Browsing by Subject "Neck pain"
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Item Cost-effectiveness of spinal manipulation therapy for neck or back pain(2023-01) Leininger, BrentChronic pain is a major public health problem, affecting more adults in the United States than heart disease, diabetes, and cancer combined. Low back and neck pain are the most common chronic pain conditions and are two of the most disabling and costly conditions in the U.S. Approximately 4% of all healthcare spending in the U.S. is directed towards the management of back and neck pain, more than any other condition. Spine pain management has gathered increased scrutiny amidst concerns about overutilization of costly and potentially harmful interventions such as opioids, injections, and surgeries. Complementary and integrative interventions may reduce the clinical and cost burden of spine pain and are now recommended by clinical guidelines, but their use remains limited.This dissertation addresses the cost-effectiveness of spinal manipulation therapy and other complementary and integrative therapies for neck or back pain. First, we used individual patient data from eight randomized trials to conduct standardized cost-effectiveness analyses of spinal manipulation therapy (SMT), one of the most common complementary and integrative interventions, compared to home exercise or supervised exercise approaches. We found the cost-effectiveness of SMT varied by population and comparison. When compared to or added to home exercise, cost-effectiveness findings were favorable for acute neck pain, chronic neck pain in older adults, and chronic back-related leg pain; however, SMT was not likely cost-effective for chronic back pain. When compared to or added to supervised exercise, cost-effectiveness findings were favorable for chronic back pain in multiple age groups (adolescents, adults, older adults) and older adults with chronic neck pain. For adults with chronic neck pain, findings were mixed where SMT was not likely cost-effective relative to supervised exercise, but maybe cost-effective when added to supervised exercise. Next, we assessed the generalizability of the randomized clinical trial populations by comparing socio-demographic characteristics and clinical features to representative samples of US adults with chronic spine pain using data from the National Health Interview and Medical Expenditure Panel Surveys. We found the clinical trials had an under-representation of individuals from underserved communities with lower percentages of racial and ethnic minorities, less educated, and unemployed adults relative to the U.S. population with spine pain. While the odds of chiropractic use in the U.S. were lower for individuals from underserved communities, the trial populations also under-represented these populations relative to U.S. adults with chronic spine pain who visit a chiropractor. Finally, we estimated the cost-effectiveness of spinal manipulation and other complementary and integrative approaches for spine pain using a decision analysis model incorporating multiple sources of evidence. We found that yoga resulted in the lowest costs and largest health benefits relative to all other treatments across multiple populations. Other complementary and integrative approaches such as massage, mindfulness-based stress reduction, cognitive behavioral therapy, and SMT were also shown to be cost-effective options relative to home exercise and advice for chronic spine pain across different populations. Findings for these treatments were not sensitive to changes in key model parameters impacting costs or effectiveness. In summary, our work contributes to the understanding of the cost-effectiveness of complementary and integrative approaches including spinal manipulation in U.S. healthcare settings. We used both clinical trial-based and decision model analyses to assess cost-effectiveness and found general consistency of findings across the two approaches. There is a need to better understand the impact of these approaches in populations most severely impacted who are often under-represented in clinical trials.Item Measurement properties of quality-adjusted life year (QALY) measures among older adults with chronic neck pain(2016-04) Leininger, BrentBackground Quality-adjusted life year (QALY) measures are an important outcome for assessing the cost-effectiveness of healthcare interventions. Ideally, the choice of QALY measures will be informed by the measurement properties within the population of interest. Currently, the EQ-5D and SF-6D are the most commonly used QALY measures within cost-effectiveness analyses for spine pain. A number of studies have assessed the measurement properties of QALY measures for individuals with spine pain, but primarily within surgical populations. The psychometric properties of QALY measures may vary substantially within non-surgical populations. The primary aim of this thesis is to assess the psychometric properties (reliability, validity, and responsiveness) of commonly used QALY measures (SF-6D, EQ-5D, EQ Visual Analog Scale) among older U.S. adults with chronic mechanical neck pain managed non-surgically. The secondary aim of the thesis is to assess differences in the psychometric properties of QALY measures derived from the same instrument (SF-6D), but using different valuation