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Spinal manipulation epidemiology: Systematic review of cost effectiveness studies
Abstract
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.
To investigate the cost-effectiveness of SMT compared to other treatment options for people with spinal pain of any duration.
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.
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.
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.
... A Dutch study found that MT for neck pain was more effective and less costly when compared with physiotherapy or care by a general practitioner, in primary care [24]. The findings were supported by a systematic literature review, but the authors stated that more high-quality research is needed to make firm conclusions about the use of MT as a cost-effective treatment in clinical practice [25]. To the authors' knowledge only one published health economic study found no advantages in health improvement, costs, or recurrence rate for MT [26]. ...
... Our results are in accordance with a Swedish study where the indirect costs for low back pain were substantially higher than the direct costs [22], and with a Dutch study that observed that MT was more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner [24]. Further, two systematic literature reviews support our findings [25,37], although the authors in one of them stated that more high-quality research is needed to make firm conclusions about the use of spinal MT as a cost-effective treatment in clinical practice [25]. In addition, in that review, only one study found no differences in health improvement, costs, or recurrence rate for MT compared with physiotherapy [26]. ...
... Our results are in accordance with a Swedish study where the indirect costs for low back pain were substantially higher than the direct costs [22], and with a Dutch study that observed that MT was more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner [24]. Further, two systematic literature reviews support our findings [25,37], although the authors in one of them stated that more high-quality research is needed to make firm conclusions about the use of spinal MT as a cost-effective treatment in clinical practice [25]. In addition, in that review, only one study found no differences in health improvement, costs, or recurrence rate for MT compared with physiotherapy [26]. ...
Background
Low back and neck pain are the most common musculoskeletal disorders worldwide, and imply suffering and substantial societal costs, hence effective interventions are crucial. The aim of this study was to evaluate the cost-effectiveness of manual therapy compared with advice to stay active for working age persons with nonspecific back and/or neck pain.
Methods
The two interventions were: a maximum of 6 manual therapy sessions within 6 weeks, including spinal manipulation/mobilization, massage and stretching, performed by a naprapath (index group), respectively information from a physician on the importance to stay active and on how to cope with pain, according to evidence-based advice, at 2 occasions within 3 weeks (control group). A cost-effectiveness analysis with a societal perspective was performed alongside a randomized controlled trial including 409 persons followed for one year, in 2005. The outcomes were health-related Quality of Life (QoL) encoded from the SF-36 and pain intensity. Direct and indirect costs were calculated based on intervention and medication costs and sickness absence data. An incremental cost per health related QoL was calculated, and sensitivity analyses were performed.
Results
The difference in QoL gains was 0.007 (95% CI − 0.010 to 0.023) and the mean improvement in pain intensity was 0.6 (95% CI 0.068–1.065) in favor of manual therapy after one year. Concerning the QoL outcome, the differences in mean cost per person was estimated at − 437 EUR (95% CI − 1302 to 371) and for the pain outcome the difference was − 635 EUR (95% CI − 1587 to 246) in favor of manual therapy. The results indicate that manual therapy achieves better outcomes at lower costs compared with advice to stay active. The sensitivity analyses were consistent with the main results.
Conclusions
Our results indicate that manual therapy for nonspecific back and/or neck pain is slightly less costly and more beneficial than advice to stay active for this sample of working age persons. Since manual therapy treatment is at least as cost-effective as evidence-based advice from a physician, it may be recommended for neck and low back pain. Further health economic studies that may confirm those findings are warranted.
Trial registration Current Controlled Trials ISRCTN56954776. Retrospectively registered 12 September 2006, http://www.isrctn.com/ISRCTN56954776 .
... Recent data from the U.S. Medical Expenditures Panel Survey suggests complementary and integrative therapies, including SMT, reduce healthcare expenditures for spinal pain conditions; however, the cost-effectiveness of SMT within U.S. healthcare settings has not received much attention [16][17][18]. Given the increasing financial and societal burden of spinal pain, and concerns surrounding current management strategies, robust cost-effectiveness analyses (CEA) of SMT and other complementary and integrative treatments for spine pain are much needed [18][19][20][21]. ...
... While systematic reviews have found promising evidence of the cost-effectiveness of SMT for spinal pain, particularly when productivity costs are considered, [58][59][60][61][62] the original studies have limitations that draw attention to the need for further high quality CEAs [18,20]. Few existing CEAs have adopted both societal (including lost productivity costs) and healthcare perspectives [59,61,62] to facilitate the applicability of findings to multiple audiences (including policy makers and health-care systems) [30]. ...
... The generalizability of existing cost-effectiveness studies to the U.S. healthcare system is also a concern [18,20,21]. A limited number of studies have been conducted in the U.S [62,63]. ...
Background
Spinal pain is a common and disabling condition with considerable socioeconomic burden. Spine pain management in the United States has gathered increased scrutiny amidst concerns of overutilization of costly and potentially harmful interventions and diagnostic tests. Conservative interventions such as spinal manipulation, exercise and self-management may provide value for the care of spinal pain, but little is known regarding the cost-effectiveness of these interventions in the U.S. Our primary objective for this project is to estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management for spinal pain using an individual patient data meta-analysis approach.
Methods/design
We will estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management using cost and clinical outcome data collected in eight randomized clinical trials performed in the U.S. Cost-effectiveness will be assessed from both societal and healthcare perspectives using QALYs, pain intensity, and disability as effectiveness measures. The eight randomized clinical trials used similar methods and included different combinations of spinal manipulation, exercise therapy, or self-management for spinal pain. They also collected similar clinical outcome, healthcare utilization, and work productivity data. A two-stage approach to individual patient data meta-analysis will be conducted.
Discussion
This project capitalizes on a unique opportunity to combine clinical and economic data collected in a several clinical trials that used similar methods. The findings will provide important information on the value of spinal manipulation, exercise therapy, and self-management for spinal pain management in the U.S.
... The literature search yielded 11 reviews and 63 primary studies for LBP and 2 reviews and 15 primary studies for NP. Of them, five LBP reviews [19e23] (45%) and two NP reviews [22,24] (100%) were published after January 1, 2009 ( Table 4). The majority of primary studies on LBP (78%) and NP (80%) were published after 2005 and 2006, respectively. ...
... Acute LBP: The first review [22] identified one economic evaluation. From the healthcare perspective, it found spinal manipulation plus general practitioner care to be cost-effective compared with general practitioner care alone among patients with LBP and NP of 2e12-week duration [22]. ...
... Acute LBP: The first review [22] identified one economic evaluation. From the healthcare perspective, it found spinal manipulation plus general practitioner care to be cost-effective compared with general practitioner care alone among patients with LBP and NP of 2e12-week duration [22]. The second review identified a cost-minimization analysis comparing the costs of spinal manipulation, general practitioner care only, general practitioner care plus physical therapy, and an intensive training program, but the researchers did not perform a full economic evaluation because there were no differences in effect [20,25]. ...
Despite the increased interest in economic evaluations, there are difficulties in applying the results of such studies in practice. Therefore, the “Research Agenda for Health Economic Evaluation” (RAHEE) project was initiated, which aimed to improve the use of health economic evidence in practice for the 10 highest burden conditions in the European Union (including low back pain [LBP] and neck pain [NP]). This was done by undertaking literature mapping and convening an Expert Panel meeting, during which the literature mapping results were discussed and evidence gaps and methodological constraints were identified. The current paper is a part of the RAHEE project and aimed to identify economic evidence gaps and methodological constraints in the LBP and NP literature, in particular.
The literature mapping revealed that economic evidence was unavailable for various commonly used LBP and NP treatments (e.g., injections, traction, and discography). Even if economic evidence was available, many treatments were only evaluated in a single study or studies for the same intervention were highly heterogeneous in terms of their patient population, control condition, follow-up duration, setting, and/or economic perspective. Up until now, this has prevented economic evaluation results from being statistically pooled in the LBP and NP literature, and strong conclusions about the cost-effectiveness of LBP and NP treatments can therefore not be made. The Expert Panel identified the need for further high-quality economic evaluations, especially on surgery versus conservative care and competing treatment options for chronic LBP. Handling of uncertainty and reporting quality were considered the most important methodological challenges.
... Low back pain is the second most common cause for visits to a primary care physician [1], and accounts for billions of dollars in annual costs through medical expenses, missed work, reduced job performance [2], and is increasing significantly in prevalence [3]. Spinal manipulation is a cost-effective treatment when used alone or in combination with other techniques [4], and clinical practice guidelines recommend it as an accepted treatment for spine pain [5,6]. The forces produced during spinal manipulation (SM) have been shown to induce individual vertebral motion, increase facet joint gapping, and produce changes in intradiscal pressure, pain thresholds, and paraspinal muscle activity [7]. ...
... Low back pain is the second most common cause for visits to a primary care physician [1], and accounts for billions of dollars in annual costs through medical expenses, missed work, and reduced job performance [2]. Spinal manipulation is a cost-effective treatment when used alone or in combination with other techniques [4], and is an accepted treatment for low back pain [5]. The forces produced during spinal manipulation (SM) have been shown to induce individual vertebral motion, increase facet joint gapping, and produce changes in intradiscal pressure, pain thresholds, and paraspinal muscle activity [7]. ...
The forces applied during a spinal manipulation produce a neuromuscular response in the paraspinal muscles. A systematic evaluation of the factors involved in producing this muscle activity provides a clinical insight. The purpose of this study is to quantify the effect of treatment factors (manipulation sequence and manipulation site) and response factors (muscle layer, muscle location, and muscle side) on the neuromuscular response to spinal manipulation. The surface and indwelling electromyographies of 8 muscle sites were recorded during lumbar side-lying manipulations in 20 asymptomatic participants. The effects of the factors on the number of muscle responses and the muscle activity onset delays were compared using mixed-model linear regressions, effect sizes, and equivalence testing. The treatment factors did not reveal statistical differences between the manipulation sequences (first or second) or manipulation sites (L3 or SI) in the number of muscle responses (p = 0.11, p = 0.28, respectively), or in muscle activity onset delays (p = 0.35 p = 0.35, respectively). There were significantly shorter muscle activity onset delays in the multifidi compared to the superficial muscles (p = 0.02). A small effect size of side (d = 0.44) was observed with significantly greater number of responses (p = 0.02) and shorter muscle activity onset delays (p < 0.001) in the muscles on the left side compared to the right. The location, layer, and side of the neuromuscular responses revealed trends of decreasing muscle response rates and increasing muscle activity onset delays as the distance from the manipulation site increased. These results build on the body of work suggesting that the specificity of manipulation site may not play a role in the neuromuscular response to spinal manipulation—at least within the lumbar spine. In addition, these results demonstrate that multiple manipulations performed in similar areas (L3 and S1) do not change the response significantly, as well as contribute to the clinical understanding that the muscle response rate is higher and with a shorter delay, the closer it is to the manipulation.
... It is suggested that the external force induced by SM, transmitted across the patient's biological tissues has been found to trigger neurophysiological effects on both the central and the peripheral nervous system [4][5][6][7]. In addition, SM has been found to be a cost-effective intervention and to improve patient-reported and performance-based outcome measures [8][9][10][11][12]. Accordingly, SM is an evidence-based intervention which may form part of a management strategy for individuals with a variety of spinal conditions [8][9][10][11][12]. ...
... In addition, SM has been found to be a cost-effective intervention and to improve patient-reported and performance-based outcome measures [8][9][10][11][12]. Accordingly, SM is an evidence-based intervention which may form part of a management strategy for individuals with a variety of spinal conditions [8][9][10][11][12]. ...
Background and Objective
High-velocity low-amplitude thrust spinal manipulation (SM) is a recommended and commonly used manual therapy intervention in physiotherapy. Beliefs surrounding the safety and effectiveness of SM have challenged its use, and even advocated for its abandonment. Our study aimed to investigate the knowledge and beliefs surrounding SM by Italian physiotherapists compared with similar practitioners in other countries.
Methods
An online survey with 41 questions was adapted from previous surveys and was distributed via a mailing list of the Italian Physiotherapists Association (March 22–26, 2020). The questionnaire was divided into 4 sections to capture information on participant demographics, utilization, potential barriers, and knowledge about SM. Questions were differentiated between spinal regions. Attitudes towards different spinal regions, attributes associated with beliefs, and the influence of previous educational background were each evaluated.
Results
Of the 7398 registered physiotherapists, 575 (7.8%) completed the survey and were included for analysis. The majority of respondents perceived SM as safe and effective when applied to the thoracic (74.1%) and lumbar (72.2%) spines; whereas, a smaller proportion viewed SM to the upper cervical spine (56.8%) as safe and effective. Respondents reported they were less likely to provide and feel comfortable with upper cervical SM (respectively, 27.5% and 48.5%) compared to the thoracic (respectively, 52.2% and 74.8%) and lumbar spines (respectively, 46.3% and 74.3%). Most physiotherapists (70.4%) agreed they would perform additional screening prior to upper cervical SM compared to other spinal regions. Respondents who were aware of clinical prediction rules were more likely to report being comfortable with SM (OR 2.38–3.69) and to perceive it as safe (OR 1.75–3.12). Finally, physiotherapists without musculoskeletal specialization, especially those with a traditional manual therapy background, were more likely to perform additional screening prior to SM, use SM less frequently, report being less comfortable performing SM, and report upper cervical SM as less safe ( p < 0.001).
