness), and 0.12 (IQR 0.02 to 0.32) in comparison groups.

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence that exercise is probably effective for treatment of chronic low back pain compared to no treatment, usual care or placebo for pain. The observed treatment effect for the exercise compared to no treatment, usual care or placebo comparisons is small for functional limitations, not meeting our threshold for minimal clinically important difference. We also found exercise to have improved pain (low-certainty evidence) and functional limitations outcomes (moderate-certainty evidence) compared to other conservative treatments; however, these effects were small and not clinically important when considering all comparisons together. Subgroup analysis suggested that exercise treatment is probably more effective than advice or education alone, or electrotherapy, but with no differences observed for manual therapy treatments.

Economic evaluations of educational, physical, and psychological treatments for fibromyalgia: a systematic review with meta-analysis

ABSTRACT

Nonpharmacological interventions are recommended for the treatment of fibromyalgia, but there is a lack of knowledge about the cost-effectiveness of these interventions. The aim of this study was to systematically review economic evaluations of educational, physical, and psychological interventions for the treatment of fibromyalgia. The search was performed in PUBMED, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, PsycINFO, EconLit, National Health Service Economic Evaluation Database, and Health Technology Assessment. Economic evaluations of educational, physical, and psychological interventions for adult patients with fibromyalgia were included. Primary outcomes were healthcare and societal costs, and quality-adjusted life-years, and secondary outcomes were any disease-specific clinical outcome. Costs and effects were pooled in a meta-analysis, when possible. Eleven studies were included, of which 7 compared a psychological intervention with another intervention or usual care/control. Over a 6-month time horizon, healthcare and societal costs of the psychological intervention were significantly lower than usual care (mean difference: $-2087, 95% confidence interval [CI]: -3061 to -1112; mean difference: $-2411, 95% CI: -3582 to -1240, respectively), and healthcare costs were significantly lower for the psychological intervention compared with a pharmacological intervention (mean difference: $-1443, 95% CI: -2165 to -721). Over a 12-month time horizon, healthcare costs for the psychological intervention were significantly lower than for usual care (mean difference: $-538, 95% CI: -917 to -158). Incremental cost-effectiveness ratios for quality-adjusted life-years and impact of fibromyalgia showed that the psychological intervention was cost-effective compared with other interventions and control conditions. There is a need of more economic evaluations conducted alongside randomized controlled trials with interventions recommended for the treatment of fibromyalgia, such as physical exercise.

Cross-cultural Adaptation and Validation of the Simplified Chinese Version of the Copenhagen Neck Function Disability Scale

STUDY DESIGN

A cross-sectional study.

OBJECTIVE

Th aim of this study was to translate and cross-culturally adapt Copenhagen Neck Function Disability Scale into a Simplified Chinese version (CNFDS-C), and evaluate the reliability and validity of CNFDS-C in patients with nonspecific chronic neck pain.

SUMMARY OF BACKGROUND DATA

The CNFDS is a reliable and valid evaluation instrument for chronic neck pain. However, Simplified Chinese version of CNFDS hasn't been validated.

METHODS

A total of 150 participants were included in this study. Internal consistency was estimated according to Cronbach alpha. Test-retest reliability was assessed by intra-class correlation coefficient (ICC). Construct validity was analyzed by correlations between CNFDS-C and the Neck Disability Index (NDI), Visual Analogue Scale (VAS) as well as the short form (36) health survey (SF-36).

RESULTS

The original version of the CNFDS was cross-culturally adapted and translated into Simplified Chinese. CNFDS-C was indicated to have excellent reliability (Cronbach alpha = 0.810, ICC = 0.927). Moderate to substantial correlations between CNFDS-C and NDI (r = 0.642, P < 0.001), VAS (r = 0.581, P < 0.001), as well as Physical Function (r = -0.583, P < .001), Role Physical (r = -0.478, P < 0.001), Bodily Pain (r = -0.610, P < 0.001), and General Health (r = -0.439, P < 0.001) subscales of SF-36 were observed.

CONCLUSION

CNFDS-C was demonstrated to have acceptable reliability and validity in patients with nonspecific chronic neck pain, which could be recommended for patients in Chinese mainland.Level of Evidence: 3.

