Cost-effectiveness of specialised manual therapy versus orthopaedic care for musculoskeletal disorders: long-term follow-up and health economic model.

Background: Physiotherapy is usually the first line of treatment for musculoskeletal disorders. If pain persists, an appointment with an orthopaedic surgeon is indicated, but many disorders for which patients are placed on orthopaedic waiting lists cannot be treated in an orthopaedic clinic. Specialised manual therapy, although not mainstream, can be an effective alternative to orthopaedic care, although its cost-effectiveness beyond 12 months is unknown. Objectives: To perform an 8-year follow-up of the quality of life and costs of specialised manual therapy versus standard orthopaedic care for working-age patients with common nonsurgical musculoskeletal disorders referred to orthopaedic surgeons and to develop a health economic model. Design: Cost-effectiveness study using Markov modelling. Methods: The index group of a previously published pragmatic randomised controlled trial received a maximum of five treatment sessions of specialised manual therapy, while the control group received orthopaedic 'care as usual'. At 3, 6, 12 and 96 months, Health-Related Quality of Life and costs were measured with Short Form Health Survey 36, Short Form Health Survey 6D and Diagnostic Related Groups. An incremental cost-effectiveness ratio was calculated, a Markov model was developed and a sensitivity analysis was performed. Results: Overall, 95% (n = 75) of the participants completed the 8-year follow-up. Recovery rates during the first 3 months ('per protocol') in the index and control group were 69% and 58%, respectively. The index group had 0.159 more gains in quality-adjusted life years and cost 40,270 SEK (€4027) less per patient over 8 years. The sensitivity analysis results were consistent with the main results. Conclusion: Specialised manual therapy dominated standard care after 8 years. The results of this small but very first study are promising; therefore, further exploration within other health care professions, clinics and/or countries is required. Our study raises questions about the triaging of orthopaedic outpatients, cost-effectiveness and resource allocation. Registration: Not applicable per the information provided by ClinicalTrials.gov. Plain Language Summary: Specialised manual therapy is more cost-effective than 'care as usual' for working-age patients referred to an orthopaedist. This study provides an 8-year follow-up of the cost effects and quality of life of a previously published trial. Why was this study conducted? The standard care for musculoskeletal pain consists of exercises with a physiotherapist in primary care. If the pain persists, a referral to an orthopaedic clinic is often made. Many of these referrals are inappropriate because they concern pain from muscles and joints that do not benefit from surgery or the resources available in an orthopaedic clinic. There is a gap in competence and treatment between primary and specialised care that is costly, time- and resource-consuming and causes prolonged patient suffering. Although specialised manual therapy (MT) is effective, its use is not mainstream. Costs and effects after more than 12 months of treatment that may shorten waiting lists have never been evaluated. What did the researchers do? Quality of life and costs were compared in 75 patients with nonsurgical disorders referred to orthopaedic surgeons at 8 years after treatment with specialised MT or standard orthopaedic care. A health economics model for the probability of recovery was also developed and tested. What did the researchers find? Compared with the control group, the study participants treated with specialised MT had a better quality of life, required fewer health care interventions, underwent less surgery, incurred significantly lower costs and demonstrated an increased probability of recovery. What do these findings mean? It seems probable that using specialised MT for an old, well-known structural problem may yield better treatment effects at a significantly lower cost. Our study findings suggest that policy recommendations should focus on costs and effects rather than resource utilisation alone. The study is small and requires expansion using its economic health model.

Attitudes, skills and implementation of evidence-based practice: a national cross-sectional survey of licensed naprapaths in Sweden.

BACKGROUND: Evidence-based practice (EBP) is fundamental to the delivery of high-quality, safe and effective health care. Naprapaths, manual therapy providers that specialize in the treatment of musculoskeletal pain and dysfunction, became a Swedish licensed health profession in 1994. This study investigated the attitudes, skills and implementation of EBP among licensed naprapaths in Sweden. METHODS: Licensed naprapaths (n = 950) of Svenska Naprapatförbundet (the Swedish Naprapathy Association) were invited by email to take part in this cross-sectional anonymous online study using the Evidence-Based Practice Attitude and Utilisation Survey in February 2019. RESULTS: Fourteen percent (137/950) of invited naprapaths completed the survey. There was an approximately equal gender divide among responders; most were in the mid-career age range, practiced in city areas, and had a university or college certificate/diploma as their highest qualification. The majority of naprapaths agreed or strongly agreed that EBP was necessary in the practice of naprapathy, assisted them in making care decisions, and improved the quality of patient care. Naprapaths' self-reported skills in EBP were mostly in the moderate to moderate-high range. The majority of participating naprapaths reported infrequent implementation of EBP. Perceived minor or moderate barriers to EBP uptake included a lack of colleague support for EBP and a lack of relevant resources. Access to the internet and free online databases were reported as very useful enablers to improving EBP uptake. CONCLUSIONS: The licensed naprapaths participating in this survey reported positive attitudes toward EBP, moderate levels of EBP skills, and infrequent implementation of EBP.

