Megan Brooks
December 28, 2022
Two conservative interventions are effective for treating acute and subacute spine pain, new research suggests.
Results from the SPINE CARE randomized controlled trial showed that 6–8 weeks of an individualized postural therapy (IPT) or a multidisciplinary biopsychosocial intervention known as ICE that includes physical therapy were associated with small but statistically significant reductions in pain-related disability at 3 months compared with usual care.
In addition, spine-related healthcare spending did not differ significantly between ICE and usual care. However, IPT significantly increased spending compared with usual care.
Dr Niteesh Choudhry
“We found that, compared to usual primary care, both interventions reduced pain-related disability at 3 months and that these changes were sustained and clinically meaningful at 12 months ― long after the interventions were over,” lead author Niteesh K. Choudhry, MD, PhD, Brigham and Women’s Hospital and Harvard Medical School in Boston, Massachusetts, told Medscape Medical News.
The findings were published online December 20 in JAMA.
Common Complaint
Spine pain is defined as pain that occurs in the neck or back, the investigators note. It “accounted for more health spending than any other health condition in the US in 2016,” they add.
“Spine pain is an exceptionally common reason for patients to visit their primary care providers,” Choudhry said.
The SPINE CARE trial enrolled 2971 adults (60% women; mean age, 51 years) with back or neck pain that had lasted less than 12 weeks. All were randomly allocated to usual care (no intervention, n = 992) or to the ICE (n = 829) or IPT (n = 1150) interventions.
The “identify, coordinate, and enhance” (ICE) care model stratifies patients on the basis of their risk of progression from acute to chronic pain and addresses biopsychosocial contributors to pain. Low-risk patients received one physical therapy (PT) visit and one coaching call, while higher-risk patients received three PT visits, three coaching calls, and one e-consultation.
The IPT intervention, which was delivered in 8 weekly sessions, focuses on postural realignment. IPT also emphasizes self-efficacy and self-management, including daily exercises to improve postural control, coordination, and muscle balance.
Results at 3 months showed that both the ICE and IPT groups improved significantly more in Oswestry Disability Index (ODI) scores than the usual care group.
| Intervention | Mean ODI change at 3 months |
|---|---|
| ICE | 31.2 to 15.4 |
| IPT | 29.3 to 15.4 |
| Usual care | 28.9 to 19.5 |
At 3 months, the absolute difference in ODI score vs usual care was −5.8 for ICE (95% CI, −7.7 to −3.9; P < .001) and −4.3 for IPT (95% CI, −5.9 to −2.6; P < .001) for IPT.
Both interventions reduced resource utilization, such as diagnostic imaging, procedures, and specialist visits, Choudhry reported. “Because of this, both reduced spending unrelated to the interventions themselves,” he added.
When the intervention costs were included, ICE resulted in lower costs overall than usual care ($139 less), while overall spending for IPT was higher than usual care (by $941).
“We tested the interventions in a way that was integrated into primary care, so implementing them in other practice settings should be quite straightforward,” Choudhry said.
He noted that the ICE model does not currently exist as a complete program ― but its components, such as physical therapy or specialist e-consults, do. “And we think that our results justify exploring how to set this up more broadly,” he said.
Choudhry added that IPT was tested using a specific provider (Egoscue), “which has locations in a variety of places in the US and internationally, and so should also be straightforward to integrate into routine practice.”
However, other important factors, such as insurance coverage, will need to be explored in the future, he said.
Confirmatory Evidence?
In an accompanying editorial, Erin Krebs, MD, Minneapolis VA Health Care System, Minnesota, and colleagues note that past systematic reviews have concluded that exercise therapies are “generally effective” for chronic back and neck pain, which is usually defined as pain lasting more than 12 weeks, but not for acute pain, defined as pain lasting less than 4 to 6 weeks.
“The present trial contributes evidence for effectiveness of exercise therapy among patients with a current episode of less than 12 weeks, meaning not yet chronic, but not necessarily acute,” the editorialists write.
“Clinicians should more often recommend structured exercise programs for subacute back or neck pain, especially when the pain is recurrent,” they add.
The study was funded by unrestricted philanthropic gifts to Stanford University. Choudhry received grants from Stanford University during the conduct of the study. A full list of disclosures for the investigators and editorialists is available in the original article.
JAMA. Published online December 20, 2022
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