Interpretation of trial-based economic evaluations of musculoskeletal physical therapy interventions

BACKGROUND

As resources for healthcare are scarce, decision-makers increasingly rely on economic evaluations when making reimbursement decisions about new health technologies, such as drugs, procedures, devices, and equipment. Economic evaluations compare the costs and effects of two or more interventions. Musculoskeletal disorders have a high prevalence and result in high levels of disability and high costs worldwide. Because physical therapy interventions are usually the first line of treatment for musculoskeletal disorders, economic evaluations of such interventions are becoming increasingly important for stakeholders in the field of physical therapy, including physical therapists, decision-makers, and reseachers. However, economic evaluations are relatively difficult to interpret for the majority of stakeholders.

OBJECTIVE

To support physical therapists, decision-makers, and researchers in the field of physical therapy interpreting trial-based economic evaluations and translating the results of such studies to clinical practice.

METHODS

The design, analysis, and interpretation of economic evaluations performed alongside randomized controlled trials are discussed. To further illustrate and explain these concepts, we use a case study assessing the cost-effectiveness of exercise therapy compared to standard advice in patients with musculoskeletal disorders.

CONCLUSIONS

Economic evaluations are increasingly being used in healthcare decision-making. Therefore, it is of utmost importance that their design, conduct, and analysis are state-of-the-art and that their interpretation is adequate. This masterclass will help physical therapists, decision-makers, and researchers in the field of physical therapy to critically appraise the quality and results of trial-based economic evaluations and to apply the results of such studies to their own clinical practice and setting.

Effects of Workplace-Based Intervention for Shoulder Pain: A Systematic Review and Meta-analysis

The main objective of this study is to update the evidence related to the effectiveness of exercise and ergonomic interventions in the perception of shoulder pain intensity in workers considering the shoulder pain intensity and the minimum clinically important change in the analysis. The bibliographic search was conducted in seven databases (Cochrane, EMBASE, SciELO, PubMed, PEDro, Web of Science and Scopus) from March to April 2019. The study selection included randomized controlled trials (RCTs) involving workers with shoulder pain who underwent physical exercises, ergonomics, and combined interventions. To analyze the RCTs, the intensity of pain was divided into two subgroups < 3 and ≥ 3 (0-10 points scale). A total of 27 RCTs were included in the qualitative synthesis considering the perception scales of shoulder pain intensity and the PEDro scale score of assessment of RCTs quality and risk of bias. Within these, seven RCTs were included in the quantitative synthesis. The overall effectiveness of interventions was calculated using a meta-analysis method, and the associated measurement used as a mean difference. The meta-analysis revealed that exercise interventions in workers with shoulder pain > 3 presented a minimally clincially important difference (MCID), but with no difference in workers with pain < 3. The interventions with exercise in workers with pain ≥ 3 at baseline reported a beneficial effect in reducing shoulder pain intensity, and a MCID. However, there was no significant difference for workers with pain < 3 and the effects of ergonomic interventions are still uncertain to reduce shoulder pain in workers.

Neck pain is the leading cause of disability burden in China: Findings from the Global Burden of Disease Study 2017

Background

Neck pain (NP) is a common musculoskeletal problem; however, the prevalence and years lived with disability (YLD) of NP in China are still unclear. This study sought to estimate the age-, sex- and province-specific prevalence and YLD of NP in China.

Methods

Adopting the methodology framework and analytical strategies used in the Global Burden of Disease (GBD), Injuries, and Risk Factors Study (2017), the prevalence and YLD of NP in China were estimated by age, sex, year, and provinces/regions.

Results

In China, the age-standardized point prevalence rate of NP was 4,532.6 per 100,000 persons in 1990 and increased slightly to 4,634.4 per 100,000 persons in 2017. The prevalence of NP was 48.0 million in 1990 and rose dramatically to 87.3 million in 2017 (an increase of 82.0%). The age-standardized YLD rate of NP was 454.0 per 100,000 persons in 1990, and there was a slight increase to 465.6 per 100,000 persons in 2017. The all-age YLD of NP was 4.8 million in 1990 and rose to 8.8 million in 2017 (which represents an increase of 81.1%). In 1990, NP was the third leading cause of YLD in China, and in 2017, NP was the leading cause of disability burden.

Conclusions

This study estimated the prevalence and disability burden of NP in China. NP is currently the leading cause of disability burden in China; however, it is currently inadequately recognized and should receive further attention and be subject to further research.