Discussion
The beliefs and attitudes of physiotherapists surrounding the use of SM are significantly different when comparing the upper cervical spine to other spinal regions. An educational background in traditional manual therapy significantly influences beliefs and attitudes. We propose an updated framework on evidence-based SM.
... Quando ocorre na coluna vertebral, pode ser classificada em específica ou inespecífica. Inespecífica quando ocorre sem uma doença ou lesão adjacente conhecida, e específica quando diagnosticada por profissionais da saúde como causada por doenças, por exemplo: infecção, tumor e hérnia de disco (MICHALEFF et al., 2012). ...
... Terapias complementares tornam-se uma alternativa, visto que sua relação custo-benefício em comparação à medicina convencional é mais vantajosa ao paciente (DANTAS et al., 2014;FONSECA;LOPES;RAMOS, 2013). Dentre as formas complementares, a terapia manual tem sido frequentemente usada por fisioterapeutas, apresentando, dentro seus efeitos, redução dos níveis de dor (MICHALEFF et al., 2012;PRADO;GOUVEIA, 2014;RAUSCHKOLB;GOMES, 2016). Dentro da terapia manual, pode-se destacar duas técnicas: a manipulação articular (MA) e a liberação miofascial (LM) (ESTEVAM JUNIOR et al., 2015;RAUSCHKOLB;GOMES, 2016). ...
... Therefore manual therapy might increase as well as decrease health service utilization and direct health care costs. A systematic review of cost effectiveness studies, mostly from the United Kingdom concluded that provision of SMT is cost-effective from the health sector perspective [12]. ...
... The slightly lower total costs and average sick leave in the billing period prior to the index billing period of patients receiving SMT support this assumption (Tables 2 and 4). Our analysis cannot be compared directly to the review of cost effectiveness of SMT which found SMT to be cost-effective [12]. This review included data from patients managed within clinical trials while we report on health claims data from patients in routine care and cost for hospitalization and sick pay could not be directly linked to LBP. ...
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.
... In a literature review of systematic reviews, Michaleff et al. (2012) investigated the cost effectiveness of spinal manipulative therapy (SMT), which included HVLA thrust manipulation and low velocity mobilization techniques, compared to other treatment options available for people with spinal pain of any duration. This study followed the guidelines established by the Cochrane back review group. ...
... The authors emphasize that heath care policy makers and those making financial allocation decisions (i.e. governments, policy makers, and insurance companies) rely on economic studies to make informed policy decisions (Michaleff et al., 2012). The authors purport that SMT is a costeffective treatment option in managing spinal pain, but its effectiveness is comparable to other treatments that could cost more. ...
Background & purpose:
Neck and low back pain (NLBP) are global health problems, which diminish quality of life and consume vast economic resources. Cost effectiveness in healthcare is the minimal amount spent to obtain acceptable outcomes. Studies on manual therapies often fail to identify which manual therapy intervention or combinations with other interventions is the most cost effective. The purpose of this commentary is to sample the dialogue within the literature on the cost effectiveness of evidence-based manual therapies with a particular focus on the neck and low back regions.
Methods:
This commentary identifies and presents the available literature on the cost effectiveness of manual therapies for NLBP. Key words searched were neck and low back pain, cost effectiveness, and manual therapy to select evidence-based articles. Eight articles were identified and presented for discussion.
Results:
The lack of homogeneity, in the available literature, makes difficult any valid comparison among the various cost effectiveness studies.
Discussion:
Potential outcome bias in each study is dependent upon the lens through which it is evaluated. If evaluated from a societal perspective, the conclusion slants toward "adequate" interventions in an effort to decrease costs rather than toward the most efficacious interventions with the best outcomes. When cost data are assessed according to a healthcare (or individual) perspective, greater value is placed on quality of life, the patient's beliefs, and the "willingness to pay."
... Previous reviews have examined the cost effectiveness of chiropractic care for occupational LBP, spinal manipulation therapy (SMT) for spine pain, treatments endorsed by clinical practice guidelines (CPGs) for LBP, conservative care for neck pain, and complementary and alternative medical (CAM) therapies for spine pain [11][12][13][14][15][16][17]. However, such reviews included a multitude of therapies and countries, and were therefore not focused on chiropractic care for spine pain in the US. ...
... most commonly used by chiropractors) for acute and chronic LBP is likely comparable to that of other recommended conservative approaches, including non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, or self-care [52,53]. Previous reviews have also highlighted the methodological weaknesses of economic evaluations related to spine pain, concluding that the health outcomes achieved with chiropractic care were similar to various comparators, with small differences in costs [12,14,54]. ...
Background
Although chiropractors in the United States (US) have long suggested that their approach to managing spine pain is less costly than other health care providers (HCPs), it is unclear if available evidence supports this premise.
Methods
A systematic review was conducted using a comprehensive search strategy to uncover studies that compared health care costs for patients with any type of spine pain who received chiropractic care or care from other HCPs. Only studies conducted in the US and published in English between 1993 and 2015 were included. Health care costs were summarized for studies examining: 1. private health plans, 2. workers’ compensation (WC) plans, and 3. clinical outcomes. The quality of studies in the latter group was evaluated using a Consensus on Health Economic Criteria (CHEC) list.
Results
The search uncovered 1276 citations and 25 eligible studies, including 12 from private health plans, 6 from WC plans, and 7 that examined clinical outcomes. Chiropractic care was most commonly compared to care from a medical physician, with few details about the care received. Heterogeneity was noted among studies in patient selection, definition of spine pain, scope of costs compared, study duration, and methods to estimate costs. Overall, cost comparison studies from private health plans and WC plans reported that health care costs were lower with chiropractic care. In studies that also examined clinical outcomes, there were few differences in efficacy between groups, and health care costs were higher for those receiving chiropractic care. The effects of adjusting for differences in sociodemographic, clinical, or other factors between study groups were unclear.
Conclusions
Although cost comparison studies suggest that health care costs were generally lower among patients whose spine pain was managed with chiropractic care, the studies reviewed had many methodological limitations. Better research is needed to determine if these differences in health care costs were attributable to the type of HCP managing their care.
... The findings of this review are not directly comparable with those of other systematic reviews, [28][29][30][31][32][33][71][72][73][74][75][76][77][78][79][80][81] given the differences in scope, research question, study inclusion/ exclusion criteria, types of economic evaluation, and interventions. The findings of these reviews were either inconclusive because of the paucity and heterogeneity of the evidence for manual therapy [28][29][30][31][32][33] or showed some costeffectiveness of manual therapy over alternative treatments (eg, usual care and exercise). ...
... The findings of these reviews were either inconclusive because of the paucity and heterogeneity of the evidence for manual therapy [28][29][30][31][32][33] or showed some costeffectiveness of manual therapy over alternative treatments (eg, usual care and exercise). 71,75,76,78,79,81 The applicability of findings of the included studies, despite them being pragmatic, may be limited to only countries with similar health care system and considerations of utility (eg, calculations based on the same QOL instrument). The applicability may also be limited by the differences in components of manual therapy interventions and short follow-ups of the studies. ...
Objectives:
The purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions.
Methods:
A comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases.
Results:
Twenty-five publications were included (11 trial-based economic evaluations). The studies compared cost-effectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (e.g., osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain.
Conclusions:
Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients.
... S pinal manipulative therapy (SMT) is a form of manual therapy commonly used to provide care for people with low back pain and other disorders of the lumbar spine and pelvis. 1 The frequency of SMT use by health care providers has increased over the past several decades. 2 Spinal manipulative therapy is generally recommended by treatment guidelines [3][4][5] and appears to be a costeffective therapeutic option for patients with spinal pain. 6 Previous prospective analyses of harm following lumbopelvic SMT have primarily reported benign and self-limiting events, such as muscle soreness and local discomfort, but have not observed and, hence, reported the occurrence of serious adverse events. Senstad et al 7 investigated the outcomes of a large cohort of chiropractic patients (n = 1058) and reported that when SMT was included in the course of care, an adverse reaction was associated with 25% of SMT treatments and 55% of patients reported at least 1 adverse event. ...
... Recent evidence supports the clinical and cost-effectiveness of lumbopelvic SMT when applied to patients with nonspecific low back pain. 3,4,6 However, the existence of a subgroup of patients for whom SMT is most appropriate may be important when considering the therapy's risk profile. Preliminary evidence suggests that SMT's clinical effect may in part be moderated by changes in back muscle function, 63,64 and recent research suggests that those patients who are most likely to experience improved muscle function 65 or clinical outcome 66,67 following SMT can be identified by information from the history and physical examination. ...
... • four of the five recent systematic reviews about the cost-effectiveness of mobilizations and manipulations found some evidence of the cost-effectiveness of mobilizations and manipulations alone or in combination with other treatments. [215][216][217][218][219] the guideline panel advises to only consider mobilization and/or manipulation as a supplement to exercise therapy because: ...
Background:
Significant progress and new insights have been gained since the Dutch Physical Therapy guideline on low back pain (LBP) in 2013 and the Cesar en Mensendieck guideline in 2009, necessitating an update of these guidelines.
Aim:
To update and develop an evidence-based guideline for the comprehensive management of LBP and lumbosacral radicular syndrome (LRS) without serious specific conditions (red flags) for Dutch physical therapists and Cesar and Mensendieck Therapists.
Design:
Clinical practice guideline.
Setting:
Inpatient and outpatient.
Population:
Adults with LBP and/or LRS.
Methods:
Clinically relevant questions were identified based on perceived barriers in current practice of physical therapy. All clinical questions were answered using published guidelines, systematic reviews, narrative reviews or systematic reviews performed by the project group. Recommendations were formulated based on evidence and additional considerations, as described in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. Patients participated in every phase.
Results:
The guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health (ICF) Core Set for LBP and LRS, including the identification of alarm symptoms and red flags. Patients are assigned to three treatment profiles (low, moderate and high risk of persistent symptoms) based on prognostic factors for persistent LBP. The guideline recommends offering simple and less intensive support to people who are likely to recover quickly (low-risk profile) and more complex and intensive support to people with a moderate or high risk of persistent complaints. Criteria for initiating and discontinuing physical therapy, and referral to a general practitioner are specified. Recommendations are formulated for information and advice, measurement instruments, active and passive interventions and behavior-oriented treatment.
Conclusions:
An evidence based physical therapy guideline for the management of patients with LBP and LRS without red flags for physical therapists and Cesar and Mensendieck therapists was developed. Cornerstones of physical therapy assessment and treatment are risk stratification, shared decision-making, information and advice, and exercises.
Clinical rehabilitation impact:
This guideline provides guidance for clinicians and patients to optimize treatment outcomes in patients with LBP and LRS and offers transparency for other healthcare providers and stakeholders.
... The term nonspecific is adopted throughout almost all international practice guidelines, and the term is used because no specific biological cause can be established as the cause of the LBP. 30,35,42 So how and why should a specific treatment be able to affect a condition classi-effect reported in favor for the targeted mobilization could be due to chance. This should be investigated in future studies including sufficient sample sizes. ...
OBJECTIVE: We aimed to examine whether targeting spinal manipulative therapy (SMT), by applying the intervention to a specific vertebral level, produces superior clinical outcomes than a nontargeted approach in patients with nonspecific low back pain.
DESIGN: Systematic review with meta-analysis.
LITERATURE SEARCH: MEDLINE, Embase, CENTRAL, CINAHL, Scopus, PEDro, and Index to Chiropractic Literature were searched up to May 31, 2023.
STUDY SELECTION CRITERIA: Randomized controlled trials comparing targeted SMT (mobilization or manipulation) to a nontargeted approach in patients with nonspecific low back pain, and measuring the effects on pain intensity and patient-reported disability.
DATA SYNTHESIS: Data extraction, risk of bias, and evaluation of the overall certainty of evidence using the GRADE approach were performed by 2 authors independently. Meta-analyses were performed using the restricted maximum likelihood method.
RESULTS: Ten randomized controlled trials (n = 931 patients) were included. There was moderate-certainty evidence of no difference between targeted SMT and a nontargeted approach for pain intensity at postintervention (weighted mean difference = −0.20 [95% CI: −0.51, 0.10]) and at follow-up (weighted mean difference = 0.05 [95% CI: −0.26, 0.36]). For patient-reported disability, there was moderate-certainty evidence of no difference at postintervention (standardized mean difference = −0.04 [95% CI: −0.36, 0.29]) and at follow-up (standardized mean difference = −0.05 [95% CI: −0.24, 0.13]). Adverse events were reported in 4 trials, and were minor and evenly distributed between groups.
CONCLUSION: Targeting a specific vertebral level when administering SMT for patients with nonspecific low back pain did not result in improved outcomes on pain intensity and patient-reported disability compared to a nontargeted approach. J Orthop Sports Phys Ther 2023;53(9):529-539. Epub: 28 July 2023. doi:10.2519/jospt.2023.11962
... Spinal manipulative therapy (SMT) is one such recommended treatment option. [11][12][13][14]23,24 Spinal manipulative therapy has been demonstrated to be a cost-effective treatment option for the management of back pain [25][26][27][28] and results in high reported levels of patient satisfaction [29][30][31] . Chiropractic care, which involves spinal manipulation and adjunctive therapies, is consistent with recent CPGs [11][12][13][14] and is a viable first line treatment option prior to the use of opioid prescription medication. ...
