J Manipulative Physiol Ther. 2014 (Jul); 37 (6): 343362 ~ FULL TEXT
Alexander Tsertsvadze, MD, MSc, Christine Clar, PhD, Rachel Court, MA,
Aileen Clarke, MD, Hema Mistry, PhD, Paul Sutcliffe, DPhil
Senior Research Fellow,
Warwick Medical School,
University of Warwick, Coventry, UK.
OBJECTIVES: The purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions.
METHODS: A comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases.
RESULTS: Twenty-five publications were included (11 trial-based economic evaluations). The studies compared cost-effectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain.
CONCLUSIONS: Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients.
From the FULL TEXT Article
Manual therapy is a skilled nonsurgical conservative management using the practitioner's hands and/or fingers on the patient's body for the purpose of assessing, diagnosing, and treating a variety of symptoms and conditions. [1, 2] Manual therapy is used within the traditional medical (eg, physiotherapy, orthopedics, and sports medicine) and complementary and alternative medicine context (eg, chiropractic and osteopathy) and consists of different techniques (eg, manipulation, mobilization, static stretching, and muscle energy techniques). The definition and purpose of manual therapy vary across health care professionals.
The use of manipulation and mobilization has been recommended in clinical practice guidelines in the United States, Great Britain, Canada, and the Netherlands.  Although past research evidence on the clinical effectiveness  and safety  of manual therapy relative to other interventions is abundant, the evidence on cost-effectiveness is insufficient and inconclusive.  Moreover, to our best knowledge, a systematic review of full economic evaluations of recent evidence (ie, cost-effectiveness [CEA] and/or cost-utility analysis [CUA]) alongside randomized controlled trials (RCTs) of manual therapy has not been conducted.
In light of limited health care resources, policy makers, health care providers, and researchers need to make informed decisions in prioritizing and allocating resources to the provision of health care interventions that are both effective and cost saving. Ideally, the decision-making process should be based on high-quality evidence summarizing incremental costs and effects of a health care intervention of interest compared with alternative interventions.
The aim of this review was to systematically identify, appraise, and evaluate the evidence on trial-based economic evaluations (cost-effectiveness and/or cost-utility) of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions.
This review identified limited evidence indicating that manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy consisting of manipulation and mobilization techniques, and chiropractic manipulation), in addition to other treatments or alone, are more cost-effective than usual GP care (alone or with exercise), spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back pain and/or disability. Similarly, one study  demonstrated that spinal manipulation in addition to GP care was more cost-effective than GP care alone in reducing shoulder pain and related disability. The extra costs needed for 1unit improvement in low back or shoulder pain/disability score or 1 QALY gained were lower than the WTP thresholds reported across the studies.
The cost-effectiveness of manual therapy for improving neck pain, disability, and QALYs gained in comparison with other treatments was not consistent across the studies. For example, one trial [63, 64] demonstrated the domination of chiropractic manipulation over physiotherapy or GP care in improving neck pain and QALYs gained. In 2 other trials, either alternative intervention (behavioral graded activity) was more cost-effective than manual therapy  or the probability for manual therapy being more cost-effective compared with advice plus exercise was too low. 
The evidence regarding cost-effectiveness of manual therapy compared with physiotherapy for reducing pain and disability related to ankle fractures, as reported in one study,  has been insufficient and inconclusive because of small sample size and uncertainty around the cost-effectiveness measure.
It is difficult to draw definitive conclusions regarding the comparative cost-effectiveness of manual therapy techniques in patients with spinal pain due to the paucity, clinical heterogeneity (eg, different techniques, wide variety of comparators), and study-related shortcomings (eg, small sample, short follow-up, high uncertainty in the estimates of ICERs) of the identified evidence. For example, the use of different manual therapy techniques (eg, manipulation, mobilization, and chiropractic care) in combination with other interventions (eg, physiotherapy, exercise, and GP care) leads to differential effectiveness profiles, thereby limiting the comparability of results across studies. The nonspecific or contextual effects (eg, intervention fidelity, placebo effect, practitioner's experience) due to the complexity of interventions and lack of patient blinding may have biased the study results for subjective outcome measures such as pain, disability, and QOL. Because none of the studies used a sham/control arm, it is difficult to tease out the specific effects of treatment from patients' differential expectation (or practitioner's experience/skill set) across the study treatment arms. 
