Research Review By Dr. Michael Haneline©


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Date Posted:

January 2022

Study Title:

The Nordic maintenance care program: patient experience of maintenance care – a qualitative study


Hjertstrand J, Palmgren P, Axén I & Eklund A

Author's Affiliations:

Unit of Intervention and Implementation Research for Worker Health, Institute of Environmental Medicine (IMM), Karolinska Institute, Stockholm, Sweden.

Publication Information:

Chiropractic & Manual Therapies 2021; 29: 28.

Background Information:

Exercise and education are considered the most promising interventions for secondary prevention of LBP (1), although some patients may require a more structured framework of ongoing support (2). Preplanned, supportive long-term chiropractic manual care (a.k.a. ‘Maintenance Care’ [MC]) has been shown to be effective for some patients with recurrent and persistent LBP (3-6). Patients with high pain severity, marked interference with everyday life, high affective distress, low perception of life control and low activity levels, reported clinically significant improvements from MC with little or no additional cost in prior studies.

The use of MC is common among chiropractors in Scandinavian countries, with around 22–41% of all visits being dedicated to MC and 98% of Swedish clinicians believing that MC is useful for some patients. A survey on the perceptions of patients who received MC reported that the purpose of MC was to prevent pain, to remain as pain free as possible, and to prevent disease in general, with most of the patients reporting that those goals were achieved to a high degree (7).

However, little is known about patients’ experiences and preferences, or about factors which facilitate or hinder MC, and no previous qualitative studies have been performed about how patients experience MC and what their preferences are. This information would be helpful in facilitating high compliance, patient-centered care, and the optimum effectiveness of MC.

To understand patient behaviors related to MC, the theory of planned behavior (TPB) may be used as a theoretical framework to observe and understand patients’ behavioral intentions. TPB assumes that a person’s behavior is deliberate and planned and can be predicted. It has been shown that there is a moderate (r = 0.44–0.48) correlation across different populations and behaviors between planned behavior and actual behavior.

The aims of this study were to:
  1. explore patients’ experiences and preferences regarding MC, emphasizing the barriers to and facilitators of engaging in and maintaining a MC plan; and
  2. contrast the interview data using 3 psychological subgroups: i) adaptive copers, ii) interpersonally distressed, and iii) dysfunctional.

Pertinent Results:

Seven categories and three themes were identified which describe participants’ experiences of factors that facilitate engaging in and maintaining a maintenance care (MC) plan. Themes were presented with underlying categories, as follows.
  • Care that improves quality of life, with three underlying categories: 1) Free of pain – moving & performing better, 2) Makes me feel great! and 3) I don’t want to be off work. According to the patients, these components have value relating to improved quality of life.
  • Care that is structured, accessible and appreciated, which also included three categories: 1) It fits into my life, 2) A form of care: framework for regularity & support, and 3) MC being an important piece of the puzzle. Patients perceived these categories as care that is structured, accessible and appreciated.
  • Care that is patient‑centered, where patients stressed the importance of a good relationship with their clinician and a chiropractor who was professional and caring.
Barriers to engaging in and maintaining a MC plan were evident in the analysis, resulting in the following three themes which were expressed as questions:
  • Does the benefit of maintenance care outweigh the cost? Participants expressed concerns that MC required undue commitment in terms of time and costs. Participants also expressed the need to feel that there was something wrong with their musculoskeletal health that would motivate them to engage in MC. One participant commented that some MC visits were unnecessary because they didn’t think they had any problems.
  • Is maintenance care accessible? Participants reported several barriers to engaging in and maintaining a care plan, including perceived practitioner unavailability due to various aspects such as – no (or few) chiropractors within close proximity, lack of available treatment times, difficulty finding a good clinician, and logistical challenges like difficulty in physically accessing the clinic. Another aspect of this theme related to MC being perceived as separate from mainstream health care. Patients mentioned cultural and social beliefs concerning antiquated ideas about the chiropractic profession and treatment methods. Patients mentioned that MC was not integrated into mainstream health care and there was minimal financial support from the government, which were described as system faults. Some participants thought there was a widespread lack of understanding of MC, as well as the chiropractic profession, which was perceived to be a potential barrier to engaging in and maintaining such a care plan.
  • Is maintenance care being delivered in a way that is congruent with a patient-centered perspective? This theme developed from statements about inadequate patient-doctor relationships and unpleasant feelings and experiences during care, including fear of adverse reactions, and lack of communication, trust and professional rapport between clinician and patient. Participants complained that they were not given care-related information, which one indicated was a reason to not continue with MC. There were also comments about treatment being uncomfortable, about discomfort with close physical contact, getting undressed in front of the clinician, and the gender of the clinician. Some were concerned about whether the chiropractor was trying to keep them under care against their personal preference.

Clinical Application & Conclusions:

This study identified barriers to and facilitators of patients engaging in and maintaining a MC plan. Participating patients expressed both positive and negative experiences of MC which were considered across three psychological subgroups.