Balneotherapy for Fibromyalgia Syndrome: A Systematic Review and Meta-Analysis

(1) Background: The efficiency of balneotherapy (BT) for fibromyalgia syndrome (FMS) remains elusive. (2) Methods: Cochrane Library, EMBASE, MEDLINE, PubMed, Clinicaltrials.gov, and PsycINFO were searched from inception to 31 May 2020. Randomized controlled trials (RCTs) with at least one indicator were included, i.e., pain, Fibromyalgia Impact Questionnaire (FIQ), Tender Points Count (TPC), and Beck’s Depression Index (BDI). The outcome was reported as a standardized mean difference (SMD), 95% confidence intervals (CIs), and I² for heterogeneity at three observational time points. GRADE was used to evaluate the strength of evidence. (3) Results: Amongst 884 citations, 11 RCTs were included (n = 672). Various BT regimens were reported (water types, duration, temperature, and ingredients). BT can benefit FMS with statistically significant improvement at different time points (pain of two weeks, three and six months: SMD = −0.92, −0.45, −0.70; 95% CI (−1.31 to −0.53, −0.73 to −0.16, −1.34 to −0.05); I² = 54%, 51%, 87%; GRADE: very low, moderate, low; FIQ: SMD = −1.04, −0.64, −0.94; 95% CI (−1.51 to −0.57, −0.95 to −0.33, −1.55 to −0.34); I² = 76%, 62%, 85%; GRADE: low, low, very low; TPC at two weeks and three months: SMD = −0.94, −0.47; 95% CI (−1.69 to −0.18, −0.71 to −0.22); I² = 81%, 0; GRADE: very low, moderate; BDI at six months: SMD = −0.45; 95% CI (−0.73 to −0.17); I² = 0; GRADE: moderate). There was no statistically significant effect for the TPC and BDI at the remaining time points (TPC at six months: SMD = −0.89; 95% CI (−1.85 to 0.07); I² = 91%; GRADE: very low; BDI at two weeks and three months: SMD = −0.35, −0.23; 95% CI (−0.73 to 0.04, −0.64 to 0.17); I² = 24%, 60%; GRADE: moderate, low). (4) Conclusions: Very low to moderate evidence indicates that BT can benefit FMS in pain and quality-of-life improvement, whereas tenderness and depression improvement varies at time phases. Established BT regimens with a large sample size and longer observation are needed.

Immediate Effects of a Telerehabilitation Program Based on Aerobic Exercise in Women with Fibromyalgia

Background: We analyzed the immediate effects of a Telerehabilitation Program (TP) based on aerobic exercise in women with fibromyalgia (FM) syndrome during the lockdown declared in Spain due to the COVID-19 pandemic. Methods: A single-blind randomized controlled trial was designed. Thirty-four women with FM were randomized into two groups: TP group and Control group. The intervention lasted 15 weeks, with 2 sessions per week. The TP based on aerobic exercise was guided by video and the intensity of each session was monitored using the Borg scale. Pain intensity (Visual Analogue Scale), mechanical pain sensitivity (algometer), number of tender points, FM impact (Revised Fibromyalgia Impact Questionnaire), pain catastrophizing (Pain Catastrophizing Scale), physiological distress (Hospital Anxiety and Depression Scale), upper (Arm Curl Test) and lower-limb physical function (6-min Walk Test) were measured at baseline and after the intervention. Results: The TP group improved pain intensity (p = 0.022), mechanical pain sensitivity (p < 0.05), and psychological distress (p = 0.005), compared to the Control group. The Control group showed no statistically significant changes in any variable (p > 0.05). Conclusions: A TP based on aerobic exercise achieved improvements on pain intensity, mechanical pain sensitivity, and psychological distress compared to a Control group during the lockdown declared in Spain due to COVID-19 pandemic.

Why is exercise prescribed for people with chronic low back pain? A review of the mechanisms of benefit proposed by clinical trialists

BACKGROUND

Exercise is recommended for the management of chronic low back pain (CLBP). Trialists have proposed numerous mechanisms to explain why exercise improves pain and function in people with CLBP, but these are yet to be synthesised.

OBJECTIVE

To synthesise the proposed mechanisms of benefit for exercise in people with CLBP.

DESIGN

Review.

METHODS

The Physiotherapy Evidence Database (PEDro) was searched from inception to July 2019. Randomised controlled trials of adults with CLBP, indexed in PEDro as 'fitness training', were included. Two reviewers independently screened and extracted data from each study. Data were analysed quantitatively and qualitatively using thematic analysis.

RESULTS

186 studies were identified and 110 were included in the analysis. Thirty-six studies (33%) did not provide a mechanism of benefit for exercise in people with CLBP. Of the remaining studies, most provided more than one mechanism, from which 33 unique mechanisms were identified. These were grouped into five themes which, from most to least common, were: neuromuscular (n = 105 (44%)); psychosocial (n = 87 (36%)); neurophysiological (n = 22 (9%)); cardiometabolic (n = 15 (6%)); and tissue healing (n = 12 (5%)). The effects of these proposed mechanisms on outcomes for people with CLBP were seldom examined.

