Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review

Updated meta‑analysis on the therapeutic effects of botanical extract interventions for chronic lower back pain

Chronic lower back pain (CLBP) severely affects an individual's quality of life and increases reliance on healthcare services. Previous meta-analyses have primarily examined the effects of essential oils and herbal remedies separately, without considering their combined therapeutic potential. The present meta-analysis integrated both treatment modalities to evaluate the efficacy of botanical extract-based therapies for CLBP management. A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with data extracted from randomized controlled trials (RCTs) conducted up to July 2024. A comprehensive search of several databases identified 13 RCTs that met the inclusion criteria, focusing on interventions using plant extracts, including various herbal formulations and essential oils. The meta-analysis demonstrated that botanical extract-based treatments, whether applied topically, combined with massage or administered orally, were more effective compared with a placebo in reducing pain, enhancing lumbar flexibility and extending walking duration in patients with CLBP. These findings support the role of botanical extracts as viable therapeutic options for CLBP management, emphasizing their potential integration into comprehensive pain management strategies. However, further research is necessary to explore their long-term efficacy and underlying mechanisms. The present study is registered in PROSPERO (registration no. CRD42024554015).

A cost-effectiveness analysis of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain

BACKGROUND CONTEXT

Randomized trials have demonstrated the superiority of intraosseous basivertebral nerve ablation (BVNA) compared with sham and standard care in terms of improvements in pain, disability, and health-related quality of life in patients with vertebrogenic chronic low back pain (cLBP).

PURPOSE

To assess the cost effectiveness of BVNA in patients with vertebrogenic cLBP compared to standard care alone.

STUDY DESIGN/SETTING

A model-based economic analysis.

PATIENT SAMPLE

Base case analysis used INTRACEPT, a randomized trial comparing BVNA with standard care in 140 patients with vertebrogenic cLBP, recruited from 23 sites across the United States, with a follow-up, up to 5 years. Scenario analyses compared data from the Surgical Multicenter Assessment of Radiofrequency Ablation for the Treatment of Vertebrogenic Back Pain (SMART) randomized trial against a sham control, and a single-arm study.

OUTCOME MEASURES

Costs and quality-adjusted life years (QALYs) were calculated to determine the incremental cost-effectiveness ratio (ICER).

METHODS

A cost-effectiveness model was built in Microsoft Excel to evaluate the costs and health outcomes of patients undergoing BVNA using the Intracept Procedure (Relievant Medsystems) to treat vertebrogenic cLBP from a US payor perspective. Alternative scenario sensitivity analyses and probabilistic sensitivity analyses were conducted to assess the robustness of the model results. QALYs were discounted at 3.0% per year.

RESULTS

Base case analysis showed that BVNA relative to standard care alone was a cost-effective strategy for the management of patients with vertebrogenic cLBP, with an ICER of US$11,376 per QALY at a 5-year time horizon from introduction of the procedure. Modeling demonstrated a >99% probability that this was cost effective in the US, based on a willingness-to-pay threshold of US$100,000 to US$150,000. Various sensitivity and scenario analyses produced ICERs that all remained below this threshold.

CONCLUSIONS

BVNA with the Intracept Procedure offers patients with vertebrogenic cLBP, clinicians, and healthcare systems a cost-effective treatment compared to standard care alone.

Prognostic Factors for Outcome of Fusion Surgery in Patients With Chronic Low Back Pain - A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

This systematic review aims to identify prognostic factors, encompassing biomedical and psychosocial variables, linked to outcome of fusion surgery for chronic low back pain (CLBP) in single or two-level lumbar degenerative spinal disorders. Identifying these factors is crucial for decision making and therefore long-term treatment outcome.

METHODS

A systematic search (PROSPERO ID: CRD4202018927) from January 2010 to October 2022 was conducted, utilizing Medline, Embase, and the Cochrane Database of Systematic Reviews (CDSR, CENTRAL). Prognostic factors associated with various outcomes, including functional status, back and leg pain, health-related quality of life, complications, return to work, and analgesic use, were assessed. Risk of bias was determined using QUIPS, and the quality of evidence was evaluated using GRADE approach.

RESULTS

Of the 9852 initially screened studies, eleven studies (n = 16,482) were included in the analysis. In total, 161 associations were identified, with 67 prognostic factors showing statistical significance (P < 0.05). Thirty associations were supported by two or more studies, and only eight associations were eligible for meta-analyses: female gender remained statistically significant associated with decreased postoperative back pain, but negatively associated with complication rates and functional status, and smoking with increased postoperative back pain.

CONCLUSION

Only female gender and smoking were consistently associated with outcome of fusion for CLBP. Most of the included studies exhibited low to moderate methodological quality, which may explain the relatively weak associations identified for the assessed prognostic factors.

Modulation effects of imagery acupuncture and no-touch double-blinded placebo acupuncture, a cross-over pilot study

Both imagery and acupuncture are the oldest medical practices. Recently, we have developed a new treatment modality, video-guided acupuncture imagery treatment (VGAIT), which combines acupuncture and imagery. In this crossover study, we investigated the modulation effects of video-guided acupuncture imagery treatment compared with placebo acupuncture using no-touch double-blind placebo acupuncture needles and a no-treatment resting control. Pressure pain threshold and electroencephalogram (EEG) data were collected before and after each intervention. 12 healthy participants completed the study. Results showed that pressure pain thresholds were significantly increased after VGAIT compared to the resting control condition. In addition, we found that VGAIT, but not the no-touch placebo acupuncture or the resting control, significantly increased alpha and beta band power. Our findings demonstrate the potential of VGAIT as a remote therapeutic method (e-health treatment option) for pain and the value of no-touch double-blind placebo acupuncture in acupuncture research.

Duloxetine and cognitive behavioral therapy with phone-based support for the treatment of chronic musculoskeletal pain: study protocol of the PRECICE randomized control trial

BACKGROUND

Chronic musculoskeletal pain (CMP) is the most common, disabling, and costly of all pain conditions. While evidence exists for the efficacy of both duloxetine and web-based cognitive behavioral therapy (CBT) as monotherapy, there is a clear need to consider study of treatment components that may complement each other. In addition, given the reported association between patient's adherence and treatment outcomes, strategies are needed to enhance participant's motivation to adopt and maintain continued use of newly learned pain coping skills from CBT.

METHODS

Two hundred eighty participants will be recruited from the primary care clinics of a large academic health care system in North Carolina. Participants with CMP will be randomized to one of three treatment arms: (1) combination treatment (duloxetine + web-based self-guided CBT) with phone-based motivational interviewing (MI), (2) combination treatment without phone-based MI, and (3) duloxetine monotherapy. Participants will be in the study for 24 weeks and will be assessed at baseline, week 13, and week 25. The primary outcome is the Brief Pain Inventory (BPI)-Global Pain Severity score, which combines BPI pain severity and BPI pain interference. Secondary measures include between-group comparisons in mean BPI pain severity and BPI pain interference scores. Data collection and outcome assessment will be blinded to treatment group assignment.

DISCUSSION

This randomized controlled trial (RCT) will determine if combination treatment with duloxetine and web-based CBT is superior to duloxetine monotherapy for the management of CMP. Furthermore, this RCT will determine the effectiveness of phone-based motivational interviewing in promoting the continued practice of pain coping skills, thereby enhancing treatment outcomes.

TRIAL REGISTRATION

NCT04395001 ClinicalTrials.gov. Registered on May 15, 2020.

Duloxetine and Cognitive Behavioral Therapy with Phone-based Support for the Treatment of Chronic Musculoskeletal Pain: Study Protocol of the PRECICE Randomized Control Trial

Background

Chronic musculoskeletal pain (CMP) is the most common, disabling, and costly of all pain conditions. While evidence exists for the efficacy of both duloxetine and web-based cognitive behavioral therapy (CBT) as monotherapy, there is a clear need to consider study of treatment components that may complement each other. In addition, given the reported association between patient's adherence and treatment outcomes, strategies are needed to enhance participant's motivation to adopt and maintain continued use of newly learned pain coping skills from CBT.

Methods

Two hundred eighty participants will be recruited from the primary care clinics of a large academic health care system in North Carolina. Participants with CMP will be randomized to one of 3 treatment arms: (1) combination treatment (duloxetine + web-based self-guided CBT) with phone-based motivational interviewing (MI), (2) combination treatment without phone-based MI and (3) duloxetine monotherapy. Participants will be in the study for 24 weeks and will be assessed at baseline, week 13, and week 25. The primary outcome is the Brief Pain Inventory (BPI)-Global Pain Severity score, which combines BPI pain severity and BPI pain interference. Secondary measures include between-group comparisons in mean BPI pain severity and BPI pain interference scores. Data collection and outcome assessment will be blinded to treatment group assignment.

