Cost-effectiveness of Multidisciplinary Interventions for Chronic Low Back Pain: A Narrative Review

Top Ten Tips Palliative Care Clinicians Should Know About Total Pain

"Total pain" is a fundamental concept in palliative care. It emphasizes the multidimensional nature of pain and suffering in patients with advanced illnesses. Originally introduced by Dame Cicely Saunders, the spectrum of total pain extends beyond pure physical pain to further encompass psychological, social, and spiritual distress. By focusing on the above four components of total pain, clinicians can provide better care for their patients with advanced illnesses and ultimately improve their overall quality of life. Compiled by a multidisciplinary team of experts in the field, this article provides ten key strategies (tips) for palliative care clinicians to enhance their understanding and management of total pain in clinical settings.

Biopsychosocial Approaches for the Management of Female Chronic Pelvic Pain: A Systematic Review

BACKGROUND/OBJECTIVE

Current guidelines recommend biopsychosocial-informed treatment for chronic pelvic pain (CPP). The objective of this systematic review was to describe the available biopsychosocial approaches for the treatment of CPP, and the outcomes reported, to understand how guideline-recommended treatments can be applied.

SEARCH STRATEGY

MEDLINE, CINAHL, PsycINFO, EMBASE, Emcare, AMED and Cochrane trial registries were searched (inception to 17 November 2023).

SELECTION CRITERIA

CPP Studies in women where the principal treatment modality was a biopsychosocial approach were included. Prospero registration: CRD42022374256.

DATA COLLECTION/ANALYSIS

Data extraction included study setting, population, study design, intervention characteristics and outcome measures and is described via a narrative synthesis.

RESULTS

The review included 14 RCTs (871 patients) and identified four broad intervention categories (Acceptance Commitment Therapy n = 2, Cognitive Behavioural Therapy n = 6, Mindfulness-based approaches n = 2, and Physiotherapy-based interventions n = 4). Pain science education (PSE) and, exposure/engagement with valued activity were recognised as important aspects of treatment regardless of intervention type. The most utilised outcomes were pain reduction and emotional functioning, with all studies reporting improvements in these domains. Heterogeneity in outcomes prevented efficacy comparison. High risk of bias was identified in six studies (1/4 physiotherapy-based approaches, 2/6 CBT, 1/2 ACT and 2/2 mindfulness-based interventions).

CONCLUSIONS

CBT and ACT-based biopsychosocial approaches were found effective in reducing pain and improving psychometric outcomes for CPP. Evaluation indicated PSE, and exposure/engagement in valued activity are important components of biopsychosocial management. Outcome heterogeneity needs to be addressed in future trials.

The Comparison of Cost-Effectiveness Between Magnetic Resonance Spectroscopy and Provocative Discography in the Identification of Chronic Low Back Pain Surgery Candidates

Background/Context

Chronic low back pain (CLBP) is a significant US healthcare burden with millions of lumbar spine procedures annually. Diagnostic tests are essential to guide treatment but provocative discography (PD), the most common diagnostic procedure, is without robust evidence of its value. A non-invasive alternative using Magnetic Resonance Spectroscopy (MRS) offers a potential solution.

Context/Purpose

We assess cost-effectiveness of MRS with NOCISCAN diagnostic algorithm compared to PD for identifying lumbar discs requiring surgical intervention.

Study Design/Setting

We conducted cost-effectiveness analysis using modelling.

Patient Sample

We used data from a clinical study of 139 CLBP patients who met criteria for and received PD of lumbar spine and presented with an ODI score ≥40; comparing PD and MRS-based diagnostics.

Outcome Measures

We considered diagnostic costs, adverse events, surgical costs and outcomes based on a 15-point improvement on the Oswestry Disability Index.

Methods

Incremental cost-effectiveness ratios (ICERS) and probabilistic sensitivity analyses were determined. Some authors have consulted for Aclarion.

Results

Mean total cost per PD patient was $59,711, and $57,998 for MRS, demonstrating $1712 cost savings per MRS diagnosed patient. Diagnostic costs ($1950 for PD; $1450 for MRS), saved $500 per MRS patient. PD incurred adverse event costs ($57,323) for 1% of patients, which MRS eliminated. MRS-based diagnosis showed 78% surgical success, whereas PD achieved 68%. MRS was the dominant diagnostic strategy, with better clinical outcomes and cost savings. Probabilistic sensitivity analysis confirmed MRS dominance and was cost-effective across a wide range of willingness-to-pay thresholds and across 2 different scenarios which vary base-case outcomes and surgical rates.