Manual therapy versus advice to stay active for nonspecific back and/or neck pain: a cost-effectiveness analysis.

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 .

Naprapathy versus orthopaedic standard care for common musculoskeletal disorders: an 8-year follow-up of a pragmatic randomized controlled trial in Sweden.

BACKGROUND: Musculoskeletal pain is among the most common reasons for seeking care, specialist competence for its treatment in primary care limited and waiting lists for orthopaedics often amongst the longest. Many referrals to orthopaedics do not concern disorders that benefit from surgery. Manual therapy is effective, yet not integrated in national health care systems, and there is a lack of research on other than neck and low back pain, and a lack of long-term follow-ups. The present study evaluates the long-term effects of a manual therapy (naprapathy) for common orthopaedic disorders. METHODS: An 8-year follow-up (96 months) of a pragmatic randomized controlled trial of naprapathy (experimental group) versus standard orthopaedic care (control group) for non-surgical patients of working age with the most common musculoskeletal disorders on the waiting lists (n = 78). Bodily pain, physical function (SF36), Quality of life (QoL; SF6D), and data on health care utilization were collected. The treatments lasted from January 2007 to November 2007. RESULTS: N = 75 participants in the original study sample completed the 8-year follow-up. The differences in bodily pain (21.7 (95% CI: 9.1-34.3)), physical function (17.6 (6.7-28.4)), and QoLs (0.823 (95% CI: 0.785-0.862) compared with 0.713 (95% CI: 0.668-0.758)) were statistically significantly in favor of the experimental group (p-values < 0.01). After sensitivity analysis the experimental group had altogether 260 health care visits compared with 1161 in the control group. CONCLUSIONS: Naprapathy is a continuously effective treatment. Together with earlier research our study suggests that specialized manual therapy should be considered when triaging patients with common non-surgical musculoskeletal disorders in national health care systems. TRIAL REGISTRATION: Not applicable, as per information given by ClinicalTrials.gov.

Skills, attitudes and uptake of evidence-based practice: a cross-sectional study of chiropractors in the Swedish Chiropractic Association.

BACKGROUND: Evidence-based practice (EBP) is integral to the delivery of high-quality health care. Chiropractic has been a licensed health profession in Sweden since 1989, but little is known of the uptake of EBP in this professional group. This study explored the self-reported skills, attitudes and uptake of EBP, and the enablers and barriers of EBP uptake, among licensed chiropractors in Sweden. METHODS: Licensed chiropractors (n = 172) of the Swedish Chiropractic Association (Legitimerade Kiropraktorers Riksorganisation) were invited to participate in an anonymous online questionnaire, using the Evidence-Based Practice Attitude and Utilisation Survey (EBASE) in February 2019. RESULTS: Fifty-six (33%) chiropractors completed the survey. Participants were predominantly male, aged 30-49 years, held a Master's degree, and had received their highest qualification and practiced chiropractic for over a decade. Chiropractors rated their EBP skill-level mostly in the moderate to moderate-high range. The majority of chiropractors reported positive attitudes towards EBP, with most agreeing or strongly agreeing that EBP is necessary in the practice of chiropractic, and that EBP assists in making decisions about patient care. Chiropractors reported an average level of engagement in EBP activities. All participants indicated professional literature and research findings were useful in their day-to-day chiropractic practice. The main perceived enabler of EBP uptake was internet access in the workplace, whereas the main barrier to EBP uptake was lack of clinical evidence in chiropractic. CONCLUSIONS: Participating chiropractors of the Swedish Chiropractic Association were generally favourable of EBP, though only reported modest levels of EBP-related skills and engagement in EBP activities. Our findings suggest future studies investigating interventions focussed on improving chiropractors' skills and uptake of EBP are warranted.

The importance of weak physical performance in older adults for the development of musculoskeletal pain that interferes with normal life. A prospective cohort study.