Discussion

This randomized controlled trial (RCT) will determine if combination treatment with duloxetine and web-based CBT is superior to duloxetine monotherapy for the management of CMP. Furthermore, this RCT will determine the effectiveness of phone-based motivational interviewing in promoting the continued practice of pain coping skills; thereby, enhancing treatment outcomes.

Trial Registration

NCT04395001. Registered in ClinicalTrials.gov on May 15, 2020.

Low back pain in beauty salons professionals in the city of Fortaleza-CE

Introduction

Low back pain can be defined as pain below the ribs and above the upper gluteal line.

Objectives

The study aimed to analyze low back pain in professionals from beauty salons in the city of Fortaleza, state of Ceará.

Methods

Descriptive, quantitative-qualitative, transversal, non-probabilistic research in the snowball modality, conducted between June and August 2021 in the José Walter neighborhood. Two sociodemographic questionnaires and the Quebec Back Pain Disability scale were applied, which seeks to assess how pain affects the participants' daily lives.

Results

Forty-two professionals were interviewed, of which 32 women (76.2%), with a mean age of 39.45 ± 10.99 years. Women were more likely to have an onset of low back pain and to live with pain for a longer time compared to men, in addition to these professionals having a significant overload for the hours worked. 52% of respondents showed significant clinical changes, mainly in relation to stand up for 20-30 minutes (16.7%), sit in a chair for several hours (14.3%), walk several kilometers (19%), carry two bags with groceries (14.3%) and lift and carry a heavy suitcase (28.6%).

Conclusions

It was evidenced that low back pain may be related to personal or environmental factors, with a sedentary lifestyle, length of service and working hours as strong indications for the onset of low back pain, with impairment in daily tasks.

Neuromuscular exercise and counseling for treating recurrent low back pain in female healthcare workers-Findings from a 24-month follow-up study of a randomized controlled trial

BACKGROUND

Female healthcare workers have a high prevalence of low back pain (LBP)-related sickness absence. Here, we report findings of a 24-month follow-up of a previously published 6-month randomized controlled trial (RCT).

METHODS

By adopting an RCT with 6 months of intervention and follow-up at 6, 12, and 24 months, we assessed the maintenance of changes in the effectiveness (LBP and fear of pain) of the interventions (neuromuscular exercise [NME], back-care counseling, both combined) using a generalized linear mixed model adjusted for baseline covariates. The incremental cost-effectiveness ratio was calculated in terms of quality-adjusted life years (QALY). A bootstrap technique was used to estimate the uncertainty around a cost-effectiveness acceptability curve.

RESULTS

Of the 219 females, 71% had data at 24 months. Between 6 and 24 months, LBP intensity (primary outcome) remained low in all intervention arms (-20% to -48%) compared to the control (-10% to -16%). Pain interfering with work remained low in the combined and exercise arms for up to 24 months. At 24 months, the total costs were lowest in the combined arm (€484 vs. €613-948, p < 0.001), as were the number of back-related sickness absence days (0.16 vs. 1.14-3.26, p = 0.003). The analysis indicated a 95% probability of the combined arm to be cost-effective per QALY gained at €1120.

CONCLUSIONS

Six months of weekly NME combined with four counseling sessions was cost-effective for treating LBP and the effect was maintained over 24 months.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01465698, 7/11/2011, prospective.

Cost-effectiveness of 10-kHz spinal cord stimulation therapy compared with conventional medical management over the first 12 months of therapy for patients with nonsurgical back pain: randomized controlled trial

OBJECTIVE

This analysis evaluated if spinal cord stimulation (SCS) at 10 kHz plus conventional medical management (CMM) is cost-effective compared with CMM alone for the treatment of nonsurgical refractory back pain (NSRBP).

METHODS

NSRBP subjects were randomized 1:1 into the 10-kHz SCS (n = 83) or CMM (n = 76) group. Outcomes assessed at 6 months included EQ-5D 5-level (EQ-5D-5L), medication usage, and healthcare utilization (HCU). There was an optional crossover at 6 months and follow-up to 12 months. The incremental cost-effectiveness ratio (ICER) was calculated with cost including all HCU and medications except for the initial device and implant procedure, and cost-effectiveness was analyzed based on a willingness-to-pay threshold of < $50,000 per quality-adjusted life-year.

RESULTS

Treatment with 10-kHz SCS resulted in a significant improvement in quality of life (QOL) over CMM (EQ-5D-5L index score change of 0.201 vs -0.042, p < 0.001) at a lower cost, based on reduced frequency of HCU resulting in an ICER of -$4964 at 12 months. The ICER was -$8620 comparing the 6 months on CMM with postcrossover on 10-kHz SCS.

CONCLUSIONS

Treatment with 10-kHz SCS provides higher QOL at a lower average cost per patient compared with CMM. Assuming an average reimbursement for device and procedure, 10-kHz SCS therapy is predicted to be cost-effective for the treatment of NSRBP compared with CMM within 2.1 years.

Individualized Exercise in Chronic Non-Specific Low Back Pain: A Systematic Review with Meta-Analysis on the Effects of Exercise Alone or in Combination with Psychological Interventions on Pain and Disability

This systematic review, meta-analysis and meta-regression investigated the effects of individualized interventions, based on exercise alone or combined with psychological treatment, on pain intensity and disability in patients with chronic non-specific low-back-pain. Databases were searched up to January 31, 2022 to retrieve respective randomized controlled trials of individualized and/or personalized and/or stratified exercise interventions with or without psychological treatment compared to any control. Fifty-eight studies (n = 10084) were included. At short-term follow-up (12 weeks), low-certainty evidence for pain intensity (SMD -0.28 [95%CI -0.42 to -0.14]) and very low-certainty evidence for disability (-0.17 [-0.31 to -0.02]) indicates effects of individualized versus active exercises, and very low-certainty evidence for pain intensity (-0.40; [-0.58 to -0.22])), but not (low-certainty evidence) for disability (-0.18; [-0.22 to 0.01]) compared to passive controls. At long-term follow-up (1 year), moderate-certainty evidence for pain intensity (-0.14 [-0.22 to -0.07]) and disability (-0.20 [-0.30 to -0.10]) indicates effects versus passive controls. Sensitivity analyses indicates that the effects on pain, but not on disability (always short-term and versus active treatments) were robust. Pain reduction caused by individualized exercise treatments in combination with psychological interventions (in particular behavioral-cognitive therapies) (-0.28 [-0.42 to -0.14], low certainty) is of clinical importance. Certainty of evidence was downgraded mainly due to evidence of risk of bias, publication bias and inconsistency that could not be explained. Individualized exercise can treat pain and disability in chronic non-specific low-back-pain. The effects at short term are of clinical importance (relative differences versus active 38% and versus passive interventions 77%), especially in regard to the little extra effort to individualize exercise. Sub-group analysis suggests a combination of individualized exercise (especially motor-control based treatments) with behavioral therapy interventions to booster effects. PERSPECTIVE: The relative benefit of individualized exercise therapy on chronic low back pain compared to other active treatments is approximately 38% which is of clinical importance. Still, sustainability of effects (> 12 months) is doubtable. As individualization in exercise therapies is easy to implement, its use should be considered. PROSPERO REGISTRATION: CRD42021247331.

Availability of Physical Rehabilitation Facilities for People with Disabilities in Iran: A Comparative Study on Universal Health Coverage

BACKGROUND

Iran, like many other countries, has committed to providing universal and equal access to health care and rehabilitation for people with disabilities by joining the Convention on the Rights of People with Disabilities. Thus, this study aimed to examine the availability of rehabilitation facilities on national and sub-national levels.

METHODS

This cross-sectional study was conducted between May and December 2019. The data of rehabilitation facilities including infrastructure and rehabilitation workforce in health system settings were obtained using rehabilitation master list. The data were collected from the Vice-Chancellor for the Treatment Ministry of Health and Medical Education, the Rehabilitation of the State Welfare Organization, and Licensing and Planning the Medical Council in the 32 provinces of Iran and analyzed using Excel version 2016.

RESULTS

On the national level, the following situation was found: in inpatient settings: 1.1 beds per million population; in outpatient settings: physiotherapy 42.6, optometry 16.4, audiology 10.5,occupational therapy 8.2, speech therapy 8.1, orthotic & prosthetic 4.5, physical medicine & rehabilitation 3.8 centers; day-care centers 11.7 and rehabilitation centers 1.3 centers, community-based rehabilitation (CBR): 15.9 units, rehabilitation home care 2 centers, rehabilitation nursing home care 1.6 centers and medical rehabilitation home care 0.3; Long-term care centers: residential care 4.1 centers per million population. Regarding rehabilitation work force: physiotherapists 84, speech therapists 34.8, occupational therapists 32.5, optometrists 31.2, audiologists 27.9, prosthetists and orthotists 10.3 therapists and physical medicine & rehabilitation 5.1 specialists per million populations. On the sub-national level, there were no outpatient rehabilitation centers in 12 of the provinces and the distribution of day rehabilitation centers in the rich provinces was 10 times higher. The number of CBR units, rehabilitation home care and rehabilitation nursing home were 40, 22, and 23 times higher in rich provinces than in poor provinces, respectively and there were no medical rehabilitation home care centers in 21 provinces. Regarding long-term care, the residential care centers in the richest province were 8 times higher.