Conclusion

This study demonstrates cost-effectiveness dominance of MRS with the Nociscan diagnostic algorithm over PD for identifying CLBP surgical candidates. MRS provides significant cost savings and leads to better surgical outcomes, making it a preferred choice for insurers and health systems.

Psychophysiological biomarkers to assess the effectiveness of surface electromyography biofeedback as an alternative therapy to reduce chronic low back pain: protocol for a randomised controlled trial

The prevalence of chronic low back pain (CLBP) among the Pakistani population is reported to be as high as 78%, leading towards different physiological and psychosocial alterations, with the worst cases suffering from disabilities. This study protocol will be a randomised controlled trial designed to compare the effectiveness of biofeedback surface electromyography (sEMG) for CLBP in the Pakistani population. This will be a single-centre study to be conducted on patients with CLBP randomised into two groups, namely, Group A (intervention group) and Group B (control group) to receive biofeedback sEMG therapy as an intervention or no intervention, respectively. All participants will receive treatment for 8 weeks virtually. The primary and secondary outcomes will be assessed during the study, including the pain intensity and interference (Brief Pain Inventory), anxiety and depression (State-Trait Anxiety Inventory (STAI)), disability (The Oswestry Disability Index (ODI)) and quality of life. Further, physiological parameters, including altered cortisol levels, beta-endorphins and substance P, will also be measured. All outcomes will be assessed at baseline, immediately post-intervention and 3 months follow-up.

Postural and Lumbopelvic Control: Crucial Factors in the Functionality of Patients with Low Back Pain-A Descriptive Cross-Sectional Study

Background: Low back pain (LBP) is one of the most prevalent musculoskeletal disorders in adults worldwide. Alterations in postural and lumbopelvic control and functionality appear to be determining factors in its resolution. Methods: A cross-sectional study was performed. Patients with LBP were enrolled. Lumbar pain; postural control (PC), total area of the center of pressure (TACOP), and the velocity of the center of pressure (VCOP); lumbopelvic control (LPC); and functionality were evaluated. Statistical tests were implemented to determine differences between sex and age and correlation models among the variables. Results: Thirty adult patients with LBP were analyzed. A strong relationship was found between pain and functionality [r = 0.64; p < 0.001]. A moderate relationship was found between pain and TACOP [r = 0.395; p = 0.031]. A moderate relationship was observed between TACOP and functionality [0.413; p = 0.023] and between LPC and TACOP [r = 0.416; p = 0.001]. Conclusions: This study demonstrates the significant impact of LBP on postural control, lumbopelvic control, and functionality. These results highlight the importance of addressing postural and lumbopelvic control in LBP treatment. No significant differences based on gender and age were found, but all clinical variables differed significantly between the LBP and control groups, underscoring the unique impairments associated with LBP.

Productivity outcomes from chronic pain management interventions in the working age population; a systematic review

ABSTRACT

Productivity loss because of chronic pain in the working age population is a widespread concern internationally. Interventions for chronic pain in working age adults might be expected to achieve enhanced productivity in terms of reduced costs of workers' compensation insurance, reduced disability support, and improved rates of return to work for injured workers. This would require the use of measures of productivity in the evaluation of chronic pain management interventions. The aim of this review was to identify and interpret the productivity outcomes of randomised controlled trials reported by studies that conducted economic evaluations (eg, cost-effectiveness and cost-utility) of chronic pain management interventions in the working age population published from database inception to March 2023. Econlit, Embase, and Pubmed electronic databases were searched, yielding 12 studies that met the selection criteria. All 12 studies used absenteeism to measure productivity, translating return to work measures into indirect costs. Only one study included return to work as a primary outcome. Ten studies found no statistically significant improvements in productivity-related costs. Despite evidence for reduced pain-related disability after pain management interventions, this review suggests that the use of measures for assessing productivity gains is lacking. Including such measures would greatly assist administrators and payers when considering the broader societal benefits of such interventions.

