In April 2025, an important study was published in the journal Medicina, titled (1):

Dynamic Cycle of Low Back Pain:
A 17-Year, Population-Based Study Analyzing the National Health Insurance Service Data in South Korea

The objective of this study was to describe the long-term recurrence patterns and healthcare utilization associated with low back pain (LBP) in a South Korean nationwide cohort over a 17-year period. It assessed 3,086,665 patients, which is quite robust.

To analyze back pain patterns and their associated burden, both the frequency and duration of back pain episodes and associated healthcare utilization were examined. The duration of each episode of LBP was measured in days.

The authors focused on the natural history of non-specific LBP. Approximately 85% of LBP cases are labeled as “non-specific” because a definitive diagnosis cannot be made (2). Patients with specific low back pathologies, such as intervertebral disc disorders, spinal stenosis, and lumbar radiculopathy, were excluded.

The authors summarized the relevance of this investigation by stating:

“Low back pain is a highly prevalent musculoskeletal condition that frequently recurs, leading to increased healthcare utilization and socioeconomic burden.”

“Chronic lower back discomfort is a significant global public health issue, affecting individuals across diverse demographic and socioeconomic groups.”

“Low back pain is one of the most frequent reasons for patient visits in primary care, highlighting its substantial influence on healthcare resource utilization.”

“The working population is particularly affected, as low back-related disabilities significantly contribute to both short-term and long-term work absenteeism.”

“Research indicates that LBP often follows a recurrent pattern, with episodes typically reappearing within 1–3 years.”

“On average, 62% of patients with LBP report ongoing pain after 12 months, and annual recurrence rates range from 40 to 70%.”

The findings from this 17-year study include:

• 80% of patients experienced more than one episode of LBP throughout the study period.
• “Patients experienced an average of 3.5 ± 9.6 episodes during this period.”
• “As the number of episodes increased, the intervals between episodes shortened, while healthcare utilization intensified, reflecting a progressive burden on healthcare resources.”
• “After the first episode, approximately half of the patients had their second episode around 500 days later.”
• “An analysis of LBP episodes revealed that later episodes tended to last longer than earlier ones.”
• There is decreasing time intervals between successive episodes of back pain in patients.

The authors made these conclusions:

• Low back pain is not an isolated condition, but a recurrent problem that poses significant challenges to patients and healthcare systems.
• “LBP follows a progressive course, with increasing episode frequency, prolonged duration, and escalating healthcare utilization over time.”
• “The findings reaffirm that recurrent back pain is a common and episodic condition, imposing a progressively greater burden on affected individuals and the healthcare infrastructure over time.”
• “The progressive shortening of intervals and increasing episode duration, are consistent with prior studies reporting the cyclic and worsening nature of LBP over time.”
• “This 17-year nationwide cohort study underscores the dynamic and progressive nature of LBP, with patients experiencing an average of 5.0 episodes characterized by progressively shorter intervals between recurrences and longer episode durations over time.”
• “These findings align with that of previous research suggesting that LBP is a cyclic condition that evolves over time.”

The authors made these recommendations pertaining to the management of LBP in an effort to reduce its recurrent nature:

• There is a need for early intensive management and long-term follow-up strategies to mitigate the growing burden of recurrent LBP on individuals and healthcare systems.
• “This study underscores the need for healthcare systems to shift from episodic management to comprehensive, longer-term strategies for addressing LBP.”
• “These studies similarly observed that patients with recurrent LBP tend to experience more frequent and prolonged episodes, highlighting the need for early and sustained intervention strategies.”
• The frequent recurrence of healthcare visits for LBP may be attributed to “the use of symptomatic treatments such as analgesics rather than interventions targeting the underlying cause. This clinical approach may lead to only temporary symptom relief and contribute to repeated medical consultations.”
• “These results highlight the importance of shifting healthcare systems from episodic care models to comprehensive, sustained management approaches for chronic musculoskeletal conditions.”

At the end of this study, the authors offer a physiological explanation for the recurrent nature of low back pain:

“[It] highlights persistent deficits in neuromotor and sensorimotor control, even during pain-free intervals.”

This concept and language is consistent with the chiropractic subluxation complex. The studies presented below support the value of chiropractic maintenance care during the “pain-free” intervals.

•••••

As noted above, an important complication following the successful management of chronic low back pain is its recurrent nature (3, 4). It is commonly thought and taught that about ninety percent of low back pain episodes permanently resolve. This is not the case.

A study on this topic was published in 1998 in the British Medical Journal and titled (3):

Outcome of Low Back Pain in General Practice:
A Prospective Study

This was a prospective study of 463 adult low back pain subjects who were followed for twelve months. The authors found that seventy-five percent of these subjects still had back problems a year later.

