cost-effectiveness
Ten years after Brexit, it seems reasonable to ask what effects Brexit has caused on health-related matters for the UK and beyond. Here is my attenpt to provide an answer; these are the 8 issues that come to my mind:
- Workforce Disruption and Recruitment Shift: The ending of free movement led to a sharp drop in EU-trained doctors, nurses, and social care staff. To plug these vacancy gaps, the UK was forced into recruiting heavily from non-EU nations. This created a fragile reliance on international recruitment from countries facing their own healthcare worker shortages. In turn, this further supported the xenophobic sentiments of some UK citizens.
- Medicine Supply Problems: Leaving the EU single market introduced significant customs and regulatory friction. This friction directly contributed to the frequency and severity of local pharmaceutical shortages in the UK.
- Loss of Regulatory Leverage: By exiting the European Medicines Agency (EMA), the UK became a standalone market. Pharmaceutical companies now regularly prioritize the much larger EU and US markets for rolling out cutting-edge new treatments, leaving the UK Medicines and Healthcare products Regulatory Agency (MHRA) to act as a “rule-taker” by fast-tracking approvals already granted elsewhere.
- Cross-Border Friction: Reciprocal healthcare arrangements became more complex under the new Global Health Insurance Card (GHIC) system. While basic travel is covered, specialized cross-border medical networks face ongoing administrative and legal hurdles. Many British ex-pats’ found themselves without health cover.
- Regulatory Divergence in Training and Innovation: The UK has increasingly diverged from EU rules, such as lowering the mandatory clinical training hours required for a nursing degree to get staff into hospitals faster. Additionally, medical technology and AI developers now face double-compliance costs (clearing separate UK and EU hurdles). This makes the UK a more expensive market to launch new health technologies.
- The Macro-economic Squeeze: The overall economic downturn resulting from Brexit reduced UK GDP, shrinking the available tax revenues. This has directly limited the government’s financial capacity to fund the NHS, to clear post-pandemic backlogs, and to invest in long-term social care reform.
- Exacerbating Health Inequalities: As inflation, food costs, and supply chain disruptions damaged the UK, vulnerable socioeconomic groups have been hit the hardest. These economic pressures, combined with a chronically strained social care sector, significantly widen UK health inequalities.
- Compounding Pressure on Patient Outcomes: While ultimate health metrics, such as mortality rates and overall life expectancy, are influenced by dozens of complex variables, an underfunded NHS, chronic staffing vulnerabilities, and restricted access to new drugs create a persistent, negative headwind against public health which, in the long run, can only negatively affect patient outcomes.
All of these effects are clearly negative.
Can anyone think of a positive effect?
I can’t!
A contentious debate has just erupted in Germany over the government’s plan to remove homeopathy and anthroposophic medicine from coverage under statutory health insurance (GKV). Former prominent politicians, including Green Party leader Winfried Kretschmann (former Minister President of Baden-Württemberg) and SPD leader Malu Dreyer (former Minister President of Rhineland-Palatinate), signed an “open letter” opposing the removal, arguing it would harm patients and violate ethical principles.
The open letter, launched by the German Central Association of Homeopathic Doctors (DZVhÄ) on June 17, 2026, claims that removing these therapies would be “an expensive wrong decision at the expense of patients.” It cites studies suggesting homeopathy is effective beyond the placebo effect and argues that the majority of German citizens value and benefit from these treatments. Signatories include former Federal Interior Minister Otto Schily (SPD), Greens co-founder Lukas Beckman, actress Sarah Wiener, Alo natura founder Götz Rehn, and “Tatort” actors Hans-Jochen Wagner and Felix Klare, along with former BMG state secretaries Marion Caspers-Merk and Edgar Franke.