Integrated pain care models and the importance of aligning stakeholder values

Sustained widespread deployment of clinically and cost-effective models of integrated pain care could be bolstered by optimally aligning shared stakeholder values.

What is the volume, quality and characteristics of evidence relating to the effectiveness and cost-effectiveness of multi-disciplinary occupational health interventions aiming to improve work-related outcomes for employed adults? An evidence and gap map of systematic reviews

Background

In the UK, tens of millions of working days are lost due to work-related ill health every year, costing billions of pounds. The role of Occupational Health (OH) services is vital in helping workers to maintain employment when they encounter injury or illness. OH providers traditionally rely on a clinical workforce to deliver these services, particularly doctors and nurses with OH qualifications. However, the increasing demand for OH services is unlikely to be met in the future using this traditional model, due to the declining number of OH-trained doctors and nurses in the UK. Multi-disciplinary models of OH delivery, including a more varied range of healthcare and non-healthcare professionals, could provide a way to meet this new demand for OH services. There is a need to identify collaborative models of OH service delivery and review their effectiveness on return-to work outcomes. There is an existing pool of systematic review evidence evaluating workplace based, multi-disciplinary OH interventions, but it is difficult to identify which aspects of the content and/or delivery of these interventions may be associated with improved work-related outcomes.

Objectives

The aim of this evidence and gap map (EGM) was to provide an overview of the systematic review evidence that evaluates the effectiveness and cost-effectiveness of multi-disciplinary OH interventions intending to improve work-related outcomes.

Search Methods

In June 2021 we searched a selection of bibliographic databases and other academic literature resources covering a range of relevant disciplines, including health care and business studies, to identify systematic review evidence from a variety of sectors of employment. We also searched Google Search and a selection of topically relevant websites and consulted with stakeholders to identify reports already known to them. Searches were updated in February 2023.

Selection Criteria

Systematic reviews needed to be about adults (16 years or over) in employment, who have had absence from work for any medical reason. Interventions needed to be multi-disciplinary (including professionals from different backgrounds in clinical and non-clinical professions) and designed to support employees and employers to manage health conditions in the workplace and/or to help employees with health conditions retain and/or return to work following medical absence. Effectiveness needed to be measured in terms of return to work, work retention or measures of absence, or economic evaluation outcomes. These criteria were applied to the title and abstract and full text of each systematic review independently by two reviewers, with disagreements resolved through discussion. We awarded each systematic review a rating of 'High', 'Medium' or 'Low' relevance to indicate the extent to which the populations, interventions and their contexts synthesised within the review were consistent with our research question. We also recorded the number of primary studies included within each of the 'High' and 'Medium' reviews that were relevant to research question using the same screening process applied at review level.

Data Collection and Analysis

Summary data for each eligible review was extracted. The quality of the systematic reviews, rated as 'High' or 'Medium' relevance following full text screening, was appraised using the AMSTAR-2 quality appraisal tool. All data were extracted by one reviewer and checked by a second, with disagreements being settled through discussion. Summary data for all eligible systematic reviews were tabulated and described narratively. The data extracted from reviews of 'High' and 'Medium' relevance was imported into EPPI-Mapper software to create an EGM.

Stakeholder Involvement

We worked alongside commissioners and policy makers from the Department of Health and Social Care (DHSC) and Department of Work and Pensions (DWP), OH personnel, and people with lived experience of accessing OH services themselves and/or supporting employees to access OH services. Individuals contributed to decision making at all stages of the project. This ensured our EGM reflects the needs of individuals who will use it.

Main Results

We identified 98 systematic reviews that contained relevant interventions, which involved a variety of professionals and workplaces, and which measured effectiveness in terms of return to work (RTW). Of these, we focused on the 30 reviews where the population and intervention characteristics within the systematic reviews were considered to be of high or medium relevance to our research questions. The 30 reviews were of varying quality, split evenly between High/Moderate quality and Low/Critically-Low quality ratings. We did not identify any relevant systematic review evidence on any other work-related outcome of interest. Interventions were heterogenous, both within and across included systematic reviews. The EGM is structured according to the health condition experienced by participants, and the effectiveness of the interventions being evaluated, as reported within the included systematic reviews. It is possible to view (i) the quality and quantity of systematic review evidence for a given health condition, (ii) how review authors assessed the effectiveness or cost-effectiveness of the interventions evaluated. The EGM also details the primary studies relevant to our research aim included within each review.