Background:
Non-pharmacologic treatment, including chiropractic care, is now recommended instead of opioid prescriptions as the initial management of chronic spine pain by clinical practice guidelines. Chiropractic care, commonly including spinal manipulation, has been temporally associated with reduced opioid prescription in veterans with spine pain.
Purpose:
To determine if chiropractic management including spinal manipulation was associated with decreased pain or opioid usage in financially disadvantaged individuals utilizing opioid medications and diagnosed with musculoskeletal conditions.
Methods:
A retrospective analysis of quality assurance data from a publicly funded healthcare facility was conducted. Measures included numeric pain scores of spine and extremity regions across three time points, opioid utilization, demographics, and care modalities.
Results:
Pain and opioid use significantly decreased concomitant with a course of chiropractic care.
Conclusions:
A publicly funded course of chiropractic care temporally coincided with statistically and clinically significant decreases in pain and opioid usage in a financially disadvantaged inner-city population.
... Some regard it as a beneficial and cost-effective therapy compared to other conservative modalities. However, many disagree [1,2]. One systematic review concluded that spinal manipulative therapy has no statistically or clinically significant advantage in treating spinal pain [2]. ...
A 16-year-old boy was diagnosed with spondyloptosis of the cervical spine at the C5–6 level with a neurologic deficit following cervical manipulation. He could not move his upper and lower extremities, but the sensory and autonomic function was spared. The pre-operative American Spinal Cord Injury Association (ASIA) Score was B with SF-36 being 25%, and Karnofsky's score was 40%. The patient was disabled and required special care and assistance. We performed anterior decompression, cervical corpectomy at the level of C6 and lower part of C5, deformity correction, cage insertion, bone grafting, and stabilization with an anterior cervical plate. The patient's objective functional score had increased after six months follow up and assessed objectively with the ASIA Impairment Scale (AIS) E or Excellent, SF-36 score 94%, and Karnofsky score was 90%. The patient could carry on regular activity with minor signs or symptoms of the disease. This case report highlights severe complications following cervical manipulation, a summary of the clinical presentation, surgical treatment choices, and a review of the relevant literature. In addition, the sequential improvement of the patient's functional outcome after surgical correction will be discussed.
... TJM techniques are characterised as involving a specific high-velocity low-amplitude thrust with the aim of achieving joint cavitation [1]. Evidence, including clinical practice guidelines, supports TJM for all spinal regions for improving patient-reported and performance-based outcomes [2][3][4][5][6][7]. Although recommended, TJM techniques have been linked with side-effects and, in rare cases, serious adverse events [8][9][10][11][12][13][14]. ...
Introduction
Thrust Joint Manipulation (TJM) is a widely used intervention in spinal care, however there are differences in its use between countries and spinal regions. This survey analyzes the frequency of use of TJM, examines the thoughts about the effectiveness of, and the perceptions of Dutch certified manual therapists regarding safety, comfort, use and barriers related to the application of spinal TJM techniques.
Method
The 19-question e-survey was based on a similar survey in the U.S. Since the Netherlands has a separate professional standard for the upper cervical spine, questions enabled differentiation between upper- and mid/lower cervical spine. The survey was launched during a national manual therapy congress and distributed via social media (April-July 2018). Descriptive analyses, MANOVA and qualitative analyses were used.
Results
From the 211 responses, 150 were male, with a mean age of 44.9 (±11.2) years, a mean clinical experience of 12.8 (±9.6) years as manual therapist, 87% had a master’s degree and 97% worked in a private practice. Except for the upper cervical spine, more than 80% of the participants felt that TJM was safe, were comfortable performing TJM. Overall >80% of participants perform additional screening prior to TJM. Concerns about safety is the greatest barrier for upper cervical TJM.
Discussion
Findings indicate that overall Dutch manual therapists believe TJM to be safe and effective and are comfortable performing them, except for the upper cervical spine, where concerns exist regarding safety and acquiring written informed consent.
Level of evidence
2b.
... Spinal manipulative techniques have been suggested as a cost-effective treatment tool and are frequently used in multimodal therapeutic programs for management of various musculoskeletal complaints of the spine (Michaleff et al., 2012). A previous model suggests that clinical outcomes are related to the interplay between biomechanical and neurophysiological effects of manual therapy (Bialosky et al., 2009). ...
Background
Spinal manipulative techniques are commonly used in manual therapies but quantified descriptive and reliability data are lacking considering supine thoracic thrust manipulation.
Objectives
The purpose of this study is to explore and compare kinetic parameters during supine thoracic thrust manipulation performed at two different thoracic regions. Intra-rater task repeatability and influence of practitioners were estimated.
Design
Exploratory and agreement study.
Methods
Kinetic parameters were assessed by examining reaction force magnitude and orientation (on the basis of the zenithal angle) using force platforms. Manipulative procedure (consisting in the application of 3 preloads followed by one thrust adjustment) at both intervertebral and costovertebral region was performed by different practitioners at three sessions. Application of thrust was allowed for experienced practitioners only. Preload force, peak force magnitude and vector force orientation were compared between anatomical sites, sessions and practitioners, and bias with limit of agreement were estimated.
Results
Repeatability analysis showed that practitioners achieved similar preload and peak force independent of the session, with comparable force orientation. Differences between practitioners were observed for preload and peak force but not regarding the zenithal angle during the thrust phase.
Conclusions
The present study is the first that explores kinetic parameters for supine thoracic thrust manipulation applied on two different regions of the thorax. Results confirm consistency of performance among practitioners for supine manipulative techniques at intervertebral and costovertebral region. While task repeatability was confirmed, several differences were observed between practitioners. Further investigations would examine velocity, acceleration and potential neurophysiological effect of such manipulative technique.
... In this study, osteopaths reported mostly treating patients with acute symptoms, which were primarily spinal conditions, mainly low back and neck pain, as confirmed by a recent Swiss study [16] and other international studies [10,11,16,40]. Cost-effectiveness studies showed encouraging results [41][42][43] in the use of osteopathy in acute settings. However, regarding the small number of consultations scheduled by our respondents for acute low back pain and neck pain management, further studies should explore whether these prompt management capabilities provide a clinically meaningful difference for pain or disability in people with LBP when compared with the natural course of back pain [44,45]. ...
Background
Osteopathy is commonly used for spinal pain, but knowledge about back pain management by osteopaths is scarce.
Objective
The aim of this study was to survey osteopaths across the French-speaking part of Switzerland about the scope of their practice and their management of patients with back pain.
Design
This cross-sectional observational study was based on an online survey conducted from March to June 2017. Setting and participants: All registered osteopaths of the French-speaking part of Switzerland were asked to complete the survey. Outcome measures: In addition to descriptive statistics (practice characteristics, patients’ profiles, scope of treatment modalities, health promotion, research, and osteopathic practice), we explored variables associated with osteopaths’ practice, such as age and gender.
Results
A total of 241 osteopaths completed the questionnaire (response rate: 28.8%). Almost two thirds of osteopaths were female. Ages ranged from 25 to 72 years with an overall mean of 42.0 (SD 10.7) years. Male osteopaths reported more weekly working hours than female osteopaths did (38.2 [SD 11.0] vs 31.6 [SD 8.9], respectively, p<0.001). Almost a third (27.8%,) of osteopaths could arrange an appointment for acute conditions on the same day and 62.0% within a week. Acute or subacute spinal conditions, mainly low back and neck pain, were the most frequent conditions seen by our respondents. For 94.4% of osteopaths, one to three consultations were required for the management of such conditions.
Conclusion
Osteopaths play a role in the management of spinal conditions, especially for acute problems. These findings, combined with short waiting times for consultations for acute conditions, as well as prompt management capabilities for acute low back and acute neck pain, support the view that the osteopathic profession constitutes an added value to primary care.
... Spinal manipulative technique has been demonstrated as a cost-effective treatment and is frequently used by health professionals to manage various musculoskeletal complaints. 1 The thrust manipulation technique is typically described as a high-velocity, low-amplitude procedure (HVLA), which means a short-time force or moment application displaying minimal displacement of a target joint segment. 2 The mechanical profile of HVLA is characterized by different phases: the preload, the impulse, and the resolution phases. The preload phase corresponds to the positioning of the targeted segment to reach the critical load, the impulse phase is depicted by a sudden increase of the force magnitude to a peak over a short period, and the resolution period defines the decrease of the forces applied. ...
Objective
The main purpose of this study was to explore specific kinetic parameters during supine thoracic thrust manipulation and to analyze task reliability and differences between various practitioners
Methods
Kinetic parameters were assessed by examining ground reaction force magnitude and orientation (on the basis of the zenithal angle) using force platforms. The manipulative procedure (consisting of the application of 3 preloads followed by 1 single thrust adjustment) was performed by different practitioners at 3 sessions. Application of thrust was allowed for trained practitioners only. Preload force, peak force, and vector force orientation were compared between sessions and practitioners.
Results
Reliability analysis showed that practitioners achieved similar preload and peak force independent of the session, with comparable force orientation data. Differences between practitioners were observed for preload and peak force but not regarding the zenithal angle during the thrust phase.
Conclusion
This study is the first that explores kinetic parameters for supine thoracic thrust manipulation. Task repeatability was confirmed and several differences were observed between practitioners. Certainly, there is a need for further investigation examining both dynamic parameters (ie, velocity and accelerations) and the potential neurologic effect of such manipulative technique.
... 73 86 Another recent systematic review that focused on the effects of SMT for spinal pain concluded that SMT is a cost effective option when used alone or in combination with other treatments. 87 However, this conclusion was based on six studies, including studies that examined the effect of SMT for the treatment of neck pain, and was limited to the same two studies cited previously. 73 86 To our knowledge, no other economic evaluations have been done of SMT for the treatment of chronic low back pain. ...
Objective
To assess the benefits and harms of spinal manipulative therapy (SMT) for the treatment of chronic low back pain.
Design
Systematic review and meta-analysis of randomised controlled trials.
Data sources
Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, Physiotherapy Evidence Database (PEDro), Index to Chiropractic Literature, and trial registries up to 4 May 2018, including reference lists of eligible trials and related reviews.
Eligibility criteria for selecting studies
Randomised controlled trials examining the effect of spinal manipulation or mobilisation in adults (≥18 years) with chronic low back pain with or without referred pain. Studies that exclusively examined sciatica were excluded, as was grey literature. No restrictions were applied to language or setting.
Review methods
Two reviewers independently selected studies, extracted data, and assessed risk of bias and quality of the evidence. The effect of SMT was compared with recommended therapies, non-recommended therapies, sham (placebo) SMT, and SMT as an adjuvant therapy. Main outcomes were pain and back specific functional status, examined as mean differences and standardised mean differences (SMD), respectively. Outcomes were examined at 1, 6, and 12 months. Quality of evidence was assessed using GRADE. A random effects model was used and statistical heterogeneity explored.
Results
47 randomised controlled trials including a total of 9211 participants were identified, who were on average middle aged (35-60 years). Most trials compared SMT with recommended therapies. Moderate quality evidence suggested that SMT has similar effects to other recommended therapies for short term pain relief (mean difference −3.17, 95% confidence interval −7.85 to 1.51) and a small, clinically better improvement in function (SMD −0.25, 95% confidence interval −0.41 to −0.09). High quality evidence suggested that compared with non-recommended therapies SMT results in small, not clinically better effects for short term pain relief (mean difference −7.48, −11.50 to −3.47) and small to moderate clinically better improvement in function (SMD −0.41, −0.67 to −0.15). In general, these results were similar for the intermediate and long term outcomes as were the effects of SMT as an adjuvant therapy. Evidence for sham SMT was low to very low quality; therefore these effects should be considered uncertain. Statistical heterogeneity could not be explained. About half of the studies examined adverse and serious adverse events, but in most of these it was unclear how and whether these events were registered systematically. Most of the observed adverse events were musculoskeletal related, transient in nature, and of mild to moderate severity. One study with a low risk of selection bias and powered to examine risk (n=183) found no increased risk of an adverse event (relative risk 1.24, 95% confidence interval 0.85 to 1.81) or duration of the event (1.13, 0.59 to 2.18) compared with sham SMT. In one study, the Data Safety Monitoring Board judged one serious adverse event to be possibly related to SMT.
Conclusion
SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT.
... Evidence report that spinal manipulative therapy provides greater improvement for pain and function than a placebo or no treatment [4,46] . A systematic review of Michaleff et al. found that SMT is a cost-effective treatment to manage spinal pain when used alone or in combination with general practice care , like mobilization [106] . Spinal manipulative therapy (spinal manipulation and mobilization ) is usually provided by manual therapists, osteopaths and chiropractic doctors or therapists. ...
Spinal manipulation and mobilization are commonly used for musculoskeletal and spine problems. Evidence about neurophysiological reactions indicates that spinal manipulation and mobilization initiate neurovegetative responses.
The objective of this literature review is to analyse evidence on neurovegetative responses following spinal manipulation and mobilization compared to a sham or control group. The secondary objective is to establish level of neurovegetative change and differences between manual spinal techniques.
Method: A systematic search in MEDLINE and Cochrane Library with(MeSH)terms: ‘spinal manipulation’, ‘chiropractic manipulation’, ‘osteopathic manipulative treatment’, ‘manual therapy’, ‘sympathetic nervous system’, ‘parasympathetic nervous system’, ‘autonomic nervous system’, ‘enteric nervous system’, blood supply’, ‘vasomotor system’, ‘blood flow velocity’, ‘sweat glands’, ‘viscera’, ‘visceral pain’, ‘piloerection’, ‘skin temperature’ and ‘pain’ for eligible RCTs and systematic reviews between 2000 and May 2016. Data were extracted and analysed. Quality of the studies is assessed according to the PEDro scale.