CONCLUSIONS

This review identified a variety of mechanisms proposed in clinical trials to explain why 'fitness training' works for people with CLBP, but these mechanisms were seldom tested. Randomised controlled trials investigating the mediating effects of these mechanisms may be warranted to better understand why exercise works for CLBP.

Acute Effects of Global Postural Re-Education on Non-Specific Low Back Pain. Does Time-of-Day Play a Role?

Low back pain is one the most common forms of musculoskeletal disorders. Thus, several physiotherapeutic strategies (e.g., global postural re-education therapy) have been used for reducing low back pain. The aim of this study was to determinate if acute application of global postural re-education session associated effects are influenced by the time-of-day when this physical therapy is applied. Eight participants in a randomized, counterbalanced order were acutely tested both before and 24 h after a global postural re-education therapy session (10 min session) in three different time-of-day points; morning (i.e., AM; 7:00–9:00 h), midday (i.e., AM; 12:00–14:00 h) and afternoon (i.e., PM; 18:00–20:00 h). In each session, low back pain Visual Analogue Pain Scale [VAS]), flexibility, function capacity (Roland Morris Questionnaire [RMQ], and physical functioning Oswestry Disability Index [ODI]) were recorded. Results showed a pain reduction (VAS Scale) 24 h post Global postural re-education [GPR] session (p = 0.001) and increasing of flexibility pre-post GPR session in all the time-of-day points (morning, midday, and afternoon) (p = 0.001) while no differences were reported in RMQ (p = 0.969) and ODI (p = 0.767). Thus, acute GPR session produces the same effects on flexibility, low back pain, function capacity, and physical functioning values independently of time-of-day when it is applied.

Effect of Scraping Therapy on Chronic Low Back Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The purpose of this study was to review the literature on the effect of scraping therapy on chronic low back pain (LBP) from randomized controlled trials (RCTs).

METHODS

Three English medical electronic databases (PubMed, Embase, and the Cochrane Library) and 2 Chinese databases (China National Knowledge Infrastructure and Wanfang) were searched. Only randomized controlled trials related to the effects of scraping therapy on chronic LBP were included in this systematic review. Study selection, data extraction, and validation were conducted independently by 2 reviewers. The methodological quality of the studies was evaluated by the Cochrane risk-of-bias tool. RevMan 5.3 software was applied to perform meta-analysis of the data.

RESULTS

Ten studies comprising 627 participants were included. Overall, the quality of evidence was moderate owing to a lack of blinding and allocation concealment in some studies and unclear risk of selective reporting. Meta-analysis of 9 RCTs indicated that scraping therapy had a statistically significant effect on pain reduction (standard mean difference = -0.66, 95% confidence interval [CI], -0.83 to -0.49, P < .001). However, if only a single scrape treatment was carried out, the results did not show that scraping was superior to the control group regarding pain relief (mean difference = -0.35, 95% CI, -1.23 to 0.53, P = .44). Moreover, the results of 6 RCTs involving 468 participants showed significantly greater improvement in lumbar dysfunction (mean difference = -10.05, 95% CI, -13.52 to -2.32, P < .001). In addition, the results of 5 RCTs involving 393 participants showed a favorably significant effect on the overall efficacy (odds ratio = 4.74, 95% CI, 2.34-9.62, P < .001). As for follow-up effects, meta-analysis of 3 RCTs involving 241 participants showed a promising effect on pain reduction and lumbar function improvement at 1 month and 3 months after the end of treatment, respectively. Only 1 study reported adverse effects, and none were serious.

CONCLUSION

Scraping therapy may have a therapeutic effect for some individuals with chronic LBP. However, due to the limited amount of research and the low methodological quality of the included studies, additional large-scale, multicenter, high-quality RCTs on relieving pain intensity and improving lumbar dysfunction are still necessary.

Reducing the prevalence of low-back pain by reducing the prevalence of psychological distress: Evidence from a natural experiment and implications for health care providers

OBJECTIVE

To determine whether exogenously reduced psychological distress reduces reported low-back pain (LBP) and is associated with reduced medical visits for LBP.

DATA SOURCES

National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, 1998-2004.

STUDY DESIGN

We estimate a fuzzy regression discontinuity model in which a discontinuity in the prevalence of psychological distress is identified by exogenous national events. We examine whether this discontinuity induced a corresponding discontinuity in the prevalence of LBP. We additionally estimate a regression discontinuity model to determine associated changes in medical visits with LBP as the primary complaint.