BACKGROUND AND AIMS: There are associations between pain, comorbidity and risk of falling, and falling increases the risk of mortality in older persons, but few studies have investigated the development of pain as a result of impaired physical function. The aim of this study was to examine possible associations between weak physical performance and the development of musculoskeletal pain that interferes with normal life in a sample of older adults. The sample derived from a national, longitudinal multicenter study; the Swedish National Study on Ageing and Care; SNAC-B. METHODS: The participants (n = 490) were between 60 and 78 years at the baseline examinations. Three variables were chosen for the exposure physical function, from the baseline examinations; One Leg Stand, Grip strength and Sit-to-Stand. The outcome musculoskeletal pain that interferes with normal life was measured using EQ5D and SF-12 6 years later, and logistic regression was used to investigate possible associations between the exposures and the outcome. RESULTS: Maximum grip strength (Grippit) was inversely associated with musculoskeletal pain that interferes with normal life (OR 2.31; 95% CI 1.15-4.61), and One-Leg Stand and Sit-to-Stand were not associated with the development of pain (OR 1.30; 95% CI 0.64-2.64) and (OR 0.91; 95% CI 0.45-1.86), respectively. CONCLUSIONS: Weak grip strength was inversely associated with the development of musculoskeletal pain that interferes with normal life in older adults. IMPLICATIONS: Impaired proprioceptive function, strength and mobility in elderly with pain have been found in earlier research. Since pain increases the risk of falling, it is important to investigate if it may develop as a function of an impaired physical function. The results of the present study could be of importance for future prevention programs aiming to protect elderly from falling.

Experiences of Older Adults With Mobile Phone Text Messaging as Reminders of Home Exercises After Specialized Manual Therapy for Recurrent Low Back Pain: A Qualitative Study.

BACKGROUND: Clinical experience of manual therapy for musculoskeletal pain is that patients often suffer from recurrent pain and disorders, but that they do not continue to perform their physical home exercises when they are free from symptoms. The chance of positive long-term effects of manual therapy would probably increase if patients were reminded that they are to continue to perform their exercises. Mobile phone text messaging (short messaging service, SMS) is increasingly used as an innovative intervention to remind patient to exercise. However, there are only a few studies on such interventions in the field of low back pain (LBP). Qualitative studies of patients' experiences of receiving text messages as reminders of home exercises after manual treatment for recurrent LBP have to the best of our knowledge never been published. OBJECTIVES: The aim of this study was to explore older persons' common experiences of receiving reminders of home exercises through mobile phone text messaging after specialized manual therapy for recurrent LBP. METHODS: A total of 7 men and 8 women (67-86 years), who had sought specialized manual therapy (Naprapathic manual therapy) for recurrent LBP were included in the study. Individual one-way text messages as reminders of home exercises (to be performed on a daily basis) were sent to each patient every third day for 3 weeks, then once a week for another 2 weeks. Semistructured interviews with 2 broad, open-ended questions were held and data were analyzed with systematic text condensation, based on Giorgi's principles of psychological phenomenological analysis. RESULTS: The participants appreciated the messages, which were perceived as timely and usable, and also stimulated memorizing. The messages made the participants reflect on the aim of the exercise, value of being reminded, and on their improvement in pain. During the interviews, the participants created their own routines for continued adherence to the exercises. CONCLUSIONS: It seems plausible that mobile phone text messaging may serve as a useful tool for patient empowerment with regard to recurrent LBP in older persons. Further studies are needed to explore whether future compliance with the exercises will be as large if the participants are not being interviewed.

Negative psychosocial and heavy physical workloads associated with musculoskeletal pain interfering with normal life in older adults: cross-sectional analysis.

AIMS: Pain is one of the most frequent reasons for seeking health care, and is thus a public health problem. Although there is a progressive increase in pain and impaired physical function with age, few studies are performed on older adults. The aim of this study was to investigate if there are associations between musculoskeletal pain interfering with normal life in older adults and physical and psychosocial workloads through life. METHODS: The association of heavy physical workload and negative psychosocial workload and musculoskeletal pain interfering with normal life (SF 12) was analyzed by multiple logistic regression. The model was adjusted for eight background covariates: age, gender, growing-up environment, educational level, if living alone or not, obesity, smoking, and leisure physical activity. RESULTS: Negative psychosocial and heavy physical workloads were independently associated with musculoskeletal pain interfering with normal life (adjusted OR: 4.44, 95% CI: 2.84-6.92), and (adjusted OR: 1.88, 95% CI: 1.20-2.93), respectively. The background covariates female gender and higher education were also associated with musculoskeletal pain interfering with normal life, and physical leisure activity was inversely associated. CONCLUSIONS: The findings suggest that negative psychosocial and heavy physical workloads are strongly associated with musculoskeletal pain interfering with normal life in older adults.

