Study protocol of cost-effectiveness and cost-utility of a biopsychosocial multidisciplinary intervention in the evolution of non-specific sub-acute low back pain in the working population: cluster randomised trial

The Efficacy and Effectiveness of Education for Preventing and Treating Non-Specific Low Back Pain in the Hispanic Cultural Setting: A Systematic Review

A systematic review was conducted to assess the efficacy and effectiveness of education programs to prevent and treat low back pain (LBP) in the Hispanic cultural setting. Electronic and manual searches identified 1148 unique references. Nine randomized clinical trials (RCTs) were included in this review. Methodological quality assessment and data extraction followed the recommendations from the Cochrane Back Pain Review Group. Education programs which were assessed focused on active management (3 studies), postural hygiene (7), exercise (4) and pain neurophysiology (1). Comparators were no intervention, usual care, exercise, other types of education, and different combinations of these procedures. Five RCTs had a low risk of bias. Results show that: (a) education programs in the school setting can transmit potentially useful knowledge for LBP prevention and (b) education programs for patients with LBP improve the outcomes of usual care, especially in terms of disability. Education on pain neurophysiology improves the results of education on exercise, and education on active management is more effective than “sham” education and education on postural hygiene. Future studies should assess the comparative or summatory effects of education on exercise, education on pain neurophysiology and education on active management, as well as explore their efficiency.

The effectiveness of patient education in improving pain, disability and quality of life among older people with low back pain: A systematic review

OBJECTIVES

This study aimed to gain an overview of patient education and the effects of patient education for older people with low back pain (LBP).

METHODS

The search strategies were performed via EBSCO MEDLINE, EBSCO CINAHL, Science Direct, PubMed, and PEDro databases from 2006 to 2016. The keywords "patient education", "low back pain", "elderly", "older adults", "older persons" and "older people" were used during the literature search. Boolean operators were used to expand or limit the searching scope and manual exclusion was performed to choose articles eligible for this study.

RESULTS

A total of 2799 articles were retrieved but only five articles were related with patient education for older people with LBP. Findings suggest that patient education for older people may differ in terms of its contents such as health education, self-management, video education, and postural education. The high methodological quality of the studies revealed that patient education showed improvement in terms of pain, disability and quality of life among older people with LBP.

CONCLUSIONS

Patient education improved pain and had positive effects on disability and quality of life among older people with LBP. However, due to the limited number of RCTs more studies are needed to provide evidence for its effectiveness.

Treatment of Patients with Low Back Pain: A Comparison of Physical Therapy and Chiropractic Manipulation

Low back pain (LBP) is a pandemic and costly musculoskeletal condition in the United States (U.S.). Patients with LBP may endure surgery, injections, and expensive visits to emergency departments. Some suggest that using physical therapy (PT) or chiropractic in the earlier stage of LBP reduces the utilization of expensive health services and lowers the treatment costs. Given that there are costs and benefits with each of these treatments, the remaining question is in a short period of time which of these treatments is optimal. The purpose of this study was to investigate the cost-effectiveness of chiropractic versus PT in the U.S. A decision tree analytic model was used for estimating the economic outcomes. The findings showed that the total average cost in the chiropractic group was $48.56 lower than the PT group. The findings also showed that the daily adjusted life years (DALY) in the chiropractic group was 0.0043 higher than the PT group. Chiropractic care was shown to be a cost-effective alternative compared with PT for adults with at least three weeks of LBP over six months.

Analysis of intra and extramyocellular lipids in the multifidus muscle in patients with chronic low back pain using MR spectroscopy

OBJECTIVE

To analyse the intra- (IMCL) and extramyocellular lipids (EMCL) concentration in the multifidus muscle (Mm) using MR spectroscopy (MRS) in patients with low back pain (LBP), and to evaluate the correlation between those lipid concentrations and age, obesity, atrophy of the Mm and LBP intensity.

METHODS

60 LBP patients underwent routine diagnostic MRI of the lumbar spine before undergoing imaging for the study. Body mass index, as an indicator of obesity and visual analogue scale, as an indicator of LBP were also measured. Proton MRS was acquired with a single-voxel point-resolved spectroscopy sequence. Furthermore, the MRS volume of interest for measuring the IMCL and EMCL concentration at L4/5 for the right Mm was determined, and we measured the cross-sectional area of Mm as an indicator of muscle atrophy.

RESULTS

Age showed correlation with EMCL concentration (r = 0.314, p = 0.008). The body mass index showed correlation with EMCL concentration (r = 0.358, p = 0.005). The cross-sectional area of Mm showed correlation with EMCL concentration (r = -0.543, p < 0.001). Moreover, the LBP visual analogue scale showed correlation with IMCL concentration (r = 0.367, p = 0.004).

CONCLUSION

There were correlations between age, obesity, muscle atrophy, and EMCL concentration in Mm. IMCL concentration in Mm showed a correlation with LBP intensity. This may suggest that IMCL concentration could become an effective objective indicator of chronic LBP intensity. Advances in knowledge: We investigated the characteristics of fat content in Mm with LBP patients. This study was demonstrated the association of the IMCL and EMCL concentration in Mm with various patient parameters.

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.