Findings:13 RCTs were included. Statistically significant changes were seen with increased skin conductance, increased pressure pain thresholds, increased breathing rate, decreased pain on Visual Analog Scale, decreased local allodynia, hyperalgesia and changes in heart rate and heart rate variability. Inconsistent changes are seen in skin temperature. No significant changes are seen in thermal pain thresholds, pupillary reactions and cutaneous blood flow. No clear differences in spinal manual technique efficiency.
In conclusion, this literature review provide evidence that spinal manipulation and mobilization evoke neurovegetative reactions. Some parameters are consistent, but in other parameters there is an inconsistency in neurovegetative effect. Despite the evidence, neurophysiological mechanisms are still relatively unclear. Due to the unequal distribution of the number of mobilization repetitions, number of sessions, different measurement methods and treatment locations, it is not possible to make concrete statements which technique is superior. Long-term effects of multi-technique sessions and multiple sessions are too scarce to draw clear practical conclusions. There is a need of high quality, large sample RCTs on selective symptomatic subjects with a multi-technique or intersession design. Only then is a representative therapeutic outcome measurable of strong clinical importance.
Keywords: neurovegetative nervous system, autonomic nervous system, spinal manipulation, spinal mobilization, osteopathy, chiropractic, manual therapy.
Neurovegetative Reactions of Spinal Manipulations and Mobilizations in Manual Therapy, Chiropractic and Osteopathic Medicine A literature review Master Thesis. Available from: https://www.researchgate.net/publication/325248512_Neurovegetative_Reactions_of_Spinal_Manipulations_and_Mobilizations_in_Manual_Therapy_Chiropractic_and_Osteopathic_Medicine_A_literature_review_Master_Thesis [accessed May 19 2018].
... 15 In recent years, only a few articles have reviewed the efficacy, clinical utility and cost-effectiveness of treatments for persistent LBP or persistent NSLBP. [16][17][18][19][20][21][22] This article reviews recent evidence, covering the period up to July 2017. ...
Study Design
Systematic review.
Objectives
To review the current literature on the treatment efficacy, clinical utility, and cost-effectiveness of multidisciplinary biopsychosocial rehabilitation (MBR) for patients suffering from persistent (nonspecific) lower back pain (LBP) in relation to pain intensity, disability, health-related quality of life, and work ability/sick leave.
Methods
We carried out a systematic search of Web of Science, Cochrane Library, PubMed Central, EMBASE, and PsycINFO for English- and German-language literature published between January 2010 and July 2017. Study selection consisted of exclusion and inclusion phases. After screening for duplication, studies were excluded on the basis of criteria covering study design, number of participants, language of publication, and provision of information about the intervention. All the remaining articles dealing with the efficacy, utility, or cost-effectiveness of intensive (more than 25 hours per week) MBR encompassing at least 3 health domains and cognitive behavioral therapy–based psychological education were included.
Results
The search retrieved 1199 publications of which 1116 were duplicates or met the exclusion criteria. Seventy of the remaining 83 articles did not meet the inclusion criteria; thus 13 studies were reviewed. All studies reporting changes in pain intensity or disability over 12 months after MBR reported moderate effect sizes and/or p-values for both outcomes. The effects on health-related quality of life were mixed, but MBR substantially reduced costs. Overall MBR produced an enduring improvement in work ability despite controversy and variable results.
Conclusions
MBR is an effective treatment for nonspecific LBP, but there is room for improvement in cost-effectiveness and impact on sick leave, where the evidence was less compelling.
... A review of Michaleff et al. [53] supported the use of spinal manipulative therapy (SMT) in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. This review showed that while the effectiveness of SMT is comparable to other treatments, SMT is the more cost-effective Abbreviations: MTU Manual Therapy Utrecht, PT Physical Therapy, NRS Numeric Rating Scale, n number, min minutes, hr hours treatment option. ...
Background
Manual therapy according to the School of Manual Therapy Utrecht (MTU) is a specific type of passive manual joint mobilization. MTU has not yet been systematically compared to other manual therapies and physical therapy. In this study the effectiveness of MTU is compared to physical therapy, particularly active exercise therapy (PT) in patients with non-specific neck pain. Methods
Patients neck pain, aged between 18–70 years, were included in a pragmatic randomized controlled trial with a one-year follow-up. Primary outcome measures were global perceived effect and functioning (Neck Disability Index), the secondary outcome was pain intensity (Numeric Rating Scale for Pain). Outcomes were measured at 3, 7, 13, 26 and 52 weeks. Multilevel analyses (intention-to-treat) were the primary analyses for overall between-group differences. Additional to the primary and secondary outcomes the number of treatment sessions of the MTU group and PT group was analyzed. Data were collected from September 2008 to February 2011. ResultsA total of 181 patients were included. Multilevel analyses showed no statistically significant overall differences at one year between the MTU and PT groups on any of the primary and secondary outcomes. The MTU group showed significantly lower treatment sessions compared to the PT group (respectively 3.1 vs. 5.9 after 7 weeks; 6.1 vs. 10.0 after 52 weeks). Conclusions
Patients with neck pain improved in both groups without statistical significantly or clinically relevant differences between the MTU and PT groups during one-year follow-up. Trial registrationClinicalTrials.gov Identifier: NCT00713843.
... Physical therapists use a range of manual therapy techniques including manipulation, mobilisation, neurodynamic techniques, and exercise as part of their patient management strategies (Gross et al, 2007(Gross et al, , 2010Hurwitz, 2012;Michaleff et al., 2012;Rubinstein et al., 2012).These techniques are first taught in entry-level educational programmes and developed to an advanced level through postgraduate programmes with specialisation in orthopaedic manipulative physical therapy (OMPT). Educational standards for postgraduate OMPT programmes are set and monitored by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) across its 22 Member Organisations (countries). ...
Background:
Physical therapists (PTs) use a range of manual therapy techniques developed to an advanced level through postgraduate orthopaedic manipulative physical therapy (OMPT) programmes. The aim of this study was to describe the adverse effects experienced by students after having techniques performed on them as part of their OMPT training.
Design:
A descriptive online survey of current students and recent graduates (≤5 years)m of OMPT programmes across the 22 Member Organisations of the International Federation of Orthopaedic Manipulative Physical Therapists.
Results:
The questionnaire was completed by 1640 respondents across 22 countries (1263 graduates, 377 students. Some 60% of respondents reported never having experienced adverse effects during their manual therapy training. Of the 40% who did, 66.4% reported neck pain, 50.9% headache and 32% low back pain. Most reports of neck pain started after a manipulation and/or mobilisation, of which 53.4% lasted ≤24 h, 38.1% > 24 h but <3 months and 13.7% still experienced neck pain to date. A small percentage of respondents (3.3%) reported knowing of a fellow student experiencing a major adverse effect.
Conclusion:
Mild to moderate adverse effects after practising manual therapy techniques are commonly reported, but usually resolve within 24 h. However, this survey has identified the reported occurrence of major adverse effects that warrant further investigation.
... Regulations govern the appropriate scheduling and degree of servicing in plans of management [50]. Current data support the management of spinal pain with an approach that includes spinal manipulation and chiropractic compares favourably in cost effectiveness studies [89][90][91]. ...
Background:
Various models and decision-making aids exist for chiropractic clinical practice.
Results:
"PICO-D Man" (Patient-Intervention-Comparator-Outcome-Duration Management) is a decision-aid developed in an educational setting which field practitioners may also find useful for applying defensible evidence-based practice. Clinical decision-making involves understanding and evaluating both the proposed clinicalintervention(s) and the relevant and available management options with respect to describing the patient and their problem, clinical and cost effectiveness, safety, feasibility and time-frame.
Conclusions:
For people consulting chiropractors this decision-aid usually requires the practitioner to consider a comparison of usual chiropractic care, (clinical management including a combination of active care and passive manual interventions), to usual medical care usually including medications, or other allied healthmanagement options while being mindful of the natural history of the persons' condition.
... Economic evaluation of health interventions, such as osteopathic care, can be undertaken based either on clinical trial data or the modelling of data from a range of data sources (Goeree and Diaby, 2013). Whilst there have been some attempts to understand the cost-effectiveness of health services encompassing osteopathic healthcare, such as spinal manipulation (Michaleff et al., 2012) or manual therapy more generally (Tsertsvadze et al., 2014), the findings of these studies have not yet provided firm conclusions regarding the cost effectiveness of osteopathic care as a discrete treatment option. Furthermore, cost-effectiveness studies in OMT have not previously been reviewed in relation to CER, despite the natural synergies between these approaches. ...
In recent years, evidence has emerged regarding the effectiveness of osteopathic manipulative treatments (OMT). Despite growing evidence in this field, there is need for appropriate research designs that effectively reflect the person-centred system of care promoted in osteopathy and provide data which can inform policy decisions within the healthcare system. The purpose of this systematic review is to identify, appraise and synthesise the evidence from comparative effectiveness and economic evaluation research involving OMT. A database search was conducted using CINAHL, PubMed, PEDro, AMED, SCOPUS and OSTMED.DR, from their inception to May 2015. Two separate searches were undertaken to identify original research articles encompassing the economic evaluation and comparative effectiveness of OMT. Identified comparative effectives studies were evaluated using the Cochrane risk of bias tool and appraised using the Good Reporting of Comparative Effectiveness (GRACE) principles. Identified economic studies were assessed with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. Sixteen studies reporting the findings of comparative effectiveness (n = 9) and economic evaluation (n = 7) research were included. The comparative effectiveness studies reported outcomes for varied health conditions and the majority (n = 6) demonstrated a high risk of bias. The economic evaluations included a range of analyses and considerable differences in the quality of reporting were evident. Despite some positive findings, published comparative effectiveness and health economic studies in OMT are of insufficient quality and quantity to inform policy and practice. High quality, well-designed, research that aligns with international best practice is greatly needed to build a pragmatic evidence base for OMT.
... A number of systematic reviews of the randomized controlled trial literature have concluded that SM is effective in the reduction of spinal pain and is cost-effective [96][97][98] Despite this, there has been much controversy over many years regarding the risk of adverse events following the application of spinal manipulation, in particular cervical spine manipulation. 99 Risk estimates have focused on dissection injury to the vertebral artery leading to stroke, but vary widely from 1 in 163 000 100 manipulations to about 1 in 5 000 000. 101 Most estimates are inherently flawed as they have usually relied on retrospective methodologies, usually surveys of practitioners or searches of insurance or medical records. ...
Grieve's Modern Musculoskeletal Physiotherapy continues to bring together the latest state-of-the-art research, from both clinical practice and the related basic sciences, which is most relevant to practitioners. The topics addressed and the contributing authors reflect the best and most clinically relevant contemporary work within the field of musculoskeletal physiotherapy.
With this as its foundation and a new six-strong editorial team at its helm, the fourth edition now expands its focus from the vertebral column to the entire musculoskeletal system. For the first time both the spine and extremities are covered, capturing the key advances in science and practices relevant to musculoskeletal physiotherapy.
The book is divided into five parts containing multiple sections and chapters. The first part of the book looks at advances in the sciences underpinning musculoskeletal physiotherapy practice. Here there is commentary on topics such as movement, the interaction between pain and motor control as well as neuromuscular adaptations to exercise. Applied anatomical structure is covered in addition to the challenges of lifestyle and ageing. A new section highlights the important area of measurement and presents the scope of current and emerging measurements for investigating central and peripheral aspects relating to pain, function and morphological change. Another section discusses some contemporary research approaches such as quantitative and qualitative methods as well as translational research.
Part III contains sections on the principles of and broader aspects of management which are applicable to musculoskeletal disorders of both the spine and periphery. Topics include models for management prescription, communication and pain management and contemporary principles of management for the articular, nervous and sensorimotor systems. In recognition of the patient centred and inclusive nature of contemporary musculoskeletal practice, there is also discussion about how physiotherapists may use cognitive behavioural therapies when treating people with chronic musculoskeletal disorders.
The final part of the book focuses on selected contemporary issues in clinical practice for a particular region, condition or the most topical approaches to the diagnosis and management of a region. A critical review of the evidence (or developing evidence) for approaches is given and areas for future work are highlighted.
... Spinal manipulation therapy (SMT) has been reported as a cost-effective therapy for spine related pain and is part of the therapeutic arsenal of numerous practitioners such as physiotherapists, chiropractors and osteopaths [1]. Although publications on SMT effectiveness have increased in the past years, evidences supporting the physiological mechanisms underlying its effects are scarce [2,3]. ...
