Primary Care

Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomised controlled trialCommentary: Bootstrapping simplifies appreciation of statistical inferences

BMJ 2003; 326 doi: http://dx.doi.org/10.1136/bmj.326.7395.911 (Published 26 April 2003) Cite this as: BMJ 2003;326:911

Abstract

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

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

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

Footnotes

    • Accepted 26 February 2003

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

    1. Ingeborg B C Korthals-de Bos, research fellow (ibc.korthals-de_bos.emgo{at}med.vu.nl)a,
    2. Jan L Hoving, research fellowa,
    3. Maurits W van Tulder, senior investigatora,
    4. Maureen P M H Rutten-van Mölken, senior investigatorb,
    5. Herman J Adèr, biostatisticiana,
    6. Henrica C W de Vet, professor in clinimetricsa,
    7. Bart W Koes, professor of general practice researchc,
    8. Hindrik Vondeling, senior investigatora,
    9. Lex M Bouter, professor in epidemiologya
    1. a Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands
    2. b Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
    3. c Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
    4. Universitätsklinik für Notfallmedizin, Allgemeines Krankenhaus Wien, Währinger Gürtel 18-20/6D, A-1090 Vienna, Austria
    1. Correspondence to: I B C Korthals-de Bos
    • Accepted 26 February 2003

    Abstract

    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

    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

    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

    Footnotes

    • Funding Netherlands Organization for Scientific Research (904-66-068) and the Health Insurance Council's fund for investigative medicine (OG95-008).

    • Competing interests None declared.

    • Ethical approval The medical ethics committee of the VU University Medical Centre approved the study protocol.

    • Accepted 26 February 2003

    Commentary: Bootstrapping simplifies appreciation of statistical inferences

    1. Marcus Müllner, clinical epidemiologist (marcus.muellner{at}univie.ac.at)
    1. a Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands
    2. b Institute for Medical Technology Assessment, Erasmus University, Rotterdam, Netherlands
    3. c Department of General Practice, Erasmus Medical Centre, Rotterdam, Netherlands
    4. Universitätsklinik für Notfallmedizin, Allgemeines Krankenhaus Wien, Währinger Gürtel 18-20/6D, A-1090 Vienna, Austria
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