Cost effectiveness of complementary treatments in the United Kingdom: systematic review
Canter et al. · BMJ · 2005
Evidence Level
MODERATEOBJECTIVE
Evaluate the cost-effectiveness of complementary therapies in the United Kingdom
WHO
Patients with low back pain, neck pain, and chronic migraine
DURATION
Studies of 6 to 12 months
POINTS
Individualized acupuncture (specific points not reported)
🔬 Study Design
Acupuncture + usual care
n=401
up to 3 sessions over 3 months
Chiropractic
n=741
up to 10 sessions over 12 months
Osteopathy
n=210
3 sessions
Manipulation + exercise
n=1334
2-8 sessions over 12 weeks
📊 Results in numbers
Cost per QALY - acupuncture
Cost per QALY - osteopathy
Headache reduction with acupuncture
Cost per QALY - manipulation + exercise
Percentage highlights
📊 Outcome Comparison
Total annual cost (£)
Direct cost of treatment (£)
This study shows that acupuncture and manual therapies such as chiropractic and osteopathy can be effective but represent additional costs to the British National Health Service. The cost-effectiveness values are comparable to other treatments already approved by the NHS.
Article summary
Plain-language narrative summary
This systematic review represented the first comprehensive effort to evaluate the cost-effectiveness of complementary therapies in the United Kingdom through 2005. The researchers analyzed five high-quality randomized controlled trials, involving 2,726 participants, focusing on acupuncture for chronic migraine and different manual therapy modalities for spinal pain. The acupuncture study for chronic migraine demonstrated promising results, with a 34% reduction in headache frequency compared with 16% in the usual care group. The total annual cost was £403 for additional acupuncture versus £217 for usual care, resulting in a cost of £9,180 per quality-adjusted life-year (QALY).
This value is considered acceptable within NHS standards. The four manual therapy studies addressed different types of spinal pain. The comparison between individualized chiropractic and hospital mobilization showed direct costs of £165 versus £111, respectively, with chiropractic showing better functional outcomes in the long term. The osteopathy study for subacute pain showed superior efficacy to usual care at two months, with an estimated cost of £3,560 per QALY.
The most comprehensive study compared manipulation, exercise, and combined treatment for chronic low back pain, finding that combined treatment was more effective with a cost of £3,800 per QALY. All studies presented important methodological limitations, including inability to blind, incomplete measurement of indirect costs, and absence of sham controls. Follow-up costs and potential adverse effects were not adequately considered. Cost-effectiveness estimates may be less favorable in routine clinical practice compared with the controlled environment of clinical trials.
Despite these limitations, the results suggest that both acupuncture and manual therapies may represent cost-effective options within the British health system, with QALY values comparable to other interventions approved by the NHS.
Strengths
- 1First systematic review of cost-effectiveness of complementary therapies in the United Kingdom
- 2Included only high-quality randomized controlled trials
- 3Rigorous economic analyses with QALY calculation
- 4Robust total sample with more than 2,700 participants
Limitations
- 1Incomplete measurement of indirect and follow-up costs
- 2Inability to blind participants
- 3Lack of adequate sham controls
- 4Results may not reproduce in routine clinical practice
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
The question of cost-effectiveness rarely enters the clinical reasoning of the office, but it should — especially in a context of pressured private health insurance and public systems that must justify coverage. This systematic review, in consolidating five high-quality randomized clinical trials with more than 2,700 participants, offers the clinician concrete data to support the indication of acupuncture and manual therapies before managers and payers. The cost of £9,180 per QALY for acupuncture in chronic migraine and £3,800 per QALY for manipulation combined with exercise fall within ranges considered acceptable by health technology assessment agencies. In pain and rehabilitation practice, this translates into an objective argument for including acupuncture in the therapeutic plan of patients with refractory headache or chronic low back pain, especially when pharmacological escalations with high cost and unsatisfactory functional impact have already been exhausted.
▸ Notable Findings
The most expressive data point in this review is the 34% reduction in headache frequency with acupuncture, versus 16% in the usual care group — a clinically meaningful difference, not merely statistical. For anyone routinely treating chronic migraine, this magnitude of response is relevant and difficult to obtain with isolated oral prophylaxis adjustment in patients with a history of multiple therapeutic failures. Another notable finding is the performance of osteopathy in subacute pain, with £3,560 per QALY, a value lower than that of acupuncture itself in this analysis — signaling that early manual interventions in the subacute phase may be particularly cost-efficient by shortening chronification. The study comparing chiropractic with hospital mobilization reinforces that superior long-term functional outcomes may justify a higher initial direct cost, an argument that applies directly to discharge planning in rehabilitation services.
▸ From My Experience
In my practice at the musculoskeletal pain clinic, the discussion of cost-effectiveness with the patient is routine — and having solid numbers from a review published in the BMJ greatly facilitates this conversation. For chronic migraine, I typically see a perceptible response between the third and fifth acupuncture session, with an initial protocol of eight to ten weekly sessions before spacing to monthly maintenance. The patients who respond best are those with an associated cervical tension component who have already poorly tolerated oral prophylaxis due to adverse effects. For chronic low back pain, I combine acupuncture with a supervised exercise program from the start — exactly the model of the most effective arm of this review. I do not indicate isolated acupuncture when there is acute motor neurological deficit or suspicion of structural cause not yet investigated. The response profile I see in the service is consistent with the data consolidated here: gradual functional gain, more visible in quality of life outcomes than in pure pain scores.
Full original article
Read the full scientific study
BMJ · 2005
DOI: 10.1136/bmj.38625.575903.79
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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