Background
Neuromechanical responses to spinal manipulation therapy (SMT) have been shown to be modulated through the variation of SMT biomechanical parameters: peak force, time to peak force, and preload force. Although rate of force application was modulated by the variation of these parameters, the assumption that neuromuscular responses are modulated by the rate of force application remains to be confirmed. Therefore, the purpose of the present study was to evaluate the effect of a constant rate of force application in neuromechanical responses to SMT in healthy adults. Methods
Four SMT force-time profiles presenting different time to peak force and peak force, but with a constant rate of force application were applied on 25 healthy participants’ T7 transverse processes. Muscular responses were recorded through surface electromyography electrodes (T6 and T8 levels), while vertebral displacements were assessed through pasted kinematic markers on T6 to T8 spinous processes. Effects of SMT force-time profiles on neuromechanical responses were assessed using repeated-measures ANOVAs. ResultsThere was no main effect of SMT force-time profile modulation on muscular responses (ps > .05) except for the left T8 (F (3, 72) = 3.23, p = .03) and left T6 (F (3, 72) = 2.94, p = .04). Muscular responses were significantly lower for the lowest peak force condition than the highest (for T8) or second highest (for T6). Analysis showed that increasing the SMT peak force (and concomitantly time to peak force) led to a significant vertebral displacement increase for the contacted vertebra (FT7 (1, 17) = 354.80, p < .001) and both adjacent vertebras (FT6(1, 12) = 104.71, p < .001 and FT8 (1, 19) = 468.68, p < .001). Conclusion
This study showed that peak force modulation using constant rate of force application leads to similar neuromuscular responses. Coupled with previous investigations of SMT peak force and duration effects, the results suggest that neuromuscular responses to SMT are mostly influenced by the rate of force application, while peak force modulation yields changes in the vertebral displacement. Rate of force application should therefore be defined in future studies. Clinical implications of various SMT dosages in patients with spine related pain should also be investigated. Trial registrationClinicalTrials.gov NCT02550132. Registered 8 September 2015
... We checked the reference lists of the other 12 reviews about costeffectiveness of interventions applied by different health professionals, which we, therefore, called "nonspecific systematic reviews." The manual search of the reference lists of these 12 nonspecific systematic reviews (Pinto et al, 10 Driessen et al, 14 Indrakanti et al, 15 Maund et al, 16 Furlan et al, 17 Michaleff et al, 18 Lauche et al, 19 Bermingham et al, 20 Armstrong et al, 21 Boyers et al, 22 O'Doherty et al, 23 and Boland et al 24 ) yielded 40 references; 1 article met the selection criteria. At the end of the selection process, 18 references met the selection criteria ( Figure) and were included in the analyses. ...
Introduction
Au vu de l’augmentation continue des frais de santé, les interventions des professionnels de la santé doivent être efficaces et optimisées. Cette étude avait pour objectif de synthétiser le rapport coût/efficacité actuel de la physiothérapie. Les objectifs spécifiques étaient d’analyser le rapport coût/efficacité de la physiothérapie en la comparant aux soins habituels seuls, d’analyser le rapport coût/efficacité de la physiothérapie ajoutée aux soins habituels par rapport aux soins habituels seuls et de préciser pour quelles pathologies la physiothérapie seule ou la physiothérapie ajoutée aux soins habituels offrait le meilleur rapport coût/efficacité.
Méthodes
Nous avons recherché des analyses du rapport coût/efficacité de la physiothérapie dans les bases de données Medline, CINAHL, PEDro et Cochrane Library ; nous avons également consulté des revues systématiques sur papier. Nous avons inclus des études publiées entre 1998 et 2014 portant sur le rapport coût/efficacité des interventions de physiothérapie. La qualité méthodologique a été évaluée au moyen de l’outil d’évaluation du risque de biais Cochrane (Cochrane Risk of Bias Assessment) pour les études portant sur les interventions, ainsi qu’au moyen de la Quality of Health Economic Analyses Scale. Nous avons calculé les rapports coût/efficacité incrémentaux (ICER) et rapporté les conclusions des auteurs ainsi que nos propres conclusions.
Résultats
Les 18 études incluses présentent un faible risque de biais. Elles contiennent 8 comparaisons de la physiothérapie seule avec les soins habituels seuls et 11 comparaisons de la physiothérapie en complément des soins habituels avec les soins habituels seuls. En se basant sur les ICER, la physiothérapie seule ou en complément des soins habituels offre un rapport coût/efficacité satisfaisant dans 9 comparaisons sur 19, et dans 10 comparaisons selon les conclusions des auteurs. Le rapport coût/efficacité de la physiothérapie a été démontré pour les troubles musculosquelettiques tels que les cervicalgies, les lombalgies chroniques, l’arthrose du genou, l’arthrose de la hanche et le syndrome rotulien (articulation fémoro-patellaire). Ce résultat est utile au vu de la prévalence élevée des troubles musculo-squelettiques. Il a aussi été possible de montrer le rapport coût/efficacité de la physiothérapie pour les patients atteints de la maladie de Parkinson et de claudication intermittente.
Discussion et conclusion
La physiothérapie seule ou en complément des soins habituels permet une amélioration de l’état de santé dans presque toutes les études. Le rapport coût/efficacité de ces interventions est démontré dans la moitié des études. Ce résultat peut avoir été influencé par le fait qu’il existe plusieurs définitions de la notion « coût/efficacité ».
Il est probable que le caractère actif et formateur des interventions de physiothérapie contribue au bon rapport coût/efficacité. Les séances en groupes sont par ailleurs moins onéreuses que les séances individuelles ; elles favorisent le partage bénéfique des connaissances entre patients atteints d’un même problème de santé.
Le nombre de séances ne semble pas influer sur les coûts. Cependant, une évaluation régulière des effets du traitement (après 6 à 9 séances par exemple) est recommandée pour limiter les dépenses inutiles. À l’avenir, les études randomisées contrôlées évaluant l’efficacité de la physiothérapie devraient inclure une perspective socioéconomique.
... We checked the reference lists of the other 12 reviews about costeffectiveness of interventions applied by different health professionals, which we, therefore, called "nonspecific systematic reviews." The manual search of the reference lists of these 12 nonspecific systematic reviews (Pinto et al, 10 Driessen et al, 14 Indrakanti et al, 15 Maund et al, 16 Furlan et al, 17 Michaleff et al, 18 Lauche et al, 19 Bermingham et al, 20 Armstrong et al, 21 Boyers et al, 22 O'Doherty et al, 23 and Boland et al 24 ) yielded 40 references; 1 article met the selection criteria. At the end of the selection process, 18 references met the selection criteria ( Figure) and were included in the analyses. ...
Background:
Given the continually rising health-care costs, interventions of health-care providers should be cost-effective.
Purpose:
This review aimed to summarize current cost-effectiveness of physical therapy. Specific aims were a) to analyze cost-effectiveness of physical therapy only compared to usual care only, b) to analyze cost-effectiveness of physical therapy added to usual care compared to usual care only, and c) to specify in which health condition physical therapy only or physical therapy added to usual care was cost-effective.
Data sources:
We searched in Medline, CINAHL, PEDro and Cochrane Library; and manually in topic-related systematic reviews.
Study selection:
We included studies published between 1998 and 2014 that investigated cost - effectiveness of interventions carried out by physical therapists. The methodological quality was assessed with the Cochrane risk of bias assessment for intervention studies as well as with the Quality of Health Economic Analyses Scale.
Data extraction:
We extracted effectiveness and cost data for calculating incremental cost-effectiveness ratios (ICRs) and extracted the original authors' conclusions.
Data synthesis:
The 18 included studies presented low risk of bias and contained 8 comparisons of physical therapy only with usual care only; and 11 comparisons of physical therapy added to usual care with usual care only. Based on ICERs physical therapy only or added to usual care was cost-effective in 9 out of the 19 comparisons and in 10 comparisons according to the original authors' conclusion.
Conclusion:
Physical therapy only or added to usual care implies improved health in almost all studies. The cost-effectiveness of such interventions is demonstrated in half of the studies. This result might have been influenced by the fact that different definitions of the notion of "cost-effectiveness" exist.
... SRs reported only limited and often inconsistent evidence on cost-effectiveness or cost-utility of different rehabilitation interventions, such as conservative treatments for neck pain, 32 spinal manipulation for back or neck pain, 53 and interventions for ankylosing spondylitis. 36 An SR of guideline-endorsed interventions for lower back pain (LBP) reported that ''interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive behavioral therapies were cost-effective in people with sub-acute or chronic LBP.'' ...
Background:
Health related rehabilitation is instrumental in improving functioning and promoting participation by people with disabilities. To make clinical and policy decisions about health-related rehabilitation, resource allocation and cost issues need to be considered.
Objectives:
To provide an overview of systematic reviews (SRs) on economic evaluations of health-related rehabilitation.
Methods:
We searched multiple databases to identify relevant SRs of economic evaluations of health-related rehabilitation. Review quality was assessed by AMSTAR checklist.
Results:
We included 64 SRs, most of which included economic evaluations alongside randomized controlled trials (RCTs). The review quality was low to moderate (AMSTAR score 5-8) in 35, and high (score 9-11) in 29 of the included SRs. The included SRs addressed various health conditions, including spinal or other pain conditions (n = 14), age-related problems (11), stroke (7), musculoskeletal disorders (6), heart diseases (4), pulmonary (3), mental health problems (3), and injury (3). Physiotherapy was the most commonly evaluated rehabilitation intervention in the included SRs (n = 24). Other commonly evaluated interventions included multidisciplinary programmes (14); behavioral, educational or psychological interventions (11); home-based interventions (11); complementary therapy (6); self-management (6); and occupational therapy (4).
Conclusions:
Although the available evidence is often described as limited, inconsistent or inconclusive, some rehabilitation interventions were cost-effective or showed cost-saving in a variety of disability conditions. Available evidence comes predominantly from high income countries, therefore economic evaluations of health-related rehabilitation are urgently required in less resourced settings.
... Manual spinal joint mobilisations and manipulations are widely used treatments in patients with these complaints [7,8]. Although the underlying mechanisms of these treatments are far from understood, spinal joint mobilisations and manipulations are effective as well as cost-effective in patients with non-specific neck and low-back pain although no more effective than other treatment modalities [9][10][11][12][13][14]. ...
Background
Manual spinal joint mobilisations and manipulations are widely used treatments in patients with neck and low-back pain. Inter-examiner reliability of passive intervertebral motion assessment of the cervical and lumbar spine, perceived as important for indicating these interventions, is poor within a univariable approach. The diagnostic process as a whole in daily practice in manual therapy has a multivariable character, however, in which the use and interpretation of passive intervertebral motion assessment depend on earlier results from the diagnostic process. To date, the inter-examiner reliability among manual therapists of a multivariable diagnostic decision-making process in patients with neck or low-back pain is unknown.
Methods
This study will be conducted as a repeated-measures design in which 14 pairs of manual therapists independently examine a consecutive series of a planned total of 165 patients with neck or low-back pain presenting in primary care physiotherapy. Primary outcome measure is therapists’ decision about whether or not manual spinal joint mobilisations or manipulations, or both, are indicated in each patient, alone or as part of a multimodal treatment. Therapists will largely be free to conduct the full diagnostic process based on their formulated examination objectives. For each pair of therapists, 2×2 tables will be constructed and reliability for the dichotomous decision will be expressed using Cohen’s kappa. In addition, observed agreement, prevalence of positive decisions, prevalence index, bias index, and specific agreement in positive and negative decisions will be calculated. Univariable logistic regression analysis of concordant decisions will be performed to explore which demographic, professional, or clinical factors contributed to reliability.
Discussion
This study will provide an estimate of the inter-examiner reliability among manual therapists of indicating spinal joint mobilisations or manipulations in patients with neck or low-back pain based on a multivariable diagnostic reasoning and decision-making process, as opposed to reliability of individual tests. As such, it is proposed as an initial step toward the development of an alternative approach to current classification systems and prediction rules for identifying those patients with spinal disorders that may show a better response to manual therapy which can be incorporated in randomised clinical trials. Potential methodological limitations of this study are discussed.
... Consensus on the clinical effectiveness of SM is far from being defined. Michaleff, Lin, Maher, & van Tulder (2012) suggested SM to be a cost-effective treatment to manage spinal pain and recent work suggested beneficial effects larger than conventional antiinflammatory therapy (Von Heymann, Schloemer, Timm, & Muehlbauer, 2012). This despite systematic reviews suggesting some beneficial effects (Goertz, Pohlman, Vining, Brantingham, & Long, 2012) of SM on pain. ...
Objectives
To analyse the acute effects of spinal manipulation on neuromuscular function in asymptomatic individuals.
Design
Randomised controlled, cross-over trial.
Settings
Spinal manipulation (SM) is used as therapeutic modality for various neuromuscular disorders and also in sport with asymptomatic individuals to improve range of motion and/or facilitate motor control. Experimental evidence of its effectiveness is lacking.
Participants
27 asymptomatic participants (15 males and 12 females) [age (mean ± standard deviation) 24 ± 3 years] were exposed to three separate treatments in random order: 1) Spinal Manipulation of the lumbar spine (MAN); 2) Stretching of the Lumbar spine (STR); 3) sham manipulation (SHA).
Main outcome measures
Before (PRE), after (POST) and 15 minutes after (15_MIN) each treatment, the participants were asked to perform three tasks always in the same order: 1) force fluctuation task; 2) Modified Sörensen’s test; 3) sit and reach. Surface EMG was recorded from Gastrocnemius medialis and Erector Spinae muscles using linear arrays during task 1 and 2.
Results
MAN was not shown to determine improvements superior to other treatments in the control of force output and sEMG parameters.
Conclusions
Studies with larger populations are needed in order to ascertain the effectiveness of SM on neuromuscular function.