The German Ministry of Health (BMG) defends the planned removal as part of the “GKV Contribution Rate Stabilization Act,” which aims to save €20–50 million annually. The ministry correctly states there is “insufficient scientific evidence for effectiveness” and that no evidence exists to justify cost coverage for these therapies. Under the new law, statutorily insured patients would need to pay for homeopathy and anthroposophic medicine themselves or obtain private insurance.
The Bundestag’s final reading of the law was delayed from June 26 to July 10, 2026, giving lawmakers more time to review the open letter before the parliamentary summer recess. This delay reflects the political sensitivity of the issue.
Opposition to the open letter comes from major healthcare organizations. The GKV-Spitzenverband (health insurance federation) supports removing services without scientific evidence, the Kassenärztliche Bundesvereinigung (doctors’ association) welcomes returning to “proven treatment methods.” and IQWIG, the health economics institute, confirms that homeopathy and anthroposophy lack evidence for GKV coverage.
This controversy is unusual because Kretschmann (Greens) and Dreyer (SPD) have in the past been aligned with evidence-based medicine and scientific attitude towards so-called alternative medicine (SCAM).
Allow me to congratulate the signatories for producing what possibly is the finest piece of health-related BS of 2026!
The effect of calcium, vitamin D, or combined supplementation on fractures and falls in adults were assessed in this systematic review and meta-analysis. Randomised clinical trials were eligible, if they compared calcium, vitamin D, or combined supplementation with placebo or no treatment in adults (≥18 years) not receiving drug treatment for osteoporosis. The primary outcome was the risk of any fracture. Secondary outcomes included the risk of hip fracture, non-vertebral fracture, vertebral fracture, and falling, as well as the total number of falls. Pairs of reviewers independently screened trials, extracted data, and assessed risk of bias using the second version of Cochrane’s risk of bias tool. Findings were synthesised using random effects meta-analyses and appraised using Grading of Recommendations Assessment, Development and Evaluation, with application of thresholds for absolute effects considered important.
The review included 69 trials involving 153 902 participants. Participants in most of the trials were community dwelling (87%) and not at high risk of fractures or falls (73%). For the primary outcome of any fracture, little to no effect was found from use of calcium supplements (11 trials, 9067 participants; risk ratio 0.91, 95% confidence interval 0.81 to 1.01; moderate certainty), vitamin D supplements (36 trials, 92 045 participants; 1.00, 0.95 to 1.06; high certainty), or combined supplementation (15 trials, 51 126 participants; 0.91, 0.84 to 0.99; high certainty). Calcium, vitamin D, or combined supplementation appeared to have little to no effect on other fracture and fall outcomes, based largely on moderate to high certainty of evidence. The findings remained robust after an extensive exploration of heterogeneity across multiple subgroup analyses. Evidence for high risk patients or those requiring residential care was limited for many outcomes for calcium monotherapy and for combined supplementation.
The authors concluded that, based on absolute risk reductions and thresholds considered clinically meaningful, this review found little to no benefits from use of calcium, vitamin D, or combined supplementation on the prevention of fractures and falls.
An accompanying BMJ editorial points out that observational studies have associated low dietary calcium and low serum levels of vitamin D with low bone density and falls. Consequently, calcium, vitamin D, or combined supplementation has been widely promoted for preventive musculoskeletal health in older adults…
Th editorial concludes that other interventions, such as balance and resistance exercise, and several multicomponent interventions (eg, combining exercise, hazard assessment, or education with other interventions tailored to risk assessment) have been shown to offer meaningful prevention of falls and falls related injuries.
This new systematic review is a prime example for the slaying of a beautiful hypothesis with an ugly fact. But all is not negative – think of the money that can now be saved and put to better use!
Despite overwhelming evidence proving that homeopathics are pure placebos, a faction of German healthcare professionals – predominantly people who profit from homeopathy – continues to argue against their removal from statutory insurance. They claim that defunding homeopathy would eliminate vital treatment options, ultimately driving patients toward more expensive conventional interventions. However, from a health economics perspective, this argument is fundamentally flawed; subsidizing treatments that lack proven efficacy is not a cost-saving measure, but rather a misallocation of limited healthcare resources.
