Research Review By Dr. Joshua Plener©


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Date Posted:

April 2023

Study Title:

Development and evaluation of the MAINTAIN instrument, selecting patients suitable for secondary or tertiary preventive manual care: the Nordic maintenance care program


Eklund A, Palmgren P, Jakobsson U & Axén I

Author's Affiliations:

Unit of Intervention and Implementation Research for Worker Health, The Institute of Environmental Medicine (IMM), Karolinska Institutet, Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden.; Department of Clinical Sciences Malmö, Centre for Primary Health Care Research, Lund University, Lund, Sweden

Publication Information:

Chiropractic & Manual Therapies 2022; 30: 15.

Background Information:

Low back pain (LBP) affects a large portion of the adult population worldwide. In about 80-85% of individuals, LBP episodes are often short lived but recurrent throughout one’s life (1). As a result, research has looked at strategies of preventing recurrences in people recovered from a previous episode of LBP (termed secondary prevention) and preventing the progression and consequences of LBP (termed tertiary prevention) (2).

Once the optimal treatment benefit is reached during an initial care plan, maintenance care is described as a potential long-term strategy, with treatments carried out at regular intervals regardless of symptoms. Maintenance care is aimed at preventing future episodes, progression and consequences of LBP. Maintenance care patients are commonly scheduled at a 1-3 month interval, and treatments such as manual therapy, individual exercises, and lifestyle advice are typically provided (3).

A randomized controlled trial investigating the effectiveness of maintenance care in patients with recurrent and persistent LBP found fewer days of bothersome low back pain over a year in specific subgroups of patients (4, 5). In further studies, it was found that patients with differing psychological profiles (as identified using the West Haven-Yale Multidimensional Pain Inventory [or, MPI]) responded differently to maintenance care. Specifically, the three groups identified were (6-8):
  1. Adaptive Copers (AC): characterized by low pain severity, low interference with everyday life due to their pain, low life distress, and a higher activity level and perceived control.
  2. Interpersonally Distressed (ID): characterized by dysfunctional behaviors such as low levels of social support, low levels of solicitous and distracting responses from significant others, and high scores on punishing responses (compared to AC and DYS patients).
  3. Dysfunctional (DYS): characterized by higher pain severity, pain significantly interfering with their everyday activities, and low levels of life control and activity levels (8).
It was demonstrated that those with a less favourable psychological profile (DYS, specifically) reported better outcomes from a maintenance care approach as compared to patients categorized as adaptive copers, who did a little worse with maintenance care (more days with pain and a higher number of visits) (6, 7).

The West Haven-Yale Multidimensional Pain Inventory (MPI) was developed to capture the perceptions and consequences of living with chronic pain (9). This instrument has been shown to be valid and reliable and aimed to identify and categorize individuals into three subgroups defined above (10). However, this instrument was not designed to be used as a screening instrument for daily clinical practice, but rather to be used as a comprehensive research tool. Therefore, the objective of this study was three-fold:
  1. To develop a new, brief instrument for identifying dysfunctional patients in a clinical setting with adequate sensitivity, specificity and receiver operating characteristics.
  2. To assess the instrument’s ability to reproduce the previously published effect estimate of maintenance care.
  3. To test the sensitivity, specificity and receiver operating characteristics in 3 other existing data sets to assess the external validity and utility of the model across populations.

Pertinent Results:

Based on the development of the MAINTAIN instrument (10 questions covering 5 domains, scored from -12 to 48), thresholds were identified. First, a threshold of a score of 18 was found to do reasonably well in identifying dysfunctional individuals. At a score of 18 or higher, there was a sensitivity of 95.8%, and a specificity of 64.3%. This means 95.8% of participants were correctly classified as dysfunctional (remember, these are the individuals who are most likely to benefit from maintenance care foe LBP). Second, at a score of 22 or higher, 81.1% of all dysfunctional individuals were correctly classified and specificity was 79.2%.

When assessing the clinical outcomes from the original RCT, the number of days with activity-limiting pain was used to estimate the effect of the intervention between the maintenance care and control groups for patients classified within the Dysfunctional category. A positive trend was observed, demonstrating a higher effect of maintenance care with a higher MAINTAIN score cut-off. Patients in the maintenance care group who were classified as dysfunctional at a score of 18 or more experienced, on average, 24.4 fewer days with activity-limiting pain compared to dysfunctional patients in the control group. With a MAINTAIN score of 22 or higher, those in the maintenance care group had, on average, 34.5 fewer days with activity-limiting pain.

In all external validation datasets, the tests showed very good to excellent diagnostic accuracy.

Clinical Application & Conclusions:

The MAINTAIN instrument is a brief clinical tool that has shown very good to excellent diagnostic accuracy for identifying dysfunctional patients in a clinical setting. By using the identified thresholds on this instrument, patients can be categorized into low probability (< 18), moderate probability (18-21), and high probability (22 or greater) of having a good outcome from maintenance care for low back pain. Implementing the MAINTAIN instrument could potentially improve outcomes by identifying high-risk patients early in the clinical course and stratifying them to appropriate interventions with a higher chance of achieving treatment success.

This is the first study to develop and assess a brief version of the Swedish West Haven-Yale Multidimensional Pain Inventory with the purpose of identifying dysfunctional subjects suitable for maintenance care for LBP in a clinical setting. The instrument displayed an acceptable trade-off between the sensitivity and specificity across populations and can be used with different thresholds depending on the rate of false positive tests that are acceptable in the clinical encounter. Rather than a single threshold, the authors recommend 3 ranges to illustrate that the instrument represents a scale where the likelihood of a good outcome from maintenance care changes in a dose-response-like relationship.