CONCLUSION

According to the WHO report and the rehabilitation expert panel, it was concluded that the number of rehabilitation facilities including rehabilitation centers and workforce was limited in Iran and that the available centers were also poorly distributed in the provinces of the country. This made it difficult for people to have fair access to rehabilitation services. It appears that health policymakers should pay special attention to further developing rehabilitation facilities.

The impact of comorbid spinal pain in depression on work participation and clinical remission following brief or short psychotherapy. Secondary analysis of a randomized controlled trial with two-year follow-up

Objectives

This explorative study analyses the influence of baseline comorbid long-lasting spinal pain (CSP) on improvement of long term work participation and clinical remission of mental health illness following either brief coping-focussed or short-term psychotherapy for depression. Whether type of treatment modifies outcome with or without CSP is also analysed.

Design

A secondary post hoc subgroup analysis of a pragmatic randomised controlled trial.

Interventions

Brief or standard short psychotherapy.

Methods

Based on baseline assessment, the sample was subdivided into a subgroup with and a subgroup without CSP. Work participation and clinical remission of depression and anxiety were assessed as treatment outcome at two-year follow-up. Simple and multivariate logistic regression analyses, across the intervention arms, were applied to evaluate the impact of CSP on treatment outcome. Selected baseline variables were considered as potential confounders and included as variates if relevant. The modifying effect of CSP on treatment outcome was evaluated by including intervention modality as an interaction term.

Main results

Among the 236 participants with depressive symptoms, 83 participants (35%) were identified with CSP. In simple logistic regression analysis, CSP reduced improvements on both work participation and clinical remission rate. In the multivariate analysis however, the impact of CSP on work participation and on clinical remission were not significant after adjusting for confounding variables. Reduction of work participation was mainly explained by the higher age of the CSP participants and the reduced clinical remission by the additional co-occurrence of anxiety symptoms at baseline. The occurrence of CSP at baseline did not modify long term outcome of brief compared to short psychotherapy.

Conclusions

CSP at baseline reduced work participation and worsened remission of mental health symptoms two-year following psychotherapy. Older age and more severe baseline anxiety are associated to reduced effectiveness. Type of psychotherapy received did not contribute to differences.

Publication Trends in Rehabilitative Effects of Acupuncture: A Visual Analysis of the Literature

Objectives

To conduct a comprehensive analysis of scientific outputs in 2011–2021 regarding the rehabilitative effects of acupuncture on diseases.

Methods

The study was conducted in the form of knowledge graph and data visualization, with data being drawn from the Web of Science Core Collection database.

Results

Articles and reviews were the dominant types; China, Guangzhou University of Chinese Medicine and Medicine ranked was the active country, institution, and journal, respectively, in terms of issued articles. Systematic reviews and the meta-analyses of stroke and pain were extensively carried out in the past decade, whose principal interventions were manual acupuncture, electroacupuncture, scalp acupuncture, and dry needling correspondingly at Baihui (DU20) and Zusanli (ST36). And most frequently utilized rehabilitation assessment criteria were the Fugl-Meyer Assessment Scale and the Barthel Index. More recently, motor function and chronic obstructive pulmonary disease have captured researchers' attention, which might be the futuristic frontier.

Conclusions

This article provided a relatively panoramic picture of the scientific outputs in acupuncture for disease rehabilitation, which may help readers embrace the heated topic and grasp the recent research focus on this field.

Effects of a motor control exercise program on lumbopelvic pain recurrences and intensity in pregnant women with a history of lumbopelvic pain: a study protocol for a randomized controlled feasibility trial

Background

About 50% of women experience lumbopelvic pain (LBPP) during their pregnancy. LBPP has negative repercussions on sleep, social and sexual life, physical and work capacity, and psychological health and contributes to physical inactivity. The benefits of LBPP prevention or treatment in pregnant women through specific exercises should therefore be further investigated. This study protocol has been designed to establish the feasibility of implementing motor control exercise program with pregnant women presenting with a history of LBPP.

Methods/design

Forty pregnant women with a history of LBPP will be recruited and randomly allocated to a control (20 participants) or intervention (20 participants) group. The control group will receive standard prenatal care, including basic information on what to do when suffering from LBPP. The intervention group will participate in three 40-min exercise sessions per week from < 20 weeks until 34–36 weeks of gestation: one supervised group session via the Zoom platform (once a month, this session will take place at the Université du Québec à Trois-Rivières) and two unsupervised sessions at home. A motor control exercise program will be developed to target strengthening of the lumbo-pelvic-hip core muscles and improve spinal and pelvic stabilization. Participants of this group will also receive standard prenatal care. Women of the control group will receive after 6 weeks postpartum an exercise program designed to reduce LBPP they may have developed during pregnancy and that may persist after delivery. Primary outcomes will be participants’ recruitment, retention and adherence rates, safety, and acceptability of the intervention. Secondary outcomes will include LBPP incidence, frequency, and intensity, as well as self-reported functional disability, physical activity levels, fear avoidance behavior, anxiety, and depression.

Discussion

This study will inform the feasibility of conducting a full-scale randomized controlled study to test the effectiveness of a motor control exercise program on the prevention and treatment of LBPP in women with a history of LBPP. Adequate prevention and treatment of pregnant women with a history of LBPP should help limit the recurrences of LBPP or the aggravation of its intensity during pregnancy.

Trial registration

US National Institutes of Health Clinical Trials registry NCT04253717 April 27, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01024-0.

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.

Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study

BACKGROUND

Low back pain (LBP) is common, costly, and disabling. This study assesses a novel and simple LBP evaluation method and its merit in guiding the direction of a self-treatment exercise.

METHODS

Randomized open-label intention is used to treat the study. Consecutive patients with LBP ≥ three months and pain ≥ 5/10 were evaluated in a Vancouver clinic with the sacroiliac forward flexion test (SIFFT) by comparing the height of posterior superior iliac spines using a level. Those with asymmetry ≥ 5 mm were offered participation. The assistant, who generated and encrypted the randomization, assigned participants: group 1 learned a two-minute, SIFFT-derived, sacroiliac-leveling exercise (SIFFT-E) as needed for LBP relief; group 2 used a pelvic stabilization belt as needed to prevent LBP, and group 3 continued the usual care. After one month, all participants used SIFFT-E and belt as needed for one month. The identifier number of this article in Clinicaltrials.gov is #NCT03888235. The trial is closed. Our primary outcome measure was the Oswestry disability index (ODI) (decrease) from baseline to one and two months. We also followed SIFFT improvement (decrease).

FINDINGS

Of 72 LBP patients, 62 (86%) had ≥ 5 mm asymmetry. From zero to one month, the 21 (one dropout) SIFFT-E participants outperformed the 20 usual care participants for ODI improvement (12.5 ± 14.8 vs. -3.4 ± 14.9 points; mean difference 15.9 [CI 6.7-25.0]; P = 0.002 with number needed to treat (NNT) of 3.0 for ODI improvement ≥ 11). Belt use results were intermediate. At two months, after all the 62 participants used the exercise and belt as needed, combined ODI improvements were clinically significant (12.0 ± 18.4 points), and SIFFT asymmetry was reduced by 8.6 ± 8.6 mm. Five (8%) exercise and 12 (19%) belt wearers experienced mild side effects.

INTERPRETATION

Sacroiliac asymmetry appears to be frequent. SIFFT may be clinically useful as an evaluation tool for prescribing a simple self-directed corrective exercise as seen by clinically significant improvements in function and asymmetry.

Association Between Pregnancy-Related Hormones and Lumbopelvic Pain Characteristics in Pregnant Women: A Scoping Review

OBJECTIVES

The objectives of this scoping review were (1) to document and quantify the potential associations between lumbopelvic pain characteristics and pregnancy-related hormones, and (2) to identify research approaches and assessment tools used to investigate lumbopelvic pain characteristics and pregnancy-related hormones.

METHODS

The literature search was conducted in 6 databases (MEDLINE, Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature, SportDiscus, PsycINFO, and Cochrane) from inception up to March 2020 and completed using search terms relevant to pregnant women, pregnancy-related hormones, and lumbopelvic pain. The risk of bias was assessed using the characteristics recommended by Guyatt et al. for observational studies.