PRINCIPAL FINDINGS

The prevalence of LBP was discontinuously reduced by one-fifth due to the exogenous national discontinuous reduction in psychological distress. This discontinuity in LBP cannot be explained by discontinuities in employment, insurance, injuries/poisoning, general health status, or other factors. We find an associated three-fifth discontinuous reduction in medical visits with LBP as the primary complaint.

CONCLUSIONS

On a monthly basis, 2.1 million (P < .01) adults ceased to suffer LBP due to the national reduction in psychological distress, and associated medical visits with LBP as the primary complaint declined by 685 000 (P < .01).

Addition of specific hip strengthening exercises to conventional rehabilitation therapy for low back pain: a systematic review and meta-analysis

OBJECTIVE

To examine the effectiveness of hip strengthening exercises in reducing pain and disability in persons with low back pain.

METHODS

We searched for randomized controlled clinical trials on MEDLINE, the Physiotherapy Evidence Database, the Cochrane Central Register of Controlled Trials, LILACS, Scielo and CINAHL from the earliest date available to June 2020. Studies that included hip strengthening exercises for persons with low back pain and included pain and/or disability as an outcome measure were evaluated by two independent reviewers. Mean difference (MD), and 95% confidence interval (CI) were estimated by random effect models.

RESULTS

Five studies met the eligibility criteria (309 patients). Four studies included hip strengthening in conjunction with other interventions, while one study evaluated hip strengthening as a standalone intervention. Hip strengthening exercises improved pain (MD -5.4 mm, 95% CI: -8.9 to -1.8 mm), and disability (MD -2.9; 95% CI: -5.6 to -0.1) in persons with low back pain compared to interventions in which hip strengthening was not utilized. The quality of evidence for the pain outcome, was assessed as being moderate. The quality of evidence for the outcome of self-reported disability, was assessed as being low.

CONCLUSION

Addition of specific hip strengthening exercises to conventional rehabilitation therapy may be beneficial for improving pain and disability in persons with low back pain.

The ProFitMap-neck - a questionnaire for measuring symptoms and functional limitations in neck pain: reliability, validity and cross-cultural adaptation of the Turkish version

Background/aim

The Profile Fitness Mapping neck questionnaire (ProFitMap-neck) is a reliable and valid assessment instrument for measuring neck-related symptoms and functional limitations in people with neck pain, but a Turkish version of it had not been published. The purpose of this study was to investigate the adaptation, validity, and intrarater reliability of the Turkish version of the ProFitMap-neck.

Materials and methods

Two hundred and thirty-five individuals with chronic neck pain were enrolled in the study. Intrarater reliability was assessed by intraclass correlation coefficient (ICC) and Cronbach’s alpha was calculated for internal consistency. For concurrent validity, ProFitMap-neck scores were compared with neck disability index (NDI) and visual analoguepain scale (VAS) scores using Pearson’s correlation coefficient analysis. The ProFitMap-neck, NDI, VAS, and short form health survey (SF-36) were administered to all participants.

Results

For intrarater analysis, ICC ranged between 0.72 and 0.84. The total score was 0.83, indicating excellent reliability. The correlation of the ProFitMap-neck with NDI and VAS was 0.71 and 0.68, respectively, indicating good concurrent validity.

Conclusion

The ProFitMap-neck is an evaluation instrument with sufficient validity and reliability to be used for evaluating Turkish patients with neck pain. Use of this scale can reveal how, how often, and how much these patients’ pain affects their symptoms and functional activities.

Cost-utility analysis of antibiotic treatment in patients with chronic low back pain and Modic changes: results from a randomised, placebo-controlled trial in Norway (the AIM study)

OBJECTIVE

To evaluate the cost-utility of 100 days of antibiotics in patients with chronic low back pain (LBP) and type I or II Modic changes included in the Antibiotic treatment In patients with chronic low back pain and Modic changes (AIM) study.

DESIGN

A cost-utility analysis from a societal and healthcare perspective alongside a double-blinded, parallel group, placebo, multicentre trial.

SETTING

Hospital outpatient clinics at six hospitals in Norway. The main results from the AIM study showed a small effect in back-related disability in favour of the antibiotics group, and slightly larger in those with type I Modic changes, but this effect was below the pre-defined threshold for clinically relevant effect.

PARTICIPANTS

180 patients with chronic LBP, previous disc herniation and Modic changes type I (n=118) or type II (n=62) were randomised to antibiotic treatment (n=89) or placebo-control (n=91).

