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Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review

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Abstract

Background

Low back pain (LBP) is a major health problem, having a substantial effect on peoples’ quality of life and placing a significant economic burden on healthcare systems and, more broadly, societies. Many interventions to alleviate LBP are available but their cost effectiveness is unclear.

Objectives

To identify, document and appraise studies reporting on the cost effectiveness of non-invasive and non-pharmacological treatment options for LBP.

Methods

Relevant studies were identified through systematic searches in bibliographic databases (EMBASE, MEDLINE, PsycINFO, Cochrane Library, CINAHL and the National Health Service Economic Evaluation Database), ‘similar article’ searches and reference list scanning. Study selection was carried out by three assessors, independently. Study quality was assessed using the Consensus on Health Economic Criteria checklist. Data were extracted using customized extraction forms.

Results

Thirty-three studies were identified. Study interventions were categorised as: (1) combined physical exercise and psychological therapy, (2) physical exercise therapy only, (3) information and education, and (4) manual therapy. Interventions assessed within each category varied in terms of their components and delivery. In general, combined physical and psychological treatments, information and education interventions, and manual therapies appeared to be cost effective when compared with the study-specific comparators. There is inconsistent evidence around the cost effectiveness of physical exercise programmes as a whole, with yoga, but not group exercise, being cost effective.

Conclusions

The identified evidence suggests that combined physical and psychological treatments, medical yoga, information and education programmes, spinal manipulation and acupuncture are likely to be cost-effective options for LBP.

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References

  1. World Health Organisation. The burden of musculoskeletal conditions at the start of the new millennium. World Health Organ Tech Rep Ser. 2003;919:i–x (1–218).

    Google Scholar 

  2. Murray CJ, Vos T, Lozano R, Naghavi M, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2197–223.

    Article  PubMed  Google Scholar 

  3. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163–96.

    Article  PubMed  Google Scholar 

  4. Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain. 2000;84(1):95–103.

    Article  CAS  PubMed  Google Scholar 

  5. Maetzel A, Li L. The economic burden of low back pain: a review of studies published between 1996 and 2001. Best Pract Res Clin Rheumatol. 2002;16(1):23–30.

    Article  PubMed  Google Scholar 

  6. Luo X, Pietrobon R, Sun SX, et al. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine. 2004;29(1):79–86.

    Article  PubMed  Google Scholar 

  7. Asche CV, Kirkness CS, McAdam-Marx C, Fritz JM. The societal costs of low back pain: data published between 2001 and 2007. J Pain Palliat Care Pharmacother. 2007;21(4):25–33.

    PubMed  Google Scholar 

  8. Dagenais S, Caro J, Haldeman S. A systematic review of low back pain cost of illness studies in the United States and internationally. Spine. 2008;8(1):8–20.

    Article  Google Scholar 

  9. Costa LdCM, Koes BW, Pransky G, et al. Primary care research priorities in low back pain: an update. Spine. 2013;38(2):148–56.

    Article  Google Scholar 

  10. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007;147(7):492–504.

    Article  PubMed  Google Scholar 

  11. Cherkin DC, Deyo RA, Wheeler K, Ciol MA. Physician views about treating low back pain: the results of a national survey. Spine. 1995;20(1):1–9.

    Article  CAS  PubMed  Google Scholar 

  12. Bishop A, Foster NE, Thomas E, Hay EM. How does the self-reported clinical management of patients with low back pain relate to the attitudes and beliefs of health care practitioners? A survey of UK general practitioners and physiotherapists. Pain. 2008;135(1–2):187–95.

    Article  PubMed  PubMed Central  Google Scholar 

  13. National Institute for Health and Clinical Excellence. Low back pain: early management of persistent non-specific low back pain. Royal College of General Practitioners. 2009. Available from: https://www.nice.org.uk/guidance/cg88/evidence/full-guideline-243685549. Accessed 14 Jul 2014.

  14. National Institute for Health and Care Excellence. Low back pain and sciatica: management of non-specific low back pain and sciatica. Draft guidelines. 2016. Available from: https://www.nice.org.uk/guidance/GID-CGWAVE0681/documents/html-content. Accessed 25 May 2016.

  15. Drummond MF, Sculpher MJ, Claxton K, et al. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press; 2005.

    Google Scholar 

  16. Evers S, Goossens M, de Vet H, et al. Criteria list for assessment of methodological quality of economic evaluations: Consensus on Health Economic Criteria. Int J Technol Assess Health Care. 2005;21(2):240–5.

    PubMed  Google Scholar 

  17. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. The Cochrane Collaboration; 2011. Available from: http://handbook.cochrane.org/. Accessed 13 Mar 2014.

  18. Loisel P, Lemaire J, Poitras S, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occup Environ Med. 2002;59(12):807–15.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Skouen JS, Grasdal AL, Haldorsen EM, Ursin H. Relative cost-effectiveness of extensive and light multidisciplinary treatment programs versus treatment as usual for patients with chronic low back pain on long-term sick leave: randomized controlled study. Spine. 2002;27(9):901–9 (discussion 9–10).

