Chiropractic Maintenance Care of persistent or recurrent Low Back Pain. A randomized controlled trial with a 1- year follow up.

Transkript

1 Chiropractic Maintenance Care of persistent or recurrent Low Back Pain. A randomized controlled trial with a 1- year follow up. Iben Axén, DC, PhD Post Doc Spinecenter of Southern Denmark Hospital Lillebælt & Institute of Regional Health Research University of Southern Denmark

2 Maintenance care what do we know? No evidence-based definition No indications for care No prevalence estimates Effect not studied Cost-effectiveness not studied Leboeuf-Yde et al; Chiropractic & Osteopathy 2008, 16:3 2

3 Prevalence 39 % (Breen, UK 1977)* 34 % (Rupert, USA 2000)* 14 % (Leboeuf-Yde, Norway 2005) scrutiny of files 28 % (Axén, Sweden, 2008)* 41 % (Bringsli, Denmark 2012) observation in MC clinics * Estimated by the chiropractors 3

4 Maintenance Care, intention Optimize health (90%) Prevent illness (88%) stated by Palliative (86%) chiropractors Minimize recurrence/deterioration (95%) Rupert, JMPT 2000, 23: 1-9, Questionnaire study Prevent recurrent problems stated by Maintain optimal function patients Stay as pain free as possible Bringsli et al: Chiropractic & Manual Therapies 2012, Observations and patient questionnaires. 4

5 Maintenance Care, content Exercises (96%) Manipulation (97%) stated by Nutrition (93%) chiropractors Life style (84%) Rupert, JMPT 2000, 23: 1-9, Questionnaire Passive treatment (88%) History & examination (92%) observed in Discussion of other health issues (17 %) clinic Exercises (10%) Ergonomy & life style (20%) Bringsli et al: Chiropractic & Manual Therapies 2012, Observations and patient questionnaires 5

6 Maintenance Care frequency As observed in clinic an interval between 2 weeks and 3 months is common, 2 months is typical Sandnes et al: The Nordic Maintenance Care Program Time intervals between treatments of patients with low back pain: how close and who decides? Chiropractic & Osteopathy 2010, 18:5 Bringsli et al: The Nordic Maintenance Care Program: Maintenance care what happens during the consultation? Observations and patient questionnaires. Chiropractic & Manual Therapies 2012, 20: 25 6

7 Maintenance Care = preventive treatment? Public Health terminology: Primary prevention Secondary prevention Tertiary prevention Maintenance care? 7

8 Maintenance care - indications Focus group discussion in Sweden determined that secondary prevention: past frequency ++ tertiary prevention: improvement, i.e. - if 50 % improvement: most consider MC - if 75 % improvement: definitely MC Axén et al; Chiropractic & Osteopathy 2009, 17/1/1 8

9 Case management of chiropractic patients with low back pain A questionnaire explored Swedish chiropractors strategies uncomplicated patients treatments are terminated, difficult cases are referred on, recurrent cases are treated with MC. Axén et al; Chiropractic & Osteopathy 2008, 16:6 9

10 Is MC effective? A randomised controlled study Patients with recurrent and persistent LBP Excluding; Acute patients Patients under 18 or over 65 years Specific LBP Patients with subsidized fee No mobile phone No knowledge of sending SMS 10

11 Inclusion criteria 1. Recurrent and persistent LBP 2. Definitely improved by the 4 th visit as defined by chiropractic clinicians 11

12 Study inclusion New patients with recurrent or persistent LBP Initial treatment as ususal, must be definitely improved by the 4 th visit Study starts when the interval between treatments is 1 month 12

13 KOD Datum: För kvinnor: Är Du gravid?...nej...ja Födelseår: Före 1947 Efter 1994 Har Du ont i ländryggen (nedre delen av ryggen)? Ja.Nej Har Du ont även i benet?...ja, endast i låret Ja, i både lår och underben Ja, i underbenet Nej Ryggsmärtans intensitet (i genomsnitt)det senaste dygnet Inte alls ont Outhärdligt ont Har Du varit hos kiropraktor för dessa besvär tidigare?...nej Ja, för mer än 3 månader sedan Ja, för mindre än 3 månader sedan Har Du haft episoder av ländryggssmärta de senaste åren? Ja...Nej Under det senaste året: Hur många dagar totalt har Du haft ländryggssmärta?...mer än 30 dagar. Maximalt 30 dagar Har Du även haft smärta i nacke eller bröstrygg (mellan skulderbladen)? Nej.Ja, mindre än 30 dagar Ja, maximalt 30 dagar Har Du tillgång till en mobiltelefon?...ja Nej Kan Du skicka SMS?. Ja Nej Är behandlingen helt eller delvis betalat av andra (vårdavtal, försäkring, arbetsgivare eller annat)? Nej, jag betalar allt själv Ja, delvis...ja, helt Hur stor tror Du att chansen är, att din ryggsmärta kommer att bli avsevärt bättre? Ingen chans Mycket stor chans

14 Treatment arms Intervention Treatment at regular intervals 12 months, SMS Control Treatment when needed 12 months, SMS 14

15 SMS Track An automated web-based system for sending and receiving data frequently to a large number of respondents using text messages In this study, participants receive a text every Sunday afternoon: How many days this previous week has your low back pain been bothersome (affected your daily activities or routines)? Please answer with a number from 0 to 7. 15

16 Intervention/ maintenance care Chiropractor decides: - content - frequency (minimum 4, maximum 12 treatments) Descriptive analysis will determine if content is as previously reported Frequency must be within intervals previously established 16

17 Outcomes Primary: number of days with bothersome pain Secondary: Quality of life (EQ-5D) Function (RMDQ) do patients who are treated with regular intervals experience fewer days with bothersome LBP than patients who are treated only when they perceive a need? 17

18 Further.. The study is a multicentre study The procedures aim to mimic clinical practise should aid transferability of study results 18

19 Thank you! Charlotte Leboeuf-Yde & Alice Kongsted Andreas Eklund, Peter Lövgren, Laszlo Halasz, Christian Calvert, Jakob Petersen-Klingberg & Mattias Jonsson Den Danske Fond, LKR & ECU for economic support Members of the SCA