J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 655–662 ~ FULL TEXT
Michaleff ZA, Lin CW, Maher CG, van Tulder MW.
The George Institute for Global Health,
The University of Sydney,
Missenden Road, Sydney, NSW 2050, Australia.
BACKGROUND: Spinal manipulative therapy (SMT) is frequently used by health professionals to manage spinal pain. With many treatments having comparable outcomes to SMT, determining the cost-effectiveness of these treatments has been identified as a high research priority.
OBJECTIVE: To investigate the cost-effectiveness of SMT compared to other treatment options for people with spinal pain of any duration.
METHODS: We searched eight clinical and economic databases and the reference lists of relevant systematic reviews. Full economic evaluations conducted alongside randomised controlled trials with at least one SMT arm were eligible for inclusion. Two authors independently screened search results, extracted data and assessed risk of bias using the CHEC-list.
RESULTS: Six cost-effectiveness and cost-utility analysis were included. All included studies had a low risk of bias scoring =16/19 on the CHEC-List. SMT was found to be a cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to GP care, exercise and physiotherapy.
CONCLUSIONS: This review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches. However, as this conclusion is primarily based on single studies more high quality research is needed to identify whether these findings are applicable in other settings.
From the Full-Text Article:
Spinal pain, including neck pain and back pain, is a common
condition in modern society (Woolf and Pfleger, 2003; Côté et al., 2003 ). It presents major social and economic burdens due to the
high levels of chronicity and resultant long term disability which
are associated with high costs in health care and losses of productivity
(e.g. sick leave) (Woolf and Pfleger, 2003). While existing
practice guidelines inform the individual, clinicians and policy
makers on the effectiveness of a range of interventions, few provide
information on the cost-effectiveness of treatments. It is arguable
that cost-effectiveness of treatment is an equally important
consideration as effectiveness, as all health administrators need
to make decisions about how they allocate scarce health resources.
Economic evaluations are frequently conducted alongside randomised
controlled trials of treatment effectiveness and involve
the identification, measurement, valuation and then comparison
of the costs and consequences (benefits) of two or more alternatives
(Drummond et al., 2005). Economic evaluations are most useful
when the treatments under question have been evaluated in
terms of efficacy (can the treatment work in those who comply
with the recommendations), effectiveness (is the treatment
acceptable and does the treatment work in those who the treatment
is offered) and availability (is the treatment accessible to
all who would benefit from it). The result of an economic evaluation
supplements the evidence base on treatment effectiveness
by providing information on the efficiency or ‘‘value for money’’
of treatment alternatives (Drummond et al., 2005). This information
can be used to inform consumers, insurers, governments and
policy makers where the health budget should be spent.
Spinal manipulative therapy (SMT), including both manipulation
(a high velocity thrust technique) and mobilisation (low velocity
technique), is frequently used by a number of health
professions, including physiotherapists, chiropractors and osteopaths,
to manage people with neck pain and back pain (Gross
et al., 2010; Assendelft et al., 2004). The effectiveness of SMT to
treat spinal pain has been summarised in recent Cochrane Reviews
(Gross et al., 2010; Assendelft et al., 2004; Rubinstein et al., 2011).
Overall the evidence suggests that SMT provides greater improvements
for pain and function than a placebo or no treatment but
similar improvements to many competing treatments such as general practitioner management, medication and exercise. With many treatments for spinal pain having comparable outcomes to
SMT, determining the cost effectiveness of these treatment alternatives
has been identified as a high priority (Rubinstein et al., 2011).
The purpose of this systematic review is to investigate the costeffectiveness
of SMT compared to other treatment options for people
with spinal pain of any duration.