All the included studies were trial-based economic evaluations. None of the studies used economic modeling to extrapolate beyond the trial data to look at the longer-term cost-effectiveness of the different interventions. Studies reporting cost-effectiveness acceptability curves (CEACs) used bootstrapping, none of the studies used simple one-way or multiway sensitivity analyses to check for uncertainty in any of the key cost factors, which may be driving the ICER.
Limitations and Strengths
The findings of this review are not directly comparable with those of other systematic reviews, [2833, 7181] given the differences in scope, research question, study inclusion/exclusion criteria, types of economic evaluation, and interventions. The findings of these reviews were either inconclusive because of the paucity and heterogeneity of the evidence for manual therapy  or showed some cost-effectiveness of manual therapy over alternative treatments (eg, usual care and exercise). [71, 75, 76, 78, 79, 81]
The applicability of findings of the included studies, despite them being pragmatic, may be limited to only countries with similar health care system and considerations of utility (eg, calculations based on the same QOL instrument). The applicability may also be limited by the differences in components of manual therapy interventions and short follow-ups of the studies.
The strengths of the current review include the reviewer's use of systematic and independent strategies to minimize the ROB in searching, identifying, selecting, extracting, and appraising the primary studies. The search strategy was applied to multiple electronic databases and other sources such as references of relevant primary studies and systematic reviews. Also, this review summarized the evidence from studies that evaluated costs and effectiveness simultaneously through cost-effectiveness and/or CUAs by providing ICERs. As a limitation, this review included only RCT-based cost-effectiveness evaluations.
This paper provides a platform for further research into the cost-effectiveness of manual therapy for the management of musculoskeletal conditions. The findings underscore the paucity of good-quality published evidence on this issue. This is based on the small number of identified RCTs focus of which is rather limited (ie, nonspecific spinal pain). The insufficient evidence on cost-effectiveness may be explained by difficulties in obtaining cost data, lack of expertise in economic outcomes, and/or perceived societal discomfort with assigning monetary units to human health.  Raising awareness among the chiropractic community about the importance of undertaking more high quality economic evaluations is needed.
Because several studies did not use QALYs as an outcome measure, this presents difficulty for decision makers if they wish to compare value for money across musculoskeletal conditions with other health conditions such as cancer and cardiovascular disease, in line with the cost-effectiveness thresholds set by NICE. Consideration of the competing demand/supply side issues of manual therapy and how these issues may vary across countries is needed. Furthermore, it is not clear whether the affordability of manual therapy in countries where the provision of such services fall outside publicly funded arrangements is likely to influence utilization; this raises questions about the generalizability of the current reported findings.
We recommend that future studies report unit cost calculation with costs broken down by each service to allow the judgment as to whether all relevant costs for a given perspective were considered and how the total costs were calculated. If ethically justifiable, future trials need to include sham or no treatment arm to allow the assessment and separation of nonspecific effects (eg, patient's expectation) from treatment effects. More exploration is warranted about which characteristics of manual therapy (eg, mode/frequency of administration or choice of spinal regions) are important for clinically relevant and patient-centered outcomes. Finally, greater consideration is needed to improve reporting quality of primary studies evaluating manual therapy.
Preliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients.
Farrell, JP and Jensen, GM.
Manual therapy: a critical assessment of role in the profession of physical therapy.
Phys Ther. 1992; 72: 843852
DeStefano, LA and Greenman, PE.
Greenman's principles of manual medicine. 4th ed.
Lippincott Williams & Wilkins, ; 2010
Jette, AM and Delitto, A.
Physical therapy treatment choices for musculoskeletal impairments.
Phys Ther. 1997; 77: 145154
Bryans, R, Decina, P, Descarreaux, M et al.
Evidence-based guidelines for the chiropractic treatment of adults with neck pain.
J Manipulative Physiol Ther. 2014; 37: 4263
Brantingham, JW, Cassa, TK, Bonnefin, D et al.
Manipulative and multimodal therapy for upper extremity and temporomandibular disorders:
a systematic review.
J Manipulative Physiol Ther. 2013; 36: 143201
Bryans, R, Decina, P, Descarreaux, M et al.
Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Headache
J Manipulative Physiol Ther. 2011 (Jun); 34 (5): 274289
Farabaugh, RJ, Dehen, MD, and Hawk, C.
