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OR-CS-002
COST-EFFECTIVENESS OF NECK-SPECIFIC EXERCISE IN THE TREATMENT OF CHRONIC WHIPLASH ASSOCIATED DISORDERS
M. Landn Ludvigsson 1,*, A. Peolsson, G. Peterson 1 2, . Dedering 3, G. Johansson 4, L. Bernfort 5
1
Medical and Health Sciences, Physiotherapy, Linkping University, Linkping, 2Centre for Clinical Research Srmland, Uppsala University, Eskilstuna, 3Division of
Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 4Institute of Environmental Medicine, Unit of Occupational Medicine,
Karolinska Insitutet, Stockholm, 5Medical and Health Sciences, Division of Health Care Analysis, Linkping University, Linkping, Sweden
Background: Whether neck-specific exercise is cost-effective in whiplash associated disorders (WAD) treatment has not been presented.
Purpose: The purpose of this study was to analyse cost-effectiveness following three exercise regimes in chronic WAD grade 2 or 3.
Methods: This is cost-effectiveness analysis of a multicenter prospective randomized clinical trial with assessor and group allocation blinding (n=170 aged 18-63
years). Participants were randomized to one of three exercise interventions for 12 weeks: physiotherapist-led neck-specific exercise (NSE), NSE with the addition of a
behavioral approach (NSEB) or prescription of physical activity (PPA). Quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs), including
direct (health care) and indirect (production loss) costs, were determined after 1 year and data are presented from both a health-care and societal perspective.
Results: There was trend for higher QALY gains in the NSEB group compared to the NSE group, but the costs were higher. The addition of a behavioural approach to
neck-specific exercise was not cost-effective from a societal perspective compared to neck-specific exercise alone, but from a health care perspective the ICER
comparing NSEB versus NSE could been seen as reasonable (< 42,200). The prescription of physical activity did not result in any QALY gain and was thus not costeffective regardless of costs. Furthermore, even though the intervention cost was lower for the PPA group, additional health care costs were instead significantly
higher.
Conclusion: The results of this study suggest that physiotherapist neck-specific exercise is cost-effective. Health-related quality of life improved following
physiotherapist-led neck-specific exercise both with or without a behavioural approach. However, the addition of a behavioural approach was not cost-effective from
a societal perspective. Prescription of physical activity did not result in any QALY gains, and was thus not cost-effective. Future studies need to also consider costeffectiveness of the treatments given.
Implications: Physiotherapist-led neck-specific exercise in primary care is a relatively cheap intervention from a health care perspective. It may improve general
health and can be cost-effective in the management of chronic WAD grade 2 and 3. It may therefore be an important option to consider.
Funding Acknowledgements: The study was supported by the Swedish Research Council, the Swedish government through the REHSAM foundation, the Medical
Research Council of Southeast Sweden, County Council of stergtland Centres for Clinical Research in stergtland and in Srmland at Uppsala University, and
Uppsala-rebro Regional Research Council, Sweden.
Ethics Approval: The study was approved by the Regional Ethics Committee of Linkping, Sweden.
Disclosure of Interest: None Declared
Keywords: whiplash injury, cost-effectiveness, exercise
Background: Neck pain is a global health burden. Data tracking the course of recovery for idiopathic neck pain and whiplash indicate that recovery is poor for many.
Besides patient characteristics and psychological factors, quantitative measures of pain sensitisation have been identified as predictive of poor recovery in some
categories of neck pain e.g. acute whiplash. Recent research has proposed clinical measures of pain sensitisation suitable for use in clinical practice; the predictive
ability of these methods has yet to be determined.
Purpose: The purpose of this study was to examine the unique contributions of quantitative and clinical measures of pain sensitisation to predict pain and disability at
long term follow up in people with chronic neck pain.
Methods: A prospective cohort study involving adults with chronic neck pain was conducted. Participants (n=64) completed self-reported measures of pain, disability,
psychological factors and co-morbidities, and underwent quantitative measures of cold and pressure pain thresholds. They also underwent assessment of sensitivity
to clinical measures of cold and pressure and provided pain ratings for brachial plexus provocation tests.
Univariate and multivariable hierarchical regression analyses were conducted to examine the relationship between these measures and pain intensity or neck
disability at 12-month follow-up.