We followed the method guidelines of the Cochrane Back Review
Group (van Tulder et al., 2003; Furlan et al., 2009), Campbell and
Cochrane Economic Methods Group (http://www.med.uea.ac.uk/
research/research_econ/cochrane/cochrane_home.htm), and the
NHS Economic Evaluation Database Handbook (Craig and Rice,
2007). Full economic evaluations (i.e. cost-effectiveness, cost–utility
or cost–benefit analysis) undertaken from any perspective conducted
alongside randomised controlled trials were included in
this review (Drummond et al., 2005). Studies which collected data
on costs and/or utilisation but did not relate this information to a
measure of benefit (e.g. cost minimisation analysis), or did not make
inferences about the relative efficiency of the treatment alternatives,
were excluded (Drummond et al., 2005; Briggs and O’Brien,
2001; Dakin and Wordsworth, 2011). Studies that recruited adults
with non-specific spinal (neck or back) pain (i.e. pain is not the result
of an accident, trauma or specific spinal pathology) of any duration,
reported costs and effects of the interventions and included
SMT in at least one intervention group were eligible for this review.
We included studies where SMT was administered as the only intervention
or as a mandatory component of a combined intervention.
No restrictions were placed on the type of health professional performing
the interventions or the comparison group used. Studies
that recruited multiple musculoskeletal conditions (e.g. neck and
shoulder pain), or investigated interventions implemented after
spinal surgery were excluded. There was no language restriction.
Data sources and searches
Studies evaluating the cost-effectiveness of SMT for spinal pain
were identified from the reference lists of three systematic reviews
on the cost-effectiveness of neck pain and back pain treatments
(Lin et al., 2011a,b; Driessen et al., accepted for publication). Because
these reviews were conducted exclusively for neck or back
pain, we also screened the articles which were excluded after
full-text screening, in case any study was excluded due to including
both neck and back pain. An electronic database search was
also conducted on MEDLINE (via OvidSP), EMBASE (via OvidSP),
CINAHL (via EBSCO), the American Economic Association’s electronic
bibliography (EconLit), National Health System Economic
Evaluation Database (NHS EED), and European Network of Health
Economic Evaluation Databases (EURONHEED) to identify studies
published since the previous literature searches were completed
(June 2010–July 2011). Economic search terms (e.g. economics,
costs and cost analysis) were developed from search strategies
used by the NHS EED (http://www.york.ac.uk/inst/crd/nhseedfaq02.htm)
and combined with the Cochrane Back Review Group’s
search strategy to identify randomised controlled trials in neck
pain and back pain (Bombardier et al., 2011). See Appendix 1 for
an example of a full search strategy.
Study selection, risk of bias assessment and data extraction
Two reviewers independently screened first the titles and abstracts
(if available), and then full papers. Risk of bias was assessed
using the 19-item Consensus on Health Economic Criteria (CHEClist)
Evers et al., 2005. Studies were included in the analysis regardless
of their risk of bias. Data were extracted using a standardised
data extraction sheet which was piloted on a cost-effectiveness
study (Manca et al., 2006) before use. The risk of bias rating and
data extraction were conducted by two reviewers. Publications related
to the included studies (e.g. published protocol or clinical
outcomes paper, listed in Appendix 2) were used to assist these
processes. Throughout the review, disagreements between the
two reviewers were resolved first in discussion, and then by an
independent third reviewer if necessary.
Data extracted from each study included:
(i) the type and perspective of the economic evaluation,
(ii) characteristics of participants,
(iii) treatment comparators,
(iv) year, study duration, country and currency of the study, and
(v) identification, measurement and valuation of costs and outcomes
used in the economic evaluation, and
(vi) results of the study.
The primary outcome used
was the relative cost-effectiveness of the interventions, usually reported
as an incremental cost-effectiveness or cost–utility ratio
(ICER). The ICER indicates the incremental difference in costs between
the competing treatment alternatives relative to the incremental
difference in effects, and can be interpreted as the
additional monetary investment needed for an intervention to gain
one extra unit of effect compared to the alternative treatment
(Drummond et al., 2005). Whether the effects are worth the costs
(value for money), is the key question in economic evaluations,
which often triggers intense debate. In some countries consensus
exists about thresholds for cost-effectiveness. For example, the
British National Institute for Health and Clinical Excellence (NICE)
uses a cost-effectiveness threshold of GBP20,000–GBP30,000 per
QALY gained as an indicator of cost-effectiveness (Appleby et al.,
2007; Towse, 2009). In other countries no threshold exists leading
to difficult discussions about whether an intervention is cost-effective
or not. When one treatment incurs lower costs and generates
higher benefits compared to the alternative treatment, the treatment
is said to be dominant. In these cases there will not be a
big debate about the interpretation of the results and the choice
will be in favour of the dominant treatment.
