Chronic Spinal Pain

Cost-effectiveness of Spinal Manipulative Therapy, Supervised Exercise, and Home Exercise for Older Adults with Chronic Neck Pain

The Chiro.Org Blog

SOURCE:   Spine J. 2016 (Nov);   16 (11):   1292–1304

Brent Leininger, DC, MS, Christine McDonough, PT, PhD, Roni Evans, DC, MS, PhD, Tor Tosteson, ScD, Anna N.A. Tosteson, ScD, Gert Bronfort, DC, PhD

Integrative Health & Wellbeing Research Program,
Center for Spirituality & Healing,
University of Minnesota,
B296 Mayo Memorial Building,
420 Delaware St SE, Minneapolis, MN 55455, USA.

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

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

STUDY DESIGN/SETTING:   Cost-effectiveness analysis conducted alongside a randomized clinical trial (RCT) was performed.

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

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

METHODS:   This work was supported by grants from the National Center for Complementary and Integrative Health (#F32AT007507), National Institute of Arthritis and Musculoskeletal and Skin Diseases (#P60AR062799), and Health Resources and Services Administration (#R18HP01425).
The RCT is registered at ClinicalTrials.gov (NCT00269308 ).

A societal perspective was adopted for the primary analysis. A healthcare perspective was adopted as a sensitivity analysis. Cost-effectiveness was a secondary aim of the RCT which was not powered for differences in costs or QALYs. Differences in costs and clinical outcomes were estimated using generalized estimating equations and linear mixed models, respectively. Cost-effectiveness acceptability curves were calculated to assess the uncertainty surrounding cost-effectiveness estimates.

RESULTS:   Total costs for spinal manipulative therapy (SMT) + home exercise and advice (HEA) were 5% lower than HEA (mean difference: –$111; 95% confidence interval [CI] –$1,354 to $899) and 47% lower than supervised rehabilitative exercise (SRE) + HEA (mean difference: –$1,932; 95% CI –$2,796 to –$1,097).

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

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A Modern Neuroscience Approach to Chronic Spinal Pain:
Combining Pain Neuroscience Education with Cognition-targeted Motor Control Training

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SOURCE:   Phys Ther. 2014 (May); 94 (5): 730–738

Jo Nijs, Mira Meeus, Barbara Cagnie, Nathalie A. Roussel, Mieke Dolphens, Jessica Van Oosterwijck, Lieven Danneels

Pain in Motion Research Group,
Departments of Human Physiology and Physiotherapy,
Faculty of Physical Education & Physiotherapy,
Vrije Universiteit
Brussels, Belgium

Chronic spinal pain (CSP) is a severely disabling disorder, including nontraumatic chronic low back and neck pain, failed back surgery, and chronic whiplash-associated disorders. Much of the current therapy is focused on input mechanisms (treating peripheral elements such as muscles and joints) and output mechanisms (addressing motor control), while there is less attention to processing (central) mechanisms. In addition to the compelling evidence for impaired motor control of spinal muscles in patients with CSP, there is increasing evidence that central mechanisms (ie, hyperexcitability of the central nervous system and brain abnormalities) play a role in CSP. Hence, treatments for CSP should address not only peripheral dysfunctions but also the brain. Therefore, a modern neuroscience approach, comprising therapeutic pain neuroscience education followed by cognition-targeted motor control training, is proposed. This perspective article explains why and how such an approach to CSP can be applied in physical therapist practice.

From the FULL TEXT Article:

Introduction

Chronic spinal pain (CSP) includes nonrecurrent chronic low back pain, failed back surgery, chronic whiplash-associated disorders, and chronic nontraumatic neck pain, among other conditions, and accounts for a large proportion of the chronic pain population. [1] Chronic spinal pain is a severely disabling disorder characterized by tremendous personal and socioeconomic impact, with long-term sick leave, low quality of life, and very high socioeconomic costs. [2]

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