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.