Recognizing this inconsistency, German policymakers have finally shifted towards a more evidence-based approach. The federal cabinet recently approved a draft law to reform the statutory health insurance system, which includes a pivotal provision: homeopathic and anthroposophic medicines, along with their associated services, will no longer be eligible for reimbursement as optional benefits (Satzungsleistungen) by public insurers.
This legislative move serves as a long-overdue correction to a historically irrational policy that was initiated by the Nazis during the Third Reich. Excluding these treatments, the government is now finally acknowledging that public healthcare contributions should not fund therapies devoid of scientific backing. This decision brings Germany in line with other European countries like France and the UK, and marks a significant alignment of national policy with the dual principles of evidence-based medicine and responsible fiscal management.
At its core, this reform addresses a long-standing critique of how so-called alternative medicine (SCAM) has been integrated into the German healthcare system. For many decades, institutional tolerance allowed ineffective treatments to gain a veneer of legitimacy and public financing. Consequently, this shift is more than a mere technical adjustment; it represents a symbolic turning point in the relationship between science, medicine, and public policy.
The removal of homeopathy from insurance coverage is undoubtedly both scientifically justified and economically imperative. It signals a decisive transition of German medicine towards a more rational, evidence-based healthcare system that prioritizes proven outcomes over tradition.
On this blog, some people insist that homeopathy goes from strength to strength. Here I counter this notion by pointing out that several contries have stopped reimbursing homeopathy and that loss of trust in homeopathy has grown significantly.
Several converging factors explain the erosion of confidence:
- Lack of evidence of effectiveness: Large reviews by national and international bodies (for example the Australian NHMRC and the European Academies’ Science Advisory Council) concluded there is no reliable evidence that homeopathic remedies are effective for any health condition beyond placebo.
- Scientific implausibility: Homeopathy’s principles (high dilutions, “water memory”) conflict with established chemistry and physics, which weakens its credibility among scientists and the informed publics.
- Placebo and expectation effects: Empirical work suggests any benefits are best explained by non-sepecific effects such as placebo responses, contextual care, and patient expectations rather than pharmacological action of the remedies.
- Health literacy: Studies indicate that higher health literacy is associated with greater perceived credibility of conventional medicine and relatively lower credibility of homeopathy, which means better-informed patients tend to trust it less.
- Safety and opportunity costs: Critics emphasize that relying on ineffective remedies can delay effective treatment, prolong illness, and in some cases contribute to preventable harm or death.
A range of actors has shaped this loss of trust:
- Scientific bodies and advisory councils: Organizations such as the NHMRC in Australia and EASAC in Europe have issued high‑profile reports stating that homeopathy lacks robust evidence of efficacy and should not be claimed to treat health conditions.
- National health systems and regulators: NHS England, for instance, has advised against prescribing homeopathy, describing it as unsafe or ineffective where better, cost‑effective options exist, and warning that giving it institutional endorsement risks misleading patients.
- Skeptical and consumer‑protection movements: Skeptics’ groups and consumer advocates have campaigned against public funding of homeopathy and organized public “overdose” demonstrations to highlight the extreme dilutions and question the idea that the products contain active ingredients.
- Critical scientists and physicians: Numerous clinicians and researchers have published analyses arguing that homeopathy violates basic scientific and ethical principles, has no explanatory power, and undermines science‑based medicine.
The loss of trust has produced several consequences across healthcare systems and societies:
- Several public health systems have reduced or eliminated reimbursement and institutional support for homeopathy, reallocating funds towards treatments backed by compelleing evidence.
- Market contraction and repositioning: Declining official endorsement and critical media coverage have contributed to shrinking markets in some countries.
- Manufacturers and practitioners increasingly market homeopathy as “wellness” or “complementary” rather than curative medicine, a notion that would make Hahnemann turn in his grave.
