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Table 3

The cost-effectiveness of interdisciplinary rehabilitation, exercise, spinal manipulation and cognitive-behavioural therapy (CBT) for sub-acute or chronic low back pain

StudyComparative treatmentsDetails of economic evaluationResults of economic evaluation
Critchley et al. [33]Physiotherapy
Spinal stabilization exercises
Pain management programme using CBT
Type: CEA/CUA
Perspective: healthcare sector
Setting: United Kingdom, 2002–2005
Follow-up: 18 months
No raw data reported, but pain management programme associated with least costs and acceptability curve shows that it is likely to be most cost-effective
Hlobil et al. [26]Advice
Advice plus graded activity using CBT
Type: CBA
Perspective: employer
Setting: The Netherlands, 1999–2000
Follow-up: 1 year for costs, 3 years for other outcomes
Mean cost benefit = 999 (1999 Euro) favouring advice plus graded activity (95% CI −1,073 to 3,115)
Hollinghurst et al. [34]GP care
GP care plus exercise and behavioural counselling
Type: CEA/CUA
Perspective: healthcare sector, patients, societal
Setting: United Kingdom 2002–2004
Follow-up: 18 months
ICER for GP care plus exercise and behavioural counselling compared to GP care (in 2005 GBP per 1 unit of effect gained, from the healthcare sector’s perspective only):
 Disability (RMDQ) = 61
 Pain-free days = 9
 QALY gained (EQ-5D) = 2,847
Johnson et al. [35]GP care
Exercise and education using CBT
Type: CEA/CUA
Perspective: not stated
Setting: United Kingdom 2002–2003
Follow-up: 15 months
ICER for exercise and education using CBT compared to GP care:
 5,000 (2003–2004 GBP) per QALY gained (EQ-5D)
Kominski et al. [30]GP care
Chiropractic care (manipulation, instruction in back care and exercise)
Type: CMA
Perspective: not stated
Setting: United States 1995–1998
Follow-up: 18 months
Costs over 18 months in USD [price year not stated, mean (SD)]:
 GP care = 463 (1,225)
 Chiropractic care = 550 (834)
 GP care significantly cheaper
Lamb et al. [36]Group cognitive behavioural intervention plus advice
Advice
Type: CEA/CUA
Perspective: healthcare sector
Setting: United Kingdom, price year 2008
Follow-up: 1 year
ICER for Group cognitive behavioural intervention plus advice = 1,786 (2008 GBP) per QALY gained (EQ-5D)
Loisel et al. [25]GP care
Clinical rehabilitation (back pain specialist, back school ± multidisciplinary rehabilitation)
Type: CEA/CUA and CBA
Perspective: insurance provider
Setting: Canada 1991–1993
Follow-up: mean 6.4 years
ICER for treatments compared to GP care (in 1998 Canadian dollars per 1 day on full benefit):
 Clinical rehabilitation = −67.6
 dominant
Niemisto et al. [23, 24]Advice (advice, education and simple exercises)
Advice plus manipulation and stabilizing exercises
Type: CEA/CUA
Perspective: societal
Setting: Finland, study initiated in 1999
Follow-up: 2 years
ICER for advice plus manipulation and stabilizing exercises compared to advice [in 2002 USD per 1 point gained, mean (95% CI)]:
 Pain (0–100) = 512 (77–949)
 Disability (Oswestry, 0–100) = −78 (−655 to 499)
Rivero-Arias et al. [39]Outpatient rehabilitation
Spinal surgery
Type: CEA/CUA
Perspective: healthcare sector and patient
Setting: United Kingdom, 1996–2002
Follow-up: 2 years
ICER for spinal surgery compared to outpatient rehabilitation [in 2002–2003 GBP]:
 48,588 per QALY gained (95% CI −279,883 to 372,406)
Schweikert et al. [44]Inpatient rehabilitation
Inpatient rehabilitation plus CBT
Type: CEA/CUA
Perspective: societal
Setting: Germany, price year 2001
Follow-up: 6 months
ICER for inpatient rehabilitation plus CBT compared to inpatient rehabilitation
 −126,731 (2001 Euro) per QALY gained (EQ-5D, dominant)
Skouen et al. [28]GP care
Light interdisciplinary rehabilitation
Extensive interdisciplinary rehabilitation
Type: CBA
Perspective: societal
Setting: Norway 1996–1997
Follow-up: 2 years after end of treatment
Cost benefit for treatments compared to GP care:
 Light interdisciplinary rehabilitation in male patients = 7,240,900 (1998 Norwegian kroner) for the male participants (n = 21) over 24 months
 Extensive interdisciplinary rehabilitation —no data reported
Torstensen et al. [29]Medical exercise therapy
Physiotherapy
Walking
Type: CBA
Perspective: not reported
Setting: Norway, 1993–1996
Follow-up: 15 months
Cost benefit compared to walking in Norwegian Kroner (price year not reported):
 Medical exercise therapy (n = 69) = 906,732 less
 Physiotherapy (n = 67) = 1,882,560 less
UK BEAM Trial Team [40]GP care
GP care plus exercise
GP care plus manipulation
GP care plus manipulation followed by exercise
Type: CEA/CUA
Perspective: healthcare sector
Setting: United Kingdom, 1999–2002
Follow-up: 1 year
ICER for treatments compared to GP care [in 2000–2001 GBP per QALY gained (EQ-5D)]:
 GP care plus exercise = 8,300
 GP care plus manipulation = 4,800
 GP care plus manipulation followed by exercise = 3,800
Van der Roer et al. [43]Exercise and back school (using behavioural principles)
Physiotherapy
Type: CEA/CUA
Perspective: societal
Setting: The Netherlands, price year 2004
Follow-up: 1 year
ICER for exercise and back school compared to physiotherapy (in 2004 Euro per unit of effect gained):
 Disability (RMDQ) = 16,349
 Pain (numerical rating scale) = −175 (dominant)
 Perceived effects (Global perceived effects scale) = 1,720
 QALY (EQ-5D) = 5,141
Whitehurst et al. [32]Physiotherapy
Pain management programme using CBT
Type: CEA/CUA
Perspective: healthcare sector
Setting: United Kingdom, price years 2001–2002
Follow-up: 1 year
ICER for physiotherapy compared to pain management (in 2001–2002 GBP per unit of effect gained):
 Disability (RMDQ) = 156
 QALY (EQ-5D) = 2,362

CBA cost-benefit analysis, CEA cost-effectiveness analysis, CUA cost-utility analysis, GBP British pounds, GP care care provided by a general practitioner or a primary care physician, ICER incremental cost-effectiveness ratio, LBP low back pain, QALY quality-adjusted life-years, USD United States dollars

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