INTERVENTIONS

Oral treatment with either 750 mg amoxicillin or placebo three times daily for 100 days.

MAIN OUTCOME MEASURES

Quality-adjusted life years (QALYs) by EuroQoL-5D over 12 months and costs for healthcare and productivity loss measured in Euro (€1=NOK 10), in the intention-to-treat population. Cost-utility was expressed in incremental cost-effectiveness ratio (ICER).

RESULTS

Mean (SD) total cost was €21 046 (20 105) in the amoxicillin group and €19 076 (19 356) in the placebo group, mean difference €1970 (95% CI; -3835 to 7774). Cost per QALY gained was €24 625. In those with type I Modic changes, the amoxicillin group had higher healthcare consumption than the placebo group, resulting in €39 425 per QALY gained. Given these ICERs and a willingness-to-pay threshold of €27 500 (NOK 275 000), the probability of amoxicillin being cost-effective was 51%. Even when the willingness-to-pay threshold increased to €55 000, the probability of amoxicillin being cost-effective was never higher than 53%.

CONCLUSIONS

Amoxicillin treatment showed no evidence of being cost-effective for people with chronic LBP and Modic changes during 1-year follow-up.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02323412.

How effective and efficient are different exercise patterns in reducing back pain?

BACKGROUND

Exercise is considered an effective intervention to relieve chronic back pain. However, it is still unknown whether specific exercise patterns vary in terms of their efficiency and effectiveness.

AIM

To investigate the differential health and economic effects of intensity, specificity and degree of subjective perceived physical exertion across five exercise patterns (endurance, gymnastics, fitness, back gymnastics, multimodal back exercise) in adults with back pain.

DESIGN

Longitudinal observational cohort study over a period of 24 months.

SETTING

Various non-therapeutic exercise facilities (e.g. outdoor, fitness centers, health insurance programs, sports clubs) across one federal state of Germany (Baden-Wuerttemberg).

POPULATION

Adults with back pain (N.=2,542, Mean =46.9 years, 66% females, graded chronic back pain [GCPS] 1=40.5%, GCPS 2=27.3%, GCPS 3=20.7%, GCPS 4=11.5%).

METHODS

Self-reported back pain (functional restrictions and pain = back pain function score, [BPFS]) and characteristics of exercising behavior (frequency, duration, type, physical exertion) were assessed at baseline and at 6, 12, 18 and 24 months. Direct medical costs for back disorders (international classification of diseases, dorsopathies: M40-M54) were compiled from health insurance records.

RESULTS

Moderate- to high-intensity exercise patterns were effective in reducing back pain, particularly at lower levels of subjective perceived physical exertion. At these intensity levels, multimodal back exercise (i.e. exercising the spine-stabilizing muscles specifically, ergonomic training) was 14.5 times more effective than non-back specific fitness exercise in reducing BPFS. The beneficial effects of both exercise types increased with the initial severity of back pain. However, only multimodal back exercise (moderate- to high-intensity/high back specificity) was associated with a significant decrease in direct medical costs for back pain.

CONCLUSIONS

Targeted exercise of the spine-stabilizing musculature at moderate to high intensities without maximum perceived exertion is effective and efficient in reducing back pain.

CLINICAL REHABILITATION IMPACT

The combination of high-intensity and high-specificity exercises yielded a significant reduction in medical costs. However, the intensities in terms of muscular load in endurance training and gymnastics may not be sufficient to reduce back pain effectively.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BACKGROUND

The past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of the procedures remain controversial.

METHODS

After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, letters were sent to a dozen pain societies, as well as representatives from the US Departments of Veterans Affairs and Defense. A steering committee was convened to select preliminary questions, which were revised by the full committee. Questions were assigned to 4-5 person modules, who worked with the Subcommittee Lead and Committee Chair on preliminary versions, which were sent to the full committee. We used a modified Delphi method, whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chair, who incorporated the comments and sent out revised versions until consensus was reached.

RESULTS

17 questions were selected for guideline development, with 100% consensus achieved by committee members on all topics. All societies except for one approved every recommendation, with one society dissenting on two questions (number of blocks and cut-off for a positive block before RFA), but approving the document. Specific questions that were addressed included the value of history and physical examination in selecting patients for blocks, the value of imaging in patient selection, whether conservative treatment should be used before injections, whether imaging is necessary for block performance, the diagnostic and prognostic value of medial branch blocks (MBB) and intra-articular (IA) injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for a prognostic block, how many blocks should be performed before RFA, how electrodes should be oriented, the evidence for larger lesions, whether stimulation should be used before RFA, ways to mitigate complications, if different standards should be applied to clinical practice and clinical trials and the evidence for repeating RFA (see table 12 for summary).