For data analysis and presentation, studies were grouped by the
intervention that SMT was compared to and then the affected region
(neck or back). Studies reporting ICER using generic outcomes
(e.g. cost per quality-adjusted life-years (QALYs) gained) from the
same perspective were compared as able. We used the cost-effectiveness
threshold of NICE (see above) as an indicator of cost-effectiveness
(Appleby et al., 2007; Towse, 2009). That is, if a treatment
has an ICER lower than the NICE threshold when compared to an
alternative, the treatment is said to be cost-effective compared
with the alternative.
The search yielded 95 references; 48 references were identified
through the electronic database search and 55 references from the
three previous systematic reviews (Lin et al., 2011a,b; Driessen
et al., accepted for publication). A total of six studies were included
after screening (Figure 1). Most full papers were excluded because
they did not evaluate SMT. All of the included studies were designed
as a randomised controlled trial and published in English.
The number of participants in each study ranged from 146
(Bosmans et al., in press) to 1334 (UK BEAM Trial Team, 2004).
Characteristics of the included studies can be seen in Table 1.
Flow of studies.
Three studies reported on the cost-effectiveness of interventions
for neck pain, two studies reported on LBP and one reported
on a mixed neck and LBP population. The duration of neck and LBP
symptoms varied between studies with the majority recruiting
people with acute and sub-acute pain (P2–12 weeks). The
duration of symptoms was not specified in one study (Lewis et al.,
2007). All six studies conducted both cost-effectiveness and cost–
utility analyses (Bosmans et al., in press; UK BEAM Trial Team,
2004; Lewis et al., 2007; Niemisto et al., 2005; Korthals-de Bos
et al., 2003; Williams et al., 2004). The economic analysis was conducted
from a societal perspective in three studies (Bosmans et al.,
in press; Niemisto et al., 2005; Korthals-de Bos et al., 2003),
healthcare perspective in two studies (UK BEAM Trial Team,
2004; Williams et al., 2004), one study from both the societal
and healthcare perspective (Lewis et al., 2007). SMT was delivered
by physiotherapists, chiropractors and osteopaths with treatments
often involving a combination of manipulation, mobilisation
(active or passive) and advice. On average patients received one
20–40 min session once per week for 4–6 weeks.
Risk of bias of the economic evaluation (Table 2)
All six studies scored 16 or more out of 19 on the CHEC-list.
One study did not justify the perspective chosen (UK BEAM Trial
Team, 2004). Discounting was not applicable in five studies and
was not performed by one study which had a follow up duration
of longer than 12 months (Niemisto et al., 2005). Two of
six studies performed appropriate sensitivity analyses (UK BEAM
Trial Team, 2004; Korthals-de Bos et al., 2003). An incremental
cost-effectiveness analysis was conducted by all six studies, five
studies presented cost-effectiveness planes (Bosmans et al., in
press; Lewis et al., 2007; Niemisto et al., 2005; Korthals-de
Bos et al., 2003; Williams et al., 2004) and four studies
presented cost-effectiveness acceptability curves (Bosmans
et al., in press; Lewis et al., 2007; Niemisto et al., 2005; Williams
et al., 2004).
Characteristics of included studies.
Methodological quality assessment
of economic evaluations.
Cost-effectiveness of SMT
SMT compared to GP care
One study investigated the cost-effectiveness of SMT versus
general practitioner (GP) care (advice, education and drug prescription).
In patients with neck pain, Korthals-de Bos et al. (2003) demonstrated SMT to be dominant over GP care, from a
societal perspective, in terms of recovery and quality of life, as
SMT was associated with lower total costs and higher rates of
recovery. Interestingly, no difference was shown in the cost-effectiveness
of SMT versus GP care for pain intensity and functional
disability (Korthals-de Bos et al., 2003) which are the outcomes
typically selected to judge effectiveness of SMT (Table 3). No studies
were found to investigate the cost-effectiveness of SMT versus
GP care for LBP.
