FROM:
British Medical Journal 2003 (Apr 26); 326 (7395): 911 ~ FULL TEXT
Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, de Vet HC, Koes BW, Vondeling H, Bouter LM
Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands. ibc.korthals-de_bos.emgo@med.vu.nl
Neck problems account for considerable pain and stiffness that can lead to work absenteeism, disability and use of health care resources. Various conservative interventions have been proposed for treating neck pain, but few scientific evaluations have included any analysis of their cost-effectiveness.
This randomized, controlled trial compared the efficacy of manual therapy, physiotherapy and general practitioner care in reducing neck pain. One hundred eighty-three patients with neck pain of at least two weeks' duration were randomly assigned to one of three groups: manual therapy (spinal mobilization); physiotherapy (mainly exercise); or general practitioner care (counseling, education and analgesics). Manual therapy consisted of a range of interventions: muscular mobilization, specific articular mobilization, coordination or stabilization. Spinal mobilization was defined as low-velocity, passive movements within or at the limit of joint range of motion.
Outcome measures included perceived recovery, intensity of pain, functional disability and quality of life; direct and indirect costs were measured to determine mean costs between groups, overall cost-effectiveness, and cost-utility ratios. Patients completed cost diaries for one year, providing data on direct health care costs of practitioner care; additional visits to other health care providers; drugs; professional home care; and hospitalization. Direct non-health care costs included out-of-pocket expenses; paid and unpaid help; and travel expenses. Indirect costs (lost of production attributable to work absenteeism or days of inactivity for those with or without a job) also were evaluated.
You may also enjoy this WebMD review titled: Manual Therapy Eases Neck Pain, Cheaply: Hands-On Approach Effective, and More Cost-Effective, than Traditional Treatments
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 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.
CONCLUSIONS: Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.
From the Full-Text Article:
Results
The 183 patients were randomised to manual therapy (60 patients), physiotherapy (59), and general practitioner care (64). Overall, 178 patients (97%) completed the follow up measurement at one year (fig 1). All data of patients who withdrew from the trial were included in the analysis until the time of withdrawal, after which we used the group mean to impute the missing data. Similarly, group means substituted occasional missing values. Complete cost data were available for 56 (93%) patients in the manual therapy group, 56 (95%) in the physiotherapy group, and 61 (95%) in the general practitioner care group. At baseline, minor differences in prognostic factors were found between the three groups (table 2). As confounding scarcely influenced the results, we present only the unadjusted differences between interventions. [6]
Effects of interventions
Manual therapy was the most effective treatment. Recovery rates after seven weeks in the manual therapy group, physiotherapy group, and general practitioner care group were 68%, 51%, and 36%, respectively. [6] The number needed to treat was 3, that is, every third patient referred to manual therapy would make a complete recovery within seven weeks compared with patients referred to continued care by a general practitioner. [6] This percentage remained stable in the manual therapy group during the follow up period, whereas both the physiotherapy group and general practitioner care group showed a slight increase in recovery rate over 52 weeks. Differences in recovery rates between groups were still statistically significant after 26 weeks but not at 52 weeks (table 3). Differences in pain intensity were small but statistically significant between the manual therapy group and the physiotherapy group at 52 weeks. The differences in disability scores at long term follow up remained small and were not statistically significant. Minor benign short term adverse reactions such as headache, pain and tingling in the upper extremities, and dizziness were reported more often for manual therapy and physiotherapy than for general practitioner care. Eleven patients (18%) who received manual therapy reported an increase in neck pain shortly after treatment.
Healthcare utilisation and absenteeism from work
Table 4 shows the utilisation of healthcare resources by the groups. The number of manual therapy and physiotherapy treatments was substantial in the general practitioner care group, and most of these sessions took place after the intervention period. During the follow up period of 52 weeks relatively more patients (41/64; 64%) in the general practitioner care group took prescription drugs than patients in the manual therapy group (22/60; 37%) or physiotherapy group (23/59; 39%). Overall, 37% of the patients in the manual therapy group took over the counter drugs compared with almost 50% of patients in both the physiotherapy group and the general practitioner care group. Only nine patients reported the utilisation of other healthcare resources, such as radiography and professional home care (n=2). During the trial, only two patients were hospitalised for neck pain, one for additional neurological testing (physiotherapy group) and one for hernia of a cervical disc (general practitioner care group), whereas six visited a chiropractor.
Only nine patients in the manual therapy group reported absenteeism from paid work owing to neck pain compared with 12 patients in the physiotherapy group and 15 patients in the general practitioner care group. Absenteeism from unpaid work was reported by 11 patients in the manual therapy group, 18 patients in the physiotherapy group, and 15 patients in the general practitioner care group.
Costs
Table 5 shows the mean (standard deviation) costs for each intervention. Direct healthcare costs in the manual therapy and physiotherapy groups consisted mainly of the costs of the intervention treatment. The general practitioner care group showed an increase in utilisation of manual therapy, physiotherapy, and drugs after the intervention period. The total costs in the manual therapy group were around one third of the costs in the physiotherapy and general practitioner care groups. Total direct, indirect, and total costs were statistically significantly lower in the manual therapy group than in the physiotherapy and general practitioner care groups (table 5).
Cost effectiveness and cost utility analyses
Table 6 presents the cost effectiveness and cost utility ratios of all three comparisons. Figure 2 shows the cost effectiveness plane for pain intensity when comparing manual therapy and physiotherapy groups. The graph represents 5000 bootstrap replications of the cost effectiveness ratio for pain intensity comparing manual therapy with physiotherapy. Most cost-effect pairs (98%) are located in the bottom right quadrant suggesting that manual therapy is dominant over physiotherapy that is, manual therapy is associated with a larger improvement in pain and lower costs. The cost effectiveness planes showed similar dominance of manual therapy over physiotherapy on recovery and quality of life (with most bootstrapped ratios in the bottom right quadrant, 85% and 87%, respectively).
Discussion
Manual therapy for the treatment of neck pain was more cost effective than physiotherapy or care by a general practitioner. Manual therapy had significantly lower costs and slightly better effects at 52 weeks compared with physiotherapy and general practitioner care. The clinical outcome measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care up to 26 weeks. [6]
The direct healthcare costs were, as expected, highest during the intervention period. The number of patients in the general practitioner care group who visited a manual therapist was high. A recent study showed that general practitioners in the Netherlands refer most patients with neck pain to physiotherapists instead of manual therapists. [2] A possible explanation for the high referral rate to manual therapy may be that patients and general practitioners who participated in this study were better informed about the possibility of manual therapy as an alternative to physiotherapy.
Systematic reviews of trials on conservative treatments for acute, subacute, and chronic neck pain provide little evidence of one treatment being more effective than another. [4 21 22] Some evidence has shown that staying active is beneficial and that active exercises are more effective than passive modalities such as massage, heat, and traction. [21] Trials on neck pain vary in methodological quality, study populations, interventions, reference treatments, and outcome measures, leading the reviewers to conclude that no one type of treatment can be favoured over another. [22]
None of the randomised trials evaluating conservative treatment for neck pain published so far included an economic evaluation. One study, comparing chiropractic and physiotherapy for patients with low back pain and neck pain, included a cost measurement but did not conduct a full economic evaluation.5 Our economic evaluation alongside a pragmatic randomised controlled trial showed manual therapy to be more cost effective than physiotherapy and continued care provided by a general practitioner in the treatment of non-specific neck pain.
