Introduction
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Provide evidence-based information on prognosis, advise to remain active, provide information about effective self-care options (referred to as advice for the rest of the paper)
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In addition, consider the use of medications with proven benefits
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For patients who do not improve, consider the addition of spinal manipulation for acute LBP
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For patients who do not improve, consider the addition of interdisciplinary rehabilitation, exercise, acupuncture, massage, spinal manipulation, yoga, cognitive-behavioural therapy or relaxation for sub-acute or chronic LBP
Methods
Data sources and searches
Study selection and quality assessment
Data extraction, synthesis and analysis
Results
Characteristics of included trials
Risk of bias of the trial design
Risk of bias score (/11) | CHEC-list (/19)a
| |
---|---|---|
Critchley et al. [33] | 7 | 19 (0) |
Goossens et al. [41] | 2 | 14 (1) |
Herman et al. [46] | 6 | 17 (1) |
Hlobil et al. [26] | 7 | 15 (2) |
Hollinghurst et al. [34] | 7 | 17 (1) |
Johnson et al. [35] | 7 | 12 (1) |
8 | 13 (0) | |
Kominski et al. [30] | 5 | 11 (4) |
Lamb et al. [36] | 7 | 15 (1) |
Loisel et al. [25] | 5 | 14 (0) |
Molde Hagen et al. [27] | 7 | 12 (1) |
6 | 16 (0) | |
Ratcliffe et al. [37] | 5 | 19 (0) |
Rivero-Arias et al. [38] | 8 | 18 (1) |
Rivero-Arias et al. [39] | 5 | 18 (0) |
Schweikert et al. [44] | 5 | 17 (1) |
Seferlis et al. [31] | 4 | 7 (5) |
Skouen et al. [28] | 5 | 14 (1) |
Smeets et al. [42] | 8 | 18 (1) |
Strong et al. [20] | 4 | 13 (1) |
Torstensen et al. [29] | 6 | 9 (2) |
UK BEAM Trial Team [40] | 5 | 17 (1) |
Van der Roer et al. [43] | 6 | 18 (1) |
Whitehurst et al. [32] | 6 | 17 (1) |
Witt et al. [45] | 4 | 13 (1) |
Quality of the economic evaluation
Advice (provide evidence-based information on prognosis, advise to remain active, provide information about effective self-care options)
Study ID | Comparative treatments | Details of economic evaluation | Results of economic evaluation |
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Herman et al. [46] | Advice (advice and back booklet) Naturopathic care (acupuncture, relaxation) and back booklet | Type: CEA/CUA Perspective: societal, employer and patient Setting: Canada, 2005 Follow-up: 6 months | ICER for naturopathic care compared to advice: QALY (SF-6D) = naturopathic care and back booklet dominant (i.e. incurred lower costs and more effective) from societal and patient’s perspective Absenteeism = 154 (2005 USD) per absentee day avoided from employer’s perspective |
Hlobil et al. [26] | Advice Advice plus graded activity using cognitive-behavioural principles | Type: CBA Perspective: employer Setting: The Netherlands, 1999–2000 Follow-up: 1 year for costs, 3 years for other outcomes | Mean cost benefit = 999 (1999 Euro) favouring advice plus graded activity (95% CI −1,073 to 3,115) |
Lamb et al. [36] | Group cognitive behavioural intervention plus advice Advice | Type: CEA/CUA Perspective: healthcare sector Setting: United Kingdom, price year 2008 Follow-up: 1 year | ICER for Group cognitive behavioural intervention plus advice = 1,786 (2008 GBP) per QALY gained (EQ-5D) |
GP care GP care plus advice (advice, education, exercise) | Type and perspective: not stated Setting: Finland 1998–2000 Follow-up: 24 months | No ICER conducted, but advice incurred lower costs and was more effective in proving daily symptoms, pain bothersomeness, satisfaction, days on sick leave (i.e. dominant). | |