methods. Methods Data for the study was collected within a randomized clinical trial comparing different combinations of non-invasive interventions (home exercise and advice, supervised exercise therapy, spinal manipulation) for the management of chronic neck pain in older adults. Quality-adjusted life years (QALYs) were measured with the 1) SF-6D, 2) EQ-5D, and 3) Euroqol visual analogue scale (EQ VAS) using U.S. population values for the primary aim. Test-retest reliability was determined using intraclass correlation coefficients (ICCs). The Bland-Altman method for limits of agreement and the smallest detectable change (SDC) were used to assess agreement. The longitudinal known-group validity and responsiveness of QALY measures was estimated using four external criteria: 1) global perceived change in health; 2) global improvement in neck symptoms; 3) neck pain; and 4) neck disability. Known-group validity was assessed by calculating mean QALY changes for each category of global perceived change in health and neck symptoms in addition to quintiles of neck pain and disability improvement. The relative responsiveness of QALY changes was estimated using correlation and area under the receiver operating characteristic (ROC) curve analyses. Results The SF-6D demonstrated better test-retest reliability (ICC = 0.81; 95% CI 0.77 to 0.85) relative to the EQ-5D (ICC = 0.44; 95% CI 0.33 to 0.53) and EQ VAS (ICC = 0.68; 95% CI 0.61 to 0.75). In addition, the smallest detectable change was lowest for the SF-6D (0.16; 95% CI 0.14 to 0.17), followed by the EQ-5D (0.18; 95% CI 0.16 to 0.20), and EQ VAS (0.22; 95% CI 0.20 to 0.25). Differences in QALYs during the one-week baseline period were evenly spread over the range of mean QALYs for the SF-6D, but not the EQ-5D or EQ VAS. The SF-6D and EQ VAS demonstrated better longitudinal known-group validity relative to the EQ-5D. Mean SF-6D and EQ VAS QALY changes were monotonically decreasing across levels of improvement for three of the four external criteria. All three QALY measures demonstrated similar responsiveness to change. Correlations between QALY measures and three of the external criteria were similar and very low to low in strength (-0.233 to -0.391). Correlations with neck disability were low to moderate in strength with the SF-6D demonstrating the strongest association (-0.596; p-values for differences with EQ-5D and EQ VAS = 0.01). There were no significant differences among the QALY measures when measuring responsiveness with area under the ROC curve. SF-6D based QALY measures had similar reliability, agreement, validity, and responsiveness. Conclusions There were minor differences between U.S. QALY measures in terms of responsiveness; however, the SF-6D was more reliable and demonstrated less measurement error relative to the EQ-5D and EQ VAS, in addition to better known-group validity relative to the EQ-5D. The different methods for obtaining QALY values from the same instrument (SF-6D) had little to no impact on the psychometric properties.Item Multi-Axial Motion and Intervertebral Kinematics of the Cervical Spine: Implications for those with Neck Pain(2023) Kage, CraigBackgroundThe primary functions of the human spine are to move the body, transport loads, and protect the spinal cord and associated nerves [1]. Specifically, the cervical spine serves the critical role of supporting and positioning the head, thus impacting nearly all of the human senses [2], and also protecting the critical nerves and vasculature to and from the brain [3]. Neck pain is a prevalent and common insult on the cervical spine with a “variable and not entirely favorable” clinical course [4] and an annual prevalence between 30-50% annually [5]. A particular challenge that exists with neck pain is ensuring a proper diagnosis to help guide appropriate treatment and medical care. At the present, diagnostic imaging and physical examination strategies are limited and, in most instances, the direct cause of neck pain is not able to be determined [4, 6]. Diagnostic imaging is often limited to 2D, static images, and/or non-functional (supine) positions. The physical examination often includes a ROM assessment that is only able to objectively capture cardinal plane, global total ROM. This method of assessment is unable to assess the multi-axial nature of the cervical spine (outside of the cardinal planes of motion) or assess the motion of the individual vertebral levels of the cervical spine. In light of these limitations, biplane videoradiography has proven to be a valid and useful tool that can examine dynamic motion of the cervical spine at the individual vertebral level [7, 8]. Furthermore, a recently introduced task known as circumduction has demonstrated promise in exploring the multi-axial nature of the cervical spine outside of the traditional cardinal planes of motion [9, 10]. ObjectivesTo address several of the limitations highlighted above, the aims of this dissertation are to: 1) Validate a custom biplane videoradiographic setup and 2D/3D shape-matching approach at the cervical (and lumbar) spine compared to the gold standard of radiostereometric analysis (RSA). 2) Examine head-to-torso and intervertebral kinematics between individuals with chronic neck pain and a healthy cohort. 