RESULTS

The search yielded 1015 publications from which 9 met the inclusion criteria. Relaxin was the most studied pregnancy-related hormone. An association between relaxin levels and lumbopelvic pain presence or severity was found in 4 studies, while 5 studies did not report an association between them. One study reported an association between relaxin and lumbopelvic pain presence or severity while 2 studies reported no association and were considered as having a low risk of bias. One study reported measures of estrogen and progesterone levels. It showed that progesterone levels were found to be significantly higher in pregnant women with lumbopelvic pain compared to those without, while estrogen concentrations were similar in both groups.

CONCLUSION

The literature showed conflicting evidence regarding the association between pregnancy-related hormones and lumbopelvic pain characteristics in pregnant women. The assessment tools used to investigate lumbopelvic pain characteristics and pregnancy-related hormones are heterogeneous across studies. Based on limited and conflicting evidence, and due to the heterogeneity of assessment tools and overall poor quality of the literature, the association between pregnancy-related hormones and lumbopelvic pain characteristics is unclear.

Flipping the Pain Care Model: A Sociopsychobiological Approach to High-Value Chronic Pain Care

OBJECTIVE

Much of the pain care in the United States is costly and associated with limited benefits and significant harms, representing a crisis of value. We explore the current factors that lead to low-value pain care within the United States and provide an alternate model for pain care, as well as an implementation example for this model that is expected to produce high-value pain care.

METHODS

From the perspective of aiming for high-value care (defined as care that maximizes clinical benefit while minimizing harm and cost), we describe the current evidence practice gap (EPG) for pain care in the United States, which has developed as current clinical care diverges from existing evidence. A discussion of the biomedical, biopsychosocial, and sociopsychobiological (SPB) models of pain care is used to elucidate the origins of the current EPG and the unconscious factors that perpetuate pain care systems despite poor results.

RESULTS

An interprofessional pain team within the Veterans Health Administration is described as an example of a pain care system that has been designed to deliver high-value pain care and close the EPG by implementing the SPB model.

CONCLUSIONS

Adopting and implementing a sociopsychobiological model may be an effective approach to address the current evidence practice gap and deliver high-value pain care in the United States. The Phoenix VA Health Care System's Chronic Pain Wellness Center may serve as a template for providing high-value, evidence-based pain care for patients with high-impact chronic pain who also have medical, mental health, and opioid use disorder comorbidities.

Changes in Opioid Therapy Use by an Interprofessional Primary Care Team: A Descriptive Study of Opioid Prescription Data

OBJECTIVE

The purpose of this study was to describe changes in opioid-therapy prescription rates after a family medicine practice included on-site chiropractic services.

METHODS

The study design was a retrospective analysis of opioid prescription data. The database included opioid prescriptions written for patients seeking care at the family medicine practice from April 2015 to September 2018. In June 2016, the practice reviewed and changed its opioid medication practices. In April 2017, the practice included on-site chiropractic services. Opiod-therapy use was defined as the average rate of opioid prescriptions over all medical providers at the practice.

RESULTS

There was a significant decrease of 22% in the average monthly rate of opioid prescriptions after the inclusion of chiropractic services (F_1,40 = 10.69; P < .05). There was a significant decrease of 32% in the prescribing rate of schedule II opioids after the inclusion of chiropractic services (F_2,80 = 6.07 for the Group × Schedule interaction; P < .05). The likelihood of writing schedule II opioid prescriptions decreased by 27% after the inclusion of chiropractic services (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Changes in opioid medication practices by the medical providers included prescribing a schedule III or IV opioid rather than a schedule II opioid (F_6,76 = 29.81; P < .05) and a 30% decrease in the daily doses of opioid prescriptions (odds ratio, 0.70; 95% confidence interval, 0.50-0.98).

CONCLUSION

This study demonstrates that there were decreases in opioid-therapy prescribing rates after a family medicine practice included on-site chiropractic services. This suggests that inclusion of chiropractic services may have had a positive effect on prescribing behaviors of medical physicians, as they may have been able to offer their patients additional nonpharmaceutical options for pain management.

What is the impact of clinical guidelines on imaging costs?

Inappropriate and irrational use of numerous advanced diagnostic imaging technologies has recently been highlighted in many countries and has gathered the attention of policymakers. This matter has not only increased health costs in countries but also resulted in adverse health results. Various factors are involved in the inappropriate or unnecessary use of advanced medical imaging techniques including patient-related, physician-related, technological, and ultimately radiologist-related factors. This calls for the provision of new guidelines by policymakers to encourage all service providers to make appropriate use of such techniques. One of the main approaches in this regard is the application of clinical guidelines and decision support systems. The present study was a systematized review that conducted in January 2019, and the articles related to palliative care requirements on databases of Web of Science, PubMed, Scopus, ScienceDirect, Ovid, ProQuest, Wiley, and Google Scholar from January 1, 2009, to January 20, 2019, were searched. Strategy for searching and selecting the articles was Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines. Overview of the studies shows that various reasons for the overuse of diagnostic imaging technologies and effects of applying clinical guidelines on reducing diagnostic costs of treatment are investigated in this article with respect to various aspects and viewpoints. Clinical guidelines can be significantly effective in evaluating suitability and quality of referrals for diagnostic imaging, if only adapted properly.

A cost-utility analysis of multimodal pain rehabilitation in primary healthcare

OBJECTIVES

Multimodal rehabilitation programs (MMRPs) have been shown to be both cost-effective and an effective method for managing chronic pain in specialist care. However, while the vast majority of patients are treated in primary healthcare, MMRPs are rarely practiced in these settings. Limited time and resources for everyday activities alongside the complexity of chronic pain makes the management of chronic pain challenging in primary healthcare and the focus is on unimodal treatment. In order to increase the use of MMRPs incentives such as cost savings and improved health status in the patient group are needed. The aim of this study was to evaluate the cost-effectiveness of MMRPs for patients with chronic pain in primary healthcare in two Swedish regions. The aim of this study was to evaluate the cost-effectiveness of MMRPs at one-year follow-up in comparison with care as usual for patients with chronic pain in primary healthcare in two Swedish regions.

METHODS

A cost-utility analysis was performed alongside a prospective cohort study comparing the MMRP with the alternative of continuing with care as usual. The health-related quality of life (HRQoL), using EQ5D, and working situation of 234 participants were assessed at baseline and one-year follow-up. The primary outcome was cost per quality-adjusted life year (QALY) gained while the secondary outcome was sickness absence. An extrapolation of costs was performed based on previous long-term studies in order to evaluate the effects of the MMRP over a five-year time period.

RESULTS

The mean (SD) EQ5D index, which measures HRQoL, increased significantly (p<0.001) from 0.34 (0.32) to 0.44 (0.32) at one-year follow-up. Sickness absence decreased by 15%. The cost-utility analysis showed a cost per QALY gained of 18 704 € at one-year follow-up.

CONCLUSIONS

The results indicate that the MMRP significantly improves the HRQoL of the participants and is a cost-effective treatment for patients with chronic pain in primary healthcare when a newly suggested cost-effectiveness threshold of 19 734 € is implemented. The extrapolation indicates that considerable cost savings in terms of reduced loss of production and gained QALYs may be generated if the effects of the MMRP are maintained beyond one-year follow-up. The study demonstrates potential benefits of MMRPs in primary healthcare for both the patient with chronic pain and the society as a whole. The cost-effectiveness of MMRPs in primary healthcare has scarcely been studied and further long-term studies are needed in these settings.

Multicentre randomised controlled clinical trial of electroacupuncture with usual care for patients with non-acute pain after back surgery

BACKGROUND

The purpose of this study was to investigate the effectiveness and safety between electroacupuncture (EA) combined with usual care (UC) and UC alone for pain reduction and functional improvement in patients with non-acute low back pain (LBP) after back surgery.

METHODS

In this multicentre, randomised, assessor-blinded active-controlled trial, 108 participants were equally randomised to either the EA with UC or the UC alone. Participants in the EA with UC group received EA treatment and UC treatment twice a week for 4 weeks; those allocated to the UC group received only UC. The primary outcome was the VAS pain intensity score. The secondary outcomes were functional improvement (Oswestry Disability Index [ODI]) and the quality of life (EuroQol-5-dimension questionnaire [EQ-5D]). The outcomes were measured at Week 5.

RESULTS

Significant reductions were observed in the VAS (mean difference [MD] -8.15; P=0.0311) and ODI scores (MD -3.98; P=0.0460) between two groups after 4 weeks of treatment. No meaningful differences were found in the EQ-5D scores and incidence of adverse events (AEs) between the groups. The reported AEs did not have a causal relationship with EA treatment.

CONCLUSIONS

The results showed that EA with UC treatment was more effective than UC alone and relatively safe in patients with non-acute LBP after back surgery. EA with UC treatment may be considered as an effective, integrated, conservative treatment for patients with non-acute LBP after back surgery.