- Homeopathy has become a touchstone in broader debates about scientific literacy, misinformation, and the role of the state in regulating ineffective therapies.
Taken together, these dynamics show how rigorous research, scientific critique, regulatory action, and changing public expectations will gradually strip a once‑popular therapy of its medical legitimacy. Or, to put it bluntly: in medicine, evidence will aways win against belief, even if it takes several decades.
The US stands on the precipice of the destruction of public health. This might be best exemplified by the loss of its measles-free status. In 2000, the U.S. had been classified as having “eliminated” measles, meaning the virus was no longer constantly circulating within its borders. Following a year of record-breaking outbreaks, the Pan American Health Organization (PAHO) is now reviewing whether to officially revoke this status.
The technical definition of losing elimination status is the continuous transmission of the same strain of a virus for more than 12 months. In 2025, the US experienced over 2,400 confirmed cases—the highest count since 1991—driven by major outbreaks in Texas, South Carolina, Arizona, and Utah. While health officials once relied on high vaccination rates to “wall off” imported cases, that protection has now crumbled. National MMR (measles, mumps, and rubella) vaccination rates for kindergartners have fallen below the 95% threshold required for achieving herd immunity. This leaves communities vulnerable to the kind of rapid spread seen over the past year.
The resurgence of measles is inextricably linked to the shift in federal health policy under Robert F. Kennedy Jr., the current Secretary of Health and Human Services (HHS). His influence has transformed vaccine hesitancy in the US from a fringe movement into a pillar of federal discourse. Kennedy has frequently misused his position to question the safety and necessity of the MMR vaccine, at one point suggesting that “natural infection” might be preferable to vaccination—a claim experts call dangerously misleading given that measles can cause encephalitis, permanent hearing loss, and death. Under Kennedy’s leadership, the CDC has been staffed with notorious anti-vaxers and reduced the number of recommended childhood vaccines and emphasized “personal choice” over community mandates. This shift has emboldened several states to loosen school entry requirements, leading to a record number of non-medical vaccine exemptions. By replacing members of the Advisory Committee on Immunization Practices (ACIP) with anti-vaxers, Kennedy has signaled a move away from the decades of scientific consensus that underpinned the 2000 elimination achievement.
Kennedy – who has no medical background and does clearly not understand science – argues that the primary threat to US health is not infectious disease but chronic illness (e.g., diabetes, obesity, and autism), which he feels are linked to environmental factors and food quality. His alternatives include advocating for “real food,” reducing ultra-processed foods, and discouraging the use of seed oils and certain pesticides. He has promoted the consumption of unpasteurized dairy, despite warnings from health officials regarding bacterial risks. He advocates for ending water fluoridation, claiming it contributes to chronic health issues in children. Kennedy also believes that “natural infection” – contracting the disease itself – can be a preferable alternative to vaccination for certain illnesses. He has expressed his support for un- or disproven treatments such as hydroxychloroquine and ivermectin for viral infections, as well as the use of psychedelics and stem cells in broader health contexts. His MAHA plan promotes a “holistic” approach that combines conventional medicine withhis complementary therapies like supplements and acupuncture.
To make matters even worse, the US officially completed its withdrawal from the World Health Organization (WHO) on January 22, 2026. This finalized a process that began on January 20, 2025, when Trump signed Executive Order 14155 on his first day in office. His previous attempt during his 1st term to leave the WHO was reversed by the Biden administration in 2021.
Losing measles-free status is more than a symbolic blow; it has practical and dire consequences. It signals to the world that the US public health infrastructure is failing to contain one of the most contagious diseases known to man. It means that “rare” outbreaks will become a permanent fixture of American life, requiring constant vigilance for infants too young to be vaccinated and the immunocompromised. And it bodes badly, of course, for the time when the next pandemic will emerge.
