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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 doi: (Published 09 December 2004) Cite this as: BMJ 2004;329:1381
  1. UK BEAM Trial Team (am126{at}
  1. Correspondence to: Andrea Manca, research fellow, Centre for Health Economics, University of York, York YO10 5DD
  • Accepted 14 October 2004


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 ($360; €279; 95% credibility interval £85 to £308) for manipulation, £140 (£3 to £278) for exercise, and £125 (£21 to £228) 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; in economic terms it had an “incremental cost effectiveness ratio” of £3800. Manipulation alone had a ratio of £8700 relative to combined treatment. If the NHS was prepared to pay at least £10 000 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 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.


  • Full authorship details are given in the accompanying paper (doi:10.1136/bmj.38282.669225.AE.

    We thank all participants—patients, primary care staff, and collaborators listed in the accompanying clinical paper—for their contributions. We thank Mark Sculpher and Daphne Russell for advice on analysis. Members of the UK BEAM Trial Team: Ian Russell, Martin Underwood, Stephen Brealey, Kim Burton, Simon Coulton, Amanda Farrin, Andrew Garratt, Emma Harvey, Louise Letley, Andrea Manca, Jeannett Martin, Jennifer Klaber Moffett, Veronica Morton, David Torgerson, Madge Vickers, Ken Whyte, Melanie Williams.

  • Contributors See accompanying clinical paper. Funding: Medical Research Council (research costs); NHS in England, Northern Ireland, Scotland, and Wales (excess treatment and service support costs).

  • Competing interests LL, JM, MU, MV, and KW have received salaries from the MRC. MU has received fees for speaking from Menarini Pharmaceuticals, the manufacturers of dexketoprofen and ketoprofen, and Pfizer, the manufacturers of celecoxib and valdecoxib. The other 12 authors have nothing to declare.

  • Ethical approval The Northern and Yorkshire multicentre research ethics committee and 41 local research ethics committees approved the trial protocol.

  • Amendment This is Version 2 of the paper. In this version, the text relating to the figure has been amended to state that the curve in the middle panel shows the probability that manipulation is better than best care when exercise is not available, and vice versa for the curve in the bottom panel [these were incorrectly given the other way round in the previous version].

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