CLINICAL TRIAL REGISTRATION

KCT0001939.

The Clinical and Cost-Effectiveness of Telerehabilitation for People With Nonspecific Chronic Low Back Pain: Randomized Controlled Trial

BACKGROUND

Telerehabilitation can facilitate multidisciplinary management for people with nonspecific chronic low back pain (NCLBP). It provides health care access to individuals who are physically and economically disadvantaged.

OBJECTIVE

This study aimed to evaluate the clinical and cost-effectiveness of telerehabilitation compared with a clinic-based intervention for people with NCLBP in Nigeria.

METHODS

A cost-utility analysis alongside a randomized controlled trial from a health care perspective was conducted. Patients with NCLBP were assigned to either telerehabilitation-based McKenzie therapy (TBMT) or clinic-based McKenzie therapy (CBMT). Interventions were carried out 3 times weekly for a period of 8 weeks. Patients' level of disability was measured using the Oswestry Disability Index (ODI) at baseline, week 4, and week 8. To estimate the health-related quality of life of the patients, the ODI was mapped to the short-form six dimensions instrument to generate quality-adjusted life years (QALYs). Health care resource use and costs were assessed based on the McKenzie extension protocol in Nigeria in 2019. Descriptive and inferential data analyses were also performed to assess the clinical effectiveness of the interventions. Bootstrapping was conducted to generate the point estimate of the incremental cost-effectiveness ratio (ICER).

RESULTS

A total of 47 patients (TBMT, n=21 and CBMT, n=26), with a mean age of 47 (SD 11.6) years for telerehabilitation and 50 (SD 10.7) years for the clinic-based intervention, participated in this study. The mean cost estimates of TBMT and CBMT interventions per person were 22,200 naira (US $61.7) and 38,200 naira (US $106), respectively. QALY gained was 0.085 for TBMT and 0.084 for CBMT. The TBMT arm was associated with an additional 0.001 QALY (95% CI 0.001 to 0.002) per participant compared with the CBMT arm. Thus, the ICER showed that the TBMT arm was less costly and more effective than the CBMT arm.

CONCLUSIONS

The findings of the study suggested that telerehabilitation for people with NCLBP was cost saving. Given the small number of participants in this study, further examination of effects and costs of the interventions is needed within a larger sample size. In addition, future studies are required to assess the cost-effectiveness of this intervention in the long term from the patient and societal perspective.

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.

Cost-effectiveness of physiotherapeutic interventions for low back pain: a systematic review

BACKGROUND

Due to the rapid increase in healthcare costs of low back pain (LBP), it is important to provide clinically effective and cost-effective interventions to individuals with the condition.

OBJECTIVE

To evaluate all recent economic evaluations of physiotherapeutic interventions for patients with LBP.

DATA SOURCES

A literature search of Cumulative Index to Nursing and Allied Health Literature, MEDLINE, the National Health Service Economic Evaluation Database, Health Technology Assessment and Database of Abstracts of Review of Effects (January 2008 to October 2018) was undertaken.

STUDY SELECTION

Randomised controlled trials and cohort studies that assessed the cost- effectiveness of physiotherapeutic interventions on patients with LBP compared with a control group were included in this review. A Consolidated Health Economic Evaluation Reporting Standards checklist was used to assess the quality of studies.

DATA EXTRACTION/DATA SYNTHESIS

Two authors extracted data independently. A descriptive synthesis was conducted to summarise the data.

RESULTS

In total, 1531 articles were identified and 11 studies met the inclusion criteria for this review. The total number of study participants in this review was 2633 and their ages ranged from 18 to 80 years. The duration of LBP in these patients ranged from 3 weeks to 1 year. Excluding one study, all studies reported that the physiotherapeutic intervention was cost-effective compared with the control arm. Meta-analysis was not possible due to heterogeneity of the studies.

CONCLUSION

Although most studies in this review suggested that physiotherapeutic interventions were cost-effective, it is difficult to pool their results for conclusive evidence. Systematic review registration number CRD: 42018089773.

Evaluation of a multimodal pain rehabilitation programme in primary care based on clinical register data: a feasibility study

Aim:

Investigate the feasibility of identifying a well-defined treatment group and a comparable reference group in clinical register data.

Background:

There is insufficient knowledge on how to avert neck/back pain from turning chronic or to impair work ability. The Swedish Government implemented a national multimodal rehabilitation (MMR) programme in primary care intending to promote work ability, reduce sick leave and increase return to work. Since randomised control trial data for effect is lacking, it is important to evaluate existing observational data from clinical settings.

Methods:

We identified all unique patients with musculoskeletal pain (MSP) diagnoses undergoing the MMR programme in primary care in the Skåne Health care Register (n = 2140) during 2010–2011. A reference cohort in primary care (n = 56 300) with similar MSP diagnoses, same ages and the same level of sick leave before baseline was identified for the same period. The reference cohort received ordinary care and treatment in primary care. The final study group consisted of 603 eligible MMR patients and 2874 eligible reference patients. Socio-economic and health-related baseline data including sick leave one year before up to two years after baseline were compared between groups.

Findings:

There were significant socio-economic and health differences at baseline between the MMR and the reference patients, with the MMR group having lower income, higher morbidity and more sick leave days. Sick leave days per year decreased significantly in the MMR group (118–102 days, P < 0.001) and in the reference group (50–42 days, P < 0.001) from one year before baseline to two years after.

Conclusions:

It was not feasible to identify a comparable reference group based on clinical register data. Despite an ambitious attempt to limit selection bias, significant baseline differences in socio-economic and health were present. In absence of randomised trials, effects of MMR cannot be sufficiently evaluated in primary care.

Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid: A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid

OBJECTIVES

The objectives of this study were to critically evaluate the methodology and conclusions of the fiscal notes prepared by the state of Missouri for including doctors of chiropractic (DCs) under Missouri Medicaid and to develop a dynamic scoring model that calculates the savings if DCs were allowed to offer treatment under Missouri Medicaid.

METHODS

We used a secondary analysis to determine the cost-saving assumptions to be incorporated into a dynamic model. We reviewed the literature on efficiency and effectiveness of DC-delivered care regarding the most reliable assumptions concerning cost savings and utilization. The assumptions for percentage savings from DC-provided care and the avoidance of spinal surgeries were then combined in the dynamic scoring model to determine projected cost savings from adding DCs as covered providers under Missouri Medicaid. The actual cost of opioid abuse in Missouri was then determined as a basis to measure cost savings from adding DC care as an alternative therapy for the management of neck and low back pain.

DISCUSSION

The Missouri Health Division initially used the static scoring approach to evaluate proposals to cover DC care under Missouri Medicaid. This approach only considers added costs from a legislative change. Because of this, we proposed that the Missouri Health Division used flawed methodology and data in their calculations for the fiscal note regarding the cost of including care from DCs under Missouri Medicaid. After consideration of the approach used in this study, the Committee adopted some important elements of dynamic scoring. Based on our computations and the dynamic scoring model, we determined that there would be a cost savings to the state of Missouri of between $14.1 and $49.2 million once DCs are included as covered providers under Missouri Medicaid. This study also supports the proposition that treatment by DCs for neck and lower back pain may reduce the use and abuse of opioid prescription drugs.

CONCLUSION

Policymakers may unintentionally rely on flawed assumptions and methodologies such as static scoring, which we propose results in flawed conclusions. Legislative options involve some additional cost. The issue is whether proposed legislative options offer more effective outcomes along with more efficient cost. Using a dynamic scoring model to incorporate savings from 3 primary sources, we found that (1) chiropractic care provides better outcomes at lower cost, (2) chiropractic treatment and care leads to a reduction in cost of spinal surgery, and (3) chiropractic care leads to cost savings from reduced use and abuse of opioid prescription drugs.

The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain

Low-back pain (LBP) is one of the most burdensome health problems in the world. Guidelines recommend simple treatments such as advice that may result in suboptimal outcomes, particularly when applied to people with complex biopsychosocial barriers to recovery. Individualised physiotherapy has the potential of being more effective for people with LBP; however, there is limited evidence supporting this approach. A series of studies supporting the mechanisms underpinning and effectiveness of the Specific Treatment of Problems of the Spine (STOPS) approach to individualised physiotherapy have been published. The clinical and research implications of these findings are presented and discussed. Treatment based on the STOPS approach should also be considered as an approach to individualised physiotherapy in people with LBP.

A guided and unguided internet- and mobile-based intervention for chronic pain: health economic evaluation alongside a randomised controlled trial

OBJECTIVE

This study aims at evaluating the cost-effectiveness and cost-utility of a guided and unguided internet-based intervention for chronic pain patients (ACTonPain_guided and ACTonPain_unguided) compared with a waitlist control group (CG) as well as the comparative cost-effectiveness of the guided and the unguided version.

