Editor—Ernst is correct that the beneficial effects UK BEAM found for manipulation could be a non-specific effect. This was a pragmatic study testing a package of manipulatory treatment, not an explanatory study seeking to assess the effect of manipulation itself.
All the manipulation practitioners used a common treatment package agreed by the three professional groups.1 Any comparisons between the professions would be underpowered and, because participants were allocated to therapists nearest their home, non-randomised. Such a comparison was specifically precluded when the professions agreed to the treatment package.
Ernst's data do not support the assertion that adverse effects occur after 50% of spinal manipulations.2 Any such effects are usually minor and short lived. Set against the positive effect of being able to do one more daily activity one year later we would not expect this to influence general practitioners' referral decisions.
Tilett is concerned about our follow up rate. For a large nationwide trial of this nature it was, if anything, better than might be expected. Since the characteristics of those lost to follow up were consistent across all randomised groups, and the largest difference in follow up rates between treatment and control groups was only 4.1%, little risk of bias exists. Our sensitivity analysis, using the last observation carried forward, does not change our findings.
Tveito and Eriksen argue that we should recommend adding exercise to “best care” even though exercise did not produce a statistically significant benefit at one year and its overall cost is greater than either manipulation or best care. Our data do not support the premise that manipulation and exercise are equally effective.3 The average benefits of the BEAM interventions for individual patients are small. However, at a population level, our manipulation or combined packages produce an overall benefit at modest cost, as other healthcare use fell during the following year.
Church is unclear on our health economic conclusions. We are not recommending manipulation as the only treatment option. Instead we are saying that the UK BEAM manipulation package is the best strategy should the decision maker be willing to pay £8700 or more for each additional quality adjusted life year (QALY). If a decision maker is willing to pay > £3800 and < £8700 per additional QALY, combined treatment is the best strategy. When the decision maker is willing to pay < £3800 per QALY general practitioner care is the best strategy.
Competing interests: MU has received a salary from the MRC and fees for speaking from Menarini Pharmaceuticals, the manufacturers of dexketoprofen and ketoprofen, and Pfizer, the manufacturers of celecoxib and valdecoxib.
References
- 1.Harvey E, Burton AK, Moffett JK, Breen A. On behalf of the UK BEAM trial team. Spinal manipulation for low-back pain: a treatment package agreed to by the UK chiropractic, osteopathy and physiotherapy professional associations. Manual Therapy 2003;8: 46-51. [DOI] [PubMed] [Google Scholar]
- 2.Ernst E. Prospective Investigations into the safety of spinal manipulation. Journal of Pain and Symptom Management 2001;21: 238-42. [DOI] [PubMed] [Google Scholar]
- 3.Jones B, Jarvis P, Lewis JA, Ebbutt AF. Trials to assess equivalence: the importance of rigorous method. BMJ 1996;313: 36-9. [DOI] [PMC free article] [PubMed] [Google Scholar]