    Article  PubMed  Google Scholar 

  20. Molde Hagen E, Grasdal A, Eriksen HR. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain: a 3-year follow-up study. Spine. 2003;28(20):2309–15 (discussion 16).

    Article  PubMed  Google Scholar 

  21. Niemisto L, Lahtinen-Suopanki T, Rissanen P, et al. A randomized trial of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain. Spine. 2003;28(19):2185–91.

    Article  PubMed  Google Scholar 

  22. Uk BEAM. Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ. 2004;329(7479):1381.

    Article  Google Scholar 

  23. Williams NH, Edwards RT, Linck P, et al. Cost-utility analysis of osteopathy in primary care: results from a pragmatic randomized controlled trial. Fam Pract. 2004;21(6):643–50.

    Article  PubMed  Google Scholar 

  24. Haas M, Sharma R, Stano M. Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain. J Manip Physiol Ther. 2005;28(8):555–63.

    Article  Google Scholar 

  25. Niemisto L, Rissanen P, Sarna S, et al. Cost-effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up. Spine. 2005;30(10):1109–15.

    Article  PubMed  Google Scholar 

  26. Ratcliffe J, Thomas KJ, MacPherson H, Brazier J. A randomised controlled trial of acupuncture care for persistent low back pain: cost effectiveness analysis. BMJ. 2006;333(7569):626.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Rivero-Arias O, Gray A, Frost H, et al. Cost-utility analysis of physiotherapy treatment compared with physiotherapy advice in low back pain. Spine. 2006;31(12):1381–7.

    Article  PubMed  Google Scholar 

  28. Schweikert B, Jacobi E, Seitz R, et al. Effectiveness and cost-effectiveness of adding a cognitive behavioral treatment to the rehabilitation of chronic low back pain. J Rheumatol. 2006;33(12):2519–26.

    PubMed  Google Scholar 

  29. Strong LL, Von Korff M, Saunders K, Moore JE. Cost-effectiveness of two self-care interventions to reduce disability associated with back pain. Spine. 2006;31(15):1639–45.

    Article  PubMed  Google Scholar 

  30. Witt CM, Jena S, Selim D, et al. Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol. 2006;164(5):487–96.

    Article  PubMed  Google Scholar 

  31. Critchley DJ, Ratcliffe J, Noonan S, et al. Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce chronic low back pain disability: a pragmatic randomized trial with economic evaluation. Spine. 2007;32(14):1474–81.

    Article  PubMed  Google Scholar 

  32. Jellema P, van der Roer N, van der Windt DA, et al. Low back pain in general practice: cost-effectiveness of a minimal psychosocial intervention versus usual care. Eur Spine J. 2007;16(11):1812–21.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Johnson RE, Jones GT, Wiles NJ, et al. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Spine. 2007;32(15):1578–85.

    Article  PubMed  Google Scholar 

  34. Whitehurst DG, Lewis M, Yao GL, et al. A brief pain management program compared with physical therapy for low back pain: results from an economic analysis alongside a randomized clinical trial. Arthritis Rheum. 2007;57(3):466–73.

    Article  CAS  PubMed  Google Scholar 

  35. Herman PM, Szczurko O, Cooley K, Mills EJ. Cost-effectiveness of naturopathic care for chronic low back pain. Altern Ther Health Med. 2008;14(2):32–9.

    PubMed  Google Scholar 

  36. Hollinghurst S, Sharp D, Ballard K, et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain: economic evaluation. BMJ. 2008;337:a2656.

    Article  PubMed  PubMed Central  Google Scholar 

  37. van der Roer N, van Tulder M, van Mechelen W, de Vet H. Economic evaluation of an intensive group training protocol compared with usual care physiotherapy in patients with chronic low back pain. Spine. 2008;33(4):445–51.

    Article  PubMed  Google Scholar 

  38. Smeets RJ, Severens JL, Beelen S, et al. More is not always better: cost-effectiveness analysis of combined, single behavioral and single physical rehabilitation programs for chronic low back pain. Eur J Pain. 2009;13(1):71–81.

    Article  PubMed  Google Scholar 

  39. Henchoz Y, Pinget C, Wasserfallen JB, et al. Cost-utility analysis of a three-month exercise programme vs usual care following multidisciplinary rehabilitation for chronic low back pain. J Rehab Med. 2010;42(9):846–52.

    Article  Google Scholar 

  40. Kim N, Yang B, Lee T, Kwon S. An economic analysis of usual care and acupuncture collaborative treatment on chronic low back pain: a Markov model decision analysis. BMC Complement Altern Med. 2010;10:74.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Lamb SE, Hansen Z, Lall R, et al. Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet. 2010;375(9718):916–23.

    Article  PubMed  Google Scholar 

  42. Rogerson MD, Gatchel RJ, Bierner SM. A cost utility analysis of interdisciplinary early intervention versus treatment as usual for high-risk acute low back pain patients. Pain Pract. 2010;10(5):382–95.

    Article  PubMed  Google Scholar 

  43. Hill JC, Whitehurst DG, Lewis M, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802):1560–71.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Chuang LH, Soares MO, Tilbrook H, et al. A pragmatic multicentered randomized controlled trial of yoga for chronic low back pain: economic evaluation. Spine. 2012;37(18):1593–601.

