Prevention of Low Back Pain: Effect, Cost-effectiveness, and Cost-utility of Maintenance Care – Study Protocol for a Randomized Clinical Trial

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SOURCE:   Trials. 2014 (Apr 2);   15:   102

Andreas Eklund, Iben Axén, Alice Kongsted, Malin Lohela-Karlsson,
Charlotte Leboeuf-Yde, and Irene Jensen

Institute of Environmental Medicine,
Unit of Intervention and Implementation Research,
Karolinska Institutet, Nobels v13, S-171 77
Stockholm, Sweden.

BACKGROUND:   Low back pain (LBP) is a prevalent condition and a socioeconomic problem in many countries. Due to its recurrent nature, the prevention of further episodes (secondary prevention), seems logical. Furthermore, when the condition is persistent, the minimization of symptoms and prevention of deterioration (tertiary prevention), is equally important. Research has largely focused on treatment methods for symptomatic episodes, and little is known about preventive treatment strategies.

METHODS/DESIGN:   This study protocol describes a randomized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care (chiropractic maintenance care) in a population of patients with recurrent or persistent LBP.Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden. The primary outcome is the number of days with bothersome pain over 12 months. Secondary measures are self-rated health (EQ-5D), function (the Roland Morris Disability Questionnaire), psychological profile (the Multidimensional Pain Inventory), pain intensity (the Numeric Rating Scale), and work absence.The primary utility measure of the study is quality-adjusted life years and will be calculated using the EQ-5D questionnaire. Direct medical costs as well as indirect costs will be considered.

Subjects are randomly allocated into two treatment arms:

1) Symptom-guided treatment (patient controlled), receiving care when patients feel a need.

2) Preventive treatment (clinician controlled), receiving care on a regular basis.


Eligibility screening takes place in two phases: first, when assessing the primary inclusion/exclusion criteria, and then to only include fast responders, i.e., subjects who respond well to initial treatment. Data are collected at baseline and at follow-up as well as weekly, using SMS text messages.

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DISCUSSION:   This study investigates a manual strategy (chiropractic maintenance care) for recurrent and persistent LBP and aims to answer questions regarding the effect and cost-effectiveness of this preventive approach. Strict inclusion criteria should ensure a suitable target group and the use of frequent data collection should provide an accurate outcome measurement. The study utilizes normal clinical procedures, which should aid the transferability of the results.

TRIAL REGISTRATION:   Clinical; NCT01539863, February 22, 2012. The first patient was randomized into the study on April 13th 2012.


From the FULL TEXT Article


Low back pain (LBP) is a major public health problem in many countries with resulting consequences both for the individual and society. The total cost of LBP in Sweden was estimated at €1,840 million in 2001. [1] Interventions that reduce the prevalence of back pain would therefore contribute to improvements on a public health level and potentially have large economic benefits.

LBP has been shown to be a recurrent and sometimes persistent phenomenon. [2, 3] Logically, a recurrent and sometimes persistent condition that is highly prevalent invites the idea of prevention. However, knowledge about secondary prevention, to decrease the rate of recurrence, and tertiary prevention, to decrease the intensity or extent of persistent pain for this condition is scarce. [4]

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