Management of Chronic Spine-Related Conditions:
Consensus Recommendations of a Multidisciplinary Panel
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651658
Lawrence, DJ, Meeker, W, Branson, R et al.
Chiropractic Management of Low Back Pain and Low Back-Related
Leg Complaints: A Literature Synthesis
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659674
Globe, GA, Morris, CE, Whalen, WM, Farabaugh, RJ, and Hawk, C.
Chiropractic Management of Low Back Disorders:
Report From a Consensus Process
J Manipulative Physiol Ther 2008 (Nov); 31 (9): 651658
Furlan, A.D., Yazdi, F., Tsertsvadze, A. et al.
A Systematic Review and Meta-analysis of Efficacy, Cost-effectiveness,
and Safety of Selected Complementary and Alternative Medicine
for Neck and Low-back Pain
Evid Based Complemen Alt Med. 2012 (Nov 24); 2012: 953139
The Appropriateness of Spinal Manipulation for Low-back Pain
1st ed. Rand Corp, ; 1991
Shekelle, PG, Adams, AH, Chassin, MR, Hurwitz, EL, and Brook, RH.
Spinal manipulation for low-back pain.
Ann Intern Med. 1992; 117: 590598
Bigos, SJ, United States, Agency for Health Care Policy and Research, and American HC.
Acute Lower Back Problems in Adults
US Dept. of Health and Human Services,
Public Health Service, Agency for Health Care Policy and Research, ; 1994
Di Fabio, RP.
Clinical assessment of manipulation and mobilization of the lumbar spine.
A critical review of the literature.
Phys Ther. 1986; 66: 5154
Ottenbacher, K and DiFabio, RP.
Efficacy of spinal manipulation/mobilization therapy. A meta-analysis.
Spine (Phila Pa 1976). 1985; 10: 833837
Bronfort, G., Assendelft, W.J., Evans, R., Haas, M., and Bouter, L.
Efficacy of Spinal Manipulation for Chronic Headache:
A Systematic Review
J Manipulative Physiol Ther 2001 (Sept); 24 (7): 457466
Bronfort, G, Haas, M, Evans, R, Leininger, B, and Triano, J.
Effectiveness of Manual Therapies: The UK Evidence Report
Chiropractic & Osteopathy 2010 (Feb 25); 18 (1): 3
Assendelft, WJ, Morton, SC, Yu, EI, Suttorp, MJ, and Shekelle, PG.
Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness
relative to other therapies
Ann Intern Med. 2003; 138: 871881
Cherkin, DC, Deyo, RA, Battie, M, Street, J, and Barlow, W.
A Comparison of Physical Therapy, Chiropractic Manipulation, and Provision of an
Educational Booklet for the Treatment of Patients with Low Back Pain
New England Journal of Medicine 1998 (Oct 8); 339 (15): 1021-1029
Adverse Effects of Spinal Manipulation: A Systematic Review
J R Soc Med. 2007; 100: 330338
Deaths after chiropractic: a review of published cases.
Int J Clin Pract. 2010; 64: 11621165
Carnes, D, Mars, TS, Mullinger, B, Froud, R, and Underwood, M.
Adverse events and manual therapy: a systematic review.
Man Ther. 2010; 15: 355363
Gouveia, LO, Castanho, P, and Ferreira, JJ.
Safety of chiropractic interventions: a systematic review.
Spine (Phila Pa 1976). 2009; 34: E405E413
Rubinstein, SM, Peerdeman, SM, van Tulder, MW, Riphagen, I, and Haldeman, S.
A systematic review of the risk factors for cervical artery dissection.
Stroke. 2005; 36: 15751580
Vohra, S, Johnston, BC, Cramer, K, and Humphreys, K.
Adverse Events Associated with Pediatric Spinal Manipulation: A Systematic Review
Pediatrics. 2007 (Jan); 119 (1): e275e283
Stevinson, C and Ernst, E.
Risks associated with spinal manipulation.
Am J Med. 2002; 112: 566571
Carlesso, LC, Gross, AR, Santaguida, PL, Burnie, S, Voth, S, and Sadi, J.
Adverse events associated with the use of cervical manipulation and mobilization
for the treatment of neck pain in adults: a systematic review.
Man Ther. 2010; 15: 434444
Maund, E, Craig, D, Suekarran, S et al.