DESIGN

This is a health economic evaluation alongside a three-arm randomised controlled trial from a societal perspective. Assessments were conducted at baseline, 9 weeks and 6 months after randomisation.

SETTING

Participants were recruited through online and offline strategies and in collaboration with a health insurance company.

PARTICIPANTS

302 adults (≥18 years, pain for at least 6 months) were randomly allocated to one of the three groups (ACTonPain_guided, ACTonPain_unguided, CG).

INTERVENTIONS

ACTonPain consists of seven modules and is based on Acceptance and Commitment Therapy. ACTonPain_guided and ACTonPain_unguided only differ in provision of human support.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcomes of the cost-effectiveness and the cost-utility analyses were meaningful change in pain interference (treatment response) and quality-adjusted life years (QALYs), respectively. Economic evaluation estimates were the incremental cost-effectiveness and cost-utility ratio (ICER/ICUR).

RESULTS

At 6-month follow-up, treatment response and QALYs were highest in ACTonPain_guided (44% and 0.280; mean costs = €6,945), followed by ACTonPain_unguided (28% and 0.266; mean costs = €6,560) and the CG (16% and 0.244; mean costs = €6,908). ACTonPain_guided vs CG revealed an ICER of €45 and an ICUR of €604.ACTonPain_unguided dominated CG. At a willingness-to-pay of €0 the probability of being cost-effective was 50% for ACTonPain_guided (vs CG, for both treatment response and QALY gained) and 67% for ACTonPain_unguided (vs CG, for both treatment response and QALY gained). These probabilities rose to 95% when society's willingness-to-pay is €91,000 (ACTonPain_guided) and €127,000 (ACTonPain_unguided) per QALY gained. ACTonPain_guided vs ACTonPain_unguided revealed an ICER of €2,374 and an ICUR of €45,993.

CONCLUSIONS

Depending on society's willingness-to-pay, ACTonPain is a potentially cost-effective adjunct to established pain treatment. ACTonPain_unguided (vs CG) revealed lower costs at better health outcomes. However, uncertainty has to be considered. Direct comparison of the two interventions does not indicate a preference for ACTonPain_guided.

TRIAL REGISTRATION NUMBER

DRKS00006183.

Economic evaluation of a healthy lifestyle intervention for chronic low back pain: A randomized controlled trial

BACKGROUND

Economic evaluations which estimate cost-effectiveness of potential treatments can guide decisions about real-world healthcare services. We performed an economic evaluation of a healthy lifestyle intervention targeting weight loss, physical activity and diet for patients with chronic low back pain, who are overweight or obese.

METHODS

Eligible patients with chronic low back pain (n = 160) were randomized to an intervention or usual care control group. The intervention included brief advice, a clinical consultation and referral to a 6-month telephone-based healthy lifestyle coaching service. The primary outcome was quality-adjusted life years (QALYs). Secondary outcomes were pain intensity, disability, weight and body mass index. Costs included intervention costs, healthcare utilization costs and work absenteeism costs. An economic analysis was performed from the societal perspective.

RESULTS

Mean total costs were lower in the intervention group than the control group (-$614; 95%CI: -3133 to 255). The intervention group had significantly lower healthcare costs (-$292; 95%CI: -872 to -33), medication costs (-$30; 95%CI: -65 to -4) and absenteeism costs (-$1,000; 95%CI: -3573 to -210). For all outcomes, the intervention was on average less expensive and more effective than usual care, and the probability of the intervention being cost-effective compared to usual care was relatively high (i.e., 0.81) at a willingness-to-pay of $0/unit of effect. However, the probability of cost-effectiveness was not as favourable among sensitivity analyses.

CONCLUSIONS

The healthy lifestyle intervention seems to be cost-effective from the societal perspective. However, variability in the sensitivity analyses indicates caution is needed when interpreting these findings.

SIGNIFICANCE

This is an economic evaluation of a randomized controlled trial of a healthy lifestyle intervention for chronic low back pain. The findings suggest that a healthy lifestyle intervention may be cost-effective relative to usual care.

Treatment Efficacy, Clinical Utility, and Cost-Effectiveness of Multidisciplinary Biopsychosocial Rehabilitation Treatments for Persistent Low Back Pain: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

To review the current literature on the treatment efficacy, clinical utility, and cost-effectiveness of multidisciplinary biopsychosocial rehabilitation (MBR) for patients suffering from persistent (nonspecific) lower back pain (LBP) in relation to pain intensity, disability, health-related quality of life, and work ability/sick leave.

METHODS

We carried out a systematic search of Web of Science, Cochrane Library, PubMed Central, EMBASE, and PsycINFO for English- and German-language literature published between January 2010 and July 2017. Study selection consisted of exclusion and inclusion phases. After screening for duplication, studies were excluded on the basis of criteria covering study design, number of participants, language of publication, and provision of information about the intervention. All the remaining articles dealing with the efficacy, utility, or cost-effectiveness of intensive (more than 25 hours per week) MBR encompassing at least 3 health domains and cognitive behavioral therapy-based psychological education were included.

RESULTS

The search retrieved 1199 publications of which 1116 were duplicates or met the exclusion criteria. Seventy of the remaining 83 articles did not meet the inclusion criteria; thus 13 studies were reviewed. All studies reporting changes in pain intensity or disability over 12 months after MBR reported moderate effect sizes and/or p-values for both outcomes. The effects on health-related quality of life were mixed, but MBR substantially reduced costs. Overall MBR produced an enduring improvement in work ability despite controversy and variable results.

CONCLUSIONS

MBR is an effective treatment for nonspecific LBP, but there is room for improvement in cost-effectiveness and impact on sick leave, where the evidence was less compelling.

Wet-Cupping Is Effective on Persistent Nonspecific Low Back Pain: A Randomized Clinical Trial

OBJECTIVE

To compare the possible effects of wet-cupping therapy with conventional therapy on persistent nonspecific low back pain (PNSLBP).

METHODS

In this randomized clinical trial, 180 participants with the mean age of 45±10 years old, who had been suffering from PNSLBP were randomly assigned to wet-cupping and conventional groups. The wet-cupping group was treated with two separate sessions (4 weeks in total) on the inter-scapular and sacrum area. In the conventional group, patients were conservatively treated using rest (6 weeks) and oral medications (3 weeks). The primary and the secondary outcome were the quantity of disability using Oswestry Disability Index (ODI), and pain intensity using Visual Analogue Scale (VAS), respectively.

RESULTS

There was no significant difference in demographic characteristics (age, gender, and body mass index) between the two groups (P>0.05). Therapeutic effect of wet-cupping therapy was comparable to conventional treatment in the 1st month follow-up visits (P<0.05). The functional outcomes of wet-cupping at the 3rd and 6th month visits were significantly increased compared to the conventional group. Final ODI scores in the wet-cupping and conventional groups were 16.7 ± 5.7 and 22.3 ± 4.5, respectively (P<0.01).

CONCLUSION

Wet-cupping may be a proper method to decrease PNSLBP without any conventional treatment. The therapeutic effects of wet-cupping can be longer lasting than conventional therapy. (Registration No. IRCT2013021672741)).

Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis

Objective

The purpose of this review was to investigate the relationship between prenatal exercise, and low back (LBP), pelvic girdle (PGP) and lumbopelvic (LBPP) pain.

Design

Systematic review with random effects meta-analysis and meta-regression.

Data sources

Online databases were searched up to 6 January 2017.

Study eligibility criteria

Studies of all designs were eligible (except case studies and reviews) if they were published in English, Spanish or French, and contained information on the population (pregnant women without contraindication to exercise), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone [“exercise-only”] or in combination with other intervention components [eg, dietary; “exercise + co-intervention”]), comparator (no exercise or different frequency, intensity, duration, volume and type of exercise) and outcome (prevalence and symptom severity of LBP, PGP and LBPP).

Results

The analyses included data from 32 studies (n=52 297 pregnant women). ‘Very low’ to ‘moderate’ quality evidence from 13 randomised controlled trials (RCTs) showed prenatal exercise did not reduce the odds of suffering from LBP, PGP and LBPP either in pregnancy or the postpartum period. However, ‘very low’ to ‘moderate’ quality evidence from 15 RCTs identified lower pain severity during pregnancy and the early postpartum period in women who exercised during pregnancy (standardised mean difference −1.03, 95% CI −1.58, –0.48) compared with those who did not exercise. These findings were supported by ‘very low’ quality evidence from other study designs.

Conclusion

Compared with not exercising, prenatal exercise decreased the severity of LBP, PGP or LBPP during and following pregnancy but did not decrease the odds of any of these conditions at any time point.