Within a clinical situation, a brief instrument can be used to provide a quick and useful assessment of the patient. This tool allows the clinician to get an overview of the psychological dimensions of the patient’s pain experience as well as an opportunity to understand the 5 dimensions, which are pain severity, interference, life control, affective distress, and support. Next steps include further assessment of the MAINTAIN instrument to continue informing its applicability.

CLICK HERE to download the MAINTAIN instrument.

Commentary from Dr. Andreas Eklund (lead author):

Since graduating from chiropractic college over 20 years ago, I have been acutely aware of the biopsychosocial paradigm. However, for most of my career as a chiropractor, psychosocial risk factors have been used to explain why some patients did not respond to care late in the process rather than being used as information informing different care pathways early in the encounter. The biopsychosocial model has been used as an overarching theoretical framework, with little impact on the actual clinical procedures.

Many screening instruments have been developed for the purpose of screening for psychological risk factors in clinical practice. However, most of these have not been shown to improve cost-effectiveness in chiropractic practice. Although more work is needed to confirm the MAINTAIN instrument's usefulness in practice, the results are promising so far.

The purpose of the instrument is two-fold.
  1. To quickly acquire an estimate of the patient's overall psychological distress from their pain (MAINTAIN score), along with a few other parameters, assess if the patient may benefit from a long-term structured management strategy, Maintenance Care.
  2. To identify which of the 5 MAINTAIN dimensions (pain severity, interference, life control, affective distress, and support) of the pain experience results in the most distress for the patient. This information will allow the clinician to home in on the most important aspects with an in-depth line of questions. The purpose here is to elicit specific details that will form the basis of the management plan and ultimately set goals for the treatment strategy.
In other words, the MAINTAIN instrument is about operationalizing the biopsychosocial model in chiropractic practice making psychological risk factors an integral part of patient assessment and management.

About Andreas Eklund, DC, PhD:
Dr. Eklund graduated from AECC in 2002 and is a co-owner of two multidisciplinary rehab units employing a total of 50 persons. He earned this Ph.D. degree in 2016, and the title of his thesis was “Recurrent and persistent low back pain - course and prevention.” He currently works part-time (60%) with research as an assistant professor at Karolinska Institutet alongside his clinical duties (40%).

His research has mainly focused on Maintenance Care, management of recurrent/persistent pain, psychological risk factors, and he has an interest in clinical outcome research applicable to the practicing chiropractor. He frequently lectures internationally on topics related to his research area and has a genuine interest in education, dissemination, and implementation of research in clinical settings.

In 2016 he was awarded “Chiropractor of the Year” by the Swedish Chiropractic Association and won the EAC Jean Robert research award (1st prize). In 2019 he was awarded the Scott Haldeman Award for outstanding research at the WFC congress in Berlin for his work on Chiropractic Maintenance Care. He was one of the 13 fellows of the inaugural cohort of the Chiropractic Academy of Research Leadership (CARL).

Study Methods:

To address the objectives of this study, data from a randomized trial (RCT) was utilized to develop and test the instrument, while data from 3 other clinical trials were used to assess the utility of the instrument across different populations with low back pain. These three data sets consisted of patient populations experiencing pain resulting in different degrees of activity limitations, collected in different medical settings during different time periods.

Exploratory factor analysis was used to identify the items on the MAINTAIN instrument. Eight items from the original Swedish version of the West Haven-Yale Multidimensional Pain Inventory were selected to be used. During the process, 2 additional items were included to better discriminate between groups of individuals. Of the 10 items included in the questionnaire, 5 dimensions related to pain experience were recorded, including pain severity, interference, life control, affective distress and support. The MAINTAIN instrument score ranges from -12 to 48 with thresholds developed for the subgroup classifications. A positive test would signify a dysfunctional profile, while a negative test would signify an interpersonally distressed or an adaptive coper profile.

The proportion of individuals for each subgroup of the MAINTAIN instrument was calculated and depicted graphically. The diagnostic accuracy was estimated to understand the utility of this instrument. The difference in the total number of days with pain between the control and intervention groups from the RCT was used to understand how well the instrument could reproduce the effect size in the subgroups previously shown to respond to maintenance care.

Study Strengths / Weaknesses:

  • This study continues to add to the body of literature evaluating the usefulness of maintenance care in clinical practice.
  • The authors took a rigorous approach to study this instrument.
  • The cross sectional design used to develop the instrument does not allow for the exploration of measurement over time.
  • The datasets used to validate the instrument are quite old and it’s possible that societal perceptions and attitudes towards pain may have changed over time.

Additional References:

  1. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, et al. The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014; 73(6): 968–74.
  2. Ferreira G, Hancock M. Recommendations for shaping the future of low back pain prevention research. Br J Sports Med 2021; 55(16): 886–7.
  3. Axén I et al. Chiropractic maintenance care—what’s new? A systematic review of the literature. Chiropr Man Therap 2019; 27:63.
  4. Eklund A, Axén I, Kongsted A et al. Prevention of low back pain: effect, cost-effectiveness, and cost-utility of maintenance care—study protocol for a randomized clinical trial. Trials 2014; 15(1): 102.
  5. 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.
  6. 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.
  7. 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. Chiropr Man Ther 2020; 28:1.
  8. Bergström C, Hagberg J, Bodin L, Jensen I, Bergström G. Using a psychosocial subgroup assignment to predict sickness absence in a working population with neck and back pain. BMC Musculoskelet Disord 2011; 12(1): 81.
  9. Kerns RD, Turk DC, Rudy TE. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985; 23(4): 345–56.
  10. Turk DC. The potential of treatment matching for subgroups of patients with chronic pain: lumping versus splitting. Clin J Pain 2005;2 1(1): 44–55.

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