• Sandra Hollinghurst, Debbie Sharp, Kathleen Ballard, Jane Barnett, Angela Beattie, Maggie Evans, George Lewith, Karen Middleton, Frances Oxford, Fran Webley, and Paul Little.
• Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA. s.p.hollinghurst@bristol.ac.uk
• BMJ. 2008 Dec 11; 337: a2656.

ObjectiveAn economic evaluation of therapeutic massage, exercise, and lessons in the Alexander technique for treating persistent back pain.DesignCost consequences study and cost effectiveness analysis at 12 month follow-up of a factorial randomised controlled trial.Participants579 patients with chronic or recurrent low back pain recruited from primary care.InterventionsNormal care (control), massage, and six or 24 lessons in the Alexander technique. Half of each group were randomised to a prescription for exercise from a doctor plus behavioural counselling from a nurse.Main Outcome MeasuresCosts to the NHS and to participants. Comparison of costs with Roland-Morris disability score (number of activities impaired by pain), days in pain, and quality adjusted life years (QALYs). Comparison of NHS costs with QALY gain, using incremental cost effectiveness ratios and cost effectiveness acceptability curves.ResultsIntervention costs ranged from pound30 for exercise prescription to pound596 for 24 lessons in Alexander technique plus exercise. Cost of health services ranged from pound50 for 24 lessons in Alexander technique to pound124 for exercise. Incremental cost effectiveness analysis of single therapies showed that exercise offered best value ( pound61 per point on disability score, pound9 per additional pain-free day, pound2847 per QALY gain). For two-stage therapy, six lessons in Alexander technique combined with exercise was the best value (additional pound64 per point on disability score, pound43 per additional pain-free day, pound5332 per QALY gain).ConclusionsAn exercise prescription and six lessons in Alexander technique alone were both more than 85% likely to be cost effective at values above pound20 000 per QALY, but the Alexander technique performed better than exercise on the full range of outcomes. A combination of six lessons in Alexander technique lessons followed by exercise was the most effective and cost effective option.

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