Management of frozen shoulder: a systematic review and cost-effectiveness analysis.
Health Technol Assess. 2012; 16: 1264
Indrakanti, SS, Weber, MH, Takemoto, SK, Hu, SS, Polly, D, and Berven, SH.
Value-based care in the management of spinal disorders:
a systematic review of cost-utility analysis.
Clin Orthop Relat Res. 2012; 470: 11061123
Driessen, MT, Lin, CW, and van Tulder, MW.
Cost-effectiveness of Conservative Treatments for Neck Pain:
A Systematic Review on Economic Evaluations
European Spine Journal 2012 (Aug); 21 (8): 14411450
Furlan, AD, Yazdi, F, Tsertsvadze, A et al.
Complementary and alternative therapies for back pain II
Evidence Report/Technology Assessment No. 194.
(Prepared by the University of Ottawa Evidence-based Practice Center
under Contract No. 290-2007-10059-I (EPCIII). AHRQ Publication No.(11)E007.
Agency for Healthcare Research and Quality,
Rockville, MD; October 2010
Dagenais, S, Roffey, DM, Wai, EK, Haldeman, S, and Caro, J.
Can cost utility evaluations inform decision making about interventions for low back pain?
Spine J. 2009; 9: 944957
Brown, A, Angus, D, Chen, S et al.
Costs and Outcomes of Chiropractic Treatment for Low Back Pain
Technology report no 56.
Canadian Coordinating Office for Health Technology Assessment, Ottawa; 2005
Stevans, JM and Zodet, MW.
Clinical, demographic, and geographic determinants of variation in chiropractic episodes
of care for adults using the 2005-2008 Medical Expenditure Panel Survey.
J Manipulative Physiol Ther. 2012; 35: 589599
Grieves, B, Menke, JM, and Pursel, KJ.
Cost minimization analysis of low back pain claims data for chiropractic vs medicine
in a managed care organization
J Manipulative Physiol Ther. 2009; 32: 734739
Haas, M, Sharma, R, and Stano, M.
Cost-effectiveness of Medical and Chiropractic Care
for Acute and Chronic Low Back Pain
J Manipulative Physiol Ther 2005 (Oct); 28 (8): 555563
Glanville, J, Kaunelis, D, and Mensinkai, S.
How well do search filters perform in identifying economic evaluations in
MEDLINE and EMBASE.
Int J Technol Assess Health Care. 2009; 25: 522529
World Economic Outlook Database. Accessed March 26, 2014
WorldBank, International Monetary Fund, ; 2014
Organisation for Economic Co-operation and Development.
Annual national accounts: PPPs and exchange rates. Accessed March 26, 2014
National Accounts Statistics (database), ; 2014
Drummond, MF, Sculpher, MJ, and Torrance, GW.
Methods for the economic evaluation of health care programmes. 3rd ed.
Oxford University Press, USA; 2005
van Tulder, MW, Furlan, A, Bombardier, C, and Bouter, L.
Updated method guidelines for systematic reviews in the Cochrane Collaboration
Back Review Group.
Spine (Phila Pa 1976). 2003; 28: 12901299
van Tulder, MW, Suttorp, M, Morton, S, Bouter, LM, and Shekelle, P.
Empirical evidence of an association between internal validity and effect size
in randomized controlled trials of low-back pain.
Spine (Phila Pa 1976). 2009; 34: 16851692
Balk, EM, Bonis, PA, Moskowitz, H et al.
Correlation of quality measures with estimates of treatment effect in meta-analyses
of randomized controlled trials.
JAMA. 2002; 287: 29732982
Moher, D, Pham, B, Jones, A et al.
Does quality of reports of randomised trials affect estimates of intervention efficacy
reported in meta-analyses?.
Lancet. 1998; 352: 609613
Bosmans, JE, Pool, JJM, de Vet, HCW, van Tulder, MW, and Ostelo, RWJG.
Is behavioral graded activity cost-effective in comparison with manual therapy for patients
with subacute neck pain? An economic evaluation alongside a randomized clinical trial.
Spine. 2011; 36: E1179E1186
Pool, JJ, Ostelo, RW, Koke, AJ, Bouter, LM, and de Vet, HC.
Comparison of the effectiveness of a behavioural graded activity program and manual therapy
in patients with sub-acute neck pain: design of a randomized clinical trial.