Results: Univariate regression analyses revealed that depression, anxiety and stress, poor sleep, pain catastrophizing, higher baseline pain, higher manual pressure
pain sensitivity and higher pain ratings with brachial plexus provocation testing were associated with higher levels of disability at 12 months (r>0.3; p<0.05). Poorer
sleep, more co-morbidities, depression, anxiety and stress, as well as higher pain on manual pressure also demonstrated significant associations with pain at 12
months (r>0.3; p<0.05).
Multivariable regression analyses yielded models explaining 34.6% of the variance in disability and 44.4% of the variance in pain at 12 months. The resultant models
comprised self-reported measures (neuropathic symptoms, sleep, depression, co-morbidities). Neither QST nor clinical measures of pain sensitivity contributed to
either model.
Conclusion: The results of this study indicate that self-reported measures of pain and psychological factors were predictive of pain and disability at long-term follow
up. Measures of pain sensitivity did not predict long term pain and disability. These findings differ to those from acute whiplash populations, with the chronic nature
of pain in this cohort potentially explaining the difference.
Implications: Clinical and quantitative measures of pain sensitivity may be useful for profiling patients with chronic neck pain but have limited use in predicting
ongoing pain and disability in this population.
Funding Acknowledgements: TR and DB are supported by a NHMRC Research Fellowship. MH was supported by a postdoctoral fellowship from the German
Academic Exchange Service (DAAD).
Ethics Approval: Human ethics approval was obtained from University of Sydney (Protocol No. 14417) and Curtin University (Protocol No. PT0205) Human Research
Ethics Committees.
Disclosure of Interest: None Declared
Keywords: Chronic neck pain, clinical pain sensitivity, quantitative sensory testing
Background: Chronic musculoskeletal conditions are a leading cause of pain and disability within Australia, resulting in unprecedented economic burden being placed
on the public healthcare system. The Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Service (OPSC & MDS) was initiated in response to this
demand as an alternative, non-surgical pathway for patients currently on specialist consultation waiting lists. Whilst this cost-effective service has been able to
successfully remove over 70% of referred patients from specialist waitlists, there is still a large proportion of patients being discharged from the OPSC & MDS due to
non-attendance. This is now a critical time to identify those individuals who are unable to attend this service due to issues with accessibility, and redirect potentially
lost resources in order to optimise the healthcare outcomes for both patients and providers alike.
Purpose: The aim of this study is to identify the current barriers to accessing appropriate and timely healthcare for the management of chronic musculoskeletal
conditions, and to evaluate the potential need for the implementation of telerehabilitation as an additional method of service delivery within the OPSC & MDS.
Methods: Using selective and purposive sampling, a mixed methods needs assessment was undertaken involving six OPSC & MD services situated throughout
Queensland, Australia. Healthcare providers (n = 30) participated in qualitative interviews, whilst patients (n = 120) completed surveys.
Results: Preliminary thematic analysis of completed interviews suggest the following major themes: (1) barriers to accessing current care is complex and
multifaceted; (2) telerehabilitation could improve access to appropriate healthcare, however (3) would not be better than standard face-to-face care; and (4) that the
delivery of telerehabilitation should be flexible and dependent on individual patient circumstances. Patient surveys are currently in data collection phase.
Conclusion: Based on preliminary analysis, healthcare providers are cautious, but overall supportive, with respects to the implementation of telerehabilitation within
the OPSC & MDS, acknowledging that it could improve access to healthcare, which would allow for more positive outcomes for those individuals receiving no care
and remaining on a specialist waitlist.
Implications: The results of this study will provide valuable information on the current barriers and opportunities surrounding access to appropriate multidisciplinary
care in the management of chronic musculoskeletal conditions, which will assist in the introduction of a telerehabilitation service delivery option within the OPSC &
MDS.
Funding Acknowledgements: There was no funding in relation to this study.
Ethics Approval: Ethical approval was granted by the Human Research Ethics Committee (HREC), Royal Brisbane & Womens Hospital, Queensland, Australia
(HREC/15/QRBW/130).
Disclosure of Interest: None Declared
Keywords: MUSCULOSKELETAL, screening clinic, telerehabilitation
Background: There is conflicting evidence on the relationship between sagittal neck posture and neck pain. Most evidence is cross sectional in nature, and based on
weakly characterised posture and a lack of consideration of biopsychosocial factors known to be related to both neck pain and posture.
Purpose: To determine the existence of neck posture clusters in adolescents and establish whether identified clusters were associated with biopsychosocial factors
and neck pain.
