J Bodyw Mov Ther. 2019 (Apr); 23 (2): 241–246 ~ FULL TEXT
Gedin F, MSc; Dansk V, MSc; Egmar A-C, PhD; Sundberg T, PhD; Burström K, PhD
Health Economics and Economic Evaluation Research Group,
Medical Management Centre,
BACKGROUND: Chiropractic care is a common but not often investigated treatment option for back pain in Sweden. The aim of this study was to explore patient-reported outcomes (PRO) for patients with back pain seeking chiropractic care in Sweden.
METHODS: Prospective observational study. Patients 18 years and older, with non-specific back pain of any duration, seeking care at 23 chiropractic clinics throughout Sweden were invited to answer PRO questionnaires at baseline with the main follow-up after four weeks targeting the following outcomes: Numerical Rating Scale for back pain intensity (NRS), Oswestry Disability Index for back pain disability (ODI), health-related quality of life (EQ-5D index) and a visual analogue scale for self-rated health (EQ VAS).
RESULTS: 246 back pain patients answered baseline questionnaires and 138 (56%) completed follow-up after four weeks. Statistically significant improvements over the four weeks were reported for all PRO by acute back pain patients (n = 81), mean change scores: NRS -2.98 (p < 0.001), ODI -13.58 (p < 0.001), EQ VAS 9.63 (p < 0.001), EQ-5D index 0.22 (p < 0.001); and for three out of four PRO for patients with chronic back pain (n = 57), mean change scores: NRS -0.90 (p = 0.002), ODI -2.88 (p = 0.010), EQ VAS 3.77 (p = 0.164), EQ-5D index 0.04 (p = 0.022).
CONCLUSIONS: Patients with acute and chronic back pain reported statistically significant improvements in patient-reported outcomes (PRO) four weeks after initiated chiropractic care. Albeit the observational study design limits causal inference, the relatively rapid improvements of PRO scores warrant further clinical investigations.
From the FULL TEXT Article:
Back pain is a common disorder that affects both physical health and mental wellbeing
(Statens beredning för medicinsk utvärdering, 2000). In addition to the individual suffering
back pain also has significant impact on societal costs (Lidwall, 2011; Statens beredning för
medicinsk utvärdering, 2000). Back pain is a complex condition that may be caused by a
variety of biological, psychological and social factors (Statens beredning för medicinsk
utvärdering, 2010; van Tulder et al, 2006). It has been estimated that the vast majority of
back pain cases is of non-specific origin (Airaksinen et al, 2006; van Tulder et al, 2006),
which can make it especially difficult to manage efficiently. Chiropractic treatment such as
spinal manipulation is recommended in clinical guidelines of back pain management
(Globe et al, 2016; Lidwall, 2011; van Tulder et al, 2006), especially so in the care of nonspecific
back pain. Recent research also reports emerging evidence that chiropractic care is
a safe treatment for low back pain with clinically effects similar to physical therapy, and
likely similar to exercise and medical care, albeit the cost-effectiveness of chiropractic care
for low back pain is still uncertain (Blanchette et al, 2016), as is the impact on wellbeing
outcomes that are often associated with chiropractic care (Parkinson et al, 2013). Notably,
patient-reported outcomes (PRO), i.e. outcomes that details different aspects of patients'
health status that by means of patient report, e.g. health-related quality of life (HRQoL), has
been suggested as an important area of research to increase the understanding and
improvement of clinical care (Deshpande et al, 2011).
Chiropractors in Sweden become qualified to practice after five years of training at the
Scandinavian College of Chiropractic in Sweden or at an equivalent educational institution
abroad. All Swedish chiropractors need to be registered by the National Board of Health
and Welfare. In Sweden, chiropractic is a registered health care profession alongside
physiotherapy, medicine and other health professions, and chiropractors have to follow the
health care regulations set by the Swedish health care authorities. Any misconduct in
chiropractic practice has to be reported to the Health and Social Care Inspectorate. The
majority of Swedish chiropractors work in private practice outside of conventional medical
settings such as general practitioners offices or hospitals. Nonetheless, Swedish county
councils recommend chiropractic care alongside other manual therapy interventions and
physiotherapy for patients with back pain and other musculoskeletal disorders (Vårdguiden,
2017). However, despite the increased acceptance of chiropractic care in Sweden there is a
scarcity of studies investigating chiropractic practice in Sweden. The aim of the present
study was to explore PRO targeting back pain, back disability and health related quality of life (HRQoL) for patients with low back pain seeking chiropractic care in Sweden.
This study explored PRO, i.e. back pain intensity, back disability, health-related quality of
life and self-rated health, among patients with back pain receiving chiropractic care in
Sweden. Patients with acute back pain reported statistically significant improvements
between baseline and the main follow-up after four weeks for all PRO. Patients with
chronic back pain also reported statistically significant, albeit somewhat smaller,
improvements after four weeks for all PRO, except for self-rated health.
