Spinal Manipulation Epidemiology: Systematic Review of Cost Effectiveness Studies

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SOURCE:   J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 655–662 ~ FULL TEXT

Michaleff ZA, Lin CW, Maher CG, van Tulder MW.

The George Institute for Global Health, The University of Sydney, Missenden Road, Sydney, NSW 2050, Australia. zmichaleff@georgeinstitute.org.au

BACKGROUND:   Spinal manipulative therapy (SMT) is frequently used by health professionals to manage spinal pain. With many treatments having comparable outcomes to SMT, determining the cost-effectiveness of these treatments has been identified as a high research priority.

OBJECTIVE:   To investigate the cost-effectiveness of SMT compared to other treatment options for people with spinal pain of any duration.

METHODS:   We searched eight clinical and economic databases and the reference lists of relevant systematic reviews. Full economic evaluations conducted alongside randomised controlled trials with at least one SMT arm were eligible for inclusion. Two authors independently screened search results, extracted data and assessed risk of bias using the CHEC-list.

RESULTS:   Six cost-effectiveness and cost-utility analysis were included. All included studies had a low risk of bias scoring =16/19 on the CHEC-List. SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to general practitioner (GP = MD) care, exercise and physiotherapy.

CONCLUSIONS:   This review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. However, as this conclusion is primarily based on single studies more high quality research is needed to identify whether these findings are applicable in other settings.


From the Full-Text Article:


Spinal pain, including neck pain and back pain, is a common condition in modern society (Woolf and Pfleger, 2003;   Côté et al., 2003 ). It presents major social and economic burdens due to the high levels of chronicity and resultant long term disability which are associated with high costs in health care and losses of productivity (e.g. sick leave) (Woolf and Pfleger, 2003). While existing practice guidelines inform the individual, clinicians and policy makers on the effectiveness of a range of interventions, few provide information on the cost-effectiveness of treatments. It is arguable that cost-effectiveness of treatment is an equally important consideration as effectiveness, as all health administrators need to make decisions about how they allocate scarce health resources.

Economic evaluations are frequently conducted alongside randomised controlled trials of treatment effectiveness and involve the identification, measurement, valuation and then comparison of the costs and consequences (benefits) of two or more alternatives (Drummond et al., 2005). Economic evaluations are most useful when the treatments under question have been evaluated in terms of efficacy (can the treatment work in those who comply with the recommendations), effectiveness (is the treatment acceptable and does the treatment work in those who the treatment is offered) and availability (is the treatment accessible to all who would benefit from it). The result of an economic evaluation supplements the evidence base on treatment effectiveness by providing information on the efficiency or “value for money ” of treatment alternatives (Drummond et al., 2005). This information can be used to inform consumers, insurers, governments and policy makers where the health budget should be spent.

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Spinal manipulative therapy (SMT), including both manipulation (a high velocity thrust technique) and mobilisation (low velocity technique), is frequently used by a number of health professions, including physiotherapists, chiropractors and osteopaths, to manage people with neck pain and back pain (Gross et al., 2010; Assendelft et al., 2004). The effectiveness of SMT to treat spinal pain has been summarised in recent Cochrane Reviews (Gross et al., 2010; Assendelft et al., 2004; Rubinstein et al., 2011). Overall the evidence suggests that SMT provides greater improvements for pain and function than a placebo or no treatment but similar improvements to many competing treatments such as general practitioner management, medication and exercise. With many treatments for spinal pain having comparable outcomes to SMT, determining the cost effectiveness of these treatment alternatives has been identified as a high priority (Rubinstein et al., 2011). The purpose of this systematic review is to investigate the costeffectiveness of SMT compared to other treatment options for people with spinal pain of any duration.

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