i Background and purpose Although there are now many trials of the effectiveness of back pain treatments, there are few robust cost effectiveness analyses of these treatments.

ii Methods and Results: We analysed the cost-effectiveness of adding to ‘best care’ in general practice for patients consulting with low back pain: spinal manipulation; exercise classes; or manipulation followed by exercise (‘combined treatment’) alongside the UK BEAM trial. We collected health care resource use and health-related quality of life data at baseline, 3 and 12 months from 1334 trial participants. We estimated participant-specific quality-adjusted life-years (QALYs) and costs over the 12 months study period. Over one year mean treatment costs relative to ‘best care’ were: £195 (95% credibility interval £85 to £308) for manipulation; £140 (£3 to £278) for exercise; and £125 (£21 to £228) for combined treatment. All three active treatments increased participants’ average QALYs compared with ‘best care’ alone. For each extra QALY that combined treatment yielded relative to ‘best care’, it cost £3,800; in economic terms it had an ‘incremental cost-effectiveness ratio’ (ICER) of £3,800. Manipulation alone had an ICER of £8,700 relative to combined treatment. If the NHS were prepared to pay at least £10,000 for each extra QALY (lower than previous recommendations in the UK), manipulation alone would probably be the best strategy. If manipulation were not available, exercise would have an ICER of £8,300 relative to ‘best care’.

iii Conclusions The UK BEAM spinal manipulation package is a cost-effective addition to ‘best care’ for back pain in general practice.