Randomized trial of a brief physiotherapy intervention compared with usual physiotherapy for neck pain patients: cost-effectiveness analysis

Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations

BACKGROUND

Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists.

METHODS

We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist.

RESULTS

We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons.

CONCLUSIONS

High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.

Decrementally cost-effective health technologies in non-inferiority studies: A systematic review

Background: HTA guidance has generally been driven by situations where innovative and usually more expensive technologies are compared to the prevailing standards of care. Cheaper and less efficacious interventions have received scarce attention, although strategies with minimal individual efficacy losses might produce collective health gains when savings are redistributed. Purpose: This systematic review of health economic evaluations identified interventions that are both cost and outcome reducing to procure a list of candidate decrementally cost-effective technologies. Data Sources: English language searches were performed in PubMed, EMBASE and ClinicalTrials.gov covering 2005 to September 2021. Study Selection: Full economic evaluations reporting in English decrementally cost-effective health technologies based on RCT data, modelling or mixed methods. Data Synthesis: After filtering 4,975 studies found through the systematic database search, 107 decrementally cost-effective health technologies (HTs) were identified. Nearly a third were services (n = 29) and similarly for drugs (n = 31). For over half of the studies (n = 54) health outcomes were measured in QALYs and the cost-utility ratios varied from €140 to €5 million saved per QALY lost, albeit with time horizons varying from 4 days of follow-up to lifetime extrapolations. Less than a quarter of the studies were carried out from the societal perspective. Limitations: Despite including ClinicalTrials.gov as data source, unpublished studies may have been missed. Conclusions: Our results show a growth in recent years in the number of economic publications demonstrating decrementally cost-effective HTs. Economic tools are needed to facilitate the adoption of such HTs by policy-makers at the national level to maximise health outcomes at the population level. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=95504, identifier CRD42018095504.

Associations between community-based physiotherapy for musculoskeletal injury and health related quality of life (EQ-5D): a multi-centre retrospective analysis

Background

Community-based musculoskeletal physiotherapy is used to improve function and health related quality of life (HRQoL). The purpose of this retrospective, multi-centre observational study was to determine the association between community-based physiotherapy management for musculoskeletal disorders and changes in HRQoL.

Methods

Four thousand one hundred twelve patients’ data were included in the study. Patients were included if they received a single period of treatment for a musculoskeletal injury or disorder. Patients were only included if they were being treated for a single morbidity. Patients received standard physiotherapy appropriate to their specific disorder, which could include health education/advice, exercise therapy, manual therapy, taping, soft tissue techniques, electrotherapy and/or acupuncture. Health related quality of life was assessed using the EQ-5D index.

Results

EQ-5D improved by 0.203 across all patients (d = 1.10). When grouped by anatomical site of symptom, the largest increases in EQ-5D was in foot pain (0.233; d = 1.29) and lumbar pain (0.231; d = 1.13). Improvements in EQ-5D greater than the minimum clinically important difference (MCID) were seen in 68.4% of all patients. The highest proportion of patients with positive responses to treatment were in ankle pain (74.2%) and thoracic pain (73.4%). The hand (40.5%), elbow (34.7%), and hip (33.9%) showed the greatest proportion of patients that did not respond to treatment.

Conclusions

Community-based musculoskeletal physiotherapy is associated with improved health related quality of life. A randomised controlled trial is needed to determine any causal relationship between community-based physiotherapy and health related quality of life improvements.

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.

Which interventions are cost-effective for the management of whiplash-associated and neck pain-associated disorders? A systematic review of the health economic literature by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

BACKGROUND CONTEXT

Whiplash-associated disorders (WAD) and neck pain and associated disorders (NAD) are prevalent conditions that impact society and impose a significant economic burden on health-care systems. Health economic evidence on WAD and NAD interventions has been sparse: only three economic evaluations of interventions for NAD were identified by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (NPTF). An updated overview is needed to inform health-care policy and guidelines.

PURPOSE

This study aimed to determine the cost-effectiveness of interventions for grades I-III WAD and NAD in children and adults.

STUDY DESIGN

Systematic review of health economic literature, best-evidence synthesis.

