Cost Effectiveness of Physiotherapy, Manual Therapy, and General Practitioner Care for Neck Pain

Korthals-de Bos IB, Hoving JL, van Tulder MW, Rutten-van Molken MP, Ader HJ, de Vet HC, Koes BW, Vondeling H, Bouter LM

Institute for Research in Extramural Medicine, VU University Medical Centre, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands. ibc.korthals-de_bos.emgo@med.vu.nl

Neck problems account for considerable pain and stiffness that can lead to work absenteeism, disability and use of health care resources. Various conservative interventions have been proposed for treating neck pain, but few scientific evaluations have included any analysis of their cost-effectiveness.

This randomized, controlled trial compared the efficacy of manual therapy, physiotherapy and general practitioner care in reducing neck pain. One hundred eighty-three patients with neck pain of at least two weeks' duration were randomly assigned to one of three groups: manual therapy (spinal mobilization); physiotherapy (mainly exercise); or general practitioner care (counseling, education and analgesics). Manual therapy consisted of a range of interventions: muscular mobilization, specific articular mobilization, coordination or stabilization. Spinal mobilization was defined as low-velocity, passive movements within or at the limit of joint range of motion.

Outcome measures included perceived recovery, intensity of pain, functional disability and quality of life; direct and indirect costs were measured to determine mean costs between groups, overall cost-effectiveness, and cost-utility ratios. Patients completed cost diaries for one year, providing data on direct health care costs of practitioner care; additional visits to other health care providers; drugs; professional home care; and hospitalization. Direct non-health care costs included out-of-pocket expenses; paid and unpaid help; and travel expenses. Indirect costs (lost of production attributable to work absenteeism or days of inactivity for those with or without a job) also were evaluated.

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 euro; 273 pounds sterling; 402 dollars) were around one third of the costs of physiotherapy (1297 euro) and general practitioner care (1379 euro). 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.