Cost Effectiveness of Physical Treatments for Back Pain in Primary Care


Cost Effectiveness of Physical Treatments for Back Pain in Primary Care

Findings from the:
“United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial”

OBJECTIVE:   To assess the cost effectiveness of adding spinal manipulation, exercise classes, or manipulation followed by exercise (“combined treatment”) to “best care” in general practice for patients consulting with low back pain.

DESIGN:   Stochastic cost utility analysis alongside pragmatic randomised trial with factorial design.

SETTING:   181 general practices and 63 community settings for physical treatments around 14 centres across the United Kingdom.

PARTICIPANTS:   1287 (96%) of 1334 trial participants.

MAIN OUTCOME MEASURES:   Healthcare costs, quality adjusted life years (QALYs), and cost per QALY over 12 months.

RESULTS:   Over one year, mean treatment costs relative to “best care” were 195 pounds sterling (360 dollars; 279 euros; 95% credibility interval 85 pounds sterling to 308 pounds sterling) for manipulation, 140 pounds sterling (3 pounds sterling to 278 pounds sterling) for exercise, and 125 pounds sterling (21 pounds sterling to 228 pounds sterling) for combined treatment. All three active treatments increased participants’ average QALYs compared with best care alone. Each extra QALY that combined treatment yielded relative to best care cost 3800 pounds sterling; in economic terms it had an “incremental cost effectiveness ratio” of 3800 pounds sterling. Manipulation alone had a ratio of 8700 pounds sterling relative to combined treatment. If the NHS was prepared to pay at least 10,000 pounds sterling for each extra QALY (lower than previous recommendations in the United Kingdom), manipulation alone would probably be the best strategy. If manipulation was not available, exercise would have an incremental cost effectiveness ratio of 8300 pounds sterling relative to best care.

CONCLUSIONS:   Spinal manipulation is a cost effective addition to “best care” for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise.

Read more about this on the UK BEAM Trial Page

From the FULL TEXT Article:


Back pain is a major economic problem. Before the accompanying clinical paper, [1] little evidence existed for the effectiveness of two commonly used treatments—exercise classes and spinal manipulation. Until the UK BEAM trial, little evidence existed for the cost effectiveness of those treatments. [2, 3]

An economic evaluation in British primary care found that physiotherapy led exercise classes were less expensive and more effective than general practice care alone. [4] In contrast, a Finnish study found that patients randomised to exercise, different from that investigated by the British study, had higher costs and poorer outcomes than those randomised to the control group and encouraged to keep active. [5] A Swedish study found no differences in costs or outcomes between physiotherapy and chiropractic manipulation. [6] In contrast, a UK trial comparing private chiropractic and NHS outpatient treatment found that reductions in time off work more than offset the net health service cost incurred by chiropractic. [7] To reduce the uncertainty surrounding the cost effectiveness of these physical treatments for back pain, we report the economic evaluation of the UK BEAM trial.


Principal findings

This economic evaluation supports and extends the findings of the clinical evaluation of the UK BEAM trial reported in the accompanying paper.1 If decision makers value additional quality adjusted life years (QALYs) at much less than £3800, “best care” in general practice is probably the best strategy. If their valuation lies between £3800 and £8700, spinal manipulation followed by exercise classes (“combined treatment”) is likely to be the best treatment. If their valuation is well above £8700, manipulation alone is probably the best treatment.

Strengths and weaknesses of the study

Although two of our three sensitivity analyses—those that used larger unit costs in whole or in part—changed these critical thresholds a little, they did not alter the essentials of these conclusions. The other sensitivity analysis, which removed 51 “outliers” from the UK BEAM dataset, was more favourable to manipulation than was the primary analysis. Under this scenario manipulation cost only £3000 per QALY relative to best care in general practice.

We believe that this is the first study of physical therapy for low back pain to show convincingly that both manipulation alone and manipulation followed by exercise provide cost effective additions to care in general practice. Indeed, as we trained practice teams in the best care of back pain, we may have underestimated the benefit of physical therapy (spinal manipulation) when compared with “usual care” in general practice. The detailed clinical outcomes reported in the accompanying paper reinforce these findings by showing that the improvements in health status reported here reflect statistically significant improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain. [1]

Unanswered questions

Funding constraints prevented us from following up participants for more than 12 months. Given that they continued to show benefits of treatment at 12 months, the cost effectiveness of both manipulation and combined treatment may be better than we have reported.

Commissioning decisions should depend on local circumstances, notably the availability of spinal manipulation and exercise physiotherapists. Although combined therapy is an attractive option, this depends on an ample supply of both trained manipulators prepared to work for the NHS and exercise physiotherapists with access to suitable premises. As back pain is a common problem, making manipulation generally available will require many therapists. In the United Kingdom there are 2100 registered chiropractors, 3200 registered osteopaths, and about 5000 manipulative physiotherapists (Ann Thomson, Chair of British Association of Chartered Physiotherapists in Manipulation, on behalf of the Chartered Society of Physiotherapy, personal communication, 2003). According to the unit costs we used in our analysis, they can achieve higher incomes in private practice than in the NHS. In the short term it may be difficult to make manipulative or combined treatment generally available within the NHS.

Whereas physiotherapists can rapidly train to deliver the exercise package, insufficient trained manipulators are available in the United Kingdom to meet potential demand, and it will take several years to produce additional manipulators. Indeed, if this needs new training programmes, it may be decades before the NHS can implement these findings. Fortunately, using private costs for manipulation had little effect on the choice of best treatment. Purchasing manipulation from the private sector to provide treatment within the NHS would still represent good value for money if decision makers were willing to pay £10 000 per additional QALY.

What is already known on this topic


  • Back pain is a major economic problem


  • Little evidence exists for the effectiveness and cost effectiveness of two commonly used treatments—exercise classes and spinal manipulation

What this study adds


  • Spinal manipulation, exercise classes, and manipulation followed by exercise all increased participants’ quality of life over 12 months by more than did “best care” in general practice

  • Adding spinal manipulation to best care in general practice is effective and cost effective for patients in the United Kingdom


  • If the NHS can afford at least £10 000 for each quality adjusted life year yielded by physical treatments, manipulation alone probably gives better value for money than manipulation followed by exercise.

Meaning of the study

Adding spinal manipulation to best care in general practice is effective and cost effective for patients with back pain in the United Kingdom. If the NHS can afford more than £10 000 for an extra QALY, manipulation alone probably gives better value for money than manipulation followed by exercise. These conclusions hold even if the NHS has to buy spinal manipulation from the private sector.