METHODS

We systematically searched CINAHL, the Cochrane economic databases (Health Technology Assessment, NHS Economic Evaluation Database), EconLit, EMBASE, MEDLINE, PsycINFO, and Tufts CEA Registry from 2000 to 2015 for economic evaluations of WAD and NAD interventions. We appraised relevant evaluations using the Scottish Intercollegiate Guidelines Network Methodology Criteria for Economic Evaluations. We extracted data, including mean costs (standardized to 2013 Canadian dollars [CAD]) and quality-adjusted life years (QALYs), from studies with adequate methodological quality. We recalculated cost-effectiveness statistics based on the standardized currency using a willingness-to-pay of CAD $50,000 per additional QALY. Funding was provided by the Ministry of Finance.

RESULTS

Our search identified 1,616 citations. Six studies fulfilled our selection criteria, including three studies previously reviewed by the NPTF. Structured education appears cost-effective for adults with WAD. For adults with NAD, acupuncture added to routine medical care; manual therapy; multimodal care that includes manual therapy; advice and exercise; and psychological care using cognitive-behavioral therapy appear cost-effective. In contrast, adding manual therapy or diathermy to advice and exercise; multimodal care by a physiotherapist or physician; and behavioral-graded activity do not appear cost-effective for adults with NAD.

CONCLUSIONS

Our review adds to the findings of the NPTF. Recent evidence suggests that structured education is cost-effective for WAD, whereas advice and exercise and multimodal care that include manual therapy are cost-effective for NAD. Obtaining more robust health economic evidence for non-invasive interventions for WAD and NAD in children and adults remains an essential research priority.

Cost-effectiveness of spinal manipulative therapy, supervised exercise, and home exercise for older adults with chronic neck pain

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-effectivenesswas 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 SMT+HEA were 5% lower than HEA (mean difference: -$111; 95% confidence interval [CI] -$1,354 to $899) and 47% lower than 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 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.

CONCLUSION

On average, SMT+HEA resulted in better clinical outcomes and lower total societal costs relative to SRE+HEA and HEA alone, with a 0.75 to 0.81 probability of cost-effectiveness for willingness to pay thresholds of $50,000 to $200,000 per QALY.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

Psychological Care, Patient Education, Orthotics, Ergonomics and Prevention Strategies for Neck Pain: An Systematic Overview Update as Part of the ICON Project

OBJECTIVES

To conduct an overview on psychological interventions, orthoses, patient education, ergonomics, and 1⁰/2⁰ neck pain prevention for adults with acute-chronic neck pain.

SEARCH STRATEGY

Computerized databases and grey literature were searched (2006-2012).

SELECTION CRITERIA

Systematic reviews of randomized controlled trials (RCTs) on pain, function/disability, global perceived effect, quality-of-life and patient satisfaction were retrieved.

DATA COLLECTION & ANALYSIS

Two independent authors selected articles, assessed risk of bias using AMSTAR tool and extracted data. The GRADE tool was used to evaluate the body of evidence and an external panel to provide critical review.

MAIN RESULTS

We retrieved 30 reviews (5-9 AMSTAR score) reporting on 75 RCTs with the following moderate GRADE evidence. For acute whiplash associated disorder (WAD), an education video in emergency rooms (1RCT, 405participants] favoured pain reduction at long-term follow-up thus helping 1 in 23 people [Standard Mean Difference: -0.44(95%CI: -0.66 to -0.23)). Use of a soft collar (2RCTs, 1278participants) was not beneficial in the long-term. For chronic neck pain, a mind-body intervention (2RCTs, 1 meta-analysis, 191participants) improved short-term pain/function in 1 of 4 or 6 participants. In workers, 2-minutes of daily scapula-thoracic endurance training (1RCT, 127participants) over 10 weeks was beneficial in 1 of 4 participants. A number of psychosocial interventions, workplace interventions, collar use and self-management educational strategies were not beneficial.

REVIEWERS' CONCLUSIONS

Moderate evidence exists for quantifying beneficial and non-beneficial effects of a limited number of interventions for acute WAD and chronic neck pain. Larger trials with more rigorous controls need to target promising interventions.

Exercises for mechanical neck disorders

BACKGROUND

Neck disorders are common, disabling and costly. The effectiveness of exercise as a physiotherapy intervention remains unclear.

OBJECTIVES

To improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

Computerized searches were conducted up to February 2012.

SELECTION CRITERIA

We included single therapeutic exercise randomized controlled trials for adults with neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted selection, data extraction, 'Risk of bias' assessment, and clinical relevance. The quality of the body of evidence was assessed using GRADE. Relative risk and standardized mean differences (SMD) were calculated.  After judging clinical and statistical heterogeneity, we performed meta-analyses.

