BMJ 2003;326:911 ( 26 April )

Primary care

Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trial

Ingeborg B C Korthals-de Bos, research fellow, ^a Jan L Hoving, research fellow, ^a Maurits W van Tulder, senior investigator, ^a Maureen P M H Rutten-van Mölken, senior investigator, ^b Herman J Adèr, biostatistician, ^a Henrica C W de Vet, professor in clinimetrics, ^a Bart W Koes, professor of general practice research, ^c Hindrik Vondeling, senior investigator, ^a Lex M Bouter, professor in epidemiology. ^a

^a Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands, ^b Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands, ^c Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands

Correspondence to: I B C Korthals-de Bos ibc.korthals-de_bos.emgo{at}med.vu.nl

Objective: To evaluate the cost effectiveness of physiotherapy, manual therapy, and care by a general practitioner for patients with neck pain.
Design: Economic evaluation alongside a randomised controlled trial.
Setting: Primary care.
Participants: 183 patients with neck pain for at least two weeks recruited by 42 general practitioners and randomly allocated to manual therapy (n=60, spinal mobilisation), physiotherapy (n=59, mainly exercise), or general practitioner care (n=64, counselling, education, and drugs).
Main outcome measures: Clinical outcomes were perceived recovery, intensity of pain, functional disability, and quality of life. Direct and indirect costs were measured by means of cost diaries that were kept by patients for one year. Differences in mean costs between groups, cost effectiveness, and cost utility ratios were evaluated by applying non-parametric bootstrapping techniques.
Results: The manual therapy group showed a faster improvement than the physiotherapy group and the general practitioner care group up to 26 weeks, but differences were negligible by follow up at 52 weeks. The total costs of manual therapy (447; £273; $402) were around one third of the costs of physiotherapy (1297) and general practitioner care (1379). These differences were significant: P<0.01 for manual therapy versus physiotherapy and manual therapy versus general practitioner care and P=0.55 for general practitioner care versus physiotherapy. The cost effectiveness ratios and the cost utility ratios showed that manual therapy was less costly and more effective than physiotherapy or general practitioner care.
Conclusions: Manual therapy (spinal mobilisation) is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner.

What is already known on this topic The cost of treating neck pain is considerable Many conservative interventions are available, such as prescription drugs, yet their cost effectiveness has not been evaluated No randomised trials of conservative treatment for neck pain have so far included an economic evaluation What this study adds Manual therapy is more effective and less costly than physiotherapy or care by a general practitioner for treating neck pain Patients undergoing manual therapy recovered more quickly than those undergoing the other interventions

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© 2003 BMJ Publishing Group Ltd
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