Prevention of recurrent and persistent low back pain

Low back pain is a highly prevalent and costly condition. It is also a recurrent problem in most cases, and persistent (chronic) in some. However, little is known about the fluctuations, the course, over time. Further, a recurrent condition invites the idea of secondary prevention, in order to minimize the episodes of disability and pain. A persistent condition requires tertiary prevention, to stop deterioration and to minimize the effects of the problem.


Very few preventive strategies have been studied. In order to investigate a large number of subjects, a new method of gathering frequent data is used: text messages and mobile phones. Weekly measurements provide a detailed picture of course over time, on an individual and a group level. The method is cheap and user-friendly and yields high response rates and good compliance.

In a randomized controlled trial, the culmination of a strategic and long-term research effort, the Nordic Maintenance Care Program, a preventive manual treatment procedure, Chiropractic maintenance care (MC) has been investigated. In a series of publications, the primary results of the trial have been published and received worldwide attention and recognition. The preventive approach (MC) utilizing a pre-planned treatment strategy seems to be effective for a specific subgroup of patients with high interference, affective distress and low perceived control when compared to a control group receiving care only upon the recurrence/deterioration of LBP symptoms. Total number days with pain were fewer, pain free period between episodes were longer and recurrences were less acute at equal number of treatments compared to the control group. Currently a full economic evaluation is being conducted to access cost effectiveness of the procedure.


  • European Chiropractors' Union
  • Swedish Chiroprators' Association
  • The Danish Chiropractic Association


The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial. Eklund A, Hagberg J, Jensen I, Leboeuf-Yde C, Kongsted A, Lövgren P, Jonsson M, Petersen-Klingberg J, Calvert C, Axén I. Chiropr Man Therap. 2020 Apr 21;28(1):19

The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial. Eklund AJensen ILeboeuf-Yde CKongsted AJonsson MLövgren PPetersen-Klingberg JCalvert CAxén I. PLos One 2019 Oct 10;14(10):e0223349

The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided treatment for recurrent and persistent low back pain—A pragmatic randomized controlled trial Andreas Eklund, Irene Jensen, Malin Lohela-Karlsson, Jan Hagberg, Charlotte Leboeuf-Yde, Alice Kongsted, Lennart Bodin, Iben Axén PLos One 13(9): e0203029.

Analyzing repeated data collected by mobile phones and frequent text messages. An example of low back pain measured weekly for 18 weeks.
Axén I, Bodin L, Kongsted A, Wedderkopp N, Jensen I, Bergström G
BMC Med Res Methodol 2012 Jul;12():105

The use of weekly text messaging over 6 months was a feasible method for monitoring the clinical course of low back pain in patients seeking chiropractic care.
Axén I, Bodin L, Bergström G, Halasz L, Lange F, Lövgren P, et al
J Clin Epidemiol 2012 Apr;65(4):454-61

Clustering patients on the basis of their individual course of low back pain over a six month period.
Axén I, Bodin L, Bergström G, Halasz L, Lange F, Lövgren P, et al
BMC Musculoskelet Disord 2011 May;12():99

The Nordic Maintenance Care Program: when do chiropractors recommend secondary and tertiary preventive care for low back pain?
Axén I, Jensen I, Eklund A, Halasz L, Jørgensen K, Lange F, et al
Chiropr Osteopat 2009 Jan;17():1


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Iben Axén

Principal Researcher
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Andreas Eklund

Assistant Professor
Content reviewer:
Anna Frantz