As the CDC completes its genomic sequencing to determine if the 2025 outbreaks constitute a single, unbroken chain of transmission, the US faces a choice. We are witnessing a “natural experiment” in real-time—one where the cost of Kennedy’s sick ideology is being paid in the form of preventable hospitalizations and lives lost. To put it bluntly: either the US gets rid of Kennedy and swiftly reverses his detrimental initiatives, or many US citizens will suffer ill health and even die because of his actions.
This year’s ‘Christmas issue’ of the BMJ comes with a remarkable editorial. Please allow me to quote a few passages from it:
We live in a world of lies, damned lies, and AI hallucinations. A US publication calculated that Donald Trump told 30 573 lies during his first term as president. Trump is neither alone nor atypical—except that his rate of lying and the thickness of his brass neck may be unprecedented…
We live in the era of the Big Lie. The more powerful you are, the bigger the lie you can tell. Nobody holds you to account. We no longer call lies “lies”: they are alternative facts, different versions of the truth, and—in perhaps the most sinister twist—hallucinations. Our old fashioned, and possibly unfashionable, view … is that words and facts do matter…
… the term “hallucination” deserves greater scrutiny. An AI hallucination is a fabrication, a lie, a bullshit. Why does it earn such a soft name, which seeks to hide the failure or error rate of an AI tool? The answer inevitably lies in money. Tech guru and science fiction writer Cory Doctorow argues that tech companies’ primary interest is to convince investors and markets of their relentless growth. Hype about AI’s capabilities sells. Hallucinations cover its failures…
As we end the year of the Big Lie, what’s clear is that the world isn’t ruled by citizens. It never was. It’s no longer ruled by the great religions, although they may delude themselves that it is. Nor is it primarily ruled, hubris aside, by politicians or dictators. Without a doubt—and more clearly than ever before—the world bows to the power of the corporation. Hail the multinational, the conglomerate. All hail the tech bros. We live in their age of surveillance capitalism. There are many words for this unspoken calamity, but “hallucination” is regrettably not one of them.
Inspriewed by these words, I decided to list some of the biggest lies from the world of so-called alternative medicine (SCAM) as they emerged during 2025. Here they are together with some ot the blog posts that disclosed them:
- HOMEOPATHY CURES CANCER Homeopathy as a therapy for cancer? A new review from India, Homeopathy in the Fight Against Breast Cancer: ANOTHER DEATH BY HOMEOPATHY, Finally! The long-awaited ‘retraction notice’ of the infamous study by Frass et al (on homeopathy for cancer) has been published
- TRADITIONAL USAGE GUARANTEES SAFETY Kampo-induced liver injury: A case report and a systematic review
- CHIROPRACTIC IS HARMLESS Katie May died after chiropractic manipulation – but that’s not the chiro’s fault, claims chiro Steven P. Brown, Death following chiropractic neck manipulation, a rare event?, “Horrifying truth about chiropractors and why paralysis, strokes and deaths are far more common than you’d imagine”, Chiropractic Manipulation: Two Months in Bed With Pain and a Herniated a Disc, nother stroke following chiropractic neck manipulation, “After seeing the chiropractor, I was seeing things and blacking out”, Chiropractic spinal manipulation: what harm can it cause?, Patient suffers spinal bleed after chiropractor visit, Acute Spinal Epidural Hematoma: A Serious Complication of Chiropractic Therapy
- HOMEOPATHY IS INCREASINGLY POPULAR Homeopathy continues its retreat in Germany, A change of mind: The German Green Party is now against the reimbursement of homeopathy
- THE GCC IS FIT FOR PURPOSE Following the death of a young woman, the UK General Chiropractic Council received a ‘Prevent Future Deaths’ report
- THE SCAM INDUSTRY IS BENIGN The “dark underbelly” of the alternative health industry
- VARIOUS FORMS OF ENERGY HEALING ARE EFFECTIVE Faith-healing: US parents were convicted of child-abuse and murder, Is Reiki effective for postmenopausal symptoms? No, I’m afraid not!, Non- Physical Beings Assisting in Reiki Sessions: is this the most impressive BS of the year?, Healing crystals: do they work beyond placebo? … Short answer: No, Distant Reiki for Health and Wellbeing of Dogs – WHAT IS NEXT?, Impact of ‘biofield energy’ treatment on broiler chicken growth performance, feed efficiency, carcass characteristics, and meat quality, Reiki for postmenopausal symptoms? No, thanks!, Qigong for Well-Being in Pregnancy?, A placebo-controlled, randomized trial confirms: REIKI IS BOGUS!