3) Establish normative global (head-to-torso) kinematics (prediction and confidence intervals) and reliability of a multi-axial circumduction task in a healthy cohort and present a case comparison (an individual with cervical dystonia) to demonstrate clinical utility. MethodsAim 1: A custom biplane videoradiography system was utilized for aims 1 and 2. Aim 1 utilized a cadaveric specimen with implanted tantalum beads for RSA as the gold standard of comparison to a 2D/3D shape-matching algorithm at both the cervical and lumbar spine. Additionally, primary sources of RSA error were examined using a Monte Carlo simulation. Aim 2: The same biplane videoradiography system for Aim 1 was utilized to capture cervical spine kinematics during three trials each of flexion/extension, lateral bending, and axial rotation in those with chronic neck pain (NP) and controls. Head-to-torso kinematics were also acquired utilizing an optical motion capture system. The following hypotheses guided this specific aim: 3.a: Participants with NP will demonstrate altered segmental contributions relative to global kinematics compared to a healthy cohort . 3.b: Participants with NP will demonstrate greater segmental translation and/or translation per degree rotation (TPDR) compared to a healthy cohort. 3.c: Participants with NP will demonstrate altered coupling patterns (LB, AR) compared to a healthy cohort across LB, AR motion trials. Aim 3: An optical motion capture system was utilized to capture head-to-torso kinematics of thirty-nine neck-healthy participants performing a multi-axial circumduction task across two sessions. A two-way smoothing spline analysis of variance was incorporated to establish mean-fitted values and 90% confidence and prediction intervals. Within and between session reliability was also calculated for the circumduction task and a standardized effect size was aggregated across all axes to provide a summative metric of motion quality (Gene Glass Delta Root Mean Square Deviation aggregate). The motion of one individual with cervical dystonia was then compared to the prediction intervals pre- and post- botulinum toxin treatment to explore the utility of this metric in someone with pathology. ResultsAim 1: Overall root mean square error (RMSE) was found to be between 0.21-0.49mm and 0.42-1.80° at the cervical spine and 0.35-1.17mm and 0.49-1.06° at the lumbar spine. The RMSE associated with RSA ranged from 0.25-1.19mm and 1.69-4.06º for dynamic bead tracking and for bead centroid identification ranged between 0.14-0.69 mm and 0.96-2.33º. Aim 2: A significant difference was found between groups for Total ROM for the primary axis of axial rotation motion at spinal level C56 (p = 0.04), with participants with NP (8.4°±1.5°) demonstrating significantly less motion compared to controls (10.3°±1.9°) using a non-parametric permutation test approach. An exploratory aspect of this study found preliminary evidence for group differences beyond the non-parametric permutation tests. These metrics should be targeted for subsequent studies. Aim 3: Confidence and prediction intervals for the circumduction task were comparable between left and right directions. The circumduction task demonstrated excellent within and between session reliability. The average sum of the Delta RMSD aggregate was 2.76±0.55 and 2.74±0.63 for left and right circumduction, respectively. By comparison, an individual with cervical dystonia demonstrated Delta RMSD Aggregate values of 5.2 and 5.7 for left and right circumduction pre-treatment compared to 2.8 and 4.4 for left and right circumduction post-treatment. ConclusionsThe accuracy of our custom biplane videoradiography system was established for cervical and lumbar vertebral motion tracking and RSA errors were explored (Aim 1). Cardinal plane motions were examined (flexion/extension, lateral bending, and axial rotation) in those with chronic neck pain compared to controls by optical motion capture and biplane videoradiography and kinematics differences were revealed at the vertebral level (Aim 2) for total ROM. Confidence and prediction intervals were established for a dynamic, multi-axial, circumduction task for a healthy cohort for left and right directions to create a normative dataset. An individual patient with cervical dystonia was examined pre- and post- treatment and an aggregate value was explored to examine clinical utility (Aim 3). In aggregate, these three aims help to establish a novel approach to better understand the underlying kinematics of those with neck pain – utilizing a validated, custom biplane videographic system. While Aim 2 focused on kinematic differences between those with chronic mechanical neck pain and controls at the global and vertebral level and Aim 3 utilized a case with cervical dystonia and examined kinematics at the global level compared to a normative data set; the results would suggest that these two methods should be explored in combination. Specifically, those with chronic neck pain should be examined on an individual basis (individual dynamic traces for global and vertebral kinematics) compared to a normative dataset to better understand specific kinematic abnormalities, rather than only exploring scalar values collapsed across a group. A similar pre- and post-treatment approach and aggregate value could also be explored for those with chronic mechanical neck pain to better understand response to treatment and changes over time.