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It's not clear why the authors recommend manipulation alone, because
it costs more per QALY than combined and even slightly more than exercise
alone. The average effect of the combined therapy is larger in absolute
terms than the other two, as well.
Sorry for the silly title. In Germany, we are supposed to be still
able to afford, on PHS costs, up to 6 individual therapy units per 3
months, i.e. that a patient with a common back pain gets 6 x 45 minutes
within 3 months of an individual gym (or even massage) session, eye to eye
with a single physiotherapist.