The authors emphasize that there is a major problem in low back pain publications: patients who do not return to the doctor are considered to be cured, which is not logical. These authors found that the reason patients did not return to the doctor was because the care from the doctor was not helpful.

•••••

A related study was published in 2012 in the journal Physical Medicine and Rehabilitation, titled (4):

Is It Time to Rethink the Typical Course of Low Back Pain?

The authors published an analysis of a survey administered to 590 subjects from 30 separate clinical practices pertaining to low back pain. Their findings include:

“Recurrent LBP episodes were common and numerous. Recurrences often worsened over time”

“Recurrences of back pain are widely recognized as common, reported as occurring in 60%-73% of individuals within 1 year after recovery from an acute episode.”

These authors suggest that there may be an underlying biomechanical cause for recurrences of low back pain. Their explanation of the recurrence of low back pain is that it is being sub-optimally managed. They also note that 84% of total costs for patients with low back pain are related to a recurrence.

•••••

A number of published investigations have assessed the potential for maintenance chiropractic spinal manipulation as an intervention that may reduce the incidence of recurrences of low back pain (5, 6, 7, 8).

Maintenance care is the advising of the patient to return for more treatment even though the initial signs and symptoms have either resolved or have achieved maximum improvement.

A theoretical academic basis for the use of maintenance chiropractic manipulation was published in 2011 in the Journal of Chiropractic Humanities and titled (5):

A Theoretical Basis for Maintenance Spinal Manipulative Therapy for the Chiropractic Profession

The author notes that the purpose of chiropractic maintenance care is to optimize spinal function and decrease the frequency of future episodes of back pain.

The author performed a search of PubMed and of the Manual, Alternative, and Natural Therapy Index System with a combination of key words: chiropractic, maintenance and wellness care, maintenance manipulative care, preventive spinal manipulation, hypomobility, immobility, adhesions, joint degeneration, and neuronal degeneration, 1970-2011. The search revealed surveys of doctors and patients, an initial clinical pilot study, randomized control trials, and laboratory studies that provided correlative information to provide a framework for development of a hypothesis for the basis of maintenance spinal manipulative therapy. The author states:

“It is hypothesized that because spinal manipulative therapy brings a joint to the end of the paraphysiological joint space to encourage normal range of motion, routine manipulation of asymptomatic patients may retard the progression of joint degeneration, neuronal changes, changes in muscular strength, and recruitment patterns, which may result in improved function, decreased episodes of injuries, and improved sense of well-being.”

The author cites published surveys indicating that over 90% of chiropractors opined that the purpose of maintenance care was to minimize recurrences or exacerbations. Ninety-five percent of chiropractors recommended maintenance care to minimize recurrences or exacerbations of conditions. In a study, ninety-six percent of elderly patients who received maintenance care believed that it was “either considerably or extremely valuable.”

This author further states:

“It has been reported that 79% of patients in chiropractic offices are recommended maintenance care and nearly half of those patients elect to receive these services.”

“[Evidence] clearly demonstrates that the clinical consensus of dosage of maintenance manipulative therapy has been found to be most beneficial at an average of once every 2 to 4 weeks.”

“Taking into account the neurological and biomechanical consequences of manipulative therapy, it is plausible to hypothesize that monthly manipulative therapy retards the progression of adhesion formation, joint degeneration, neuronal changes, and changes in muscular strength and recruitment patterns. This could result in improved function, decreased episodes of injuries, and improved sense of well-being.”

A 2004 chiropractic study of chronic low back pain showed that the group of patients who received 9 months of maintenance manipulation at the frequency of once per every 3 weeks maintained their initial clinical improvement while the control group returned to their previous levels of disability. The authors “concluded that there were positive effects of preventive maintenance chiropractic spinal manipulation in maintaining functional capacities and reducing the number and intensity of pain episodes after the acute phase of treatment of low back pain patients.”

“There is a common thread of the time dependency noted in all the laboratory and clinical studies. The periods of onset of the anatomical and physiological changes ranged from 2 to 4 weeks. The clinical studies also provided manipulation every 4 weeks and noted positive changes in the pain and disability measures. This time interval also correlates with the common recommendations found in the surveys of chiropractic physicians.”

•••••

Physician Manuel Cifuentes, MD, and colleagues published a pertinent study on this topic in 2011. It was published in the Journal of Occupational and Environmental Medicine, titled (6):

Health Maintenance Care in Work-Related Low Back Pain and its Association with Disability Recurrence

The objective of this study was to compare occurrence of repeated disability episodes across types of health care providers (medical physician, physical therapists, chiropractor) who treat claimants with new episodes of work-related low back pain. A total of 894 cases were followed for 1-year using workers’ compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.