MAIN RESULTS

Six of the 21 selected trials had low risk of bias. Moderate quality evidence shows that combined cervical, scapulothoracic stretching and strengthening are beneficial for pain relief post treatment (pooled SMD -0.35, 95% confidence interval (CI): -0.60, -0.10) and at intermediate follow-up (pooled SMD -0.31, 95% CI: -0.57, -0.06), and improved function short term and intermediate term (pooled SMD -0.45, 95% CI: -0.72, -0.18) for chronic neck pain. Moderate quality evidence demonstrates patients are very satisfied with their care when treated with therapeutic exercise. Low quality evidence shows exercise is of benefit for pain in the short term and for function up to long-term follow-up for chronic neck pain. Low to moderate quality evidence shows that chronic neck pain does not respond to upper extremity stretching and strengthening or a general exercise program.Low to moderate quality evidence supports self-mobilization, craniocervical endurance and low load cervical-scapular endurance exercises in reducing pain, improving function and global perceived effect in the long term for subacute/chronic cervicogenic headache. Low quality evidence supports neck strengthening exercise in acute cervical radiculopathy for pain relief in the short term.

AUTHORS' CONCLUSIONS

Low to moderate quality evidence supports the use of specific cervical and scapular stretching and strengthening exercise for chronic neck pain immediately post treatment and intermediate term, and cervicogenic headaches in the long term. Low to moderate evidence suggests no benefit for some upper extremity stretching and strengthening exercises or a general exercise program.  Future trials should consider using an exercise classification system to establish similarity between protocols and adequate sample sizes. Factorial trials would help determine the active treatment agent within a treatment regimen where a standardized representation of dosage is essential. Standardized reporting of adverse events is needed for balancing the likelihood of treatment benefits over potential harms.

Cost-utility analysis in spine care: a systematic review

BACKGROUND CONTEXT

Despite the importance of the information provided by cost-utility analyses (CUAs), there has been a lack of these types of studies performed in the area of spinal care.

PURPOSE

To systematically review cost-utility studies published on spinal care between 1976 and 2010.

STUDY DESIGN

Systematic review.

METHODS

All CUAs pertaining to spinal care published between 1976 and 2010 were identified using the cost-effectiveness analysis (CEA) registry database (Tufts Medical Center, Institute for Clinical Research and Health Policy) and National Health Service Economic Evaluation Database (NHS EED). The keywords used to search both the registry databases were the following: spine, spinal, neck, back, cervical, lumbar, thoracic, and scoliosis. Search of the CEA registry provided a total of 28 articles, and the NHS EED yielded an additional 5, all of which were included in this review. Each article was reviewed for the study subject, methodology, and results. Data contained within the databases for each of the 33 articles were recorded, and the manuscripts were reviewed to provide insight into the funding source, analysis perspective, discount rate, and cost-utility ratios.

RESULTS

There was wide variation among the 33 studies in methodology. There were 17 operative, 13 nonoperative, and 3 imaging studies. Study subjects included lumbar spine (n=27), cervical spine (n=4), scoliosis (n=1), and lumbar and cervical spine (n=1). Twenty-three of the studies were based on the clinical data from prospective randomized studies, 7 on decision models, 2 on prospective observational data, and 1 on a retrospective case series. Sixty cost-utility ratios were reported in the 33 articles. Of the ratios, 19 of 60 (31.6%) were cost saving, 27 of 60 (45%) were less than $100,000/quality-adjusted life year (QALY) gain, and 14 of 60 (23.3%) were greater than $100,000/QALY gain. Only four of 33 (12%) studies contained the four key criteria of cost-effectiveness research recommended by the US Panel on Cost-Effectiveness in Health and Medicine.

CONCLUSIONS

Thirty-three CUA studies and 60 cost-utility ratios have been published on various aspects of spinal care over the last 30 years. Certain aspects of spinal care have been shown to be cost effective. Further efforts, however, are needed to better define the value of many aspects of spinal care. Future CUA studies should consider societal cost perspective and carefully consider the durability of clinical benefit in determining a study time horizon.

Supervised exercise with and without spinal manipulation performs similarly and better than home exercise for chronic neck pain: a randomized controlled trial

STUDY DESIGN

Randomized controlled trial using mixed methods.