Does the performance of five back-associated exercises relate to the presence of low back pain? A cross-sectional observational investigation in regional Australian council workers

OBJECTIVES

Investigate the relationships between the ability/inability to perform five physical test exercises and the presence or absence of low back pain (LBP).

SETTING

Regional Australian council training facility.

PARTICIPANTS

Consecutive participants recruited during 39 back education classes (8-26 participants per class) for workers in general office/administration, parks/gardens maintenance, roads maintenance, library, child care and management. Total sample (n=539) was reduced through non-consent and insufficient demographic data to n=422. Age 38.6±15.3 years, range 18-64 years, 67.1% male.

METHODS

Cross-sectional, exploratory, observational investigation. LBP presence was ascertained from a three-response option questionnaire: 0=none/rarely (no) 1=sometimes (some), 2=mostly/always (most). Statistical correlation was performed with the number of the five test exercises the individual successfully performed: (1) extension in lying: 3 s; (2) 'toilet squat'; feet flat, feet touched: 3 s; (3) full squat then stand up: 5 times; (4) supine sit-up, knees flexed: 10 times; and (5) leg extension, supine bilateral: 10 times.

INTERVENTIONS

Nil.

RESULTS

For the group 'no-some', 94.3% completed 4-5 test exercises, while for group 'With', 95.7% completed 0-1 test exercises. The relationship between LBP presence and number of exercises performed was highly significant (χ²₍₁₀₎=300.61, p<0.001). Furthermore, multinomial logistic regression predicting LBP (0=no, 1=some, 2=most) from the number of exercises completed, substantially improved the model fit (initial-2LL=348.246, final-2LL=73.620, χ²₍₂₎=274.626, p<0.001). As the number of exercises performed increased, the odds of reporting 'some LBP' or 'most LBP' dropped substantially (ORs of 0.34 and 0.17, respectively).

CONCLUSION

The ability to complete/not complete five test exercises correlated statistically and significantly with a higher LBP absence/presence in a general working population. Training individuals to complete such exercises could facilitate reductions in LBP incidence; however, causality cannot be inferred. Randomised trials are recommended to establish the potential efficacy of exercise-based approaches, considering these five selected exercises, for predicting and managing LBP.

Electroacupuncture as a complement to usual care for patients with non-acute low back pain after back surgery: a pilot randomised controlled trial

OBJECTIVES

The aim of this pilot study was to estimate the sample size for a large pragmatic study of the comparative effectiveness of electroacupuncture (EA) for low back pain (LBP) after back surgery.

DESIGN

A randomised, active-controlled, assessor-blinded trial.

PARTICIPANTS

Patients with recurrent or persistent LBP, defined as a Visual Analogue Scale (VAS) score of ≥50 mm, with or without leg pain after back surgery.

INTERVENTIONS

Patients were randomised to an EA plus usual care (UC) group or to a UC alone group at a 1:1 ratio. Patients assigned to each group received UC, including drug therapy, physical therapy and back pain education, twice a week for 4 weeks; those assigned to the EA plus UC group additionally received EA.

OUTCOME MEASURES

The primary outcome was severity of LBP as measured by VAS. Secondary outcomes included back pain-related disability, assessed using the Oswestry Disability Index (ODI) and quality of life, assessed using the EuroQol Five Dimensions (EQ-5D) questionnaire. Statistical analysis was performed using paired and independent t-tests. A p value of <0.05 was considered statistically significant.

RESULTS

Thirty-nine patients were allocated to receive EA plus UC (n=18) or UC alone (n=21). There was no statistically significant difference in VAS or EQ-5D scores between the two groups, but there was a significant decrease in ODI scores (p=0.0081). Using G*Power, it was calculated that 40 participants per group would be needed for a future trial according to VAS scores. Considering for a 25% dropout rate, 108 participants (54 per group) would be needed.

CONCLUSIONS

A future trial addressing the risk of bias and including the estimated sample size would allow for better clinical assessment of the benefits of EA plus UC in treatment of patients with non-acute pain after back surgery.

TRIAL REGISTRATION NUMBER

NCT01966250; Results.

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

OBJECTIVE

To investigate the cost-effectiveness of exercise therapy in the treatment of patients with non-specific neck pain and low back pain.

DESIGN

Systematic review of economic evaluations.

DATA SOURCES

The search was performed in 5 clinical and 3 economic electronic databases.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included economic evaluations performed alongside randomised controlled trials. Differences in costs and effects were pooled in a meta-analysis, if possible, and incremental cost-utility ratios (ICUR) were descriptively analysed.

RESULTS

Twenty-two studies were included. On average, exercise therapy was associated with lower costs and larger effects for quality-adjusted life-year (QALY) in comparison with usual care for subacute and chronic low back pain from a healthcare perspective (based on ICUR). Exercise therapy had similar costs and effect for QALY in comparison with other interventions for neck pain from a societal perspective, and subacute and chronic low back pain from a healthcare perspective. There was limited or inconsistent evidence on the cost-effectiveness of exercise therapy compared with usual care for neck pain and acute low back pain, other interventions for acute low back pain and different types of exercise therapy for neck pain and low back pain.

CONCLUSIONS

Exercise therapy seems to be cost-effective compared with usual care for subacute and chronic low back pain. Exercise therapy was not (more) cost-effective compared with other interventions for neck pain and low back pain. The cost-utility estimates are rather uncertain, indicating that more economic evaluations are needed.

REGISTRATION

PROSPERO, CRD42017059025.

Effectiveness of classic physical therapy proposals for chronic non-specific low back pain: a literature review

INTRODUCTION

Chronic low back pain is a pathological process that compromises the functionality and quality of life worldwide. The objective of the study was to evaluate the effectiveness of classical physiotherapy in the management of non-specific chronic low back pain.

METHODS

A literature search in English electronic databases was performed from November to December of 2015. Only those studies addressing chronic non-specific low back pain by manual therapy and different types of exercises methods were included, and those, which combined acute or subacute pain with systematic reviews and clinical practice guidelines, were excluded. Studies involving cognitive-behavioral approaches were also excluded.

RESULTS

487 studies were identified, 16 were analyzed and 10 were excluded. Of the 6 studies reviewed, 5 of them achieved a moderate quality and 1 of them was of a low quality. Back School exercises and McKenzie's method were all ineffective. Osteopathic spinal manipulation proved effective when performed on the lower back and the thoracic area but only immediately after it was received, and not in the medium or long term. Massages proved effective in the short term too, as well as the global postural reeducation although ultimately this study can be considered of a low methodological quality.

CONCLUSIONS

Based on the data obtained, classical physiotherapy proposals show ineffectiveness in the treatment of chronic non-specific low back pain. More multidimensional studies are needed in order to achieve a better treatment of this condition, including the biopsychosocial paradigm.

Different doses of Pilates-based exercise therapy for chronic low back pain: a randomised controlled trial with economic evaluation

Objectives

To evaluate the effectiveness and cost-utility of the addition of different doses of Pilates to an advice for non-specific chronic low back pain (NSCLBP) from a societal perspective.

Design

Randomised controlled trial with economic evaluation.

Setting

Physiotherapy clinic in São Paulo, Brazil.

Participants

296 patients with NSCLBP.

Interventions

All patients received advice and were randomly allocated to four groups (n=74 per group): booklet group (BG), Pilates once a week (Pilates group 1, PG1), Pilates twice a week (Pilates group 2, PG2) and Pilates three times a week (Pilates group 3, PG3).

Main outcome measures

Primary outcomes were pain and disability at 6-week follow-up.

Results

Compared with the BG, all Pilates groups showed significant improvements in pain (PG1, mean difference (MD)=−1.2, 95% CI −2.2 to −0.3; PG2, MD=−2.3, 95% CI −3.2 to −1.4; PG3, MD=−2.1, 95% CI −3.0 to −1.1) and disability (PG1, MD=−1.9, 95% CI −3.6 to −0.1; PG2, MD=−4.7, 95% CI −6.4 to −3.0; PG3, MD=−3.3, 95% CI −5.0 to −1.6). Among the different doses, PG2 showed significant improvements in comparison with PG1 for pain (MD=−1.1, 95% CI −2.0 to −0.1) and disability (MD=−2.8, 95% CI −4.5 to −1.1). The cost-utility analysis showed that PG3 had a 0.78 probability of being cost-effective at a willingness-to-pay of £20 000 per quality-adjusted life-year gained.

Conclusions

Adding two sessions of Pilates exercises to advice provided better outcomes in pain and disability than advice alone for patients with NSCLBP; non-specific elements such as greater attention or expectation might be part of this effect. The cost-utility analysis showed that Pilates three times a week was the preferred option.

Trial registration number

NCT02241538, Completed.

Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

A multi-center, randomized controlled clinical trial, cost-effectiveness and qualitative research of electroacupuncture with usual care for patients with non-acute pain after back surgery: study protocol for a randomized controlled trial

BACKGROUND

Although pain after back surgery is known to be difficult to control, various treatment options are available to patients and physicians. A protocol for a confirmatory randomized controlled trial (RCT) on pain and function after back surgery was designed based on the results of a pilot trial. The aim of this study is to compare the effectiveness and safety of electroacupuncture (EA) with usual care (UC) versus UC alone on pain control and functional improvement after back surgery.

METHODS/DESIGN

This study is a multi-center, randomized, assessor-blinded trial with an active control conducted in conjunction with a cost-effectiveness analysis and qualitative research. Participants with non-acute low back pain with or without leg pain after back surgery who have a Visual Analogue Scale (VAS) pain intensity score ≥ 50 mm will be randomly assigned to either the EA with UC group (n = 54) or the UC group (n = 54). Following randomization, participants in both groups will receive the same UC treatment twice a week for a four-week treatment period. Participants assigned to the EA with UC group will additionally receive EA twice a week for the same four-week period. The primary outcome measure will be assessed using a VAS pain intensity score for low back pain. The secondary outcomes will include the Oswestry Disability Index, EuroQol 5-Dimension score, and drug intake. The primary and secondary outcomes will be measured at one, four, and eight weeks post randomization.

DISCUSSION

The results of this study will provide evidence of the effectiveness and cost-effectiveness of EA in managing postoperative pain following back surgery. In addition, the qualitative research results will help improve the quality of integrative medical interventions.

TRIAL REGISTRATION

Clinical Research Information Service (CRIS), Republic of Korea, KCT0001939 . Registered on 8 June 2016.

Rehabilitative Principles in the Management of Thoracolumbar Syndrome: A Case Report

Objective

The purpose of this case report was to describe the chiropractic management of thoracolumbar syndrome using multimodal therapies.

Clinical Features

A 33-year-old woman with 3 weeks of back pain presented to a chiropractic clinic. Nerve tension tests and local tenderness were present in a pattern described by Maigne, and she was diagnosed with thoracolumbar syndrome (Maigne syndrome) at her initial visit.

Intervention and Outcomes

The Oswestry Disability Index for low back pain (62%), STarT low back screen tool for clinical outcomes (6 points total, with a 2-point subscale), numeric pain rating scale (6/10 constant, 10/10 with provocation), and test-retest exercise audits were outcome measures. She received 3 treatment sessions, each with progressive exercise audits, and discharged with advice. At discharge, the patient scores substantially improved (Oswestry Disability Index: 8%, STarT: 1 point total, numeric pain rating scale: 1/10, 10% of the time), and she exhibited greater confidence in home care. Endurance tests were performed to establish baselines for future care, which included static back endurance test (timed 52 seconds) and side bridge endurance test (timed 43 seconds).

Conclusion

The patient responded positively to chiropractic care. After a short course of care, the patient reported reduced pain, alleviated symptoms, and improved physical function.

Health economic evidence gaps and methodological constraints in low back pain and neck pain: Results of the Research Agenda for Health Economic Evaluation (RAHEE) project

Despite the increased interest in economic evaluations, there are difficulties in applying the results of such studies in practice. Therefore, the "Research Agenda for Health Economic Evaluation" (RAHEE) project was initiated, which aimed to improve the use of health economic evidence in practice for the 10 highest burden conditions in the European Union (including low back pain [LBP] and neck pain [NP]). This was done by undertaking literature mapping and convening an Expert Panel meeting, during which the literature mapping results were discussed and evidence gaps and methodological constraints were identified. The current paper is a part of the RAHEE project and aimed to identify economic evidence gaps and methodological constraints in the LBP and NP literature, in particular. The literature mapping revealed that economic evidence was unavailable for various commonly used LBP and NP treatments (e.g., injections, traction, and discography). Even if economic evidence was available, many treatments were only evaluated in a single study or studies for the same intervention were highly heterogeneous in terms of their patient population, control condition, follow-up duration, setting, and/or economic perspective. Up until now, this has prevented economic evaluation results from being statistically pooled in the LBP and NP literature, and strong conclusions about the cost-effectiveness of LBP and NP treatments can therefore not be made. The Expert Panel identified the need for further high-quality economic evaluations, especially on surgery versus conservative care and competing treatment options for chronic LBP. Handling of uncertainty and reporting quality were considered the most important methodological challenges.

Systematic Review of Costs and Effects of Self-Management Interventions for Chronic Musculoskeletal Pain: Spotlight on Analytic Perspective and Outcomes Assessment

BACKGROUND

Evidence for the cost-effectiveness of self-management interventions for chronic musculoskeletal pain (CMP) lacks consensus, which may be due to variability in the costing methods employed.

PURPOSE

The purposes of the study were to identify how costs and effects have been assessed in economic analysis of self-management interventions for CMP and to identify the effect of the chosen analytical perspective on cost-effectiveness conclusions.

DATA SOURCES

Five databases were searched for all study designs using relevant terms.

STUDY SELECTION

Two independent researchers reviewed all titles for predefined inclusion criteria: adults (≥18 years of age) with CMP, interventions with a primary aim of promoting self-management, and conducted a cost analysis.

DATA EXTRACTION

Descriptive data including population, self-management intervention, analytical perspective, and costs and effects measured were collected by one reviewer and checked for accuracy by a second reviewer.

DATA SYNTHESIS

Fifty-seven studies were identified: 65% (n = 37) chose the societal perspective, of which 89% (n = 33) captured health care utilization, 92% (n = 34) reported labor productivity, 65% (n = 24) included intervention delivery, and 59% (n = 22) captured patient/family costs. Types of costs varied in all studies. Eight studies conducted analyses from both health service and societal perspectives; cost-effectiveness estimates varied with perspective chosen, but in no case was the difference sufficient to change overall policy recommendations.

LIMITATIONS

Chronic musculoskeletal pain conditions where self-management is recommended, but not as a primary treatment, were excluded. Gray literature was excluded.

CONCLUSION

Substantial heterogeneity in the cost components captured in the assessment of self-management for CMP was found; this was independent of the analytic perspective used. Greater efforts to ensure complete and consistent costings are required if reliable cost-effectiveness evidence of self-management interventions is to be generated and to inform the most appropriate perspective for economic analyses in this field.

Essential features influencing collaboration in team-based non-specific back pain rehabilitation: Findings from a mixed methods study

The aim of the study presented in this article was to explore how professionals, without guidelines for implementing interprofessional teamwork, experience the collaboration within team-based rehabilitation for people with back pain and how this collaboration influences their clinical practice. This study employed a mixed methods design. A questionnaire was answered by 383 participants and 17 participants were interviewed. The interviews were analysed using content analysis. The quantitative results showed that the participants were satisfied with their team-based collaboration. Thirty percent reported that staff changes in the past year had influenced their clinical practice, of which 57% reported that these changes had had negative consequences. The qualitative findings revealed that essential features for an effective collaboration were shared basic values and supporting each other. Furthermore, aspects such as having enough time for reflection, staff continuity, and a shared view of the team members' roles were identified as aspects which influenced the clinical practice. Important clinical implications for nurturing and developing a collaboration in team-based rehabilitation are to create shared basic values and a unified view of all team members' roles and their contributions to the team. These aspects need to be emphasised on an ongoing basis and not only when the team is formed.

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.

Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review

BACKGROUND

Low back pain (LBP) is a major health problem, having a substantial effect on peoples' quality of life and placing a significant economic burden on healthcare systems and, more broadly, societies. Many interventions to alleviate LBP are available but their cost effectiveness is unclear.

OBJECTIVES

To identify, document and appraise studies reporting on the cost effectiveness of non-invasive and non-pharmacological treatment options for LBP.

METHODS

Relevant studies were identified through systematic searches in bibliographic databases (EMBASE, MEDLINE, PsycINFO, Cochrane Library, CINAHL and the National Health Service Economic Evaluation Database), 'similar article' searches and reference list scanning. Study selection was carried out by three assessors, independently. Study quality was assessed using the Consensus on Health Economic Criteria checklist. Data were extracted using customized extraction forms.

RESULTS

Thirty-three studies were identified. Study interventions were categorised as: (1) combined physical exercise and psychological therapy, (2) physical exercise therapy only, (3) information and education, and (4) manual therapy. Interventions assessed within each category varied in terms of their components and delivery. In general, combined physical and psychological treatments, information and education interventions, and manual therapies appeared to be cost effective when compared with the study-specific comparators. There is inconsistent evidence around the cost effectiveness of physical exercise programmes as a whole, with yoga, but not group exercise, being cost effective.

CONCLUSIONS

The identified evidence suggests that combined physical and psychological treatments, medical yoga, information and education programmes, spinal manipulation and acupuncture are likely to be cost-effective options for LBP.