The authors note that an important component of the human and economic costs for low back pain are the recurrence rate. They state:

“Health maintenance care is a clinical intervention approach thought to prevent recurrent episodes of LBP. It conceptually refers to the utilization of health care services with the aim of improving health status and preventing recurrences of a previous health condition.” Health maintenance care is defined as “treatment. . . after optimum recorded benefit was reached.”

The authors note that chiropractors are the only group of providers who explicitly state that they have an effective treatment approach to maintain health with “maintenance care.” They also noted that chiropractic patients had “less expensive medical services and shorter initial periods of disability than cases treated by other providers.” Also, chiropractic patients had “fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups.”

These authors note:

“After controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors.”

“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type.”

“After controlling for severity and demographics, no health maintenance care is generally as good as chiropractor care.”

“Our findings seem to support the use of chiropractor services, as chiropractor services generally cost less than services from other providers.”

In this study, the chiropractic patients who did suffer a recurrence did so 29 days later than the physical therapy or physician patients who suffered a recurrence. The authors speculate that the main advantage of chiropractors could be based on the dual nature of their practice, involving both regular care plus maintenance care. Chiropractic appears to be an “important advancement” in the treatment of work-related back injuries.

This study certainly supports the concept and value of chiropractic maintenance care for reducing the incidences of low back pain recurrence.

•••••

Physician Mohammed K. Senna, MD, and colleague published an important study on this topic in 2011. It appeared in the journal Spine, and was titled (7):

Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome?

This study is a prospective single blinded placebo controlled study that was conducted to assess the effectiveness of spinal manipulation therapy for the management of chronic nonspecific low back pain, and to determine the effectiveness of maintenance spinal manipulation in long-term reduction of pain and disability levels associated with chronic low back conditions.

Sixty patients with chronic, nonspecific low back pain lasting at least 6 months, were randomized to receive either:

• 12 treatments of sham spinal manipulation over a 1-month period
• 12 treatments consisting of spinal manipulation over a 1-month period
• 12 spinal manipulation treatments over a 1-month period plus maintenance spinal manipulation every two weeks for the following nine months

The spinal manipulation was a “high velocity thrust to a joint beyond its restricted range of movement.”

Follow-up evaluations occurred at 1-, 4-, 7-, and 10-months. The authors made these observations:

Patients receiving real manipulation “experienced significantly lower pain and disability scores” than patients receiving sham manipulation at the end of 1-month.

“In the non-maintained spinal manipulation group, the mean pain and disability scores returned back near to their pretreatment level.”

“Spinal manipulation is effective for the treatment of chronic nonspecific low back pain. To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative therapy.”

“One possible way to reduce the long-term effects of low back pain is maintenance care (or preventive care).”

“To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative.”

This study also supports the concept and value of chiropractic spinal manipulation maintenance care.

•••••

In 2018, researchers from Sweden and Denmark published a study in the journal Public Library of Science (PLoS) One, titled (8):

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

The aim of this trial was to investigate the effectiveness of chiropractic maintenance care on pain for patients with recurrent or persistent low back pain. It was an investigator-blinded, randomized controlled trial using 328 subjects aged 18-65 years, with non-specific low back pain.

If the initial course of chiropractic care (4 visits) resulted in substantial improvements in low back pain, the subjects were randomized to either maintenance chiropractic care (163 subjects) or control group (158 subjects). The study used 35 chiropractic clinicians with a mean number of years in practice of 17.9, ranging from 1 to 38 years.

The primary outcome was total number of days with bothersome low back pain during 52 weeks. The status was collected weekly.

The authors note that low back pain is often recurrent and has a large negative impact on society. Consequently, focusing on preventive strategies for recurrent low back pain is logical. “This is one of the first studies to test the effect of preventive manual care performed by chiropractors (maintenance care) for recurrent and persistent low back pain.”

Chiropractors have traditionally used maintenance care as a prevention strategy against new episodes of low back pain, or in reducing the impact of a new episode of low back pain. Maintenance chiropractic care may improve biomechanical and neuromuscular function and address psychosocial issues, thereby reducing the risk of relapse into pain. “It is common for chiropractors to recommend maintenance care, i.e. preventive consultations/visits for recurrent and persistent musculoskeletal pain and dysfunction.”

About one fifth of all visits to Scandinavian chiropractors are maintenance care visits and 98% of Swedish chiropractors use the approach to some extent. The authors make these comments:

“Non-specific low back pain is one of the most common and costly healthcare problems in society today.”

