BMJ  2005;330:674 (19 March), doi:10.1136/bmj.330.7492.674-a

Letter

United Kingdom back pain exercise and manipulation (UK BEAM) trial

Is manipulation the most cost effective addition to "best care"?

EDITOR—We are surprised by the conclusions of the two papers by the UK BEAM Trial Team.^{1 2} The authors compared three interventions: manipulation, exercise, and the combination of manipulation and exercise. In the recently published European guidelines for treatment of chronic low back pain (www.backpaineurope.org) the trial is rated as of high quality.³ However, the treatment effects are small, and they are not clinically significant.⁴

Surprisingly, there are no comparisons between the treatments. So far as we can tell from the information given in the papers, simple Student's t-tests do not show any significant differences between exercise and manipulation on Roland Morris or the physical component scale of the SF-36. The only significant difference is on the mental component scale of the SF-36, manipulation being significantly better than exercise at three months.

It is, therefore, difficult to follow why the authors claim that spinal manipulation is a cost effective addition to "best care" for back pain in general practice, and that manipulation alone may give better value for money than manipulation followed by exercise.

As we understand the papers, manipulation and best care were of equal benefit regarding clinical significance (Roland Morris), and there was no significant difference between exercise and manipulation (Roland Morris and SF-36 physical component). Given that there is no clinical effect, we would expect that the least expensive treatment would be recommended. If any treatment should be added on to best care, we think that exercise would be the better choice because of all the other health benefits.

Torill.Tveito{at}psych.uib.no, Department of Biological and Medical Psychology, University of Bergen, Jonas Liesvei 91, N-5009 Bergen, Norway

Department of Biological and Medical Psychology, University of Bergen, Jonas Liesvei 91, N-5009 Bergen, Norway

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Competing interests: None declared.

References

1. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ 2004;329: 1377-81. (11 December.)[Abstract/Free Full Text]
2. UK BEAM Trial Team. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 2004;329: 1381-5. (11 December.)[Abstract/Free Full Text]
3. European Commission Research Directorate General. Cost action B13. Low back pain: guidelines for its management. Available at: www.backpaineurope.org/web/html/wg2_results.html (accessed 10 Mar 2005).
4. Kovacs FM, et al. Does the UK BEAM trial really support the use of manipulation? Electronic response to: United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. bmj.com 2004. http://bmj.bmjjournals.com/cgi/eletters/329/7479/1377#92349 (accessed 10 Mar 2005.)

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