UK BEAM Trial Team (Andrea Manca)
British Medical Journal
329:1381 December 11, 2004

FROM ABSTRACT

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 centers 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 ($360) for manipulation, £140 for exercise, and £125 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; in economic terms it had an “incremental cost effectiveness ratio” of £3800.

Manipulation alone had a ratio of £8700 relative to combined treatment.

If the NHS was prepared to pay at least £10 000 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 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. [Key Point]

THIS STUDY ALSO NOTES:

“Back pain is a major economic problem.”

“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.” [Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ 1990;300: 1431-7].

In this study, “best care” in general practice consisted of advising the patient to remain active and providing them with The Back Book for patients.

Exercise program comprised an initial assessment and up to nine classes in community settings over 12 weeks.

Spinal manipulation package—The UK chiropractic, osteopathic, and physiotherapy professions agreed to use a package of techniques developed by a multidisciplinary group, during eight sessions over 12 weeks.

Combined treatment—Participants received six weeks of manipulation followed by six weeks of exercise.

Participants completed questionnaires at baseline, three months, and 12 months.

There was “no difference in clinical outcome between manipulation in private and NHS premises.”

[This is important because chiropractors are in private practice].

This study estimated how many quality adjusted life years (QALYs) participants had experienced over their year in the UK BEAM trial by ranking the cost effectiveness for the different treatments.

These authors “excluded those participants whose costs exceeded £2000 ($3700).

RESULTS

Exercise achieved a small back pain functional benefit at three months but not at one year.

Manipulation achieved a small to moderate back pain benefit at three months and a small benefit at one year.

Combined exercise and manipulation achieved a moderate back pain benefit at three months and a small benefit at one year.

Manipulation and exercise combined dominated exercise alone, which costs more and achieves less over 12 months. [IMPORTANT]

Manipulation alone yielded the highest improvement in QALYs, and did so for the lowest cost. [IMPORTANT]

“Manipulation achieves extended dominance over both exercise and combined treatment” of manipulation plus exercise.

DISCUSSION

“If decision makers value additional quality adjusted life years (QALYs)…manipulation alone is probably the best treatment.” [Key Point]

“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.”

“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.”

Patients continued to show benefits of treatment at 12 months, so the cost effectiveness of manipulation “may be better than we have reported.”

“As back pain is a common problem, making manipulation generally available will require many therapists.” [IMPORTANT]

“In the United Kingdom there are 2100 registered chiropractors, 3200 registered osteopaths, and about 5000 manipulative physiotherapists.”

“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.”

“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 THIS STUDY ADDS FROM AUTHOR:

“Spinal manipulation, exercise classes, and manipulation followed by exercise all increased participants’ quality of life over 12 months by more than “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.” [IMPORTANT]

“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.” [IMPORTANT]

MEANING OF THIS STUDY FROM AUTHOR:

“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.” [IMPORTANT]

KEY POINTS FROM THIS ARTICLE

1) Actually, this article is incredible. It basically shows that the most cost effective way to improve the quality of life for back pain sufferers, and to improve their quality of life for years, is to pay for spinal manipulation.

2) If public health authorities in the UK want to take advantage of the cost effective improvement in the quality of life of back pain sufferers, the UK will need many more spinal manipulators.

3) Spinal manipulation is a cost effective addition to “best care” for back pain in general practice.

4) Manipulation alone gives better value for the money than manipulation followed by exercise. [Important]

5) Back pain is a major economic problem.

6) A prior study comparing chiropractic and NHS outpatient treatment found that reduced time off work more than compensated for the additional cost incurred by chiropractic.

7) In this study, manipulation and exercise combined dominated exercise alone, which costs more and achieves less over 12 months.

8) In this study, manipulation alone yielded the highest improvement in quality of life, and did so for the lowest cost.

9) In this study, manipulation dominated over both exercise and combined treatment of manipulation plus exercise.

10) If decision makers value additional quality adjusted life years, manipulation alone is the best treatment.

11) This is the first study 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. [Important]

12) In this study, manipulation and manipulation/exercise resulted in statistically significant improvements in health status, including improvements in function, pain, disability, physical and mental aspects of quality of life, and beliefs about back pain.

13) In this study, patients continued to show benefits of treatment at 12 months, so the cost effectiveness of manipulation may be better than reported.