The UK BEAM trial – a review and discussion

Abstract

In the hierarchy of evidence that influences healthcare policy, randomised controlled trials (RCTs) are considered by most to be the top individual unit of research. RCTs of treatments for simple, ‘mechanical’ low back pain have consistently shown comparative treatments to have small effect sizes. There are arguments for using both explanatory and pragmatic RCTs to evaluate this field further. The UK Back pain, Exercise And Manipulation (BEAM) trial is the largest pragmatic RCT to have investigated interventions provided by UK osteopaths. The main aim of this review is to describe the UK BEAM trial and to help practitioners judge the external validity of the trial – the extent to which the results of the trial represent their own practices. Two main questions will be addressed: (1) Are the subjects in the trial similar to patients seen in practice? and (2) Are the interventions used in the trial similar to those used in practice? A further aim is to offer some reflections on the strengths and weaknesses of the study. The trial compared the ‘best care’ from General Practitioners (GPs) alone, against best care from GPs plus an exercise class, against best care from GPs plus a manipulation package, against a combination of all of these interventions (best care from GPs plus a manipulation package, followed by an exercise class). The results of the study showed a small, but statistically significant additional positive effect from the manipulation package, as well as smaller positive effects from the exercise package when each was compared to best care from GPs alone. The combination of all three interventions provided a slightly increased effect, but was found to be costly. Whether the size of these positive effects is clinically meaningful remains a point of discussion. Further studies of a more explanatory nature are called for, along with a need to use usual GP care as a control arm if future evaluations are to show the potential of these interventions to contribute to the care of back pain patients.