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The high prevalence of low-back pain (LBP) has been highlighted for many years, but until recently, awareness of its influence on the population was inadequate. The results of the Global Burden of Disease (GBD) Projects 2010 have informed us that the leading cause of disability (as measured by years lived with disability) worldwide is low back pain.  Additionally, musculoskeletal conditions as a whole are the second greatest cause of disability globally according to a report by international experts, published in The Lancet on December 15th, 2012.  In the first comprehensive study of the worldwide impact of all diseases and risk factors, musculoskeletal (MSK) conditions such as arthritis and back pain affect over 1.7 billion people worldwide, and have the fourth greatest impact on the overall health of the world population, considering both death and disability.  This burden has increased by 45% over the last 20 years and will continue to do so unless action is taken.  This landmark study of the global burden of all diseases provides indisputable evidence that musculoskeletal conditions are an enormous and emerging problem in all parts of the world and need to be given the same priority for policy and resources as other major conditions like cancer, mental health and cardiovascular disease.

With the knowledge that LBP is the number one cause of disability in the world, it is unfortunate that little is known about the detailed course, and trajectory, of LBP.  Until recently LBP was believed to be a self-limiting condition, similar to the common cold. However, research in the past two decades has shown that LBP is actually a recurrent condition that could be likened to a more chronic condition such as asthma.  In this regard, we are starting to look at LBP as not seen as a single entity, but rather to the LBP condition which can be regarded as a chain of LBP episodes.  So, we need to view LBP (and maybe all types of spine pain) as having a lifelong course – perhaps with different etiology and modifying factors as life progresses, but always existing as an underlying ‘trait’.

When researchers have looked at the non-benign, and non self-limiting nature of the condition, three large groups of LBP patients emerge: 1): those without LBP; 2) those who experience it on and off and; 3) those who have it most of the time. It is pretty clear that definite recovery with no recurrences does not appear to be common, although to date, we do not know how these patterns develop over the course of a lifetime. People with LBP will not necessarily seek care, but a person who consults a chiropractor for an episode of LBP is likely to feel better fairly quickly. In light of these findings, clinicians should observe and convey information about episodes within the context of a longer-term pain trajectory, to provide patients with a realistic view of the problem. The authors of the recent trajectories of low back pain article referenced herein suggest that effective short-term treatment strategies, pain management and activity maintenance as well as secondary and tertiary prevention should be high on the clinical agenda. ‘Management rather than cure’ might be a helpful catch phrase, similar to the well-known recommendation of ‘don’t worry – keep active’ (Axén and Leboeuf-Yde, 2013).

Given the shift in attention of LBP to view it as a chronic condition, researchers and clinicians are putting more emphasis on investigating LBP throughout the life course.  What is emerging from this life course investigation is that similar factors (e.g., genetics, parental factors, psychological factors, injury, physical activity, comorbidity) are associated with the pain at different times. There appears to be strong evidence for the links between back pain, pain at other locations (e.g., shoulder) and other health problems. This evidence leads to the potential conclusion that vulnerability for long-term back pain develops at an early age, likely in childhood, and influences the occurrence of, and recovery from, episodes of back pain (Dunn et al, 2013).

Furthermore, results of a recent meta-analysis of LBP in children and adolescents indicates higher prevalence rates of LBP in the most recent studies suggesting that this a problem that is increasing in this young population (Calvo-Muñoz et al, 2013). As a consequence, more attention should be devoted to develop and apply prevention programs and early detection programs for young children in order to reverse this tendency.

Key Points

  • The leading cause of disability worldwide is low back pain
  • Evidence is mounting that classifying low back pain as acute, subacute and chronic is no longer helpful
  • Many individuals experience multiple episodes of back pain with the first episode occurring early in life
  • LBP is now being thought of as a potentially chronic health condition in its own right

References:

1. Vos T et al.Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 Dec 15;380(9859):2163-96.

2.Axén I, Leboeuf-Yde C. Trajectories of low back pain. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):601-12.

3. Dunn KM, Hestbaek L, Cassidy JD. Low back pain across the life course. Best Pract Res Clin Rheumatol. 2013 Oct;27(5):591-600.

4. Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr. 2013 Jan 26;13:14.

Podcast

Dr. Alice KongstedJoin Dr. Kongsted and I as we discuss her unique role as an author of the recent groundbreaking Lancet series of articles on Low Back Pain as well as many other topics. Alice Kongsted, DC, PhD graduated from the University of Southern Denmark in 1999 and completed her PhD at the Faculty of Health Sciences at the University of Southern Denmark in 2005. Up till 2009 she had clinical work as a chiropractor alongside her academic work, mainly in an outpatient hospital department. Currently she holds a position as senior researcher at the Nordic Institute of Chiropractic and Clinical Biomechanics (NIKKB) and a position as Associate Professor at the Department of Sports Science and Clinical Biomechanics at University of Southern Denmark. At NIKKB she has set up a network of chiropractic primary care research clinics that regularly participates in data collection for research purposes, the data being made available to researchers both inside and outside NIKKB. Her research interests concern spinal pain with a focus on primary care. This includes investigating the prognosis of spinal pain and why people have different outcomes.