OBJECTIVE

To evaluate the relative effectiveness of high-dose supervised exercise with and without spinal manipulation and low-dose home exercise for chronic neck pain.

SUMMARY OF BACKGROUND DATA

Neck pain is a common global health care complaint with considerable social and economic impact. Systematic reviews have found exercise therapy (ET) to be effective for neck pain, either alone or in combination with spinal manipulation. However, it is unclear to what extent spinal manipulation adds to supervised exercise or how supervised high-dose exercise compares with low-dose home exercise.

METHODS

Two hundred and seventy patients with chronic neck pain were studied at an outpatient clinic. Patients were randomly assigned one of the following interventions: (1) high-dose supervised strengthening exercise with spinal manipulation (exercise therapy combined with spinal manipulation therapy [ET + SMT]), (2) high-dose supervised strengthening exercise (ET) alone, or (3) low-dose home exercise and advice (HEA). The primary outcome was patient-rated pain at baseline and at 4, 12, 26, and 52 weeks. Secondary measures were disability, health status, global perceived effect, medication use, and satisfaction.

RESULTS

At 12 weeks, there was a significant difference in patient-rated pain between ET + SMT and HEA (1.3 points, P < 0.001) and ET and HEA (1.1 points, P = 0.001). Although there were smaller group differences in patient-rated pain at 52 weeks (ET + SMT vs. HEA, 0.2 points, P > 0.05; ET vs. HEA, 0.3 points, P > 0.05), linear mixed model analyses incorporating all time points yielded a significant advantage for the 2 supervised exercise groups (ET + SMT vs. HEA, P = 0.03; ET vs. HEA, P = 0.02). Similar results were observed for global perceived effect and satisfaction.

CONCLUSION

Supervised strengthening exercise with and without spinal manipulation performed similarly, yielding better outcomes than home exercise particularly in the short term. Various stakeholders' perspectives should be considered carefully when making recommendations regarding these therapies, taking into account side effects, preferences, and costs.

Spinal manipulation epidemiology: systematic review of cost effectiveness studies

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 GP 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.

Patient education for neck pain

BACKGROUND

Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear.

OBJECTIVES

To assess the short- to long-term effects of therapeutic patient education (TPE) strategies on pain, function, disability, quality of life, global perceived effect, patient satisfaction, knowledge transfer, or behaviour change in adults with neck pain associated with whiplash or non-specific and specific mechanical neck pain with or without radiculopathy or cervicogenic headache.

SEARCH METHODS

We searched computerised bibliographic databases (inception to 11 July 2010).

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCT) investigating the effectiveness of TPE for acute to chronic neck pain.

DATA COLLECTION AND ANALYSIS

Paired independent review authors conducted selection, data abstraction, and 'Risk of bias' assessment. We calculated risk ratio (RR) and standardised mean differences (SMD). Heterogeneity was assessed; no studies were pooled.

MAIN RESULTS

Of the 15 selected trials, three were rated low risk of bias. Three TPE themes emerged.Advice focusing on activation: There is moderate quality evidence (one trial, 348 participants) that an educational video of advice focusing on activation was more beneficial for acute whiplash-related pain when compared with no treatment at intermediate-term [RR 0.79 (95% confidence interval (CI) 0.59 to 1.06)] but not long-term follow-up [0.89 (95% CI, 0.65 to 1.21)]. There is low quality evidence (one trial, 102 participants) that a whiplash pamphlet on advice focusing on activation is less beneficial for pain reduction, or no different in improving function and global perceived improvement from generic information given out in emergency care (control) for acute whiplash at short- or intermediate-term follow-up. Low to very low quality evidence (nine trials using diverse educational approaches) showed either no evidence of benefit or difference for varied outcomes. Advice focusing on pain & stress coping skills and workplace ergonomics: Very low quality evidence (three trials, 243 participants) favoured other treatment or showed no difference spanning numerous follow-up periods and disorder subtypes.  Low quality evidence (one trial, 192 participants) favoured specific exercise training for chronic neck pain at short-term follow-up.Self-care strategies: Very low quality evidence (one trial, 58 participants) indicated that self-care strategies did not relieve pain for acute to chronic neck pain at short-term follow-up.

AUTHORS' CONCLUSIONS

With the exception of one trial, this review has not shown effectiveness for educational interventions, including advice to activate, advice on stress-coping skills, workplace ergonomics and self-care strategies. Future research should be founded on sound adult learning theory and learning skill acquisition.