    Article  PubMed  Google Scholar 

  45. Whitehurst DG, Bryan S, Lewis M, et al. Exploring the cost-utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups. Ann Rheum Dis. 2012;71(11):1796–802.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Jensen C, Nielsen CV, Jensen OK, Petersen KD. Cost-effectiveness and cost-benefit analyses of a multidisciplinary intervention compared with a brief intervention to facilitate return to work in sick-listed patients with low back pain. Spine. 2013;38(13):1059–67.

    Article  PubMed  Google Scholar 

  47. Foster NE, Mullis R, Hill JC, et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann Fam Med. 2014;12(2):102–11.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Aboagye E, Karlsson ML, Hagberg J, Jensen I. Cost-effectiveness of early interventions for non-specific low back pain: a randomized controlled study investigating medical yoga, exercise therapy and self-care advice. J Rehab Med. 2015;47(2):167–73.

    Article  Google Scholar 

  49. Norton G, McDonough CM, Cabral H, et al. Cost-utility of cognitive behavioral therapy for low back pain from the commercial payer perspective. Spine. 2015;40(10):725–33.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Whitehurst DG, Bryan S, Lewis M, et al. Implementing stratified primary care management for low back pain: cost-utility analysis alongside a prospective, population-based, sequential comparison study. Spine. 2015;40(6):405–14.

    Article  PubMed  Google Scholar 

  51. Joore M, Brunenberg D, Nelemans P, et al. The impact of differences in EQ-5D and SF-6D utility scores on the acceptability of cost-utility ratios: results across five trial-based cost-utility studies. Value Health. 2010;13(2):222–9.

    Article  PubMed  Google Scholar 

  52. Marra CA, Marion SA, Guh DP, et al. Not all “quality-adjusted life years” are equal. J Cin Epidemiol. 2007;60(6):616–24.

    Article  CAS  Google Scholar 

  53. Johnston K, Buxton MJ, Jones DR, Fitzpatrick R. Assessing the costs of healthcare technologies in clinical trials. Health Technol Assess. 1999;3(6):1–76.

    CAS  PubMed  Google Scholar 

  54. Ramsey SD, Willke RJ, Glick H, et al. Cost-effectiveness analysis alongside clinical trials II: an ISPOR Good Research Practices Task Force report. Value Health. 2015;18(2):161–72.

    Article  PubMed  Google Scholar 

  55. van Tulder MW, Koes BW, Bouter LM. A cost-of-illness study of back pain in The Netherlands. Pain. 1995;62(2):233–40.

    Article  PubMed  Google Scholar 

  56. Wenig CM, Schmidt CO, Kohlmann T, Schweikert B. Costs of back pain in Germany. Eur J Pain. 2009;13(3):280–6.

    Article  PubMed  Google Scholar 

  57. Al-Janabi H, Flynn T, Coast J. Development of a self-report measure of capability wellbeing for adults: the ICECAP-A. Qual Life Res. 2011;21(1):167–76.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Whitehurst DG, Bryan S. Trial-based clinical and economic analyses: the unhelpful quest for conformity. Trials. 2013;14:421.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Lin CW, Haas M, Maher CG, et al. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Eur Spine J. 2011;20(7):1024–38.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors’ contribution

LA: Contributed to the study conception and design, data collection, data analysis and interpretation, drafting the article and carrying out critical revisions. PK: Contributed to the study conception and design, data collection, data analysis and interpretation, drafting sections of the article and carrying out critical revisions. SQ: Contributed to data collection, data analysis and interpretation, drafting sections of the article and carrying out critical revisions. DW: Contributed to the study conception and design, data collection, data analysis and interpretation, drafting sections of the article and carrying out critical revisions. SD: Contributed to data analysis and interpretation, and carrying out critical revisions. HM: Contributed to the study conception and design, data collection, data analysis and interpretation, drafting sections of the article and carrying out critical revisions. All authors approved the final version of this manuscript.

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Authors and Affiliations

  1. Health Economics Unit, Public Health Building, University of Birmingham, Birmingham, B15 2TT, UK

    Lazaros Andronis, Philip Kinghorn, Suyin Qiao & Hugh McLeod

  2. Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada

    David G. T. Whitehurst

  3. International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada

    David G. T. Whitehurst

  4. Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada

    David G. T. Whitehurst

  5. Gloucestershire Hospitals National Health Service Foundation Trust, Gloucester, UK

    Susie Durrell

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  1. Lazaros Andronis
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  2. Philip Kinghorn
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  4. David G. T. Whitehurst
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Correspondence to Lazaros Andronis.

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No funding has been received for this study.

Conflicts of interest

LA, PK, SQ, DW, SD and HM have no conflicts of interest to declare.

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Appendix

Appendix

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Table 2 Characteristics of included studies
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Andronis, L., Kinghorn, P., Qiao, S. et al. Cost-Effectiveness of Non-Invasive and Non-Pharmacological Interventions for Low Back Pain: a Systematic Literature Review. Appl Health Econ Health Policy 15, 173–201 (2017). https://doi.org/10.1007/s40258-016-0268-8

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