... B. weniger Verordnung von Physiotherapie oder weniger Folgekonsultationen belegt werden. In einem Review, der keine deutschen Studien enthält, wurde die Chirotherapie bei Rückenschmerzen als kosteneffektiv bewertet (Michaleff 2012). ...
Rückenschmerzen sind ein häufiger Konsultationsanlass bei Hausärzten, Orthopäden und anderen Fachärzten. Von Über- und Unterversorgung ist weltweit berichtet worden. Ziel dieses Buchkapitels ist es, Längsschnittdaten zu Inanspruchnahme von Gesundheitsleistungen bei Rückenschmerzen von 2006 bis 2010 und Querschnittsdaten für 2010 zur Verfügung zu stellen. Die Datenbasis sind die Abrechnungsdaten der AOK. Ein hoher Anteil (26,4%) der gesetzlich Versicherten hat innerhalb des Jahres 2010 wenigstens einmal wegen Rückenschmerzen ärztliche Hilfe in Anspruch genommen. Dabei wird ein kontinuierlicher Anstieg von Bildgebung, invasiven Injektionstherapien und Opioiden beobachtet.
Vor dem Hintergrund einer überwiegend unsicheren Evidenzlage bei den hier ausgewählten Verfahren sind Zunahmen eher kritisch zu bewerten. Die beobachtete Entwicklung steht an vielen Stellen nicht im Einklang mit den Empfehlungen der Nationalen Versorgungsleitlinie Rückenschmerzen. Das reflektiert einen Konflikt zwischen der individuellen Betreuung von Patienten, persönlichen Überzeugungen und ökonomischen Interessen der Ärzte und der Public Health Perspektive eines möglichst rationalen und effektiven Einsatzes der Ressourcen. Ein kontinuierliches Monitoring der Inanspruchnahme von Leistungen für Rückenschmerzen und der damit verbundenen Kosten sowie des Nutzen ist notwendig für die gesundheitspolitische Steuerung. Weitere Studien zum Nutzen einzelner Verfahren sind erforderlich.
Background
Lumbar spinal manipulative therapy (SMT) is a common intervention used to treat low back pain (LBP); however, the exact neurophysiological mechanisms of SMT reducing pain measured through pain pressure threshold (PPT) have not been fully explored beyond an immediate timeframe (e.g., immediately or five-minutes following) referencing a control group. Therefore, the purpose of this study was to investigate the neurophysiological effects of lumbar SMT compared to deactivated ultrasound using PPT immediately following and 30-minutes following SMT.
Methods
A longitudinal, randomized controlled trial design was conducted between September to October 2023. Fifty-five participants were randomized into a control group of deactivated ultrasound ( n = 29) or treatment group of right sidelying lumbar SMT ( n = 26). PPT, recorded at the right posterior superior iliac spine (PSIS), was documented for each participant in each group prior to intervention, immediately, and 30-minutes after. A repeated measures ANOVA, with a post-hoc Bonferroni adjustment, was used to assess within-group and between-group differences in PPT. The significance level was set at a < 0.05 a priori.
Results
Statistically significant differences were found between the deactivated ultrasound and lumbar SMT groups immediately ( p = .05) and 30-minutes ( p = .02) following intervention. A significant difference in the lumbar SMT group was identified from baseline to immediately following ( p < .001) and 30-minutes following ( p < .001), but no differences between immediately following and 30-minutes following intervention ( p = .10). The deactivated ultrasound group demonstrated a difference between baseline and immediately after intervention with a reduced PPT (p = .003), but no significant difference was found from baseline to 30-minutes ( p = .11) or immediately after intervention to 30-minutes ( p = 1.0).
Conclusion
A right sidelying lumbar manipulation increased PPT at the right PSIS immediately after that lasted to 30-minutes when compared to a deactivated ultrasound control group. Future studies should further explore beyond the immediate and short-term neurophysiological effects of lumbar SMT to validate these findings.
Trial Registration
This study was retrospectively registered on 4 December 2023 in ClinicalTrials (database registration number NCT06156605).
In Korea, Chuna was officially included in the Korean national health insurance (NHI) system in 2019. In the US, osteopathic manipulative treatment has been part of conventional healthcare since 1966. Since there are few countries that provide manual therapy in mainstream healthcare, academic exchange between experts in Chuna therapy on an international stage is essential; to date there has been a conference in 2018 and 2019, both of which were held in Korea. This review presents a summary of these conference proceedings. There were 13 keynote speakers including doctors of Korean medicine, osteopathic physicians, and policymakers. In the 1st conference, seven speakers shared their knowledge on the history of Chuna, policies, and the current body of evidence for using Chuna and osteopathic manipulative treatment of various conditions. In the following year, six speakers also included novel Chuna techniques, similarities and differences, and explored the possibilities for collaborations moving forward. Previous to these two international conferences, the last national conference was held in Korea in 2008. The timing of these two international conferences has proved significant due to the inclusion of Chuna in Korean national health insurance in 2019, and helped to provide guidance in expanding the scope of manual medicine.
Introducción.
Los trastornos músculo esqueléticos (TME), son desórdenes que afectan los nervios, tendones, músculos y estructuras de soporte como los discos intervertebrales que resulta de un esfuerzo más allá de lo que son capaces de soportar. Por eso la finalidad es determinar los factores asociados a trastornos músculo esqueléticos en columna lumbar, diagnosticados por resonancia magnética, en operarios de construcción civil de un Programa de Vigilancia Ocupacional de una empresa de Lima. Materiales y Métodos. Investigación descriptiva, transversal, retrospectiva. Se revisaron 385 resonancias magnéticas de columna lumbar, de trabajadores operarios de construcción civil de un programa de vigilancia ocupacional realizado el 2014 y 2015. Se aplicó un análisis estadístico comparando características entre los grupos de pacientes con y sin trastorno músculo esquelético. El muestreo fue no probabilístico, por conveniencia, incluyendo el total de 385 casos, siendo el universo igual a la muestra. Se usaron el programa estadístico STATA 16, las medidas de tendencia central y se efectuó el análisis bivariado de Chi cuadrado y T de Student, considerando un valor de significancia de p < 0,001. Resultados. El 41 % no presentó trastornos músculo esqueléticos. El 49,6 % presentó compresión del foramen neural, el 42.9 % protrusión discal, el 18,2 % prominencias discales, el 16,1 %, estrechamiento de los recesos laterales y el 13,2 % rectificación de la lordosis lumbar. El 58,4 % presenta algún trastorno y la presencia de dolor se reporta en el 1.3 % de los pacientes. Se halló que el promedio de edad es mayor en el grupo con el trastorno, así como el tiempo laboral y el estado civil casado. Discusión. Los factores asociados fueron la edad, el tiempo laboral y el estado civil casado.
EFFECTİVENESS OF VİDEO BASED HOME EXERCİSE PROGRAM ON
PAİN, KİNESİOPHOBİA, QUALİTY OF LİFE, PHYSİCAL ACTİVİTY AND
DEPRESSİON LEVEL İN NECK PAİN ASSOCİATED WİTH CERVİCAL
DİSC HERNİATİON
ABSTRACT
Azboy Y. Effectiveness of Video Based Home Exercise Program on Pain, Kinesiophobia, Quality of Life, Physical Activity and Depression Level in Neck Pain Associated with Cervical Disc Herniation. Istanbul Aydın University Graduate Education Institute, Physiotherapy and Rehabilitation Department. Master Thesis. Istanbul. 2020
The purpose of our study; to determine the effectiveness of video based and brochure home exercise program on pain, kinesiophobia, quality of life, physical activity and depression level in neck pain associated with cervical disc hernia. For this purpose, 82 patients with neck pain due to cervical disc hernia were included
in the study. Brochure home exercise was given to Group 1 and video home exercise program was given to Group 2. Superficial heat, Transcutaneous Electrical Nerve Stimulation (TENS), and therapeutic ultrasound were applied to both groups for 20 sessions.
Patients were evaluated for pain severity, range of motion, muscle strength, quality of life, level of kinesiophobia, level of depression, neck pain and disability and physical activity level before and at the end of the 8th week.Pain severity with visual analog scale, range of motion with goniometer, muscle strength with manual muscle test, quality of life-related health-related quality of life scale, kinesiophobia level tampa kinesiophobia scale, depression level beck depression, neck pain and disability The disability scale and physical activity level
were assessed by the short form of the international physical fitness scale.
“Paired Sample T Test” was used to evaluate the differences in the group. Positive changes were observed in pain severity, range of motion range, quality of life, level of kinesiophobia, level of depression, neck pain and disability and physical activity levels in Group 1 and Group 2. When the difference between groups was evaluated with “Indepented Sample T Test”, a significant difference was observed in all parameters except muscle strength (p <0.05). As a result of this study, it was found that the exercises given to the scapula and its
surroundings together with the cervical region, in the treatment of neck pain due to cervical disc hernia, are more functional in terms of function, and these exercises will be learned more easily by patients.
Keywords: Cervical disc herniation, neck pain, exercise, kinesiophobia, depression level, quality of life, electrotherapy
Background/purpose
A spinal cord injury without radiographic abnormality (SCIWORA) is a relatively uncommon event that occurs in children following cervical trauma primarily due to sports-related injuries and abuse.
Case description
This case report describes an 11-year-old wrestler that developed signs and symptoms consistent with a SCIWORA following neck trauma during competition. Despite all diagnostic tests being inconclusive, the patient demonstrated increased cervical, thoracic, and lumbar paraspinal tone along with pain, loss of sensation, loss of mobility, and weakness of the lower extremities. As a result, the patient was confined to a wheelchair and required maximum assistance to transfer and ambulate with a walker. The patient was referred to physical therapy nine days after the traumatic event, where he received interferential current with moist heat, myofascial release of paraspinal muscles, functional exercise, gait training, and spinal manipulative therapy targeting the cervical, thoracic, and lumbar vertebrae.
Outcome
After 13 physical therapy treatments over 5-weeks, the patient was able to ambulate independently and perform all activities of daily living without pain or limitation. The following case report outlines this patient's successful journey toward recovery.
Conclusion
This case report suggests that spinal manipulative therapy may be a safe and effective component of a multi-modal treatment strategy for patients with signs and symptoms consistent with SCIWORA. Moreover, spinal manipulative therapy may be considered a useful treatment in some pediatric patients. However, this report describes a single patient, and further research is required on the use of spinal manipulation in this patient population.
Er zijn aanwijzingen dat spinale manipulatie effectief is bij de behandeling van lagerugklachten. Chiropractoren zijn bij uitstek in staat om deze behandeling te geven en daarmee de zorglast van huisartsenpraktijken te verlichten. Chiropractie zou daarom moeten worden opgenomen in de reguliere gezondheidszorg, zoals dat ook in andere landen het geval is.
Voor huisartsen kan het nog steeds lastig zijn om de juiste aanpak te bepalen bij individuele patiënten met aspecifieke lagerugpijn. Wij denken dat manuele therapie bij een deel van de patiënten een rol van betekenis kan spelen. Maar dan wel altijd samen met op de individuele patiënt toegespitste adviezen en oefentherapie. Daarin verschillen manueel therapeuten van chiropractoren, die ook manipulaties uitvoeren, maar niet uitgaan van een biopsychosociale benadering.
Background
The presence of spinal pain in young people has been established as a risk factor for spinal pain later in life. Recent clinical practice guidelines recommend spinal manipulation (SM), soft tissue therapy, acupuncture, and other modalities that are common treatments provided by chiropractors, as interventions for spine pain. Less is known specifically on the response to chiropractic management in young people with spinal pain. The purpose of this manuscript was to describe the impact, through pain measures, of a pragmatic course of chiropractic management in young people's spinal pain at a publicly funded healthcare facility for a low-income population.
Methods
The study utilized a retrospective analysis of prospectively collected quality assurance data attained from the Mount Carmel Clinic (MCC) chiropractic program database. Formal permission to conduct the analysis of the database was acquired from the officer of records at the MCC. The University of Manitoba's Health Research Ethics Board approved all procedures.
Results
Young people (defined as 10–24 years of age) demonstrated statistically and clinically significant improvement on the numeric rating scale (NRS) in all four spinal regions following chiropractic management.
Conclusion
The findings of the present study provide evidence that a pragmatic course of chiropractic care, including SM, mobilization, soft tissue therapy, acupuncture, and other modalities within the chiropractic scope of practice are a viable conservative pain management treatment option for young people.
Introduction: Innovative drugs have been approved in ophthalmology. Thus, the number and importance of economic evaluation studies of ophthalmic drugs have been growing. This study aims to assess the methodological quality of pharmacoeconomic studies of ophthalmic drugs.
Areas covered: A systematic search was conducted in Pubmed/Embase until November 2018 to identify full pharmacoeconomic studies evaluating ophthalmic drugs. The quality of studies was evaluated using the British Medical Journal (BMJ) checklist. Quality indicators were evaluated by the Fisher’s exact test. Ninety-five studies were included, 50 (52.6%) cost-utility analysis, 28 (29.5%) cost-effectiveness and 17 (17.9%) cost-effectiveness/cost-utility. All studies presented, at least, three methodological limitations. Cost-utility studies, studies conducted from a health system perspective, with time horizons longer than one-year and that rely on observational or observational and experimental data simultaneously are associated with higher quality. Only 8 (8.4%) studies considered two eyes in the economic analysis and only 13 (13.7%) considered the natural history of the disease when extrapolating results for long-term analysis.