Methods: 1108 17-year-olds enrolled in the Western Australian Pregnancy Cohort (Raine) Study underwent photographic postural assessment in sitting. One distance
and four angular measures of the head, neck and thorax were calculated from photo-reflective markers placed on bony landmarks. Subgroups of sagittal sitting neck
posture were determined by cluster analysis. Height and weight were measured and lifestyle and psychological factors, as well as neck pain and headache, were
assessed by questionnaire. The associations between posture clusters, neck pain and other factors at 17 years were evaluated using logistic regression.
Results: Four distinct clusters of sitting neck posture were identified and characterised as upright, intermediate, slumped thorax/forward head and erect
thorax/forward head postures. Significant associations between cluster and sex, weight and height, were found. Adolescents classified as having slumped thorax
forward/head posture were at higher odds of mild, moderate or severe depression. Adolescents classified as upright posture exercised more frequently. There was no
significant difference in the odds of persistent neck pain, neck pain made worse by sitting or headache across the clusters. Female sex was strongly associated with
neck pain.
Conclusion: Sagittal sitting neck posture clusters were identified in 17-year-olds that align with common clinical perceptions. Clusters differed on biopsychosocial
profiles. The finding of no association between cluster membership and neck pain in this cross sectional analysis challenges widely held beliefs about the role of
posture in adolescent neck pain.
Implications: The premise for the clinical assessment of posture should be reconsidered and take into account other biopsychosocial factors.
Funding Acknowledgements: NHMRC program grant 353514 and NHMRC project grant 323200 and additional funding for core management from The University of
Western Australia (UWA), Raine Medical Research Foundation, Telethon Kids Institute, UWA Faculty of Medicine, Dentistry and Health Sciences, Women and Infants
Research Foundation, Curtin University and Edith Cowan University.
Ethics Approval: Ethical approval was from Curtin University Human Research Ethics Committee (Reference HR 84/2005), Princess Margaret Hospital Human
Research Ethics Committee (Reference 1214EP) and The University of Western Australia (reference RA/4/1/502).
Disclosure of Interest: None Declared
Keywords: Classification system, Neck pain, Sagittal alignment
Background: Spinal mobilisations - low velocity passive oscillatory movements - reduce spinal pain in some spinal pain patient subgroups. Identifying patients likely to
respond to mobilisations remains a challenge since mobilisations mechanism(s) of action are unclear.
Purpose: To review the evidence regarding the mechanism of action of mobilisations.
Methods: A systematic review was conducted. Medline, Web of Science, Cinahl, Embase and Scopus databases were searched for relevant studies. Reference lists of
included studies were hand searched. Studies were included if the intervention was passive spinal mobilizations, participants were symptomatic and outcomes
evaluated possible mechanisms of action. Methodological quality was independently assessed by two assessors using a modified Cochrane Back Review Group tool.
Results: 24 studies were included in the review. Four were classified high risk, fourteen moderate risk, and four low risk of bias. Commonest methodological
limitations were lack of participant blinding, adequate randomization and allocation concealment, and sample size calculation. Evidence suggests that spinal
mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation and improved muscle function.
Mobilizations have no effect on temperature pain threshold. Three out of four studies reported reduction in spinal stiffness, heterogeneous in location and timing.
There is limited evidence (one study in each case) to suggest that mobilizations produce increased nociceptive flexion reflex threshold, improved posture, decreased
concentration of Substance P in saliva and improved sway index measured in cervical extension. Evidence does not support an effect on segmental vertebral
movement. Two studies investigated correlations between hypoalgesia and mechanism: one found a correlation with sympathoexcitatory changes, whereas the other
found no correlation with change in stiffness.
Conclusion: These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system, although this is yet to be
investigated directly. There is limited evidence regarding other possible mechanisms.
Implications: Clinical reasoning models for spinal mobilisations should make greater emphasis on their neurophysiological effects. Further research is required to
ascertain to what extend neurophysiological and neuromechanical changes observed in these studies are associated with the hypoalgesic effect of mobilisations.
Direct measurement of the pain related regions of the central nervous system should be attempted.
Funding Acknowledgements: Ion Lascurain Aguirrebea is currently receiving a grant from the University of the Basque Country (Spain).
Ethics Approval: This study required no ethics approval.
Disclosure of Interest: None Declared
Keywords: mechanism, mobilisation, spine