“The burden of disabling low back pain on individuals, families, communities, industries and societies is substantial and is now the leading cause of activity limitation and work absence in the world.”      

“Chiropractors are trained to assess and treat disorders of the musculoskeletal system, of which low back pain is the most common.”

“The majority of patients seeking chiropractic care receive some form of manual therapy, of which spinal manipulation and mobilization are the most common, often along with advice on exercise.”

“Chiropractic maintenance care resulted in a reduction in the total number of days per week with bothersome low back pain compared with symptom-guided treatment.”

The maintenance group had a faster reduction in days with bothersome low back pain and reached a lower steady state earlier.

Maintenance chiropractic care was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific low back pain.

Maintenance chiropractic care should be considered an option for tertiary prevention of low back pain.

The maintenance chiropractic care group “improved faster and achieved the steady state phase earlier with a lower mean number of days with low back pain per week.”

“The treatment was not reported as being linked to any serious harm and both the intervention and the control regimes must be considered safe treatments.”

•••••

In 2019, an article was published in journal Chiropractic & Manual Therapies, titled (9):

Chiropractic Maintenance Care – What’s New?
A Systematic Review of the Literature

These authors performed a systematic review of the literature using the search terms “chiropractic OR manual therapy” AND “Maintenance Care OR Prevention,” using PubMed and Web of Science, starting from 2007. Fourteen identified studies were included in their review. Key points from this study were:

It is now an accepted fact that “spinal pain is a recurring disorder.”

“Maintenance Care is a traditional chiropractic approach, whereby patients continue treatment after optimum benefit is reached.”

“Both chiropractors and patients believe in the efficacy of Maintenance Care.”

“Maintenance Care patients experienced fewer days with low back pain compared to patients invited to contact their chiropractor ‘when needed.’”

“Maintenance Care can be considered an evidence-based method to perform secondary or tertiary prevention in patients with previous episodes of low back pain, who report a good outcome from the initial treatments.”

“Patients who received Maintenance Care had better outcome than those who received short-term treatment or short-term sham treatment.”

“Maintenance Care can clearly be said to be used as a preventive therapeutic concept.”

“Chiropractors could obviously play an important role here as ‘back pain coaches,’ as the long-term relationship would ensure knowledge of the patient and trust towards the chiropractor.”

“Back pain is a chronic disease for most, with episodes at short or long intervals. A preventive approach such as Maintenance Care, therefore, makes sense.”

SUMMARY

Evidence continues to show that low back pain is recurrent, and each episode is worse than prior episodes, resulting in greater disability and requirement for care. There is also increasing support for the use of chiropractic for maintenance to reduce the incidences of recurrent low back pain.

REFERENCES

1. Goo MR, Jun DH, Lee DY; Dynamic Cycle of Low Back Pain: A 17-Year, Population-Based Study Analyzing the National Health Insurance Service Data in South Korea; Medicina; April 23, 2025; Vol. 61; No. 5; Article 782.
2. Chiarotto A, Koes BW; Nonspecific Low Back Pain; The New England Journal of Medicine; May 5, 2022; Vol. 386; No. 18; pp. 1732-1740
3. Croft PR, Macfarlane GF, Papageorgiou AC, Thomas E, Silman AJ; Outcome of low back pain in general practice: A prospective study; British Medical Journal; May 2, 1998; 31; pp. 1356-1359.
4. Donelson R, McIntosh G; Hall H; Is It Time to Rethink the Typical Course of Low Back Pain? Physical Medicine and Rehabilitation (PM&R); June 2012; Vol. 4; No. 6; pp. 394–401.
5. Taylor DN; A theoretical basis for maintenance spinal manipulative therapy for the chiropractic profession; Journal of Chiropractic Humanities December 2011; Vol. 1; No. 1; pp. 74-85.
6. Cifuentes M, Willetts J, Wasiak R; Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence; Journal of Occupational and Environmental Medicine; April, 2011; Vol. 53; No. 4; pp. 396-404.
7. Senna MK, Shereen A, Machaly SA; Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome? Randomized Trial; SPINE; August 15, 2011; Vol. 36; No. 18; pp. 1427–1437.
8. Eklund A, Jensen I, Lohela-Karlsson M, Hagberg J, Leboeuf-Yde C, Kongsted A, Bodin L, Axen I; 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; Public Library of Science (PLoS) One; September 12, 2018; Vol. 13; No. 9; e0203029
9. Iben A, Lise H, Charlotte LY; Chiropractic Maintenance Care – What’s New? A Systematic Review of the Literature; Chiropractic & Manual Therapies; 2019; Vol. 27; Article 63.