- HOMEOPATHY IS EVIDENCE-BASED The “SCIENTIFIC EVIDENCE ON HOMEOPATHY”: does this amount to scientific misconduct?, The Mechanism of Action of Homeopathy! … Someone please inform the Nobel Prize Committee, The role of homeopathy in managing 50 common conditions, The (In)Effectiveness of Homeopathic Remedies in Treating Respiratory Infections, The absurdity of homeopathy, homeopaths and their arguments, Homeopathy for odontogenic infections?, A new study of agrohomeopathy – will it change the hitherto negative evidence?, Homoeopathy as a Complementary Approach to Migraine Management? No, thanks!, A Brazilian cow with cancer cured by homeopathy?, COMIC RELIEF: “The Principle of Homeopathy”, Homeopathy in chronic disease management: a “critical” review of the evidence, “Homeopathy addresses anemia’s complexities with finesse”
- SCAM IS ETHICAL Legal And Ethical Challenges of So-Called Alternative Medicine, Why homeopaths cannot possibly obtain informed consent from their patients, The Nuremberg Code: is it being followed by researchers of so-called alternative medicine (SCAM)?
- ACUPUNCTURE IS A PANACEA Acupuncture for the Management of Attention-Deficit/Hyperactivity Disorder, The characteristics and essence of meridians and acupoints (or: How the ‘Flat Earth Society’ can demonstrate that our planet has the shape of a disc), Acupuncture for Patients With Major Depressive Disorder? No, definitely no!
In SCAM, we live indeed in the era of the Big Lie, and not just since 2025! I will continue to do my best in disclosing untruths and farauds in 2026 and [I hope] beyond.
Why?
Mainly because I want to prevent harm done to vulnerable patients.
Homeopathy is among the most popular kinds of so-called alternative medicine (SCAM). Patients have different opinions about homeopathy because there is still debate about its efficacy and scientific foundation, despite its popularity. The purpose of this cross-sectional study was to compare homeopathic therapies to conventional medicine in terms of patient satisfaction for a range of health issues.
Secifically, the Indian researchers aimed to compare levels of patient satisfaction with homeopathic vs conventional treatments in terms of:
- treatment results,
- side effects,
- cost,
- and overall experience.
A varied group of patients undergoing therapy for long-term diseases like anxiety, asthma, and arthritis provided the data. Patients’ levels of satisfaction with their therapy, its duration, their perceptions of safety, and the quality of their interactions with their providers were measured using a standardized survey that contained Likert-scale items.
Patients who had homeopathic treatment were more likely to be satisfied with their tailored care and the low frequency of adverse effects, according to the results. On the other hand, patients receiving conventional treatments were more satisfied with the rapid alleviation of their symptoms and the fact that their treatments were based on solid evidence. But many patients in both categories were worried about how much their treatments would cost and whether or not they would be beneficial in the long run. Perceivable treatment efficacy, safety, and the total healthcare experience are three of the many aspects that impact patients’ levels of satisfaction.
The authors concluded that the significance of patient-centered care and the necessity for additional research to comprehend the elements contributing to contentment in various treatment modalities highlight the value of both conventional and homeopathic treatments.
