An Observational Study on Recurrences of Low Back Pain During the First 12 Months After Chiropractic Treatment
SOURCE: J Manipulative Physiol Ther. 2017 (Jul); 40 (6): 427–433
Christina Knecht, BMed,
Barry Kim Humphreys, DC, PhD,
Brigitte Wirth, PT, MSc, PhD
Chiropractic Medicine Department,
Faculty of Medicine,
University of Zürich and University Hospital Balgrist,
OBJECTIVES: The purpose of this study was to investigate recurrence rate and prognostic factors in a large population of patients with low back pain (LBP) up to 1 year after chiropractic care using standardized definitions.
METHODS: In Switzerland, 722 patients with LBP (375 male; mean age = 44.5 ± 13.8 years) completed the Numeric Rating Scale for pain (NRS) and the Oswestry Disability Index (ODI) before treatment and 1, 3, 6, and 12 months later (ODI up to 3 months). Based on NRS values, patients were categorized as “fast recovery,” “slow recovery,” “recurrent,” “chronic,” and “others.” In multivariable logistic regression models, age, sex, work status, duration of complaint (subacute: ≥14 days to <3 months; chronic: ≥3 months), previous episodes, baseline NRS, and baseline ODI were investigated as predictors.
RESULTS: Based on NRS values, 13.4% of the patients were categorized as recurrent. The recurrent pattern significantly differed from fast recovery in duration of complaint (subacute: odds ratio [OR] = 3.3; chronic: OR = 10.1). The recurrent and chronic pattern significantly differed in duration of complaint (chronic: OR = 0.14) and baseline NRS (OR = 0.75).
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CONCLUSION: Recurrence rate was low in this LBP patient population. The duration of complaint before treatment was the main predictor for recurrence. The fact that even subacute duration significantly increased the odds for an unfavorable course of LBP is of clinical relevance.
KEYWORDS: Chiropractic, Low Back Pain, Recurrence
From the Full-Text Article:
Low back pain (LBP) is the leading cause for years lived with a disability globally,  and the burden of LBP is expected to rise as the population ages. [1, 2] Only about 1 in 3 LBP episodes completely resolves within a year, [3, 4] and the percentage of LBP that goes from acute to chronic varies among studies from 2% to 34%.  However, apart from the quickly resolving acute and the lengthy chronic course there are vast numbers of patients — approximately 3 in 53 — who suffer from recurrent LBP episodes. [6-10] It is difficult to predict which patients will experience LBP recurrence within the next year  because the pattern of recurrent episodes is unpredictable and still not fully understood. Nevertheless, recurrent LBP episodes have a tremendous impact on physical and social functioning  and are considerably more expensive than the original episode.  Thus, the prevention of future relapse episodes is crucial.
Solid evidence about risk factors for recurrence of LBP is sparse because the majority of research has focused on prognostic factors for poor outcome, disability, or chronicity instead of recurrence. Those that did find prognostic factors for the recurrent course have reported conflicting information, most probably because a variety of definitions for recurrent LBP have been used. A systematic review concluded that among the studies in this field, only 38% used a specific but self-created definition for recurrence, whereas in 62% it was unclear how recurrence had been measured.  This lack of standardization is reflected in the 1-year recurrence rate ranging from 25% to 73%. [9, 10] Moreover, most studies lacked a definition of recovery as part of the definition of recurrence, probably including patients with persistent pain instead of recurrent episodes. 
Thus, the following consensus definition for a recurrence of an episode of LBP was reached in a modified Delphi approach: “return of LBP lasting at least 24 hours with a pain intensity of >2 on an 11-point Numeric Rating Scale (NRS) following a period of at least 30 days pain-free.” 
Thus, the main aim of this study was to determine the amount of LBP recurrences using the consensus definition of recurrence, according to Stanton et al,  in patients up to 1 year after chiropractic care based on pain intensity (NRS). The second aim was to compare the recurrent patients to all other patients (grouped according to various trajectories) in terms of certain baseline factors and to investigate whether certain baseline factors increased the risk for LBP recurrence.