Getting to value in neurological care: a roadmap for academic neurology

Academic neurology is undergoing transformational changes. The public investment in biomedical research and clinical care is enormous and there is a growing perception that the return on this huge investment is insufficient. Hospitals, departments, and individual neurologists should expect more scrutiny as information about their quality of care and financial relationships with industry are increasingly reported to the public. There are unprecedented changes occurring in the financing and delivery of health care and research that will have profound impact on the mission and operation of academic departments of neurology. With the passage of the Patient Protection and Affordable Care Act (PPACA) there will be increasing emphasis on research that demonstrates value and includes the patient's perspective. Here we review neurological investigations of our clinical and research enterprises that focus on quality of care and comparative effectiveness, including cost-effectiveness. By highlighting progress made and the challenges that lie ahead, we hope to create a clinical, educational, and research roadmap for academic departments of neurology to thrive in today's increasingly regulated environment.

Cost-effectiveness of general practice care for low back pain: a systematic review

Care from a general practitioner (GP) is one of the most frequently utilised healthcare services for people with low back pain and only a small proportion of those with low back pain who seek care from a GP are referred to other services. The aim of this systematic review was to evaluate the evidence on cost-effectiveness of GP care in non-specific low back pain. We searched clinical and economic electronic databases, and the reference list of relevant systematic reviews and included studies to June 2010. Economic evaluations conducted alongside randomised controlled trials with at least one GP care arm were eligible for inclusion. Two reviewers independently screened search results and extracted data. Eleven studies were included; the majority of which conducted a cost-effectiveness or cost-utility analysis. Most studies investigated the cost-effectiveness of usual GP care. Adding advice, education and exercise, or exercise and behavioural counselling, to usual GP care was more cost-effective than usual GP care alone. Clinical rehabilitation and/or occupational intervention, and acupuncture were more cost-effective than usual GP care. One study investigated the cost-effectiveness of guideline-based GP care, and found that adding exercise and/or spinal manipulation was more cost-effective than guideline-based GP care alone. In conclusion, GP care alone did not appear to be the most cost-effective treatment option for low back pain. GPs can improve the cost-effectiveness of their treatment by referring their patients for additional services, such as advice and exercise, or by providing the services themselves.

A Cochrane review of patient education for neck pain

BACKGROUND CONTEXT

Neck pain is common, disabling, and costly. The effectiveness of patient education strategies is unclear.

PURPOSE

To assess whether patient education strategies are of benefit for pain, function/disability, global perceived effect, quality of life, or patient satisfaction, in adults with neck pain with or without radiculopathy.

STUDY DESIGN

Cochrane systematic review.

METHODS

Computerized bibliographic databases were searched from their start to May 31, 2008. Eligible studies were randomized trials investigating the effectiveness of patient education strategies for neck pain. Paired independent reviewers carried out study selection, data abstraction, and methodological quality assessment. Relative risk and standardized mean differences were calculated. Because of differences in intervention type or disorder, no studies were considered appropriate to pool.

RESULTS

Of the 10 selected trials, two (20%) were rated as of high quality. Patient education was assessed as follows: 1) eight trials of advice focusing on activation compared with no treatment, or to various active treatments, including therapeutic exercise, manual therapy, and cognitive behavioral therapy, showed either inferiority or no difference for pain, spanning a full range of follow-up periods, acuity and disorder types. When compared with rest, two trials that assessed acute whiplash-associated disorder showed moderate evidence of no difference for advice focusing on activation; 2) two trials studying advice focusing on pain and stress coping skills found moderate evidence of no benefit for chronic neck pain at intermediate- to long-term follow-up; and 3) one trial compared the effects of neck school to no treatment, yielding limited evidence of no benefit for pain, at intermediate-term follow-up in mixed acute/subacute/chronic neck pain.

CONCLUSIONS

This review has not shown effectiveness for educational interventions for neck pain of various acuity stages and disorder types and at various follow-up periods, including advice to activate, advice on stress coping skills, and neck school. In future research, further attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of specific educational components.

Assessment of the quality of cost analysis literature in physical therapy

BACKGROUND

Policy makers, payers, and other stakeholders increasingly call for greater evidence of the cost-effectiveness of health care interventions.

OBJECTIVE

The purposes of this study were to identify and rate the quality of cost analysis literature in physical therapy and to report summary information on the findings from the reviewed studies.