The rapid improvement of back pain intensity after two weeks for acute back pain patients
could suggest a chiropractic treatment effect, which would be in line with previous studies
indicating that chiropractic care may improve pain and disability in short term (Goertz et al,
2013; Statens beredning för medicinsk utvärdering, 2010; Walker et al, 2010). However, it
has been suggested that 90% of patients with acute low back pain recover within six weeks
(van Tulder et al, 2006), which may also help explain the current findings of rapid
improvements. The observed improvement of pain intensity was of MCID and maintained
over the study period for acute back pain patients. Nonetheless, the observational study
design and lack of control group makes it impossible to distinguish potential chiropractic
treatment effects on pain reduction from the natural progression of back pain. It may further
be assumed that patients with acute back pain might naturally improve more in contrast to
patients with chronic back pain. The most recent Swedish health technology assessment
report (Statens beredning för medicinsk och social utvärdering, 2016), which addresses the
knowledge gap of the effectiveness of manipulative therapies in the management of acute
and sub-acute low back pain, requests more clinical research of available treatments in this
area. Accordingly, the current study's PRO findings of acute back pain patients receiving
chiropractic care might contribute towards generating hypotheses and informing larger
scale clinical studies in this requested area of research.
The back disability ODI values reported at baseline among patients with acute pain in this
study were similar to what patients in the general population with acute back pain report
(Rabin & de Charro, 2001). The ODI results in this study also followed the same pattern as
the EQ-5Dindex, where patients with acute pain reported similar disability/function after four
weeks as the general population without disability/function (Rabin & de Charro, 2001).
This could be an indication that patients with acute pain recovered at the end of study, but
should be interpreted carefully as the characteristics of the study populations may differ.
The baseline EQ-5Dindex for patients seeking chiropractic care was similar to general
Swedish population estimates for people with back pain (Burström et al, 2001b). This
suggests that the health status of patients seeking chiropractic care does not differ
substantially from the patients with back pain in the general population. Pain/discomfort
was the EQ-5D dimension where most patients reported problems at baseline, followed by
usual activities and mobility. Self-care was the EQ-5D dimension where fewest patients
reported problems. This is similarly shown in the general population in Stockholm where
pain/discomfort is also among the main reported problems, whereas self-care is the least
(Burström et al, 2001a). After the last follow-up at four weeks, patients who received
chiropractic care for acute back pain reported similar EQ-5Dindex after two and four weeks
as the general Swedish population without pain (Burström et al, 2001b). This improvement
suggests a normalization of back pain over time that may have been related to the
chiropractic care although it is possible that the same rapid improvements could have
occurred due to the natural history of back pain. Even so, the current study adds new
knowledge with details about changes in EQ-5D health status for patients seeking
chiropractic care. Similarly, and in line with the reported positive improvements of health
status following chiropractic care, a recent US study suggests that the majority of
chiropractic users report that chiropractic helps to improve their overall health or wellbeing
(Adams et al, 2017).
There are multiple previously reported clinical studies on chiropractic. However, these are
typically based on chiropractic practice in the US and English speaking countries, and there
is a scarcity of studies that describe routine chiropractic care in Sweden. Thus relevantly,
this study adds to the literature by describing and contextualising standard PRO of patients
receiving chiropractic care in Sweden. This may be of value since chiropractic can be
considered a marginalised, albeit regulated and licensed, health profession in Sweden, e.g.
considering that chiropractic is mainly taught outside of medical universities and that the
vast majority of Swedish chiropractors work in private practice outside of conventional
medical settings. Building on the current observational study, future studies may want to
investigate the comparative effectiveness of chiropractic care versus treatment as usual, as
well as barriers and facilitators of integrating chiropractic and conventional care, for the
target group of patients with non-specific low back pain. Future studies addressing chronic
back pain groups might also want to consider longer follow-up periods (Lidwall, 2011).
Strengths of the current study include that the chiropractic clinics were geographically
distributed all over Sweden, of varying size, some having conventional care contracts, and
that the chiropractors at each clinic had different lengths of working experience, which may
aid to the study's representativeness of general chiropractic practice. Study limitations
include the observational single arm study design which limits causal relations between
observed outcomes changes and chiropractic care, the convenience sampling of patients and
the non-randomized inclusion of chiropractic clinics which may have caused selection bias
where the most “ambitious” or appropriate clinics or patients chose to participate (Machin
& Campbell, 2005).
Additionally, the lack of specific data on the type and content of
administered chiropractic treatments, such as which exact techniques were utilized, and the
fairly large number of drop-outs, which had significantly more young patients and manual
workers than the responders remaining in the study, are limitations that ought to be
considered when interpreting the results of this study and when planning for future
investigations. The short follow-up period of four weeks, and the lack of references
detailing scientifically validated translations of the implemented instruments into Swedish,
constitute additional aspects that might be considered in future studies. The findings may
not be generalizable to the general population with back pain, as patients seeking
chiropractic care might differ in characteristics from those who do not.
Patients with acute back pain reported statistically significant and minimal clinically important difference (MCID) improvements in
back pain intensity, back disability and health related quality of
life (HRQoL), and statistically significant improvements
in self-rated health, over four weeks following chiropractic care. Patients with chronic back
pain reported statistically significant, albeit smaller and non MCID, changes for all patient-reported outcomes (PRO)
except self-rated health. The observed improvements in PRO may be of interest for
clinicians and decision makers involved in the management of back pain patients. The
study findings may additionally contribute to inform future research in the field of
chiropractic care and back pain.
We would like to thank Dr. Mesfin Tessma for technical support and the staff at the
Scandinavian College of Chiropractic for logistical support during the study. Kiropraktiska
Föreningen i Sverige provided financial support towards the administrative costs making it
possible to conduct this study, but did not have any influence on any part of the research
process of this study. The authors declare no other source of funding or conflicts of interest
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