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Master of Public Health

Effect of a Biopsychosocial Intervention or Postural Therapy on Disability and Health Care Spending Among Patients With Acute and Subacute Spine Pain: The SPINE CARE Randomized Clinical Trial

AUTHORS

Choudhry NK , Fifer S , Fontanet CP , Archer KR , Sears E , Bhatkhande G , Haff N , Ghazinouri R , Coronado RA , Schneider BJ , Butterworth SW , Deogun H , Cooper A , Hsu E , Block S , Davidson CA , Shackelford CE , Goyal P , Milstein A , , Crum K , Scott J , Marton K , Silva FM , Obeidalla S , Robinette PE , Lorenzana-DeWitt M , Bair CA , Sadun HJ , Goldfield N , Hogewood LM , Sterling EK , Pickney C , Koltun-Baker EJ , Swehla A , Ravikumar V , Malhotra S , Finney ST , Holliday L , Moolman KC , Coleman-Dockery S , Patel IB , Angel FB , Green JK , Mitchell K , McBean MR , Ghaffar M , Ermini SR , Carr AL , MacDonald J , . JAMA. ; 328(23). 2334-2344

ABSTRACT

IMPORTANCE: Low back and neck pain are often self-limited, but health care spending remains high.

OBJECTIVE: To evaluate the effects of 2 interventions that emphasize noninvasive care for spine pain.

DESIGN, SETTING, AND PARTICIPANTS: Pragmatic, cluster, randomized clinical trial conducted at 33 centers in the US that enrolled 2971 participants with neck or back pain of 3 months’ duration or less (enrollment, June 2017 to March 2020; final follow-up, March 2021).

INTERVENTIONS: Participants were randomized at the clinic-level to (1) usual care (n = 992); (2) a risk-stratified, multidisciplinary intervention (the identify, coordinate, and enhance [ICE] care model that combines physical therapy, health coach counseling, and consultation from a specialist in pain medicine or rehabilitation) (n = 829); or (3) individualized postural therapy (IPT), a postural therapy approach that combines physical therapy with building self-efficacy and self-management (n = 1150).

MAIN OUTCOMES AND MEASURES: The primary outcomes were change in Oswestry Disability Index (ODI) score at 3 months (range, 0 [best] to 100 [worst]; minimal clinically important difference, 6) and spine-related health care spending at 1 year. A 2-sided significance threshold of .025 was used to define statistical significance.

RESULTS: Among 2971 participants randomized (mean age, 51.7 years; 1792 women [60.3%]), 2733 (92%) finished the trial. Between baseline and 3-month follow-up, mean ODI scores changed from 31.2 to 15.4 for ICE, from 29.3 to 15.4 for IPT, and from 28.9 to 19.5 for usual care. At 3-month follow-up, absolute differences compared with usual care were -5.8 (95% CI, -7.7 to -3.9; P < .001) for ICE and -4.3 (95% CI, -5.9 to -2.6; P < .001) for IPT. Mean 12-month spending was $1448, $2528, and $1587 in the ICE, IPT, and usual care groups, respectively. Differences in spending compared with usual care were -$139 (risk ratio, 0.93 [95% CI, 0.87 to 0.997]; P = .04) for ICE and $941 (risk ratio, 1.40 [95% CI, 1.35 to 1.45]; P < .001) for IPT.

CONCLUSIONS AND RELEVANCE: Among patients with acute or subacute spine pain, a multidisciplinary biopsychosocial intervention or an individualized postural therapy intervention, each compared with usual care, resulted in small but statistically significant reductions in pain-related disability at 3 months. However, compared with usual care, the biopsychosocial intervention resulted in no significant difference in spine-related health care spending and the postural therapy intervention resulted in significantly greater spine-related health care spending at 1 year.

TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03083886.

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