DESIGN

This study was a targeted literature review and rating of relevant studies published in the last decade using a quality evaluation tool for economic studies.

MEASUREMENTS

The Quality of Health Economic Studies (QHES) instrument was used to obtain quality scores.

RESULTS

Ninety-five in-scope studies were identified and rated using the QHES instrument. The average quality score was 82.2 (SD=15.8), and 81 of the studies received a score of 70 or higher, placing them in the "good" to "excellent" quality range. Investigators in nearly two thirds of the studies found the physical therapy intervention under investigation to be cost-effective.

LIMITATIONS

The small number of studies meeting the inclusion criteria was a limitation of the study.

CONCLUSIONS

The quality of the literature regarding the cost-effectiveness of physical therapy is very good, although the magnitude of this body of literature is small. Greater awareness of the strengths and limitations of cost analyses in physical therapy should provide guidance for conducting high-quality cost-effectiveness studies as demand increases for demonstrations of the value of physical therapy.

Patient education for neck pain with or without radiculopathy

BACKGROUND

Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear.

OBJECTIVES

To assess whether patient education strategies, either alone or in combination with other treatments, are of benefit for pain, function, global perceived effect, quality of life, or patient satisfaction, in adults with neck pain with and without radiculopathy.

SEARCH STRATEGY

Computerized bibliographic databases were searched from their start up to May 31, 2008.

SELECTION CRITERIA

Eligible studies were quasi or randomized trials (RCT) investigating the effectiveness of patient education strategies for neck disorder.

DATA COLLECTION AND ANALYSIS

Paired independent review authors carried out study selection, data abstraction, and methodological quality assessment. Relative risk and standardized mean differences (SMD) were calculated. The appropriateness of combining studies was assessed on clinical and statistical grounds. Because of differences in intervention type or disorder, no studies were considered appropriate to pool.

MAIN RESULTS

Of the 10 selected trials, two (20%) were rated high quality. Advice was assessed as follows:Eight trials of advice focusing on activation compared to no treatment or to various active treatments, including therapeutic exercise, manual therapy and cognitive behavioural therapy, showed either inferiority or no difference for pain, spanning a full range of follow-up periods and disorder types. When compared to rest, two trials that assessed acute whiplash-associated disorders (WAD) showed moderate evidence of no difference for various forms of advice focusing on activation. Two trials studying advice focusing on pain & stress coping skills found moderate evidence of no benefit for pain in chronic mechanical neck disorder (MND) at intermediate/long-term follow-up. One trial compared the effects of ' traditional neck school ' to no treatment, yielding limited evidence of no benefit for pain at intermediate-term follow-up in mixed acute/subacute/chronic neck pain.

AUTHORS' CONCLUSIONS

This review has not shown effectiveness for educational interventions in various disorder types and follow-up periods, including advice to activate, advice on stress coping skills, and 'neck school'. In future research, further attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of the specific educational components.

Patients' preferences within randomised trials: systematic review and patient level meta-analysis

OBJECTIVE

To systematically review fully randomised patient preference trials and to explore the impact of preferences on attrition and outcome by meta-analysis of patient level data.

DATA SOURCES

Citation search using Science Citation Index and Google Scholar and search of the main electronic databases (Medline, CINAHL, Embase, and AMED) with a combination of key words.

STUDY SELECTION

Fully randomised patient preference trials that compared treatments for any clinical condition were included. Other types of preference trials and crossover trials were excluded. Other inclusion criteria: participants aged 16 years and over; primary, self-reported outcomes measured on a continuous numerical scale. From 167 studies identified and screened, 17 were identified as fully randomised patient preference trials.

DATA SYNTHESIS

Of the 17 trials identified, 11 authors provided raw data for the meta-analysis. Data collected were baseline and follow-up data for the main outcome, randomised allocation data, preference data, and demographic data. Baseline and first post-intervention follow-up data for the main outcome were standardised. To improve homogeneity, data for only the eight musculoskeletal trials (n=1594) were combined. To estimate the effects of preferences on outcomes and attrition, three groups were compared: patients who had a preference and were randomly allocated to their preferred treatment; patients who had a preference and were randomly allocated to the treatment they did not prefer; and patients who had no preference.