SMT compared to exercise
Two studies adopting a societal perspective reported on SMT
versus exercise in patients with neck pain (Bosmans et al., in press; Korthals-de Bos et al., 2003). Both studies found SMT to be a costeffective
treatment option compared to an exercise program in
terms of pain, recovery and QALY gains (Table 4). The cost-effectiveness
plane by Korthals-de Bos et al. (2003) showed 98% of
the cost-effect pairs for pain located in the South East quadrant
suggesting that SMT is dominant compared with exercise. No
studies were found to investigate the cost-effectiveness of SMT
versus exercise in patients with LBP.
SMT vs. GP care.
SMT compared to Exercise.
SMT plus GP care compared to other
Two studies reported on the cost-effectiveness of SMT plus GP
care compared to GP care alone in LBP (UK BEAM Trial Team, 2004) or neck and LBP ( Williams et al., 2004); in addition one of
the studies also compared SMT plus GP to GP care plus exercise
(UK BEAM Trial Team, 2004). From a UK health care perspective
both trials found SMT plus GP care to be a cost-effective treatment
compared to GP care alone as both ICERs fell below the NICE
threshold (GBP 20,000–GBP 30,000 per QALY gained) despite the
different pain regions being under investigation (Williams et al.:
ICER £3560 per QALY gained in 1999/2000 GBP; UK BEAM Trial
Team: ICER = £4800 per QALY gained in 2000/2001 GBP). SMT plus
GP care was also shown to be a cost-effective treatment when
compared to GP care plus exercise with an ICER of £2300 per QALY
gained in 2000/2001 GBP (Table 5).
SMT plus other treatment compared other
Three studies investigated the cost-effectiveness of a combined
treatment approach, which involved SMT plus advice (delivered by
a physiotherapist or GP) and exercise (Table 6). Two studies, one
from a societal perspective (Niemisto et al., 2005) and the other
from a health sector perspective (UK BEAM Trial Team, 2004), compared
the combined treatment approach to GP care alone for LBP
(UK BEAM Trial Team, 2004; Niemisto et al., 2005). From a societal
perspective, Niemisto et al. (2005) found no difference between
groups in terms of quality of life however the data suggest that the combined treatment incurred lower annual costs compared to
GP care alone. With respect to pain and disability outcomes the
data suggested the combined treatment was dominant over GP
care alone however this was not supported by the conclusions
made by the authors. From a healthcare perspective the UK BEAM
Trial found the combined treatment to be cost-effective over GP
care alone with a low ICER (£3800 per QALY gained in 2000/2001
GBP) (UK BEAM Trial Team, 2004).
For people with neck pain the most cost-effective treatment
was dependant on the perspective, societal or health sector, and
of the threshold for willingness to pay. Advice and exercise was
generally more cost-effective in terms of changes to neck disability
scores from both a societal and healthcare perspective. In terms of
QALY gained the combined approach was more cost-effective from
a societal perspective however from a healthcare perspective there
was more uncertainty as to the most cost-effective treatment with
SMT appearing slightly more advantageous (Lewis et al., 2007).
versus exercise in patients with LBP.
SMT plus GP compared to other
SMT plus other treatment compared to other.
Six economic evaluations were included in this systematic review
which evaluated the cost-effectiveness of SMT compared to
other treatment options for people with neck and back pain. The
studies which evaluated treatments for back pain were primarily
UK studies conducted from a health sector perspective, while the
studies of neck pain were Dutch and Finnish studies conducted
from a societal perspective. Regardless of the perspective employed
or the region of pain, SMT appears to be a cost-effective
treatment when used alone or in combination with GP care or advice
and exercise compared to GP care alone, exercise or any combination
of these. However, as a result of only six studies being
eligible for inclusion the majority of these conclusions are based
on the findings of single studies.
