Targeting treatment for non-specific musculoskeletal pain

Effect on healthcare utilization and costs of spinal manual therapy for acute low back pain in routine care: A propensity score matched cohort study

Spinal manual therapy (SMT) is a popular treatment option for low back pain (LBP). The aim of our analysis was to evaluate the effects of manual therapy delivered by general practitioners and ambulatory orthopedic surgeons in routine care on follow up consultations, sick leave, health service utilization and costs for acute LBP compared to matched patients not receiving manual therapy. This is a propensity score matched cohort study based on health claims data. We identified a total of 113.652 adult patients with acute LBP and no coded red flags of whom 21.021 (18%) received SMT by physicians. In the final analysis 17.965 patients in each group could be matched. Balance on patients’ coded characteristics, comorbidity and prior health service utilization was achieved. The provision of SMT for acute LBP had no relevant impact on follow up visits and days of sick leave for LBP in the index billing period and the following year. SMT was associated with a higher proportion of imaging studies for LBP (30.6% vs. 23%, SMD: 0.164 [95% CI 0.143–0.185]). SMT did not lead to meaningful savings by replacing other health services for LBP. SMT for acute non-specific LBP in routine care was not clinically meaningful effective to reduce sick leave and reconsultation rates compared to no SMT and did not lead to meaningful savings by replacing other health services from the perspective of health insurance. This does not imply that SMT is ineffective but might reflect a problem with selection of suitable patients and the quality and quantity of SMT in routine care. National Manual Medicine societies should state clearly that imaging is not routinely needed prior to SMT in patients with low suspicion of presence of red flags and monitor the quality of provided services.

Is it reasonable to use an individual patient's progress after treatment as a guide to ongoing clinical reasoning?

Systematic assessment of a patient's progress after an intervention is frequently used to inform decision making in ongoing conservative management of patients with musculoskeletal symptoms. Although reassessment of impairments immediately after treatment is commonplace in clinical practice, relatively little research has considered whether this method is reasonable. The history of, rationale behind, and evidence for the use of patient responses to inform clinical reasoning are explored in this commentary. Although the evidence is not conclusive, an argument is presented suggesting it is more reasonable to use a patient's response to treatment to inform ongoing clinical reasoning than to follow predetermined protocols. A methodical approach that considers change in parameters such as patient impairments is likely to be a useful guide for decision making during ongoing patient management but only when the change being reassessed can be directly linked to functional goals. Changes in active range of movement or centralization of pain appear to be better indicators of treatment effectiveness than changes in either pain intensity or assessment of joint position. There is limited evidence to support the use of changes in segmental stiffness to guide ongoing management. Although reassessment of some impairments has been found to be useful, the author suggests that care is required in the selection of reassessments used to guide ongoing management. The usefulness of any reassessment is considered to rely on how well a change in the selected impairment predicts that individual patient's ability to achieve their goals.