RESULTS

Patients who were randomised to their preferred treatment had a standardised effect size greater than that of those who were indifferent to the treatment assignment (effect size 0.162, 95% confidence interval 0.011 to 0.314; P=0.04). Participants who received their preferred treatment also did better than participants who did not receive their preferred treatment (effect size 0.152, -0.035 to 0.339), although this was not statistically significant (P=0.11). Participants allocated to their undesired treatment had outcomes that were no different from those who were indifferent. Participants who were allocated to their undesired treatment were less likely to be lost to first follow-up compared with indifferent participants (odds ratio 1.70, 1.076 to 2.693; P=0.02). No difference was found in attrition between patients allocated to their preference and those who were indifferent.

CONCLUSIONS

Preferences among patients in musculoskeletal trials are associated with treatment effects. In open randomised trials, preferences should be ascertained before randomisation.

Patient education for neck pain with or without radiculopathy

BACKGROUND

Neck disorders are common, disabling, and costly. The effectiveness of patient education strategies is unclear.

OBJECTIVES

To assess whether patient education strategies, either alone or in combination with other treatments, are of benefit for pain, function, global perceived effect, quality of life, or patient satisfaction, in adults with neck pain with and without radiculopathy.

SEARCH STRATEGY

Computerized bibliographic databases were searched from their start up to May 31, 2008.

SELECTION CRITERIA

Eligible studies were quasi or randomized trials (RCT) investigating the effectiveness of patient education strategies for neck disorder.

DATA COLLECTION AND ANALYSIS

Paired independent review authors carried out study selection, data abstraction, and methodological quality assessment. Relative risk and standardized mean differences (SMD) were calculated. The appropriateness of combining studies was assessed on clinical and statistical grounds. Because of differences in intervention type or disorder, no studies were considered appropriate to pool.

MAIN RESULTS

Of the 10 selected trials, two (20%) were rated high quality. Advice was assessed as follows:Eight trials of advice focusing on activation compared to no treatment or to various active treatments, including therapeutic exercise, manual therapy and cognitive behavioural therapy, showed either inferiority or no difference for pain, spanning a full range of follow-up periods and disorder types. When compared to rest, two trials that assessed acute whiplash-associated disorders (WAD) showed moderate evidence of no difference for various forms of advice focusing on activation.Two trials studying advice focusing on pain & stress coping skills found moderate evidence of no benefit for pain in chronic mechanical neck disorder (MND) at intermediate/long-term follow-up.One trial compared the effects of 'traditional neck school' to no treatment, yielding limited evidence of no benefit for pain at intermediate-term follow-up in mixed acute/subacute/chronic neck pain.

AUTHORS' CONCLUSIONS

This review has not shown effectiveness for educational interventions in various disorder types and follow-up periods, including advice to activate, advice on stress coping skills, and 'neck school'. In future research, further attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of the specific educational components.

Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders

STUDY DESIGN

Best evidence synthesis.

OBJECTIVE

To identify, critically appraise, and synthesize literature from 1980 through 2006 on noninvasive interventions for neck pain and its associated disorders.

SUMMARY OF BACKGROUND DATA

No comprehensive systematic literature reviews have been published on interventions for neck pain and its associated disorders in the past decade.

METHODS

We systematically searched Medline and screened for relevance literature published from 1980 through 2006 on the use, effectiveness, and safety of noninvasive interventions for neck pain and associated disorders. Consensus decisions were made about the scientific merit of each article; those judged to have adequate internal validity were included in our best evidence synthesis.

RESULTS

Of the 359 invasive and noninvasive intervention articles deemed relevant, 170 (47%) were accepted as scientifically admissible, and 139 of these related to noninvasive interventions (including health care utilization, costs, and safety). For whiplash-associated disorders, there is evidence that educational videos, mobilization, and exercises appear more beneficial than usual care or physical modalities. For other neck pain, the evidence suggests that manual and supervised exercise interventions, low-level laser therapy, and perhaps acupuncture are more effective than no treatment, sham, or alternative interventions; however, none of the active treatments was clearly superior to any other in either the short- or long-term. For both whiplash-associated disorders and other neck pain without radicular symptoms, interventions that focused on regaining function as soon as possible are relatively more effective than interventions that do not have such a focus.

CONCLUSION

Our best evidence synthesis suggests that therapies involving manual therapy and exercise are more effective than alternative strategies for patients with neck pain; this was also true of therapies which include educational interventions addressing self-efficacy. Future efforts should focus on the study of noninvasive interventions for patients with radicular symptoms and on the design and evaluation of neck pain prevention strategies.