Trial Report Cost Utility of Specialist Physiotherapy for Functional Motor Disorder (Physio4FMD), 2025, Hunter, Stone, Carson, Edwards et al

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They have a new economic analysis of the trial out. They say the intervention is cost-effective. In a tweet the main author (Nielsen) wrote: "It is possible to have a treatment that may not be significantly more clinically effective, but has a high probability of being more cost effective."

So apparently it's cost-effective, by whatever way they're calculating it. Interesting how that works.

 

What are they comparing the effect against?

If they found that it’s as effective as another intervention, but a lot cheaper, it would make sense to say it’s more cost-effective.

But if the effect is not clinically significant, it can’t be cost effective because you’d essentially be dividing by zero.

 

Amazing. They found a way of dividing by zero: find a machine that doesn't mind being stuck in an infinite loop. Yes, it's the most expensive machine in the world, and it produces nothing of value, but it will just keep on adding -1 to 1 over and over again.

"Imagine a world"-based medicine for the, uh, loss, I guess.

 

They say treatment as usual. Despite a 4% difference in costs (according to them, which is an unreliable source so whatever). Which all seems to ignore the fact that TAU remains ongoing. And for, as they admit, no difference in QALY, even though it's QALY's value that is used here. But the dividing by zero machine will happily go ahead and do that.

 

Although I guess they're actually comparing this to itself:

So I guess the idea is the difference between generic neurologic physiotherapy, and specialist psychosomatic physiotherapy, which is even more generic.

Oh, my bad, they divided by 0.03, so not quite zero:

Now, 0.03, which is somehow there despite there being "no significant difference in QALYs over the 12-month duration of the trial", amounts to a mean of 11 days.

This would sound impressive:

If QALY wasn't a measly 11 days.

Lies, damned lies, and statistics. This is basically delusional.

 

I tried to take a look at the math.

Incremental cost is how much more it cost per participant to use specialist physio (I’ll call it SP) compared to TAU.

£143 more for SP vs TAU.

A and E = accident and emergency. Inpatient = required to stay at hospital etc.

£84 more for SP vs TAU.

Outpatient = did not have to stay at hospital.

£165 more for SP vs TAU.

I do not understand where they got £374 from. It only appears as a standard deviation and is not in any of the supplementary files.

£143 + £84 + £165 = £392
With 0.03 QALY, that’s £13,067 per QALY.

If the £143 cost of SP is supposed to be £374 in the above calculation, the total would be £623 or £20,767 per QALY (more than the standard £20,000 threshold they quote).

 

The far more interesting story is found in the supplementary files. This is the first part of the table.

They excluded C because they barely completed the study due to lockdown. That’s fine.

But there is a drastic difference between pre- and post-pandemic participants.

For pre (AB):
£745 and an incremental QALY of 0.02. That’s £37,250 per QALY - almost double the threshold of £20,000.

For post (D):
SP was cheaper then TAU with a better outcome, so it would be a win-win.

If all of AB completed the intervention before the pandemic and follow up was 12 months, they would have had all of their data for half a year before they recruited group D. There is no mention of blinding in any of the papers. So they might have known that the treatment didn’t work before they decided to recruit more participants - and the new participants tipped the scales in their favour!

Edit: they use «masking» instead of blinding. So the comment above might not be correct.

 

I wonder how blinding worked if all authors had access to the data. This might not have included that key to unblind the data?

 

Regardless of the masking, the difference between A+B and D is very peculiar.

 

It feels like it must surely these days be only fools that believe the reason double-blinding is needed is because of the minds of the participants and nothing to do with the people whose fortunes will be made on them ‘submitting the right answers to tye questionnaire’ maybe being the ones who change their behaviour.

 

This is what I don't get. They're using 0.03 even though it's not a statistically significant finding but I don't see them explaining that decision anywhere, unless I missed it.

 

They «address» it towards the end of the economic analysis:

 

Oh, I see--thanks. Economics uses different methods. Ok, I get that.

This seems self-serving to me:

"Another important contributor to the different findings is likely to be that the primary outcome of clinical effectiveness was an overly narrow view of the potential benefits of physiotherapy. The secondary outcome, the patient-reported Clinical Global Impression Improvement score, allows for a broader assessment of potential impacts that specialist physiotherapy can have across various aspects of patients' lives, including the cost impact, thus capturing a wider range of outcomes. It is notable that consensus recommendations for outcome measures in FND (published after this trial was planned) have recommended the patient-reported Clinical Global Impression of Improvement as the primary outcome measure in trials of interventions in FND."

The CGI-I is basically, do you feel improved or have your symptoms improved, and you get five choices. So in that sense I guess it covers a lot of ground, like they say. But that's because it's pretty vague and non-specific. It doesn't seem to provide any yardstick beyond your prior assessment. In contrast, the SF-36 asks very specifically about a range of activities and whether you can perform them, and you rate each one, and there's a composite score that they can conpare against other populations. While both are subjective and self-reported and subject to bias, it seems like one that requires you to think about each activity and rate it has some advantages over one that just says, essentially, Do you feel better than before?

 

There's a very odd vibe over quality of life and how despite claims of curative treatments, the ideologues always fall back onto things like quality of life when it all fails. Even though they never actually improve any of it. Not for real. Only appearances on cheap biased questionnaires.

When you examine our quality of life, including people labeled FND, it's among the lowest levels of quality of life out there, and it hardly seems to bother anyone involved in this. As long as someone can report a slight uptick of 2-3 points on whatever scale, it's basically as if they solved it. That scale could be a thousand points and they'd still argue that this tiny improvement should be interpreted like the first rising part of an exponential curve that will hit max level shortly, right around the corner, inevitable.

It's been a while since I just assume they're all either lying or delusional, or probably a combination of both. Everyone involved in this. I don't know how else to interpret pretending to tweak at the margins of something this significant, and never being bothered by the sheer mass that they ignore.

That's just the natural outcome of a system built on lies and delusional fantasies. As reality keeps on disagreeing with their models, they have to increasingly ignore reality and fall back onto trivial nonsense. But among professionals, this stuff will always be presented as curative treatments that are effective for anyone who truly wants to 'get better'. They hold on to the blatant and disgusting lies that tens of millions of people have no quality of life, just because we can't accept having psychological disorders and follow the easy instructions out of it.

This is the ultimate delusion, the broader profession pretending like those delusions are anything but that. But the lies have piled up so high over decades, a literal mountain made of millions of destroyed lives, that it's not possible to walk any of it back. So they just keep piling and piling because the number of people who truly care and understand, outside of patients and the few loved ones that stick around and care, probably fit in a bus.

Sorry, maybe a bit lugubrious but this is just the sober reality of what we are dealing with. The scale of it. The sheer monstrosity of what those people do in complete, and smug, obliviousness.

 

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regarding the cost-effectiveness paper, I'm a bit perplexed about an intervention with null results that is still found to be "cost-effective." How does that work??

 

"Our study found that staring at a wall was a cost-effective solution for type I diabetes, because staring at a wall is cheaper than insulin."