Recurrent and persistent low back pain : course and prevention

Background: Non-specific low back pain (LBP) causes more disability than any other condition in the world. The need to understand the clinical course of LBP, develop effective strategies to manage and if possible prevent future episodes are greater than ever. A fundamental aspect of specifying an episode of pain is to define when it ends, however to date no evidence based definition of recovery from LBP exists.

Psychological factors have been shown to affect the prognosis and treatment response for patients with LBP. To what extent psychological and behavioral factors affect chiropractic patients and the outcome of treatment is unclear.

Although it seems logical to prevent a condition such as recurrent and persistent LBP few strategies have been shown to be effective. Many patients who seek treatment from chiropractors for recurrent and persistent LBP often get the recommendation to continue treatments after the pain has subsided with the intention to prevent future episodes. Whether this strategy is effective or cost-effective is unknown.

Aims: The overall aim of the thesis is to investigate the course of LBP from the perspective of episodes, psychological factors and prevention. The specific objectives were to investigate the: I) Prevalence of four consecutive weeks free from pain and its applicability as a marker of episode. II) Psychological and behavioral characteristics of chiropractic patients and compare them to three other back pain populations from primary and secondary care. III) Short-term predictive properties of the West-Haven Yale Multidimensional Pain Inventory (MPI-S) among patients with recurrent and persistent LBP receiving chiropractic care. IV) Effect and cost-effectiveness of Chiropractic Maintenance Care (MC) in a population with recurrent and persistent LBP.

Results: Four consecutive weeks without bothersome LBP may be applied as a marker for a LBP episode in a primary care population. Chiropractic patients are more affected by their pain compared to another primary care population, but less compared to two secondary care populations. Subgrouping patients according to MPI-S could not predict the short term treatment outcome in chiropractic patients. MC is more effective and costlier compared to symptom-guided treatment.

Conclusions: Absence of pain as a marker of LBP episodes is a novel and promising concept. Chiropractic patients are more affected by their pain than other patients from primary care. Psychological and behavioral factors could not predict a short-term differentiated treatment response in chiropractic patients. MC resulted in significantly fewer days with bothersome LBP compared to symptom-guided treatment. MC may be considered cost-effective, but further investigations are needed.

List of scientific papers

I. Eklund A, Jensen I, Lohela-Karlsson M, Leboeuf-yde C, Axen I. Absence of low back pain to demarcate an episode: a prospective multicentre study in primary care. Chiropr Man Therap, 2016, Feb, 18;24:3.
https://doi.org/10.1186/s12998-016-0085-z

II. Eklund A, Bergström G, Bodin L, Axén I. Psychological and behavioral differences between low back pain populations: a comparative analysis of chiropractic, primary and secondary care patients. BMC Musculoskelet Disord, 2015, Oct, 19;16:306.
https://doi.org/10.1186/s12891-015-0753-5

III. Eklund A, Bergström G, Bodin L, Axén I. Do psychological and behavioral factors classified by the West Haven-Yale Multidimensional Pain Inventory (Swedish version) predict the early clinical course of low back pain in patients receiving chiropractic care? BMC Musculoskelet Disord., 2016, Feb, 12;17(1):75.
https://doi.org/10.1186/s12891-016-0933-y

IV. Eklund A, Jensen I, Lohela-Karlsson M, Hagberg J, Bodin L, Lebouf-Yde C, Kongsted A, Axén I. Prevention of low back pain: effect and cost-effectiveness of preventive manual treatment (Chiropractic Maintenance Care) – a randomized clinical trial. [Manuscript]