Describing the characteristics, treatment pathways, outcomes, and costs of people with persistent noncancer pain managed by community pain clinics and generating an indicative estimate of cost-effectiveness: feasibility study protocol

Background

Low back pain (LBP) and fibromyalgia (FM), also known as chronic widespread pain (CWP), are highly prevalent chronic painful conditions that have substantial impact on patients, health care systems, and society. Diagnosis is complex and management strategies are associated with various levels of evidence for effectiveness and cost-effectiveness. Multidisciplinary pain services have been shown to be effective in some settings and therefore are recommended by clinical practice guidelines as a rational treatment option to manage these patients. Knowing that these services are resource intensive, evidence is needed to demonstrate their cost-effectiveness. This study aims to describe the management of patients with LBP and FM in two community pain clinics to derive an indicative estimate of cost-effectiveness compared with standard practice.

Methods

This is a prospective observational multicenter study, using patient-level data. The data from this study will be combined with modelling of the long-term economic impact of community pain clinics in treating people with LBP and FM. Newly referred patients with LBP and FM who provide written consent will be included. We will collect data on functional disability, pain intensity, quality of life, and health resource utilization. Follow-up data at the 3- and 6-month points will be collected by patient-completed questionnaires and health care contact diaries. Health care resource use from diaries will be compared with patient electronic records to assess the agreement between these recording methods. Patient cohort characteristics, treatment pathways, resource use, and outcomes derived from this study will be integrated in a decision analysis model to assess the cost-effectiveness of community pain clinics compared with standard care. This feasibility study will address key methodological issues such as sample estimates and retention rate to inform the design of a future randomized controlled trial.

Comparison of a Stratified Group Intervention (STarT Back) With Usual Group Care in Patients With Low Back Pain: A Nonrandomized Controlled Trial

STUDY DESIGN

A nonrandomized controlled trial.

OBJECTIVE

This study aims to explore the effectiveness of group-based stratified care in primary care.

SUMMARY OF BACKGROUND DATA

Stratified care based on psychosocial screening (STarT Back) has demonstrated greater clinical and cost-effectiveness in patients with low back pain. However, low back pain interventions are often delivered in groups and evaluating this system of care in a group setting is important.

METHODS

Patients were recruited from 60 general practices and linked physiotherapy services. A new group stratified intervention was compared with a historical nonstratified control group. Patients stratified as low, medium and high risk were offered risk-matched group care. Consenting participants completed self-report measures of functional disability (primary outcome measure), pain, psychological distress, and beliefs. The historical control received a generic group intervention. Analysis was by intention to treat.

RESULTS

In total, 251 patients in the new stratified intervention and 332 in the historical control were included in the primary analysis at 12 weeks. The mean age of patients was 43 ± 10.98 years. Overall adjusted mean changes in the RMDQ scores were higher in the stratified intervention than in the control arm at 12-week follow-up (P = 0.028). Exploring the risk groups, individually the high-risk stratified group, demonstrated better outcome over the controls (P = 0.031). The medium-risk stratified intervention demonstrated equally good outcomes (P = 0.125), and low-risk stratified patients, despite less intervention, did as well as the historical controls (P = 0.993).

CONCLUSION

Stratified care delivered in a group setting demonstrated superior outcomes in the high-risk patients, and equally good outcomes for the medium and low-risk groups. This model, embedded in primary care, provides an early and effective model of chronic disease management and adds another dimension to the utility of the STarT Back system of care.

LEVEL OF EVIDENCE

2.

Interventions available over the counter and advice for acute low back pain: systematic review and meta-analysis

This systematic review evaluated evidence from randomized controlled trials investigating interventions available over the counter and advice that could be provided to people with acute low back pain. Searches were conducted on MEDLINE, Embase, Cochrane Database of Systematic Reviews, AMED, CENTRAL, and PsycINFO for eligible randomized controlled trials. The primary outcome measure was pain. Eligible controls included placebo, no treatment, or usual care. Two reviewers extracted data and rated study quality. A random effects model was used to pool trial effects with the overall strength of evidence described using the GRADE criteria. Thirteen randomized controlled trials (2,847 participants) evaluating advice, bed rest, simple analgesics (paracetamol, nonsteroidal anti-inflammatory drugs), heat application, and a topical rubefacient were included. There was low-quality evidence that bed rest is ineffective and very-low-quality evidence that advice is ineffective in the short, intermediate, and long terms. There was very-low-quality evidence that nonsteroidal anti-inflammatory drugs (ibuprofen and diclofenac "when required" dosing) provide an immediate analgesic effect (mean differences -10.9 [95% confidence interval = -17.6 to -4.2] and -11.3 [95% confidence interval = -17.8 to -4.9], respectively). There is very-low-quality evidence that heat wrap and a capsicum-based rubefacient provide an immediate analgesic effect (mean differences -13.5 [95% confidence interval = -21.3 to -5.7] and 17.5, P < .001, respectively), but there was no information on longer-term outcomes.

PERSPECTIVE

There is limited evidence that nonsteroidal anti-inflammatory drugs, heat wrap, and rubefacients provide immediate pain relief for acute back pain and that bed rest and advice are both ineffective. Future research is needed to provide evidence to support rational use of over-the-counter remedies and advice for people with acute low back pain.