Expert opinion: The majority of the pharmacoeconomic studies were assessed as having good methodological quality, however the methodological quality scores were sensitive to several indicators. Therefore, improving the quality of studies would enhance their usefulness in the decision-making processes.
This commissioned review paper offers a summary of our current understanding of nonmalignant spinal pain, particularly persistent pain. Spinal pain can be a complex problem, requiring management that addresses both the physical and psychosocial components of the pain experience. We propose a model of care that includes the necessary components of care services that would address the multidimensional nature of spinal pain. Emerging care services that tailor care to the individual person with pain seems to achieve better outcomes and greater consumer satisfaction with care, while most likely containing costs. However, we recommend that any model of care and care framework should be developed on the basis of a multidisciplinary approach to care, with the scaffold being the principles of evidence-based practice. Importantly, we propose that any care services recommended in new models or frameworks be matched with available resources and services – this matching we promote as the fourth principle of evidence-based practice. Ongoing research will be necessary to offer insight into clinical outcomes of complex interventions, while practice-based research would uncover consumer needs and workforce capacity. This kind of research data is essential to inform health care policy and practice.
Manual therapy (MT) is a passive, skilled movement applied by clinicians that directly or indirectly targets a variety of anatomical structures or systems, which is utilized with the intent to create beneficial changes in some aspect of the patient pain experience. Collectively, the process of MT is grounded on clinical reasoning to enhance patient management for musculoskeletal pain by influencing factors from a multidimensional perspective that have potential to positively impact clinical outcomes. The influence of biomechanical, neurophysiological, psychological and nonspecific patient factors as treatment mediators and/or moderators provides additional information related to the process and potential mechanisms by which MT may be effective. As healthcare delivery advances toward personalized approaches there is a crucial need to advance our understanding of the underlying mechanisms associated with MT effectiveness.
Although several studies have compared patient outcomes by provider specialty in the treatment of back and joint pain, little is known about the cost-effectiveness of improving patient outcomes across specialties. This study uses a large-scale, nationally representative database to evaluate the cost-effectiveness of being treated by specific provider specialists for back and joint pain in the United States.
The 2002-2012 Medical Expenditure Panel Surveys were used to examine patients diagnosed with back and/or joint problems seeking treatment from doctors (internal medicine, family/general, osteopathic medicine, orthopaedics, rheumatology, neurology) or other providers (chiropractor, physical therapist, acupuncturist, massage therapist). A total of 16 546 respondents aged 18 to 85 and clinically diagnosed with back/joint pain were examined. Self-reported measures of physical and mental health and general quality of life (measured by the EuroQol-5D) were compared with average total costs of treatment across medical providers.
Total annual treatment costs per person ranged from 1205 for rheumatologists. Cost-effectiveness analysis suggests that osteopathic, family/general, internal medicine doctors and chiropractors and massage therapists were more cost-effective than other specialties in improving physical function to back pain patients. For mental health measures, family/general and orthopaedic doctors and physical therapists were more cost-effective compared with other specialties. Similar to results on physical function, family/general, osteopathic and internal medicine doctors dominated other specialties. However, only massage therapy was cost-effective among non-doctor providers in improving quality of life measures.
Patients seeking care for back and joint-related health problems face a wide range of treatments, costs and outcomes depending on which specialist provider they see. This study provides important insight on the relationship between health care costs and patients' perceived physical and mental health status from receiving treatment for diagnosed back/joint problems.
© 2015 John Wiley & Sons, Ltd.
There appears to be very little in the research literature on the safety of thrust joint manipulation (TJM) when applied to the thoracic spine.
To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AE) after receiving TJM to their thoracic spine.
Case reports published in peer reviewed journals were searched in Medline (using Ovid Technologies, Inc.), Science Direct, Web of Science, PEDro (Physiotherapy Evidence Database), Index of Chiropractic literature, AMED (Allied and Alternative Medicine Database), PubMed and the Cumulative Index to Nursing and Allied Health (CINHAL) from January 1950 to February 2015.
Case reports were included if they: (1) were peer-reviewed; (2) were published between 1950 and 2015; (3) provided case reports or case series; and (4) had TJM as an intervention. Articles were excluded if: (1) the AE occurred without TJM (e.g. spontaneous); (2) the article was a systematic or literature review; or (3) it was written in a language other than English or Spanish.
Data extracted from each case report included: gender; age; who performed the TJM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the TJM; as well as type of severe AE that resulted.
Ten cases, reported in 7 case reports, were reviewed. Cases involved females (8) more than males (2), with mean age being 43.5 years (SD=18.73, Range = 17 -71). The most frequent AE reported was injury (mechanical or vascular) to the spinal cord (7/10), with pneumothorax and hematothorax (2/10) and CSF leak secondary to dural sleeve injury (1/10).
There were only a small number of case reports published in the literature and there may have been discrepancies between what was reported and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the TJM, published the cases.
Serious AE do occur in the thoracic spine, most commonly, trauma to the spinal cord, followed by pneumothorax. This suggests that excessive peak forces may have been applied to thoracic spine, and it should serve as a cautionary note for clinicians to decrease these peak forces.
Objective To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. Design Economic evaluation alongside a randomised controlled trial. Setting Primary care. Participants 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n = 60, spinal mobilisation), physiotherapy (n = 59, mainly exercise), or general practitioner care (n = 64, counselling, education, and drugs). Main outcome measures Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between. groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. Results The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (C447; pound273; $402) were around one third of the costs of physiotherapy (C1297) and general practitioner care (C1379). These differences were significant: P < 0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P = 0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. Conclusions Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
Objective To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain. Design Economic evaluation alongside a randomised controlled trial. Setting Primary care. Participants 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs). Main outcome measures Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques. Results The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (€447; £273; $402) were around one third of the costs of physiotherapy (€1297) and general practitioner care (€1379). These differences were significant: P < 0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care. Conclusions Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
Various conservative interventions have been used for the treatment of non-specific neck pain. The aim of this systematic review was to investigate the cost-effectiveness of conservative treatments for non-specific neck pain.
Clinical and economic electronic databases, reference lists and authors' databases were searched up to 13 January 2011. Two reviewers independently selected studies for inclusion, performed the risk of bias assessment and data extraction.
A total of five economic evaluations met the inclusion criteria. All studies were conducted alongside randomised controlled trials and included a cost-utility analysis, and four studies also conducted a cost-effectiveness analysis. Most often, the economic evaluation was conducted from a societal or a health-care perspective. One study found that manual therapy was dominant over physiotherapy and general practitioner care, whilst behavioural graded activity was not cost-effective compared to manual therapy. The combination of advice and exercise with manual therapy was not cost-effective compared to advice and exercise only. One study found that acupuncture was cost-effective compared to a delayed acupuncture intervention, and another study found no differences on cost-effectiveness between a brief physiotherapy intervention compared to usual physiotherapy. Pooling of the data was not possible as heterogeneity existed between the studies on participants, interventions, controls, outcomes, follow-up duration and context related socio-political differences.
At present, the limited number of studies and the heterogeneity between studies warrant no definite conclusions on the cost-effectiveness of conservative treatments for non-specific neck pain.
An economic evaluation alongside a randomized controlled trial comparing behavioral graded activity (BGA) with manual therapy (MT).
To evaluate the cost-effectiveness of BGA in comparison with MT for patients with subacute neck pain from a societal perspective.
Neck pain is common and poses an important socioeconomic burden to society. Data on the cost-effectiveness of treatments for neck pain are scarce.
A randomized clinical trial was conducted, involving 146 patients with subacute nonspecific neck pain. The BGA program can be described as a time-contingent increase in activities from baseline toward predetermined goals. MT consists of specific spinal mobilization techniques and exercises. Clinical outcomes included recovery, pain, disability, and quality-adjusted life-years (QALYs). Costs were measured from a societal perspective using cost diaries. The follow-up period was 52 weeks. Multiple imputation was used for missing cost and effect data. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios was estimated using bootstrapping. Cost-effectiveness planes and cost-effectiveness acceptability (CEA) curves were estimated.
BGA had no significant effect on recovery or QALYs gained in comparison with MT but pain and disability did improve significantly in the BGA group in comparison with the MT group. Total societal costs in the BGA group were nonsignificantly higher than in the MT group. Cost-effectiveness analyses showed that BGA is not cost-effective in comparison with MT for recovery and QALYs gained. Substantial investments are needed to reach a 0.95 probability that BGA is cost-effective in comparison with MT for pain and disability.
On the basis of the data presented, we consider BGA not cost-effective in comparison with MT.
Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.
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.
To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain.
Economic evaluation alongside a randomised controlled trial.
Primary care.
183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs).
Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques.
The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). These differences were significant: P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care.
Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
Descriptive method guidelines.
To help reviewers design, conduct, and report reviews of trials in the field of back and neck pain.
In 1997, the Cochrane Collaboration Back Review Group published method guidelines for systematic reviews. Since its publication, new methodologic evidence emerged and more experience was acquired in conducting reviews.
All reviews and protocols of the Back Review Group were assessed for compliance with the 1997 method guidelines. Also, the most recent version of the Cochrane Handbook (4.1) was checked for new recommendations. In addition, some important topics that were not addressed in the 1997 method guidelines were included (e.g., methods for qualitative analysis, reporting of conclusions, and discussion of clinical relevance of the results). In May 2002, preliminary results were presented and discussed in a workshop. In two rounds, a list of all possible recommendations and the final draft were circulated for comments among the editors of the Back Review Group.
The recommendations are divided in five categories: literature search, inclusion criteria, methodologic quality assessment, data extraction, and data analysis. Each recommendation is classified in minimum criteria and further guidance. Additional recommendations are included regarding assessment of clinical relevance, and reporting of results and conclusions.
Systematic reviews need to be conducted as carefully as the trials they report and, to achieve full impact, systematic reviews need to meet high methodologic standards.
Musculoskeletal conditions are a major burden on individuals, health systems, and social care systems, with indirect costs being predominant. This burden has been recognized by the United Nations and WHO, by endorsing the Bone and Joint Decade 2000-2010. This paper describes the burden of four major musculoskeletal conditions: osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged > 60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020. Joint replacement surgery, where available, provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually affects multiple joints. It affects 0.3-1.0% of the general population and is more prevalent among women and in developed countries. Persistent inflammation leads to joint destruction, but the disease can be controlled with drugs. The incidence may be on the decline, but the increase in the number of older people in some regions makes it difficult to estimate future prevalence. Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4-33% of the population at any given point. Cultural factors greatly influence the prevalence and prognosis of low back pain.
Spinal pain is common and costly to health services and society. Management guidelines have encouraged primary care referral for spinal manipulation, but the evidence base is weak. More economic evaluations alongside pragmatic trials have been recommended.
Our aim was to assess the cost-utility of a practice-based osteopathy clinic for subacute spinal pain.
A cost-utility analysis was performed alongside a pragmatic single-centre randomized controlled trial in a primary care osteopathy clinic accepting referrals from 14 neighbouring practices in North West Wales. Patients with back pain of 2-12 weeks duration were randomly allocated to treatment with osteopathy plus usual GP care or usual GP care alone. Costs were measured from a National Health Service (NHS) perspective. All primary and secondary health care interventions recorded in GP notes were collected for the study period. We calculated quality adjusted life year (QALY) gains based on EQ-5D responses from patients in the trial, and then cost per QALY ratios. Confidence intervals (CIs) were estimated using non-parametric bootstrapping.
Osteopathy plus usual GP care was more effective but resulted in more health care costs than usual GP care alone. The point estimate of the incremental cost per QALY ratio was 3560 pounds (80% CI 542 pounds-77,100 pounds). Sensitivity analysis examining spine-related costs alone and total costs excluding outliers resulted in lower cost per QALY ratios.
A primary care osteopathy clinic may be a cost-effective addition to usual GP care, but this conclusion was subject to considerable random error. Rigorous multi-centre studies are needed to assess the generalizability of this approach.
A prospective, randomized controlled trial.
To examine long-term effects and costs of combined manipulative treatment, stabilizing exercises, and physician consultation compared with physician consultation alone for chronic low back pain (cLBP).
An obvious gap exists in knowledge concerning long-term efficacy and cost-effectiveness of manipulative treatment methods.
Of 204 patients with cLBP whose Oswestry Disability Index (ODI) was at least 16%, 102 were randomized into a combined manipulative treatment, exercise, and physician consultation group (i.e., a combination group), and 102 to a consultation alone group. All patients were clinically examined, informed about their back pain, and encouraged to stay active and exercise according to specific instructions based on clinical evaluation. Treatment included 4 sessions of manual therapy and stabilizing exercises aimed at correcting the lumbopelvic rhythm. Questionnaires inquired about pain (visual analog scale (VAS)), disability (ODI), health-related quality of life (15D Quality of Life Instrument), satisfaction with care, and costs.
Significant improvement occurred in both groups on every self-rated outcome measurement. Within 2 years, the combination group showed only a slightly more significant reduction in VAS (P = 0.01, analysis of variance) but clearly higher patient satisfaction (P = 0.001, Pearson chi2) as compared to the consultation group. Incremental analysis showed that for combined group compared to consultation group, a one-point change in VAS scale cost $512.
Physician consultation alone was more cost-effective for both health care use and work absenteeism, and led to equal improvement in disability and health-related quality of life. It seems obvious that encouraging information and advice are major elements for the treatment of patients with cLBP.