Clinicians who utilize MC (or contemplate using it) in their practices will acquire a deeper understanding of MC from this study and will appreciate the value of MC. Clinicians will also be better equipped to provide MC care that patients perceive as being of high value.

Study Methods:

This study was part of a larger project that utilized a prospective mixed-methods approach to pragmatic research. The findings of this type of research result from an interplay between the phenomenon under scrutiny and the investigators who took a qualitative approach to explore human experiences. The study was informed by the TPB (theory of planned behavior), which was used as a lens to understand and conceptualize the phenomenon under study.

Data were collected by 35 chiropractors who participated in a nationwide practice-based research network. Participating patients were recruited from a subset of a clinical trial that collected data on patients with recurrent and persistent LBP; these patients had been randomized to receive MC. Sixty-three participants were invited to participate in the study, with 24 (12 females and 12 males) of them accepting the invitation.

Face-to-face individual semi-structured interviews were conducted via the Zoom platform to capture patients’ experiences, opinions, feelings, and knowledge. The interviews were designed to identify potential challenges patients faced when considering MC as a preventive strategy for their condition and to describe the potential facilitating factors or perceived benefits of the MC plan.

Participants were initially assessed using the Swedish version of the West Haven-Yale Multidimensional Pain Inventory (MPI-S), which was designed to assess the cognitive-behavioral aspects of the pain experience and to classify patients into 5 psychological subgroups (pain severity, interference, life control, affective distress, and support) and 3 behavioral constructs associated with individuals in close relationships with the patient (punishing responses, solicitous responses, and distracting responses). Three psychological subgroups have been identified from the MPI-S (adaptive copers, interpersonally distressed, and dysfunctional) and have been shown to predict treatment outcome and sick leave:
  • Adaptive copers (AC) are characterized by low pain severity, low interference with everyday life, low life distress, a high activity level and a high perception of life control. They have the best prognosis and the lowest risk of long-term sick-leave.
  • The interpersonally distressed (ID) subgroup report challenges in close relationships and often describe distrust of others whom they view as responsible for their problems. Their spouses or significant others are frequently not supportive/helpful or express irritation, frustration, and anger. Interpersonally distressed individuals have a poorer prognosis and a higher risk of long-term sickness absence.
  • The dysfunctional (DYS) sub-group reports high pain severity which interferes with everyday life as well as high affective distress, low perception of life control and low activity levels. Dysfunctional individuals have the worst prognosis and the highest risk of long-term sickness absence.
The data were analyzed through a process of reviewing the transcripts line-by-line and developing subcategories and categories. The process involved: 1) one author reading the transcribed interviews to become familiar with the text; 2) all authors reading and analyzing the textual data; 3) identifying the meaning units relating to the aim of the study and the questions in the interview guide; 4) condensing the meaning units and developing codes for the phenomenon under investigation; 5) cross-contrasting subcategories and categories; and 6) conducting a primary interpretational analysis in which the investigators went beyond the explicit manifest content. The participant profiles (adaptive copers, interpersonally distressed, and dysfunctional) were then cross contrasted with emerged categories, themes, and dimensions.

Study Strengths / Weaknesses

Although this type of study is not high in the hierarchy of clinical evidence, it was methodically sound and the results will be useful to chiropractors and other clinicians who manage LBP patients using spinal manipulation.

Study strengths include the use of triangulation, whereby the study’s investigators had different professional backgrounds including a chiropractic student, a researcher/educator, and a researcher/clinician. Also, the senior investigator was well-versed in the methodology that was utilized, which ensured concurrence between the data and the findings that were reported.

The authors listed several study limitations, including:
  • this was a small-scale qualitative study which limits the generalizability of its findings;
  • there was a long interval between the study period and when the interviews were conducted which could have distorted some of the specific details of the participants’ interviews; and
  • MPI, RMDQ and TDP were not re-assessed from the time of the study, so levels of pain, activity limitation and psychological profile may have been different when the interviews were conducted.

Additional References:

  1. Steffens D, Maher C, Pereira L, et al. Prevention of low back pain: a systematic review and meta-analysis. JAMA Intern Med 2016; 176(2): 199–208.
  2. Foster N, Anema J, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018.
  3. Eklund A, Hagberg J, Jensen I, et al. 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. Chiropract Manual Therap 2020; 28(1).
  4. Iben A, Lise H, Charlotte L. Chiropractic maintenance care—what’s new? A systematic review of the literature. Chiropr Man Therap 2019; 27: 63.
  5. Eklund A, Jensen I, Leboeuf-Yde C, et al. 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. PLoS ONE 2019; 14(10): e0223349.
  6. Eklund A, Jensen I, Lohela-Karlsson M, et al. 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. PLoS ONE 2018; 13(9): e0203029.
  7. Bringsli M, Berntzen A, Olsen DB, Leboeuf-Yde C, Hestbaek L. The Nordic maintenance care program: maintenance care—what happens during the consultation? Observations and patient questionnaires. Chiropr Man Therap 2012; 20(1): 25.

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