The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial

Abstract

Background: A recent study showed that chiropractic patients had fewer days with bothersome (activity-limiting) low back pain (LBP) when receiving care at regular pre-planned intervals regardless of symptoms ('maintenance care', MC) compared to receiving treatment only with a new episode of LBP. Benefit varied across psychological subgroups. The aims of this study were to investigate 1) pain trajectories around treatments, 2) recurrence of new episodes of LBP, and 3) length of consecutive pain-free periods and total number of pain-free weeks, for all study participants as well as for each psychological subgroup.

Methods: A secondary analysis of data from a randomized controlled trial of patients (n = 319) seeking chiropractic care for recurrent or persistent LBP used 52 weekly estimates of days with bothersome (activity-limiting) LBP. First, a generalized estimating equations analysis was used to compare the pain trajectory before and after the initial treatment in every new treatment period. Thereafter, a time-to-event analysis (using Cox regression) estimated time to/risk of a new LBP episode. The analyses were performed on i) all study participants and ii) separately for each psychological sub-group (named adaptive copers, interpersonally distressed and dysfunctional) classified by the West Haven-Yale Multidimensional Pain Inventory.

Results: Patients receiving MC had flat pain trajectories around each new treatment period and reported fewer days with pain compared to patients receiving the control intervention. The entire effect was attributed to the dysfunctional subgroup who reported fewer days with activity limiting pain within each new LBP episode as well as longer total pain-free periods between episodes with a difference of 9.8 weeks (CI 95% 3.3, 16.3) compared to the control group. There were no differences in the time to/risk of a new episode of LBP in either of the subgroups.

Conclusion: Data support the use of MC in a stratified care model targeting dysfunctional patients for MC. For a carefully selected group of patients with recurrent and persistent LBP the clinical course becomes more stable and the number of pain-free weeks between episodes increases when receiving MC. Understanding how subgroups of patients are likely to be affected by MC may help align patients' and clinicians' expectations based on realistic outcomes.

Trial registration: Clinical trials.gov; NCT01539863; February 22, 2012.

Keywords: Chiropractic; Dose; Effect; Low back pain; Maintenance care; Manual treatment; Prevention; Secondary prevention; Tertiary prevention; Timing.

Conflict of interest statement

Five of the authors are paid employees of commercial companies. Andreas Eklund works 40% as a clinician at Hälsan Östertälje Praktikertjänst AB, Södertälje, Sweden. Mattias Jonsson works as a clinician at Ledakuten AB, Lidköping, Sweden. Peter Lövgren works as a clinician at Lövgrens Chiropraktorklinik, Stockholm, Sweden. Jakob Petersen-Klingberg works as a clinician at Eureka Kiropraktik, Borlänge, Sweden. Christian Calvert works as a clinician at Activate Rörelsekliniken, Falkenberg, Sweden. None of these affiliations influenced the study design, data collection and analysis, decision to publish, or preparation of the manuscript. There are no patents, products in development or marketed products associated with this research to declare.

Figures

Fig. 1

Estimated LBP trajectory 3 weeks before and after visits to a chiropractor, all study participants(n = 254), MC, Maintenance Care; LBP, Low Back Pain; CI, Confidence interval; the final GEE model was fitted with an unstructured correlation structure and included the variables: ‘Treatment group’, ‘Time (study period)’, ‘Time (study period)* Time (study period)’, ‘Time (treatment period)’ and ‘Time (treatment period)* Treatment group’

Fig. 2

Estimated LBP trajectory 3 weeks before and after visits to a chiropractor, within the Adaptive Coper sub-group (n = 80), MC, Maintenance Care; LBP, Low Back Pain; CI, Confidence Interval; AC, Adaptive Coper; The final GEE model was fitted with an unstructured correlation structure and included the variables: ‘Treatment group’, ‘Time (treatment period)’ and ‘Time (treatment period)* Time (treatment period)’

Fig. 3

Estimated LBP trajectory 3 weeks before and after visits to a chiropractor, within the Interpersonally Distressed sub-group (n = 50), MC, Maintenance Care; LBP, Low Back Pain; CI, Confidence interval; ID, Interpersonally Distressed; The final GEE model was fitted with an unstructured correlation structure and included the variables: ‘Treatment group’, ‘Time (study period)’, ‘Time (study period)*Time (study period)‘and ‘Time (treatment period)’

Fig. 4

Estimated LBP trajectory 3 weeks before and after visits to a chiropractor, Dysfunctional sub-group (n = 73), MC, Maintenance Care; LBP, Low Back Pain; CIDYS, Dysfunctional; the final GEE model was fitted with an unstructured correlation structure and included the variables: ‘Treatment group’, ‘Time (study period)’, ‘Time (treatment period)’ and ‘Treatment group*Time (treatment period)’

Fig. 5

Mean time to new low back pain episodes, Kaplan-Maier plot, all study participants(n = 250). MC, Maintenance Care

Fig. 6

Mean time to new low back pain episodes, Kaplan-Maier plot, Adaptive Coper subgroup (n = 80), MC, Maintenance Care

Fig. 7

Mean time to new low back pain episodes, Kaplan-Maier plot, Interpersonally Distressed subgroup (n = 50). MC, Maintenance Care

Fig. 8

Mean time to new low back pain episodes, Kaplan-Maier plot, Dysfunctional subgroup (n = 73). MC, Maintenance Care