The aim of the Consensus on Health Economic Criteria (CHEC) project is to develop a criteria list for assessment of the methodological quality of economic evaluations in systematic reviews. The criteria list resulting from this CHEC project should be regarded as a minimum standard.
The criteria list has been developed using a Delphi method. Three Delphi rounds were needed to reach consensus. Twenty-three international experts participated in the Delphi panel.
The Delphi panel achieved consensus over a generic core set of items for the quality assessment of economic evaluations. Each item of the CHEC-list was formulated as a question that can be answered by yes or no. To standardize the interpretation of the list and facilitate its use, the project team also provided an operationalization of the criteria list items.
There was consensus among a group of international experts regarding a core set of items that can be used to assess the quality of economic evaluations in systematic reviews. Using this checklist will make future systematic reviews of economic evaluations more transparent, informative, and comparable. Consequently, researchers and policy-makers might use these systematic reviews more easily. The CHEC-list can be downloaded freely from http://www.beoz.unimaas.nl/chec/.
To assess the cost-effectiveness of brief physiotherapy intervention versus usual physiotherapy management in patients with neck pain of musculoskeletal origin in the community setting.
A cost-effectiveness analysis was conducted alongside a multicenter pragmatic randomized controlled clinical trial. Individuals 18 years of age and older with neck pain of more than 2 weeks were recruited from physiotherapy departments with referrals from general practitioners (GPs) in the East Yorkshire and North Lincolnshire regions in the United Kingdom. A total of 139 patients were allocated to the brief intervention, and 129 to the usual physiotherapy. Resource use data were prospectively collected on the number of physiotherapy sessions, hospital stay, specialist, and GP visits. Quality-adjusted life years (QALYs) were estimated using EQ-5D data collected at baseline, 3 and 12 months from the start of the treatment. The economic evaluation was conducted from the U.K. National Health System perspective.
On average, brief intervention produced lower costs (pounds--68; 95 percent confidence interval [CI], pounds--103 to pounds--35) and marginally lower QALYs (-0.001; 95 percent CI, -0.030 to 0.028) compared with usual physiotherapy, resulting in an incremental cost per QALY of pounds 68,000 for usual physiotherapy. These results are sensitive to patients' treatment preferences.
Usual physiotherapy may not be good value for money for the average individual in this trial but could be a cost-effective strategy for those who are indifferent toward which treatment they receive.
How high should it be?
Cost-effectiveness and cost-utility analyses were conducted to compare advice and exercise plus manual therapy (MT) and advice and exercise plus pulsed shortwave diathermy (PSWD) with advice and exercise alone (A&E) in the treatment of non-specific neck disorders by experienced physiotherapists.
Between July 2000 and June 2002, 350 participants with neck disorders from 15 physiotherapy departments were randomized to: A&E (n = 115); MT (n = 114) and PSWD (n = 121). Outcome and resource-use data were collected using physiotherapist case report forms and participant self-complete questionnaires. Outcome measures were the Northwick Park Neck Pain Questionnaire (NPQ) and EuroQoL EQ-5D [used to derive quality-adjusted-life-year (QALY) utility scores]. Two economic viewpoints were considered (health care and societal). Cost-effectiveness acceptability curves were used to assess the probabilities of the interventions being cost-effective at different willingness-to-pay threshold values.
Mean improvement in NPQ at 6 months was 11.5 in the A&E group, 10.2 in the MT group and 10.3 in the PSWD group; mean QALY scores were 0.362, 0.342 and 0.360, respectively. Mean health care costs were pound sterling105, pound sterling119 and pound sterling123 in the A&E, MT and PSWD groups, respectively. Mean societal costs were pound sterling373, pound sterling303 and pound sterling 338 in each group, respectively. Depending on the viewpoint and the outcome measure, A&E or MT were most likely to be the cost-effective interventions. PSWD was consistently the least cost-effective intervention.
The cost-effective intervention is likely to be A&E or MT, depending on the economic perspective and preferred outcome, but not PSWD.
Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.
We aim to establish whether it is ever appropriate to conduct cost-minimisation analysis (CMA) rather than cost-effectiveness analysis.We perform a literature review to examine how the use of CMA has changed since Briggs & O'Brien announced its death in 2001. Examples of simulated and trial data are presented: firstly to illustrate the advantages and disadvantages of CMA in the context of non-inferiority trials and those finding no significant difference in efficacy and secondly to assess whether CMA gives biased results.We show that CMA is still used and will bias measures of uncertainty, causing overestimation or underestimation of the value of information and the probability that treatment is cost-effective. Although bias will be negligible for non-inferiority studies comparing treatments that differ enormously in cost, it is generally necessary to collect and analyse data on costs and efficacy (including utilities) to assess this bias. Cost-effectiveness analysis (including evaluation of the joint distribution of costs and benefits) is almost always required to avoid biased estimation of uncertainty. The remit of CMA in trial-based economic evaluation is therefore even narrower than previously thought, suggesting that CMA is not only dead but should also be buried. Copyright © 2011 John Wiley & Sons, Ltd.
Many therapies exist for the treatment of low-back pain including spinal manipulative therapy (SMT), which is a worldwide, extensively practiced intervention.
To assess the effects of SMT for chronic low-back pain.
An updated search was conducted by an experienced librarian to June 2009 for randomised controlled trials (RCTs) in CENTRAL (The Cochrane Library 2009, issue 2), MEDLINE, EMBASE, CINAHL, PEDro, and the Index to Chiropractic Literature.
RCTs which examined the effectiveness of spinal manipulation or mobilisation in adults with chronic low-back pain were included. No restrictions were placed on the setting or type of pain; studies which exclusively examined sciatica were excluded. The primary outcomes were pain, functional status and perceived recovery. Secondary outcomes were return-to-work and quality of life.
Two review authors independently conducted the study selection, risk of bias assessment and data extraction. GRADE was used to assess the quality of the evidence. Sensitivity analyses and investigation of heterogeneity were performed, where possible, for the meta-analyses.
We included 26 RCTs (total participants = 6070), nine of which had a low risk of bias. Approximately two-thirds of the included studies (N = 18) were not evaluated in the previous review. In general, there is high quality evidence that SMT has a small, statistically significant but not clinically relevant, short-term effect on pain relief (MD: -4.16, 95% CI -6.97 to -1.36) and functional status (SMD: -0.22, 95% CI -0.36 to -0.07) compared to other interventions. Sensitivity analyses confirmed the robustness of these findings. There is varying quality of evidence (ranging from low to high) that SMT has a statistically significant short-term effect on pain relief and functional status when added to another intervention. There is very low quality evidence that SMT is not statistically significantly more effective than inert interventions or sham SMT for short-term pain relief or functional status. Data were particularly sparse for recovery, return-to-work, quality of life, and costs of care. No serious complications were observed with SMT.
High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain. Determining cost-effectiveness of care has high priority. Further research is likely to have an important impact on our confidence in the estimate of effect in relation to inert interventions and sham SMT, and data related to recovery.
The aim of this pilot study was to assess post-treatment apparent diffusion coefficient (ADC) changes of diffuse large B-cell lymphoma lesions on respiratory-gated whole-body diffusion-weighted imaging (DWI), with integrated (18)F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (PET/CT) as the reference standard.
A total of 15 patients underwent both whole-body DWI (b = 50, 400, 800 s/mm(2)) and PET/CT before initiation and after 4 cycles of chemotherapy. ADC of residual masses (lymph node and organ lesions) was assessed both visually and quantitatively, including measurement of mean ADC (ADC).(Figure is included in full-text article.)
After chemotherapy, among 85 examined lymph node regions, residual nodes were present in 62 (73%) regions on DWI. Of these 62 regions, 26 had persistent lymph nodes with longest transverse diameter >10 mm, ie, positive based on DWI size criteria. The mean ADC of these 26 regions increased from 0.658 × 10(-3) ± 0.153 mm(2)/s (standard deviation) at baseline to 1.501 × 10(-3) ± 0.307 mm(2)/s (paired t test, P < 0.0001). Only 6 of these 26 regions were considered positive on PET/CT. Combining visual ADC analysis to size criteria reduced the number of false-positive results of DWI from 20 to 2 regions. For organ involvement, ADC values also increased compared with baseline (1.558 × 10(-3) ± 0.424 mm(2)/s vs. 0.675 × 10(-3) ± 0.135 mm(2)/s, respectively; P = 0.0009).
Whole-body DWI with ADC mapping can show a significant increase in ADC values of residual masses persisting after treatment and may help to assess the treatment response in patients with diffuse large B-cell lymphoma.
Manipulation and mobilisation are often used, either alone or combined with other treatment approaches, to treat neck pain.
To assess if manipulation or mobilisation improves pain, function/disability, patient satisfaction, quality of life, and global perceived effect in adults with acute/subacute/chronic neck pain with or without cervicogenic headache or radicular findings.
CENTRAL (The Cochrane Library 2009, issue 3) and MEDLINE, EMBASE, Manual Alternative and Natural Therapy, CINAHL, and Index to Chiropractic Literature were updated to July 2009.
Randomised controlled trials on manipulation or mobilisation.
Two review authors independently selected studies, abstracted data, and assessed risk of bias. Pooled relative risk and standardised mean differences (SMD) were calculated.
We included 27 trials (1522 participants).Cervical Manipulation for subacute/chronic neck pain : Moderate quality evidence suggested manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up. Low quality evidence showed manipulation alone compared to a control may provide short- term relief following one to four sessions (SMD pooled -0.90 (95%CI: -1.78 to -0.02)) and that nine or 12 sessions were superior to three for pain and disability in cervicogenic headache. Optimal technique and dose need to be determined.Thoracic Manipulation for acute/chronic neck pain : Low quality evidence supported thoracic manipulation as an additional therapy for pain reduction (NNT 7; 46.6% treatment advantage) and increased function (NNT 5; 40.6% treatment advantage) in acute pain and favoured a single session of thoracic manipulation for immediate pain reduction compared to placebo for chronic neck pain (NNT 5, 29% treatment advantage).Mobilisation for subacute/chronic neck pain: In addition to the evidence noted above, low quality evidence for subacute and chronic neck pain indicated that 1) a combination of Maitland mobilisation techniques was similar to acupuncture for immediate pain relief and increased function; 2) there was no difference between mobilisation and acupuncture as additional treatments for immediate pain relief and improved function; and 3) neural dynamic mobilisations may produce clinically important reduction of pain immediately post-treatment. Certain mobilisation techniques were superior.
Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function. Optimal techniques and dose are unresolved. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Objective: To estimate the effect of adding exercise classes, spinal manipulation delivered in NHS or private premises, or manipulation followed by exercise to "best care" in general practice for patients consulting with back pain.
Design: Pragmatic randomised trial with factorial design.
Setting: 181 general practices in Medical Research Council General Practice Research Framework; 63 community settings around 14 centres across the United Kingdom.
Participants: 1334 patients consulting their general practices about low back pain.
Main outcome measures: Scores on the Roland Morris disability questionnaire at three and 12 months, adjusted for centre and baseline scores.
Results: All groups improved over time. Exercise improved mean disability questionnaire scores at three months by 1.4 (95% confidence interval 0.6 to 2.1) more than "best care." For manipulation the additional improvement was 1.6 (0.8 to 2.3) at three months and 1.0 (0.2 to 1.8) at 12 months. For manipulation followed by exercise the additional improvement was 1.9 (1.2 to 2.6) at three months and 1.3 (0.5 to 2.1) at 12 months. No significant differences in outcome occurred between manipulation in NHS premises and in private premises. No serious adverse events occurred.
Conclusions: Relative to "best care" in general practice, manipulation followed by exercise achieved a moderate benefit at three months and a small benefit at 12 months; spinal manipulation achieved a small to moderate benefit at three months and a small benefit at 12 months; and exercise achieved a small benefit at three months but not 12 months.
Objective: To assess the cost effectiveness of adding spinal
manipulation, exercise classes, or manipulation followed by exercise
("combined treatment") to "best care in general practice for patients
consulting with low back pain.
Design: Stochastic cost utility analysis alongside pragmatic randomised
trial with factorial design.
Setting: 181 general practices and 63 community settings for physical
treatments around 14 centres across the United Kingdom.
Participants:
1287 (96%) of 1334 trial participants.
Main outcome measures: Healthcare costs, quality adjusted life years
(QALYs), and cost per QALY over 12 months.
Results Over one year, mean treatment costs relative to "best care"
were 1195 ($360; (sic)279; 95% credibility interval pound85 to
pound308) for manipulation, pound140 (pound3 to pound278) for exercise,
and pound125 (pound21 to pound228) for combined treatment. All three
active treatments increased participants' average QALYs compared with
best care alone. Each extra QALY that combined treatment yielded
relative to best care cost pound3800; in economic terms it had an
"incremental cost effectiveness ratio" of pound3800. Manipulation alone
had a ratio of 5:8700 relative to combined treatment If the NHS was
prepared to pay at least pound10 000 for each extra QALY (lower than
previous recommendations in the United Kingdom), manipulation alone
would probably be the best strategy. If manipulation was not available,
exercise would have an incremental cost effectiveness ratio of
pound8300 relative to best care.
Conclusions: Spinal manipulation is a cost effective addition to "best
care" for back pain in general practice. Manipulation alone probably
gives better value for money than manipulation followed by exercise.