Authors’ Conclusions

This EGM map highlights the array of systematic review evidence that exists in relation to the effectiveness or cost-effectiveness of multi-disciplinary, workplace-based OH interventions in supporting RTW. This evidence will allow policy makers and commissioners of services to determine which OH interventions may be most useful for supporting different population groups in different contexts. OH professionals may find the content of the EGM useful in identifying systematic review evidence to support their practice. The EGM also identifies where systematic review evidence in this area is lacking, or where existing evidence is of poor quality. These may represent areas where it may be particularly useful to conduct further systematic reviews.

Dynamic assessment of spine movement patterns using an RGB-D camera and deep learning

In clinical practice, functional limitations in patients with low back pain are subjectively assessed, potentially leading to misdiagnosis and prolonged pain. This paper proposes an objective deep learning (DL) markerless motion capture system that uses a red-green-blue-depth (RGB-D) camera to measure the kinematics of the spine during flexion-extension (FE) through: 1) the development and validation of a DL semantic segmentation algorithm that segments the back into four anatomical classes and 2) the development and validation of a framework that uses these segmentations to measure spine kinematics during FE. Twenty participants performed ten cycles of FE with drawn-on point markers while being recorded with an RGB-D camera. Five of these participants also performed an additional trial where they were recorded with an optical motion capture (OPT) system. The DL algorithm was trained to segment the back and pelvis into four anatomical classes: upper back, lower back, spine, and pelvis. A kinematic framework was then developed to refine these segmentations into upper spine, lower spine, and pelvis masks, which were used to measure spine kinematics after obtaining 3D global coordinates of the mask corners. The segmentation algorithm achieved high accuracy, and the root mean square error (RMSE) between ground truth and predicted lumbar kinematics was < 4°. When comparing markerless and OPT kinematics, RMSE values were < 6°. This work demonstrates the feasibility of using markerless motion capture to assess FE spine movement in clinical settings. Future work will expand the studied movement directions and test on different demographics.

Economic evaluation of management strategies for complex regional pain syndrome (CRPS)

Background: The economic impact of Complex Regional Pain Syndrome (CRPS) on both patients and the global healthcare system continues to escalate. However, the economic implications associated with management interventions for CRPS have received limited attention. Therefore, our objective is to perform a thorough examination of published economic assessments of the various management strategies utilized for CRPS. Methods: A thorough search spanning four general medical databases and three health economic databases to identify full economic evaluations on CRPS management strategies from January 1994 to June 2023 were conducted. The quality of these studies were evaluated by employing the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. To enable cross-study comparisons conducted in different countries, we adjusted the costs reported in the selected studies for inflation and converted them into 2023 US dollars. Results: A total of nine economic evaluations, consisting of eight high-quality and one medium-quality, were identified across five nations during a span of 29 years. The findings suggest that the most economically efficient intervention for CRPS are interventional approaches of Spinal Cord Stimulation (SCS) in comparison to conventional management for long periods of time. Furthermore, in situations where there is a limited time period of less than 1 year, rehabilitation therapies, particularly physical therapy, have been demonstrated to be more effective in terms of both cost and clinical outcomes. Conclusion: The interventional management strategies, particularly for severe and persistent CRPS over long periods, may offer the greatest cost efficiency. In conditions with limited timelines, rehabilitation measures, such as rehabilitation therapies, can be cost-effective. However, insufficient data for other common interventions prevents the formation of a definitive conclusion. Similarly, it is crucial to recognize that the results of these interventions might be affected by the selection of comparator and the threshold for willingness to pay.