This amazingly incompetent paper was published in the ‘Indian Journal of Ayurvedic & Alternative Medicine’ by Dr. Anil Kumar Sharma. He is the dean of the Faculty of Homoeopathy, Govt. Ayush University, Kurukshetra Professor, JRK Homoeopathic Medical College, Rohtak Teacher Code Registered with National Homoeopathic Commission, Govt. of India.
Amazingly incompetent?
I better justify this verdict!
But where to begin? I cannot possibly discuss all the fatal flaws of this paper. Let me just mention a few obvious ones:
- A “standardized survey” was used to measure the outcomes. But was it validated to ensure that it quantified what the researcher thought to measure? No!
- Were the two patient groups comparable? No!
- Were they objective? No, the homeopathy group has chosen to consult homeopaths. Thus the results are as meaningful as asking people who choose to buy a hamburger whether they like eating beef.
- The conclusions are pure fantasy and do not follow from the data.
You may feel that all this is irrelevant nonsense – and you would be entirely correct. Yet, I think that this paper might still be important for one reason: it was published by the dean of the Faculty of Homoeopathy, Govt. Ayush University, Kurukshetra Professor. Imagine the dean of the faculty of cosmology of a reputable university wrote a paper claiming without any eveidence that the earth was flat. That, in my view, would be the equivalent of the above article.
The United States spends more money on the care of back and neck pain than any other health condition. Despite this, the cost-effectiveness for many recommended treatments is unclear. Our primary objective for this project was to estimate the cost-effectiveness of spinal manipulative therapy (SMT), supervised exercise therapy (ET), and home exercise and advice (HEA) for spinal pain in the U.S.
The researchers analyzed cost and clinical outcome data from eight randomized trials conducted in the U.S. using an individual participant data meta-analysis approach. They calculated cost-effectiveness from the societal and healthcare perspective of various comparisons between SMT, ET, and HEA. Incremental cost-effectiveness ratios (ICERs) were calculated using quality-adjusted life years as the main outcome.
The 8 trials included a total of 1803 participants and 1488 (83%) provided complete data. Incremental cost-effectiveness ratios and probabilities of cost-effectiveness varied substantially between studies; thus, the reseaarchers did not conduct meta-analysis and report findings from individual trials.
Cost-effectiveness findings were favorable for SMT compared to HEA for acute neck pain (ICERs below $50k/QALY) and when added to HEA for chronic back-related leg pain and chronic neck pain in older adults (better outcomes and lower costs). However, SMT was not likely cost-effective compared to HEA for chronic back pain in adults or when added to HEA for older adults (higher costs and worse outcomes).
Findings for SMT were favorable when compared to ET in adults with chronic back pain and when added to ET for chronic neck pain in adults (better outcomes and lower costs) and chronic back pain in adolescents (ICERs below $50k/QALY). However, SMT is not likely cost-effective when compared to ET for chronic neck pain in adults (ICERs below $70k/QALY for exercise) and findings were inconsistent across outcomes in older adults with chronic back pain.
Finally, ET may be cost-effective compared to HEA for adults with chronic neck pain (ICERs largely between $100-$200k/QALY), but not for chronic back pain or when added to HEA for older adults with chronic neck or back pain (higher costs and worse outcomes).
The authors concluded that overall based on willingness to pay thresholds of $50-$200k/QALY, there was moderate to high probability that spinal manipulation is cost-effective relative to HEA for neck pain and back-related leg pain, but not for chronic back pain. There was also moderate to high probability spinal manipulation was cost-effective relative to exercise therapy for chronic back pain but findings were mixed for neck pain and more favorable in older adults. Cost-effectiveness findings for exercise therapy were mostly not favorable relative to less intensive home exercise programs as costs were higher, and outcomes were often worse.