Lately, she has been much occupied with a large project exploring ways to implement evidence-based care in practice. She has an interest in methodology and has taught PhD courses on prognostic research at University of Southern Denmark and at Curtin University in Perth, Australia. Alice Kongsted is an Associate Editor of BMC Musculoskeletal Disorders and she is a member of the editorial board for Chiropractic & Manual Therapies. She has been involved in The Danish Health Authority’s development of three national clinical guidelines for treatment of lumbar radiculopathy, cervical radiculopathy and of non-specific neck pain. She was part of the Lancet Low Back Pain Series Working Group that published three papers in March 2018 to call for worldwide recognition of the disability associated with back pain and the need for prioritizing this globally growing problem. This Lancet series will be a focus of our conversation today.

Visit Dr. Kongsted’s research profile at researchgate.net.

Here is a list of articles Dr. Kongsted mentions during the interview:

1. Prevention and treatment of low back pain: evidence, challenges, and promising directions.
Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, Ferreira PH, Fritz JM, Koes BW, Peul W, Turner JA, Maher CG; Lancet Low Back Pain Series Working Group.
Lancet. 2018 Mar 20. pii: S0140-6736(18)30489-6. doi: 10.1016/S0140-6736(18)30489-6. [Epub ahead of print] Review.
PMID: 29573872 [PubMed – as supplied by publisher]
Similar articles
2. Low back pain: a call for action.
Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P; Lancet Low Back Pain Series Working Group.
Lancet. 2018 Mar 20. pii: S0140-6736(18)30488-4. doi: 10.1016/S0140-6736(18)30488-4. [Epub ahead of print]
PMID: 29573871 [PubMed – as supplied by publisher]
Similar articles
3. What low back pain is and why we need to pay attention.
Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group.
Lancet. 2018 Mar 20. pii: S0140-6736(18)30480-X. doi: 10.1016/S0140-6736(18)30480-X. [Epub ahead of print] Review.
PMID: 29573870 [PubMed – as supplied by publisher]
Similar articles
4. Identifying subgroups of patients using latent class analysis: should we use a single-stage or a two-stage approach? A methodological study using a cohort of patients with low back pain.
Nielsen AM, Kent P, Hestbaek L, Vach W, Kongsted A.
BMC Musculoskelet Disord. 2017 Feb 1;18(1):57. doi: 10.1186/s12891-017-1411-x.
PMID: 28143458 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles
5. What have we learned from ten years of trajectory research in low back pain?
Kongsted A, Kent P, Axen I, Downie AS, Dunn KM.
BMC Musculoskelet Disord. 2016 May 21;17:220. doi: 10.1186/s12891-016-1071-2.
PMID: 27209166 [PubMed – indexed for MEDLINE] Free PMC Article
Similar articles

 

In this interview, Dr. Axén and I discuss the trajectories of low back pain, the characteristics of chiropractic patients with low back pain and practice based research. Iben Axén is a chiropractor in private practice in Stockholm, Sweden, who started to engage in practice-based research in the 1990’s. In 2011, she earned her PhD at Karolinska Institutet (KI) in Stockholm. She previously held a post-doc position shared between KI and the University of Southern Denmark. Currently she is an Associate professor in Musculoskeletal Health at the Karolinska Institutet. Her research centers on chiropractic care for low back pain (LBP). She has published work regarding predictors of treatment outcome, the clinical course and episodes of LBP and of subgrouping patients. Further, she is involved in the Nordic Maintenance Care Program, including the use of, indications for and outcomes of prevention. Iben Axen’s work is mainly based ondata from multicentre longitudinal studies. She is a firm believer in engaging chiropractic clinicians in data collection as part of the implementation process. In several studies, she has used a novel way of frequently measuring outcome using mobile phones and text messages, which allow for detailed studies of conditions that vary over time, for instance LBP.

View Dr. Axen’s research here.

Below are the articles discussed in this episode:

1. “Typical” chiropractic patients- can they be described in terms of recovery patterns?
Axén I, Leboeuf-Yde C.
Chiropr Man Therap. 2017 Aug 9;25:23. doi: 10.1186/s12998-017-0152-0. eCollection 2017.
PMID: 28804617 [PubMed] Free PMC Article
Similar articles
2. What have we learned from ten years of trajectory research in low back pain?
Kongsted A, Kent P, Axen I, Downie AS, Dunn KM.
BMC Musculoskelet Disord. 2016 May 21;17:220. doi: 10.1186/s12891-016-1071-2.
PMID: 27209166 [PubMed – in process] Free PMC Article
Similar articles
3. Trajectories of low back pain.
Axén I, Leboeuf-Yde C.
Best Pract Res Clin Rheumatol. 2013 Oct;27(5):601-12. doi: 10.1016/j.berh.2013.10.004. Epub 2013 Oct 10. Review.
PMID: 24315142 [PubMed – indexed for MEDLINE]
Similar articles
4. Conducting practice-based projects among chiropractors: a manual.
Axén I, Leboeuf-Yde C.
Chiropr Man Therap. 2013 Feb 1;21(1):8. doi: 10.1186/2045-709X-21-8.
PMID: 23369259 [PubMed] Free PMC Article
Similar articles
5. The Nordic maintenance care program: the clinical use of identified indications for preventive care.
Axén I, Bodin L.
Chiropr Man Therap. 2013 Mar 6;21(1):10. doi: 10.1186/2045-709X-21-10.
PMID: 23497707 [PubMed] Free PMC Article
Similar articles