Man Ther. 2006; 11: 297305
Pool, JJ, Ostelo, RW, Knol, DL, Vlaeyen, JW, Bouter, LM, and de Vet, HC.
Is a behavioral graded activity program more effective than manual therapy
in patients with subacute neck pain? Results of a randomized clinical trial.
Spine. 2010; 35: 10171024
Williams, NH, Edwards, RT, Linck, P et al.
Cost-utility analysis of osteopathy in primary care: results from a pragmatic
randomized controlled trial.
Fam Pract. 2004; 21: 643650
Williams, NH, Wilkinson, C, Russell, I et al.
Randomized Osteopathic Manipulation Study (ROMANS): pragmatic trial for spinal pain
in primary care.
Fam Pract. 2003; 20: 662669
UK BEAM Trial Team.
Cost Effectiveness of Physical Treatments for Back Pain in Primary Care
British Medical Journal 2004 (Dec 11); 329 (7479): 13811385
Brealey, S, Burton, K, Coulton, S et al.
UK Back Pain Exercise and Manipulation (UK BEAM) Trial-- National Randomised Trial
of Physical Treatments for Back Pain in Primary Care: Objectives, Design and Interventions
BMC Health Serv Res. 2003 (Aug 1); 3 (1): 16
UK BEAM Trial Team.
Effectiveness of Physical Treatments for Back Pain in Primary Care
British Medical Journal 2004 (Dec 11); 329 (7479): 13771384
Niemisto, L, Rissanen, P, Sarna, S, Lahtinen-Suopanki, T, Lindgren, KA, and Hurri, H.
Cost-effectiveness of combined manipulation, stabilizing exercises, and physician consultation
compared to physician consultation alone for chronic low back pain:
a prospective randomized trial with 2-year follow-up.
Spine. 2005; 30: 11091115
Niemisto, L, Lahtinen-Suopanki, T, Rissanen, P, Lindgren, KA, Sarna, S, and Hurri, H.
A randomized trial of combined manipulation, stabilizing exercises, and physician consultation
compared to physician consultation alone for chronic low back pain.
Spine. 2003; 28: 21852191
Rivero-Arias, O, Gray, A, Frost, H, Lamb, SE, and Stewart-Brown, S.
Cost-utility analysis of physiotherapy treatment compared with physiotherapy advice
in low back pain.
Spine (Phila Pa 1976). 2006; 31: 13811387
Frost, H, Lamb, SE, Doll, HA, Carver, PT, and Stewart-Brown, S.
Randomised controlled trial of physiotherapy compared with advice for low back pain.
BMJ. 2004; 329: 708
Bergman, GJ, Winter, JC, van Tulder, MW, Meyboom-de, JB, Postema, K.
Manipulative therapy in addition to usual medical care accelerates recovery
of shoulder complaints at higher costs: economic outcomes of a randomized trial.
BMC Musculoskelet Disord. 2010; 11: 200
Bergman, GJD, Winters, JC, van der Heijden, GJMG, Postema, K, and Meyboom-de Jong, B.
Groningen Manipulation Study.
The effect of manipulation of the structures of the shoulder girdle as additional treatment
for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms.
Design of a randomized controlled trial within a comprehensive prognostic cohort study.
J Manipulative Physiol Ther. 2002; 25: 543549
Bergman, GJD, Winters, JC, Groenier, KH et al.
Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction
and pain: a randomized, controlled trial.
Ann Intern Med. 2004; 141: 432439
Bergman, GJ, Winters, JC, Groenier, KH, Meyboom-de, JB, Postema, K
Manipulative therapy in addition to usual care for patients with shoulder complaints:
results of physical examination outcomes in a randomized controlled trial.
J Manipulative Physiol Ther. 2010; 33: 96101
Whitehurst, DG, Lewis, M, Yao, GL et al.
A brief pain management program compared with physical therapy for low back pain:
results from an economic analysis alongside a randomized clinical trial.
Arthritis Rheum. 2007; 57: 466473
Hay, EM, Mullis, R, Lewis, M et al.
Comparison of physical treatments versus a brief pain-management programme for back pain
in primary care: a randomised clinical trial in physiotherapy practice.
Lancet. 2005; 365: 20242030
Korthals-de Bos, IBC, Hoving, JL, van Tulder, MW et al.