CONCLUSIONS

Lumbar medial branch RFA may provide benefit to well-selected individuals, with MBB being more predictive than IA injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of more false-negatives. Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

Noninvasive brain stimulation combined with exercise in chronic pain: a systematic review and meta-analysis

Background: The use of noninvasive brain stimulation (NIBS) combined with exercise could produce synergistic effects on chronic pain conditions. This study aims to evaluate the efficacy and safety of NIBS combined with exercise to treat chronic pain as well as to describe the parameters used to date in this combination.Methods: The search was carried out in Medline, Central, Scopus, Embase, and Pedro until November 2019. Randomized clinical trials (RCTs) and quasi-experimental studies reporting the use of noninvasive brain stimulation and exercise on patients with chronic pain were selected and revised.Results: The authors included eight studies (RCTs), reporting eight comparisons (219 participants). Authors found a significant and homogeneous pain decrease (ES: -0.62, 95% CI:-0.89 to -0.34; I2 = 0.0%) in favor of the combined intervention compared to sham NIBS + exercise, predominantly by excitatory (anodal tDCS/rTMS) motor cortex stimulation. Regarding NIBS techniques, the pooled effect sizes were significant for both tDCS (ES: -0.59, 95% CI: -0.89 to -0.29, I2 = 0.0%) and rTMS (ES: -0.76, 95% CI: -1.41 to -0.11, I2 = 0.0%).Conclusions: This meta-analysis suggests a significant moderate to large effects of the NIBS and exercise combination in chronic pain. The authors discuss the potential theoretical framework for this synergistic effect.

Exercise and Chronic Pain

In this chapter, we describe the impact and etiology of chronic pain, the associated changes in the nervous system, and the mechanisms by which exercise may be able to affect and reverse these changes. Evidence for efficacy of exercise in different conditions associated with chronic pain is presented, with focus on chronic low back pain, fibromyalgia, osteoarthritis, rheumatoid arthritis, and migraines. While the efficacy of exercise and level of evidence supporting it vary in different diseases, exercise has direct and indirect benefits for most patients suffering from chronic pain. Effective exercise regimens include education and cognitive restructuring to promote behavioral activation and reconceptualization of what pain means, with the goal of gradually reversing the vicious cycle of pain, inertia, sedentary behavior, and worsening disability. Long-term, consistent, individualized exercise-based treatment approaches are most likely to result in improvements in pain and function.

The impact of modified exercise and relaxation therapy on chronic lower back pain in office workers: a randomized clinical trial

This study aimed to evaluate the effectiveness of a modified package of exercise therapy combined with relaxation on pain intensity, range of motion (ROM), anxiety, and quality of life (QoL) in office workers with chronic lower back pain. In this clinical trial, 72 office workers aged 20 to 50 years with chronic low back pain were randomized to one of four groups including; group 1, exercise therapy; group 2, psychotherapy (relaxation therapy); group 3, modified protocol (exercise therapy followed by relaxation therapy); group 4, control group (no intervention). Participants exercised 3 times weekly for 6 weeks for 40-45 min of exercise/relaxation. Pain intensity, ROM, anxiety, and QoL were evaluated at baseline, 6 weeks, and 12 weeks after the end of the intervention. Results showed significant decreases in pain intensity and anxiety in the three experimental groups compared to the control group. The three intervention groups indicated a significant decrease in pain intensity and anxiety after 6 and 12 weeks. ROM significantly improved in the exercise therapy and the modified protocol over time (after 6 and 12 weeks). A significant difference in QoL was found between the groups, with the greatest improvement found in the psychotherapy and modified protocol groups. This therapeutic package (including exercise movements and psychological interventions) was found to have a superior effect on pain intensity, ROM, anxiety, and QoL after 6 and 12 weeks compared to other interventions (only exercise and psychotherapy).

Are Mindful Exercises Safe and Beneficial for Treating Chronic Lower Back Pain? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Chronic low back pain (CLBP) is a common health issue worldwide. Tai Chi, Qigong, and Yoga, as the most widely practiced mindful exercises, have promising effects for CLBP-specific symptoms.

OBJECTIVE

We therefore conducted a comprehensive review investigating the effects of mindful exercises versus active and/or non-active controls while evaluating the safety and pain-related effects of mindful exercises in adults with CLBP.