Pain relief in a young woman with adhesive capsulitis after manual manipulation of the acromioclavicular joint for remaining symptoms after mobilisation under anaesthesia.

Adhesive capsulitis is a painful condition with a prevalence of 2-5%. There is a lack of evidence for its aetiology and for conventional treatment and cost effects. This study describes the treatment effects of manual manipulation of the acromioclavicular joint for adhesive capsulitis in a young woman for persisting pain after mobilisation of the glenohumeral joint under anaesthesia. Primary outcomes were pain and physical function, measured by a visual analogue scale and the SF36 health survey. Secondary outcomes were sleep pattern, medication and perceived recovery. The mobility after manipulation under anaesthesia: elevation 55° and no improvement in pain. After manual manipulation: unrestricted elevation and significant pain relief. The patient no longer suffered from sleeping disorders and ceased all medication. Considering the lack of knowledge in aetiology and treatment, specialised manual examination of the acromioclavicular joint should be considered early in patients diagnosed with adhesive capsulitis.

Costs and utilities of manual therapy and orthopedic standard care for low-prioritized orthopedic outpatients of working age: a cost consequence analysis.

OBJECTIVES: Treatment for musculoskeletal disorders in primary care in Sweden is generally initiated with advice and medication. Second-line therapy is physiotherapy and/or injection and radiography; third-line therapy is referral to an orthopedist. Manual therapy is not routine. It is a challenge to identify patients who benefit from treatment by different specialists. The current referral strategy probably contributes to long waiting lists in orthopedic departments, which is costly and implies prolonged suffering for the patients. The aim of this health economic evaluation was to compare costs and outcomes from naprapathic manual therapy (NMT) with orthopedic standard care for common, low-prioritized, nonsurgical musculoskeletal disorders, after second-line treatment. MATERIALS AND METHODS: Diagnose Related Groups were used to define the costs, and the SF-36 was encoded to evaluate the outcomes in cost per quality adjusted life years gained. RESULTS: Results from a 12 months' follow-up showed significantly larger improvement for the NMT than for orthopedic standard care, significantly lower mean cost per patient; 5427 SEK (*Price level 2009; 1 Euro=106,213 SEK; 1 US Dollar=76,457 SEK) (95% confidence interval, 3693-7161) compared to14298 SEK (95% confidence interval, 8322-20,274), and more gains in outcomes in cost per quality adjusted life years per patient (0.066 compared with 0.026). Thus the result is "dominant." DISCUSSION: It is plausible that improved outcomes and reasonable cost savings for low-prioritized nonsurgical outpatients would be attainable if NMT were available as an additional standard care option in orthopedic outpatient clinics.

Naprapathic manual therapy or conventional orthopedic care for outpatients on orthopedic waiting lists?: A pragmatic randomized controlled trial.

OBJECTIVES: Traditionally, orthopedic outpatient waiting lists are long, and many referrals are for conditions that do not respond to interventions available at an orthopedic outpatient department. The overall objective of this trial was to investigate whether it is possible to reduce orthopedic waiting lists through integrative medicine. Specific aims were to compare the effects of naprapathic manual therapy to conventional orthopedic care for outpatients with nonurgent musculoskeletal disorders unlikely to benefit from surgery regarding pain, physical function, and perceived recovery. METHODS: Seventy-eight patients referred to an orthopedic outpatient department in Sweden were included in this pragmatic randomized controlled trial. The 2 interventions compared were naprapathic manual therapy (index group) and conventional orthopedic care (control group). Pain, physical function, and perceived recovery were measured by questionnaires at baseline and after 12, 24, and 52 weeks. The number of patients being discharged from the waiting lists and the level of agreement concerning management decisions between the naprapath and the orthopedists were also estimated. RESULTS: After 52 weeks, statistically significant differences between the groups were found regarding impairment in pain, increased physical function, and regarding perceived recovery, favoring the index group. Sixty-two percent of the patients in the index group agreed to be discharged from the waiting list. The level of agreement concerning the management decisions was 80%. DISCUSSION: The trial suggests that naprapathic manual therapy may be an alternative to consider for orthopedic outpatients with disorders unlikely to benefit from surgery.