The authors admit that their analyses have several limitations: Randomized clinical trials are often designed to detect important differences in disease-specific clinical outcomes that are most likely to be impacted by the treatments assessed (e.g., pain severity, disability). Important measures for assessing cost-effectiveness include general health outcomes like changes in QALYs, healthcare use, and missed work. These measures were collected alongside disease-specific measures, but the trials were not powered to detect important differences in cost-effectiveness outcomes. Participants self-reported their use of healthcare and medications along with number of missed workdays. We did not have access to administrative data for healthcare use or costs. While access to administrative data would have reduced potential measurement error for these variables, it is not without limitations due to the high variability in coverage and re-imbursement policies for healthcare procedures across insurance products in the U.S. Costs for reduced productivity due to spinal pain included missed work in and outside of the home, but costs due to reduced productivity while still at work (i.e., presenteeism) were not included. This is an important limitation as costs due to reduced productivity while at work consistently account for a large proportion of total costs in spinal pain burden of illness studies. Finally, all studies were conducted in the U.S. with resources valued using U.S. prices and findings are not likely generalizable to populations or healthcare systems in other countries.
The authors stress that additional studies are needed to assess the cost-effectiveness of these approaches relative to medical care, the most common treatment approach in the US , as well as other guideline recommended treatments such as massage, acupuncture, mindfulness-based stress reduction, tai chi, yoga, and cognitive behavioral therapy
In view of these limitations and the fact that just 8 trials could be included, the relatively firm comclusions are surprising, in my view. To me, much of the data look unconvincing, somewhat random, inconsistent and implausible. could it be that the authors were trying to generate and emphacize positive results? After all, most of them are affiliated to the “Integrative Health and Wellbeing Research Program Earl E. Bakken Center for Spirituality & Healing, University of Minnesota”!
Back pain has become a widespread issue that significantly affects many aspects of the lives of those afflicted. Hydrotherapy has gained attention in the medical and sports communities and has been recognized as a valuable treatment method. The aim of the current research was to determine the effect of hydrotherapy on pain intensity and balance in people with non-specific chronic back pain.
For this systematic review, Persian and English articles were searched for between 2014 and 2024 in Google Scholar, Scopus, PubMed, SID, ISC, and Magiran databases. Finally, 21 relevant articles were selected based on the inclusion and exclusion criteria. The effect of hydrotherapy on pain intensity and balance in people with chronic non-specific low back pain was investigated.
The results of 2 studies showed that hydrotherapy and the Williams flexion model significantly reduced pain and increased dynamic balance. Three studies suggested that hydrotherapy exercises have positive effects on reducing pain and improving balance in people with chronic non-specific low back pain. One study indicated that hydrotherapy does not affect the electrical activity of the back muscles and that the improvement of pain depends on other factors. In addition, the results of 4 studies showed that hydrotherapy exercises and massage therapy help reduce pain, where 6 studies showed that specific movements in water and strengthening the core muscles are also beneficial.
The authors concluded that, based on the studies reviewed in the present research on hydrotherapy, this method can be considered one of the effective approaches for reducing pain intensity and improving balance in individuals with non-specific chronic back pain.
Great, yet another method that is effective for back pain!
The evidence is as good as for many other approaches.
Hold on, there are many caveats!!!
- Due to the nature of the treatment, most primary studies do not control for placebo effects (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The treatment is not a uniform modality but includes several different therapies which makes it impossible to say what actually works and what not (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The primary studies are burdened with many more methodological flaws (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The research is done mostly by investigators who want to show that their treatment works (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
- The effect sizes tend to be small (JUST LIKE STUDIES OF CHIROPRACTIC, FOR INSTANCE).
I could continue, but you probably get the drift.
So, if you have back pain, should you see a chiropractor (osteopath, acupuncturist, homeopath, other SCAM practitioner who claims his/her therapy works for sore backs) or a practitioner of hydrotherapy?
A difficult choice?
Let me help you:
- the evidence is flimsy for all;
- the costs for chiro etc. tend to be high;
- the risks of chiro etc. can be considerable;
Best to choose a treatment that is inexpensive and low-risk … which means?
Yes, you got it: you might as well choose hydrotherapy!