Economic analysis of patient-related effects of an interdisciplinary pain self-management program

ABSTRACT

Active Day Patient Treatment (ADAPT) is a well-established 3 week intensive cognitive-behavioural, interdisciplinary pain management program for patients with disabling chronic pain. The aim of this analysis was to conduct an economic analysis of patient-related effects of ADAPT using hospital administrative data, specifically, to compare the costs and health outcomes for patients 1 month after participating in the program, with the preprogram period when they were receiving standard care. This retrospective cohort study included 230 patients who completed ADAPT (including follow-ups) between 2014 and 17 at the Pain Management and Research Centre at the Royal North Shore Hospital in Sydney, Australia. Data on pain-related healthcare utilization and costs before and after the program were assessed. Primary outcome measures were labour force participation for patients' average weekly earnings and cost per clinically meaningful change in Pain Self-efficacy Questionnaire, Brief Pain Inventory (BPI) Severity, and BPI interference scores (n = 224). We estimated patients, on average, earned $59 more each week at 1 month follow-up compared with baseline. The cost per clinically meaningful change in pain severity and interference score based on the BPI severity and BPI interference were AU$9452.32 (95% CI: $7031.76-$12,930.40) and AU$3446.62 (95% CI: $2851.67-$4126.46), respectively. The cost per point improvement and per clinically meaningful change in the Pain Self-efficacy Questionnaire were $483 (95% CI: $411.289-$568.606) and $3381.02, respectively. Our analysis showed a better health outcome, reduced healthcare services' cost, and reduced number of medications taken 1 month after participating in ADAPT.

The invisible cost of pain management by the current International Classification of Diseases coding system: a study in a tertiary care inpatient setting

ABSTRACT

The International Classification of Diseases ( ICD ) is applied worldwide for public health data collection among other use cases. However, the current version of the ICD ( ICD-10 ), to which the reimbursement system is linked in many countries, does not represent chronic pain properly. This study aims to compare the ICD-10 with the ICD-11 in hospitalized patients in terms of specificity, clinical utility, and reimbursement for pain management. The medical records of hospitalized patients consulted for pain management at Siriraj Hospital, Thailand, were reviewed, and all pain-related diagnoses were coded into ICD-10 and ICD-11 . The data of 397 patients showed unspecified pain was coded 78% in the ICD-10 and only 0.5% in the ICD-11 version. The difference gap in the proportion of unspecified pain between the 2 versions is wider than in the outpatient setting. The 3 most common codes for ICD-10 were other chronic pain, low back pain, and pain in limb. The 3 most common codes for ICD-11 were chronic cancer pain, chronic peripheral neuropathic pain, and chronic secondary musculoskeletal pain. As in many other countries, no pain-related ICD-10 codes were coded for routine reimbursement. The simulated reimbursement fee remained the same when adding 397 pain-related codings, even if the cost of pain management, such as cost of labor, existed. Compared with the ICD-10 version, the ICD-11 is more specific and makes pain diagnoses more visible. Thus, shifting from ICD-10 to ICD-11 has the potential to improve both the quality of care and the reimbursement for pain management.

Feasibility of a multidisciplinary group videoconferencing approach for chronic low back pain: a randomized, open-label, controlled, pilot clinical trial (EN-FORMA)

BACKGROUND

Low back pain is a common condition that becomes even more prevalent with aging. A non-pharmacological multidisciplinary approach for chronic non-specific low back pain (CNSLBP) has been recommended, but integrating different healthcare professionals is challenging. A multidisciplinary group videoconferencing approach (MGVA) can be helpful. Our aim was to provide evidence on MGVA's feasibility in managing CNSLBP and its impact on clinical practice.

METHODS

We conducted an open-label, randomized, controlled, parallel-group pilot clinical trial with CNSLBP patients irresponsive to conservative treatment. Patients between 18 and 67 years of age were randomly assigned (1:1) to either Standard-of-Care + MGVA (experimental group) or Standard-of-Care alone (control group). MGVA consisted of integrated sessions for physical rehabilitation/physiotherapy, psychology, and social work treatments. The control group received standard clinical practice treatment. The feasibility was assessed by the number of study procedures completed to at least 80% as planned. The impact on clinical practice was evaluated by the number of patients who changed their status from "candidate" to "non-candidate" to low back surgery as the treatment of choice for CNSLBP. The SF-36, Oswestry Disability Index, and TMMS-24 questionnaires were used. We performed a whole population-based descriptive analysis.

