Research Review By Dr. Demetry Assimakopoulos©


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Date Posted:

October 2012

Study Title:

Spinal Manipulation Epidemiology: Systematic Review of the Cost Effectiveness Studies


Michaleff ZA, Lin CWC, Maher CG & van Tulder MW

Author's Affiliations:

The George Institute for Global Health, The University of Sidney, Australia; Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, Netherlands; Department of Health Sciences and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, Netherlands.

Publication Information:

Journal of Electromyography and Kinesiology 2012; 22(5):655-62.

Background Information:

Neck and low back pain are endemic in our society. Because of this, they present many social and economic burdens due to chronicity and the high level of long term disability. As we know, they are associated with high health care costs and losses in productivity.

It is thus important to ascertain the cost effectiveness of various treatments, in hopes of understanding how a particular intervention for a condition can help save money. This can help inform consumers, insurers, governments and policy makers where their respective allocated health care budget should be spent.

Here, the authors sought to report on the incremental cost-effectiveness or cost-utility ratio (ICER), which indicates the difference in costs between treatments relative to the incremental difference in the effects. This can be interpreted as the extra monetary investment required for an intervention to gain one extra unit of effect compared to another health care treatment. The key question in this study, and in many other forums, is whether the effects of treatment justify the cost of treatment. In this case, if a treatment requires lower costs while generating greater benefits compared to a reasonable alternative, that treatment is dominant.

The effectiveness of spinal manipulative therapy (SMT) has been well described in the literature (1-3). It is thus important to also determine SMT’s cost effectiveness. The purpose of this systematic review is to determine the cost effectiveness of SMT compared to other treatment options for people with acute, subacute and chronic spinal pain.

Pertinent Results:

Six studies were included in this review. Three of the included studies reported on the cost-effectiveness of various interventions for neck pain, while 2 reported on low back pain. The other reported on a mixed neck and low back pain population.

Three studies performed their economic analysis from a societal perspective. Two studies analyzed their data from a healthcare perspective, while one article studied their data from the perspectives of both society and healthcare.

Spinal manipulative therapy (SMT) was delivered by qualified individuals in various disciplines. Their treatments often included a combination of manipulation, mobilization (passive or active) and advice. The average frequency and duration of treatment was 20-40 minute sessions, once per week, for 4-6 weeks.

SMT Compared to GP Care:
This was investigated in one study. GP care was defined as advice, education and/or drug prescription. In those with neck pain, SMT demonstrated dominance over GP care from societal and quality of life perspectives, as it was associated with lesser total costs and greater recovery rates. However, similar effects were not seen with regards to pain and functional disability. This latter conclusion is not favorable, because these are typical outcomes selected to judge the effectiveness of SMT. No similar studies were found for low back pain.

SMT Compared to Exercise:
Two studies assessing from the societal perspective found SMT to be a cost effective intervention compared to an exercise program with regards to pain, recovery and quality-adjusted life-years gained. The authors concluded that SMT is dominant compared to exercise in terms of neck pain. No studies were found for low back pain.

SMT Plus GP Care Compared to Other:
Two studies were found in this category – they took their focus from the perspective of healthcare. These studies compared SMT and GP care combined, to GP care alone and to exercise alone in the treatment of low back pain. Both studies found that SMT plus GP care is cost effective compared to GP care alone and exercise alone.

SMT Plus Other Treatment Compared to Other:
Three studies investigated the combined effect of SMT, advice and exercise. Two studies, one from the perspective of health care, and the other from a societal perspective, compared the combination of treatments to GP care alone for low back pain. The societal study found no difference between groups with regards to quality of life. However, their data suggest that the combination of treatments resulted in lower annual costs in comparison to GP care alone. It was also found that the combined treatment was dominant over GP care alone in terms of pain and disability outcomes as well. The study which performed the healthcare analysis also found that the combined treatment was more cost-effective than GP care alone.

Advice and exercise was, for the most part, more cost-effective with regards to neck disability scores from societal and healthcare perspectives. However, in terms of quality-adjusted life-years gained, a combined approach was more cost-effective from the societal perspective, but the precise cost-effectiveness from a healthcare perspective was uncertain.

Clinical Application & Conclusions:

Whether it is from the perspective of society, healthcare or quality-adjusted life-years gained, SMT appears to be a cost-effective treatment strategy when used alone or in combination with GP care, advice and/or exercise, in comparison to GP care alone.

More studies need to be done to expand on these findings. Various systematic reviews have shown that results of one study are not often reliable. This may be true for economic evaluations, as they are often small. Additionally, the world is quite economically diverse depending on location, thus requiring further study. The studies included either took place in the UK or the Netherlands – how different would these results be in other countries or continents?

However, these results should be considered to help inform and support health care treatment and healthcare funding decisions made by insurers, governments and policy developers. While SMT may be as efficacious as other treatments for spinal pain, it is definitely a cost-effective treatment.

Study Methods:

Studies that performed interventions on adults with non-specific spinal pain of any duration, who reported costs and effects of the intervention, and utilized SMT in at least one intervention group were included. Bearing this in mind, full cost-effectiveness, cost-utility and/or cost-benefit analyses conducted alongside randomized controlled trials comparing various treatment strategies were included in this review. Evaluations which sought to collect data on costs and/or utilization but didn’t relate this information to a measure of benefit, or didn’t make conclusions about the efficiency of the treatment alternative were excluded.

Specific data were extracted from each study. First, the type and perspective of the economic evaluation were noted (i.e. healthcare, society, etc). Also, various characteristics of the participants, treatment comparators, year(s) of study, study duration, the country of origin and its currency were all included. Additionally, identification, measurement and valuation of costs, and outcomes used in the economic evaluation were reported. Lastly, the results of the study were extracted.

The authors used the CHEC-List (4); a list of qualities generated through the consensus of international experts to assess the risk of bias. Most economic evaluations in this study were judged as having a low risk of bias (? 16/19). Additionally, the authors used other methods to assess the level of uncertainty, including cost-effectiveness acceptability curves and cost-effectiveness planes.

Study Strengths / Weaknesses:

  • No language limitation during their search
  • The authors included analyses from a number of different perspectives, including quality of life, societal and healthcare. These vantage points have the power to create a very different cost:benefit ratios.
  • Very few studies included
  • No precise description of the author’s search strategy (key/text words, etc), which limits the repeatability of this study.

Additional References:

  1. Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-back pain. Cochrane Database Syst Rev 2004(1).
  2. Gross A, Miller J, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Haines T, Brønfort G, Hoving JL. Manipulation or mobilisation for neck pain. Cochrane Database Syst Rev 2010(1).
  3. Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database Syst Rev 2011(2).
  4. Evers S, Goossens M, de Vet H, van Tulder M, Ament A. 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.