METHODS

We searched five databases (MEDLINE, EMBASE, SCOPUS, Web of Science, and Cochrane Library) from inception to February 2019. Two investigators independently selected 17 eligible randomized controlled trials (RCT) against inclusion and exclusion criteria, followed by data extraction and study quality assessment. Standardized mean difference (SMD) was used to determine the magnitude of mindful exercises versus controls on pain- and disease-specific outcome measures.

RESULTS

As compared to control groups, we observed significantly favorable effects of mindful exercises on reducing pain intensity (SMD = -0.37, 95% CI -0.5 to -0.23, p < 0.001, I2 = 45.9 %) and disability (SMD = -0.39, 95% CI -0.49 to -0.28, p < 0.001, I2 = 0 %). When compared with active control alone, mindful exercises showed significantly reduced pain intensity (SMD = -0.40, p < 0.001). Furthermore, of the three mindful exercises, Tai Chi has a significantly superior effect on pain management (SMD= -0.75, 95% CI -1.05 to -0.46, p < 0.001), whereas Yoga-related adverse events were reported in five studies.

CONCLUSION

Findings of our systematic review suggest that mindful exercises (Tai Chi and Qigong) may be beneficial for CLBP symptomatic management. In particular, Tai Chi appears to have a superior effect in reducing pain intensity irrespective of non-control comparison or active control comparison (conventional exercises, core training, and physical therapy programs). Importantly, training in these mindful exercises should be implemented with certified instructors to ensure quality of movement and injury prevention.

Cost-Effectiveness of a Team-Based Integrative Medicine Approach to the Treatment of Back Pain

OBJECTIVES

To report the results of health economic analyses comparing two treatment approaches for chronic low back pain (CLBP).

DESIGN

Observational prospective cohort study comparing effectiveness and cost-effectiveness of CLBP care provided at an integrative care clinic with that provided in other clinics within the same hospital. CLBP-related medical utilization, function, quality of life, and days of work incapacity were self-reported at baseline, 3, 6, and 12 months.

SETTINGS/LOCATION

Osher Clinical Center (OCC) based at a tertiary academic hospital (Brigham and Women's Hospital [BWH]) and other clinics at BWH.

SUBJECTS

CLBP patients seeking care at OCC or non-OCC BWH clinics.

INTERVENTIONS

Integrative or conventional care for CLBP as prescribed by the treating clinician(s).

OUTCOME MEASURES

Quality-adjusted life years (QALYs) were estimated per treatment approach based on the SF-12. Cost per QALY gained was evaluated using an incremental cost-effectiveness ratio (ICER). ICERs based on CLBP-specific effectiveness measures (Roland Disability Questionnaire [RDQ] and bothersomeness of pain [BOP]) were exploratory outcomes.

RESULTS

Total adjusted annual CLBP-related costs per patient were greater in the OCC versus non-OCC group ($11,526.73 vs. $6,810.63). Between group differences in QALYs were small and ICER estimate of cost per QALY gained was high ($436,676). However, unadjusted mean direct costs per patient decreased over time in the OCC group. Savings in direct costs of $391 (95% confidence interval: -1,078 to 1,861) were observed in the OCC group for the 6- to 12-month period, driven primarily by reduced medication usage. ICERs based on adjusted RDQ and BOP group differences showed cost of $2,073 and $4,203 for a one-point reduction per respective scale.

CONCLUSIONS

When adjusted for baseline differences, self-reported costs were higher in the OCC group with only small effects on QALYs. However, trends toward decreased direct expenditures and medication usage over time warrant further investigation. Future studies evaluating potential benefits of integrative care models for the management of CLBP should employ randomized designs, longer observational periods, and explore multiple metrics of cost-effectiveness.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Tackling low back pain in Brazil: a wake-up call

BACKGROUND

Low back pain is the leading cause of years lived with disability in Brazil based upon Global Burden of Disease estimates. Since 1990, the number of years lived with disability has increased by 79.7%, and this number is expected to continue to rise due to population growth and ageing. Yet, similarly to other countries, little attention has been given to it in both the public and private health systems, arguably making it an overlooked epidemic in Brazil. There is evidence that Brazil has adopted unwarranted practices in the management of low back pain in a similar manner to what has been observed in high-income countries. To tackle the burden of low back pain in Brazil, we need highly coordinated efforts from government, the private sector, universities, health workers and civil society.

OBJECTIVE

This masterclass intends to provide an overview of the challenges faced by Brazil in relation to low back pain management and propose potential solutions that could potentially be implemented based on experiences reported in the literature.