RESULTS

We included 20 patients, but only 18 were randomized (2 withdrew consent before randomization). The mean (SD) age was 53.1 (5.9) years, and mostly women (13/18); 7 were actively employed. In the experimental group, 6/9 (67%, 95%CI:35-88%) patients attended at least 80% of the scheduled procedures, while in the control group, 8/9 (89%, 95%CI:57-98%) did. Additionally, 1 out of 4 (25%) patients in the experimental group changed their status from "candidate" for low back surgery to "non-candidate". None of the 2 patients in the control group did so. We found differences between groups in the SF-36 mental health component (p-value:0.061), Oswestry Disability Index (p-value:0.032), and TMMS-24 Repair component (p-value:0.014) at the end of the trial favoring MGVA.

CONCLUSIONS

The multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible, suggesting overall beneficial effects on patients' health and could play a role in changing a patient's status from "candidate" to "non-candidate" for surgery.

TRIAL REGISTRATION

NCT05093543 (ClinicalTrials.gov), first registered in 26/10/2021.

Prevalence of Thai People with Lumbar Instability and Associated Factors: A Cross-Sectional Study

Background

Lumbar instability has been extensively reported; however, the risk factors for lumbar instability remain poorly defined, and understanding this condition better would help health professionals and their patients.

Proposal

To determine the prevalence of lumbar instability in Thai people with chronic low back pain (CLBP) and explore the factors associated with lumbar instability in these patients.

Patients and Methods

Using multistage random sampling methods, 1762 participants with CLBP were enrolled in the study from six regions of Thailand. Data were collected using a paper-based questionnaire. Participants were interviewed by physical therapists in the hospital they attended. They were classified as having lumbar instability when they attained ≥7/14 items on the lumbar instability screening tool. Univariate and multivariate regression analysese were used to determine the possible factors associated with lumbar instability.

Results

There were 961 (54.54%) participants with lumbar instability and 801 (45.46%) participants without. The eight factors associated with lumbar instability were: (i) age ≥40 years (AOR: 1.36; 95% CI: 1.09-1.69); (ii) body mass index ≥25 kg/m² (AOR: 1.42; 95% CI: 1.16-1.74); (iii) having an underlying disease (AOR: 1.32; 95% CI: 1.06-1.65); (iv) frequent lifting ≥5 kg in occupational habits (AOR: 1.69; 95% CI: 1.36-2.09); (v) prolonged walking ≥4 hours per day (AOR: 1.31; 95% CI: 1.04-1.64); (vi) gardening in leisure time (AOR: 1.37; 95% CI: 1.10-1.71); (vii) other area of pain (AOR: 1.24; 95% CI: 1.01-2.52): and (viii) other area of numbness (AOR: 1.85; 95% CI: 1.50-2.27). When considering only women, prior pregnancy was associated with lumbar instability with OR of 1.76 (95% CI: 1.36-2.22), p-value <0.0001.

Conclusion

When treating patients with CLBP who are suspected to have lumbar instability, healthcare professionals should consider associated factors that might be modifiable targets for interventions to improve outcomes.

Multidisciplinary amyloidosis care in the era of personalized medicine

Amyloidosis refers to a group of conditions where abnormal protein-or amyloid-deposits in tissues or organs, often leading to organ malfunction. Amyloidosis affects nearly any organ system, but especially the heart, kidneys, liver, peripheral nervous system, and gastrointestinal tract. Neuromuscular deficits comprise some of its ubiquitous manifestations. Amyloidosis can be quite challenging to diagnose given its clinical heterogeneity and multi-system nature. Early diagnosis with accurate genetic and serologic subtyping is key for effective management and prevention of organ decline. In this review, we highlight the value of a multidisciplinary comprehensive amyloidosis clinic. While such a model exists at numerous clinical and research centers across the globe, the lack of more widespread adoption of such a model remains a major hindrance to the timely diagnosis of amyloidosis. Such a multidisciplinary care model allows for the timely and effective diagnosis of amyloidosis, be it acquired amyloid light amyloidosis (AL), hereditary transthyretin amyloidosis (hATTR), or wild type amyloidosis (TTR-wt), especially in the current era of personalized genomic medicine. A multidisciplinary clinic optimizes the delivery of singular or combinatorial drug therapies, depending on amyloid type, fibril deposition location, and disease progression. Such an arrangement also helps advance research in the field. We present our experience at The Ohio State University, as one example out of many, to highlight the centrality of a multi-disciplinary clinic in amyloidosis care.