Molde Hagen et al. [27] | Advice (advice and simple exercises) Usual care in primary care | Type: CBA Perspective: societal Setting: Norway, price year 1995 Follow-up: 1 year for costs, 3 years for other outcomes | Mean cost benefit = 3,497 (1995 USD) favouring advice |
Advice (advice, education and simple exercises) Advice plus manipulation and stabilizing exercises | Type: CEA/CUA Perspective: societal Setting: Finland, study initiated in 1999 Follow-up: 2 years | ICER for advice plus manipulation and stabilizing exercises compared to advice [mean (95% CI)]: Pain = 512 (2002 USD) per 1 point gained on a 100-point scale (77–949) Disability (Oswestry) = −78 (2002 USD) per 1 point gained on a 100-point scale (−655 to 499) | |
Rivero-Arias et al. [38] | Advice Physiotherapy | Type: CEA/CUA Perspective: unspecified for ICER Setting: United Kingdom, 1997–2001 Follow-up: 1 year | ICER for physiotherapy compared to advice: 3,010 (2004 GBP) per QALY gained (EQ-5D) |
Book on back pain care Advice (psychologist-led group education sessions) | Type: CEA/CUA Perspective: health insurer Setting: United States, 1996–1997 Follow-up: 1 year | ICER for advice compared to book [mean (95% CI)]: 6.13 (USD, price year not reported) per one low-impact back pain days (1.48–21.14) | |
Book on back pain care Advice (layperson-led group education sessions) | Type: CEA/CUA Perspective: health insurer Setting: United States, 1996–1997 Follow-up: 1 year | ICER for advice compared to book [mean (95% CI)]: 9.70 (USD, price year not reported) per one low-impact back pain days (−45.45 to 78.86) |
In addition, consider the use of medications with proven benefits
For patients who do not improve, consider the addition of spinal manipulation for acute LBP
For patients who do not improve, consider the addition of interdisciplinary rehabilitation, exercise, acupuncture, massage, spinal manipulation, yoga, cognitive-behavioural therapy or relaxation for sub-acute or chronic LBP
Study | Comparative treatments | Details of economic evaluation | Results of economic evaluation |
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Critchley et al. [33] | Physiotherapy Spinal stabilization exercises Pain management programme using CBT | Type: CEA/CUA Perspective: healthcare sector Setting: United Kingdom, 2002–2005 Follow-up: 18 months | No raw data reported, but pain management programme associated with least costs and acceptability curve shows that it is likely to be most cost-effective |
Hlobil et al. [26] | Advice Advice plus graded activity using CBT | Type: CBA Perspective: employer Setting: The Netherlands, 1999–2000 Follow-up: 1 year for costs, 3 years for other outcomes | Mean cost benefit = 999 (1999 Euro) favouring advice plus graded activity (95% CI −1,073 to 3,115) |
Hollinghurst et al. [34] | GP care GP care plus exercise and behavioural counselling | Type: CEA/CUA Perspective: healthcare sector, patients, societal Setting: United Kingdom 2002–2004 Follow-up: 18 months | ICER for GP care plus exercise and behavioural counselling compared to GP care (in 2005 GBP per 1 unit of effect gained, from the healthcare sector’s perspective only): Disability (RMDQ) = 61 Pain-free days = 9 QALY gained (EQ-5D) = 2,847 |
Johnson et al. [35] | GP care Exercise and education using CBT | Type: CEA/CUA Perspective: not stated Setting: United Kingdom 2002–2003 Follow-up: 15 months | ICER for exercise and education using CBT compared to GP care: 5,000 (2003–2004 GBP) per QALY gained (EQ-5D) |
Kominski et al. [30] | GP care Chiropractic care (manipulation, instruction in back care and exercise) | Type: CMA Perspective: not stated Setting: United States 1995–1998 Follow-up: 18 months | Costs over 18 months in USD [price year not stated, mean (SD)]: GP care = 463 (1,225) Chiropractic care = 550 (834) GP care significantly cheaper |