The findings of this review have important clinical, research and
policy implications. Clinically, SMT is a treatment technique frequently
used by a number of health professionals to manage neck
and back pain. Based on the available literature, this review supports
the use of SMT in clinical practice as a cost-effective treatment
when used alone or in combination with other treatment
approaches. In some studies SMT was also shown to be less costly
per unit gained when compared to education, exercise and GP care.
These results are applicable to clinicians, who make recommendations
about treatment options, as well to health consumer who
wish to make informed decision about available health care
From a research perspective this review highlights the need for
more high quality economic evaluations to be conducted alongside
randomised controlled trials of treatment effectiveness. While this
review summarised the available literature, due to a limited number
of studies with heterogeneous populations, perspectives, settings
and analyses it was not possible to pool the results of
included studies. This resulted in a number of conclusions as to
the cost-effectiveness of SMT for neck or back pain to be based
on one study alone. Systematic reviews of randomized controlled
trials have shown that results of one study are often not reliable
and precise. There is no reason to believe that this would be different
for economic evaluations, especially because sample sizes of
economic evaluations are often (too) small, and that economic consequences
differ across different health settings. Of the comparisons
supported by two studies it is worth noting the agreement
between the studies which increases the robustness of the
conclusions which can be made. For example, a comparable ICER
was reported by Williams et al. (2004) and (UK BEAM Trial Team,
2004) when SMT plus GP care was compared to GP care alone
despite the different pain regions and price years reported.
A number of tools are available to assess the risk of bias of economic
evaluations (e.g. CHEC-List Evers et al., 2005, BMJ Check-list
(Drummond and Jefferson, 1996) and The Quality of Health Economic
Studies instrument (Chiou et al., 2003). In our study we used
the CHEC-List as it was generated through the consensus of international
experts in a Delphi method (Evers et al., 2005). In general,
the economic evaluations included in this study were of low risk of
bias with all studies scoring P16 out of 19 on the CHEC-List. The
key item identified for improvement in future studies is the inclusion
of a sensitivity analysis (Item 15). While not an item in the
CHEC-List, other methods of investigating the level of uncertainty
in cost-effectiveness estimates include the cost-effectiveness
acceptability curves and cost-effectiveness plane. These methods
were presented in four of the six included studies (Bosmans
et al., in press; Lewis et al., 2007; Niemisto et al., 2005; Williams
et al., 2004) and five of the six included studies (Bosmans et al.,
in press; Lewis et al., 2007; Niemisto et al., 2005; Korthals-de
Bos et al., 2003; Williams et al., 2004), respectively. Measures of
uncertainty such as these provide a systematic way of dealing with
the level of uncertainty around the results and should be an essential
component in all economic evaluations to assess the robustness
of the conclusions made (van der Roer et al., 2005; Briggs
et al., 1994).
Economic evaluations are an essential consideration to inform
and support health care and funding decision made by insurers,
governments and policy developers. In treatments for spinal pain,
as in the case of SMT, effectiveness studies are often able to demonstrate
treatment effects when compared to no treatment, but fail
to demonstrate which active treatment is more effective (Gross
et al., 2010; Rubinstein et al., 2011). The findings of this review
show that while the treatment effectiveness of SMT is comparable
to other treatments, SMT is a cost-effective treatment option. Furthermore,
this review found the most effective treatment or the
least costly treatment to not always be the most cost-effective
treatment. This demonstrates the valuable information that can
be provided by economic evaluations beyond results of effectiveness
alone and supports the need for more economic evaluation
to be conducted.
This systematic review found SMT to be a cost-effective treatment
to manage spinal pain when used alone or in combination
with GP care or advice and exercise compared to GP care alone,
exercise or any combination of these. The findings were primarily
based on single studies conducted in the UK and the Netherlands.
More high quality studies can support whether the findings of this
review are applicable in other settings.
Conflict of interest
The authors declare that they have no competing interests.
We would like to thank Maurice Driessen for the assistance on
this review. Z.A.M. hold an Australian Government funded
Postgraduate Award, C.G.M. holds a research fellowship from the
Australian Research Council, C.-W.C.L. holds a research fellowship
from the National Health and Medical Research Council of
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