Cost Effectiveness of Physiotherapy, Manual Therapy, and General Practitioner Care
for Neck Pain: Economic Evaluation Alongside a Randomised Controlled Trial
British Medical Journal 2003 (Apr 26); 326 (7395): 911
Hoving, JL, Koes, BW, de Vet, HC et al.
Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner
for Patients with Neck Pain. A Randomized, Controlled Trial
Ann Intern Med 2002 (May 21); 136 (10): 713722
Lewis, M, James, M, Stokes, E et al.
An economic evaluation of three physiotherapy treatments for non-specific neck
disorders alongside a randomized trial.
Rheumatology (UK). 2007; 46: 17011708
Dziedzic, K, Hill, J, Lewis, M, Sim, J, Daniels, J, and Hay, EM.
Effectiveness of manual therapy or pulsed shortwave diathermy in addition to advice
and exercise for neck disorders: a pragmatic randomized controlled trial in
physical therapy clinics.
Arthritis Rheum. 2005; 53: 214222
Lin, CW, Moseley, AM, Haas, M, Refshauge, KM, and Herbert, RD.
Manual therapy in addition to physiotherapy does not improve clinical or
economic outcomes after ankle fracture.
J Rehabil Med. 2008; 40: 433439
Lin, CC, Moseley, AM, Refshauge, KM, Haas, M, and Herbert, RD.
Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial [ACTRN012605000143628].
BMC Musculoskelet Disord. 2006; 7: 46
Critchley, DJ, Ratcliffe, J, Noonan, S, Jones, RH, and Hurley, MV.
Effectiveness and cost-effectiveness of three types of physiotherapy used to reduce
chronic low back pain disability: a pragmatic randomized trial with economic evaluation.
Spine (Phila Pa 1976). 2007; 32: 14741481
Craig, P, Dieppe, P, Macintyre, S, Michie, S, Nazareth, I, and Petticrew, M.
Developing and evaluating complex interventions: the new Medical Research Council guidance.
BMJ. 2008; 337: a1655
Canter, PH, Coon, JT, and Ernst, E.
Cost-effectiveness of complementary therapies in the United Kingdoma systematic review.
Evid Based Complement Altern Med. 2006; 3: 425432
Cherkin, DC, Sherman, KJ, Deyo, RA, and Shekelle, PG.
A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture,
Massage Therapy, and Spinal Manipulation for Back Pain
Ann Intern Med. 2003; 138: 898906
Coon, JT and Ernst, E.
A systematic review of the economic evaluation of complementary and alternative medicine.
Perfusion. 2005; 18: 202214
Herman, PM, Craig, BM, and Caspi, O.
Is complementary and alternative medicine (CAM) cost-effective? A systematic review.
BMC Altern Med. 2005; 5: 11
Lin, CWC, Haas, M, Maher, CG, Machado, LAC, and van Tulder, MW.
Cost-Effectiveness of General Practice Care for Low Back Pain:
A Systematic Review
European Spine Journal 2011 (Jul); 20 (7): 10121023
Lin, CWC, Haas, M, Maher, CG, Machado, LAC, and van Tulder, MW.
Cost-effectiveness of Guideline-endorsed Treatments for Low Back Pain:
A Systematic Review
European Spine Journal 2011 (Jul); 20 (7): 10241038
Van Der Roer, N, Goossens, MEJB, Evers, SMAA, and van Tulder, MW.
What is the most cost-effective treatment for patients with low back pain?
A systematic review.
Best Pract Res Clin Rheumatol. 2005; 19: 671684
White, AR and Ernst, E.
Economic analysis of complementary medicine: a systematic review.
Complement Ther Med. 2000; 8: 111118
Herman, PM, Poindexter, BL, Witt, CM, and Eisenberg, DM.
Are complementary therapies and integrative care cost-effective?
A systematic review of economic evaluations.
BMJ Open. 2012; 2: e001046
Lewis, R, Williams, N, Matar, HE et al.
The clinical effectiveness and cost-effectiveness of management strategies
for sciatica: systematic review and economic model.
Health Technol Assess. 2011; 15: 1578
Michaleff, ZA, Lin, CW, Maher, CG, and van Tulder, MW.
Spinal Manipulation Epidemiology:
Systematic Review of Cost Effectiveness Studies
J Electromyogr Kinesiol. 2012 (Oct); 22 (5): 655662
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