Lamb et al. [36] | Group cognitive behavioural intervention plus advice Advice | Type: CEA/CUA Perspective: healthcare sector Setting: United Kingdom, price year 2008 Follow-up: 1 year | ICER for Group cognitive behavioural intervention plus advice = 1,786 (2008 GBP) per QALY gained (EQ-5D) |
Loisel et al. [25] | GP care Clinical rehabilitation (back pain specialist, back school ± multidisciplinary rehabilitation) | Type: CEA/CUA and CBA Perspective: insurance provider Setting: Canada 1991–1993 Follow-up: mean 6.4 years | ICER for treatments compared to GP care (in 1998 Canadian dollars per 1 day on full benefit): Clinical rehabilitation = −67.6 dominant |
Advice (advice, education and simple exercises) Advice plus manipulation and stabilizing exercises | Type: CEA/CUA Perspective: societal Setting: Finland, study initiated in 1999 Follow-up: 2 years | ICER for advice plus manipulation and stabilizing exercises compared to advice [in 2002 USD per 1 point gained, mean (95% CI)]: Pain (0–100) = 512 (77–949) Disability (Oswestry, 0–100) = −78 (−655 to 499) | |
Rivero-Arias et al. [39] | Outpatient rehabilitation Spinal surgery | Type: CEA/CUA Perspective: healthcare sector and patient Setting: United Kingdom, 1996–2002 Follow-up: 2 years | ICER for spinal surgery compared to outpatient rehabilitation [in 2002–2003 GBP]: 48,588 per QALY gained (95% CI −279,883 to 372,406) |
Schweikert et al. [44] | Inpatient rehabilitation Inpatient rehabilitation plus CBT | Type: CEA/CUA Perspective: societal Setting: Germany, price year 2001 Follow-up: 6 months | ICER for inpatient rehabilitation plus CBT compared to inpatient rehabilitation −126,731 (2001 Euro) per QALY gained (EQ-5D, dominant) |
Skouen et al. [28] | GP care Light interdisciplinary rehabilitation Extensive interdisciplinary rehabilitation | Type: CBA Perspective: societal Setting: Norway 1996–1997 Follow-up: 2 years after end of treatment | Cost benefit for treatments compared to GP care: Light interdisciplinary rehabilitation in male patients = 7,240,900 (1998 Norwegian kroner) for the male participants (n = 21) over 24 months Extensive interdisciplinary rehabilitation —no data reported |
Torstensen et al. [29] | Medical exercise therapy Physiotherapy Walking | Type: CBA Perspective: not reported Setting: Norway, 1993–1996 Follow-up: 15 months | Cost benefit compared to walking in Norwegian Kroner (price year not reported): Medical exercise therapy (n = 69) = 906,732 less Physiotherapy (n = 67) = 1,882,560 less |
UK BEAM Trial Team [40] | GP care GP care plus exercise GP care plus manipulation GP care plus manipulation followed by exercise | Type: CEA/CUA Perspective: healthcare sector Setting: United Kingdom, 1999–2002 Follow-up: 1 year | ICER for treatments compared to GP care [in 2000–2001 GBP per QALY gained (EQ-5D)]: GP care plus exercise = 8,300 GP care plus manipulation = 4,800 GP care plus manipulation followed by exercise = 3,800 |
Van der Roer et al. [43] | Exercise and back school (using behavioural principles) Physiotherapy | Type: CEA/CUA Perspective: societal Setting: The Netherlands, price year 2004 Follow-up: 1 year | ICER for exercise and back school compared to physiotherapy (in 2004 Euro per unit of effect gained): Disability (RMDQ) = 16,349 Pain (numerical rating scale) = −175 (dominant) Perceived effects (Global perceived effects scale) = 1,720 QALY (EQ-5D) = 5,141 |
Whitehurst et al. [32] | Physiotherapy Pain management programme using CBT | Type: CEA/CUA Perspective: healthcare sector Setting: United Kingdom, price years 2001–2002 Follow-up: 1 year | ICER for physiotherapy compared to pain management (in 2001–2002 GBP per unit of effect gained): Disability (RMDQ) = 156 QALY (EQ-5D) = 2,362 |