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Research Review By Dr. Ceara Higgins©


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Date Posted:

February 2020

Study Title:

Chiropractic maintenance care – what’s new? A systematic review of the literature


Axén I, Hestbaek L & Leboeuf-Yde C

Author's Affiliations:

Karolinska Institute, Stockholm Sweden; The Norwegian Chiropractic Research Foundation, Oslo, Norway; Department of Sport Science and Clinical Biomechanics, Odense, Denmark; Nordic Institute of Chiropractic and Clinical Biomechanics, Odense, Denmark; Institute for Regional Health Research, University of Southern Denmark, Odense, Denmark.

Publication Information:

Chiropractic & Manual Therapies 2019; 27: 63. (access this paper HERE)

Background Information:

The concept of spinal pain as a recurring disorder is gaining wider acceptance. Acute episodes may be short-lived, but the condition is often life-long, featuring periods of exacerbation and remission (1). Therefore, it may be prudent to shift the treatment focus from overtly curing the condition to managing pain trajectories and individual episodes (2).

Chiropractors have used the term “Maintenance Care” both to describe ongoing treatment beyond reduction of symptoms and also to describe treatment as a precaution to keep patients healthy, regardless of symptoms or historic factors. The former has been criticized due to a lack of evidence and a potential financial motive, while the second, although logical, also lacks scientific support.

Two previous narrative reviews from 1996 and 2007 concluded that there was no evidence-based definition of maintenance care and the indications for and nature of its use had not been clearly stated. As well, while many chiropractors seemed to believe in the usefulness of maintenance care, little evidence was available as to how it was accepted by patients. Further, the prevalence of use, efficacy and cost-effectiveness of maintenance care for various conditions was unknown. Based on these limitations in the data, “The Nordic Maintenance Care Program” (a research program we’ve Reviewed previously on RRS Education), was launched in order to increase the knowledge surrounding maintenance care.

This new systematic review aimed to address the shortcomings in the previous research by:
  1. defining the idea of maintenance care and the indications for its use;
  2. describing chiropractors’ belief in maintenance care and patients’ acceptance of it;
  3. establishing the prevalence of maintenance care among chiropractors and potential characteristics of the chiropractors who use it; and
  4. determining the efficacy and cost-effectiveness of maintenance care for various conditions.

Pertinent Results:

14 articles were included, with 10 of the 14 coming from the Nordic Maintenance Care Program line of research. The articles were a mix of qualitative and quantitative studies, with 8 collecting their data from chiropractors through estimated responses or from patient files, 4 collecting their data from patients, 1 collecting data from both chiropractors and their patients and 1 using workers’ compensation claims data.

The Rationale for Maintenance Care:
Maintenance care was described by chiropractors as a type of prolonged care delivered at regular intervals, but also as an approach aimed at preventing new episodes and maintaining clinical improvements. Patients described maintenance care as aiming to prevent recurrences (78%), remain pain-free (68%) or to prevent disease in general (17%).

Spacing of Maintenance Care Treatments:
Interview studies found the most common interval for maintenance care to be 3 months. However, studies looking at patient files showed a mean of 9 weeks and a mode of 3 months between visits, with most maintenance care visits scheduled in a range from 1 to 3 months.

Content of Maintenance Care:
Sessions of maintenance care included a variety of treatment modalities, including ordinary examination/manual treatment and packages including exercise prescription, advice about ergonomics, diet, weight loss, and stress management. Maintenance care patients were found to be treated in more areas of the spine or with full spine care when compared to non-maintenance care patients.

Indications for the Use of Maintenance Care:
Maintenance care was found to be most commonly offered in cases when the patient had experienced previous episodes of the same pain and had shown improvement with treatment. Clinicians also indicated taking into consideration other patient-related factors such as being worried, reporting high stress, and having a hard, physical job. The patient-doctor relationship was also considered. A small number of chiropractors indicated that perceived sub-optimal biomechanical function would be an indicator for maintenance care.

Chiropractors’ and Patients’ Belief in Maintenance Care:
In a single survey, 98% of chiropractors indicated that they believed maintenance care could be used as a preventive tool, in at least some cases. Some chiropractors in an interview study claimed that maintenance care was always of benefit and would prevent disease. No studies were found that examined patients’ acceptance of maintenance care. However, an RCT looking at patients’ expectations of improvement showed that patients positive expectations decreased during the duration of the study. This decrease was more pronounced in patients who were treated for a short time when compared to patients treated for a longer duration.

Prevalence of Maintenance Care in Chiropractic:
The average for patients using maintenance care with Scandinavian chiropractors was between 22-41%, with a huge variation by individual practitioner from 0-100%. The use of maintenance care was found to be more common with experienced chiropractors, clinic owners, and individuals who received their chiropractic degree in the US (as opposed to Europe). However, when the study was conducted, the older chiropractors were almost all trained in the US and the younger chiropractors were commonly educated in Denmark. Because of this, it is impossible to tell if age or educational background was responsible for the higher level of maintenance care usage in those practitioners.

The Clinical Usefulness and Cost-Effectiveness of Maintenance Care:
One study compared groups receiving either maintenance care or self-managed appointments, while three studies compared groups with different treatment duration and content. Only one study used the inclusion criteria for maintenance care as set out in the Nordic Maintenance Care Program: “recurring problems that improved well with initial treatments”. One study looked at medical doctors treating chronic LBP in a secondary care setting. In that study, comparisons were made between: 1) manual treatment involving an intense program of continued care over 9 months; 2) short term manual treatment without continued care; and 3) sham manual treatment without continued care. Best results were seen in the group receiving long-term intense continued care with manual treatment. Three studies specifically investigated chiropractic maintenance care. One looked at patients with chronic neck pain who received an initial course of treatment and then were randomized to receive maintenance care consisting of either spinal manipulative therapy (SMT) or SMT plus exercise. These treatment groups were then compared to a group who received attention only. No differences were found between groups at 10 months. Both of these studies had short follow-up periods which may affect the results.

Another study looked at elderly patients with NP and LBP who all received maintenance care consisting of SMT and supervised exercise with different durations of treatment. No significant improvements in disability were seen in patients treated for 36 weeks when compared to patients treated for 12 weeks. A final study looked at patients with episodic or persistent LBP who had improved after an initial course of chiropractic treatment. The group randomized to receive follow-up sessions scheduled at regular intervals showed an average of 13 fewer days with bothersome pain over 12 months compared to patients who were instructed to only come back when their symptoms returned. In addition, the maintenance care group only received an average of 2 additional treatments over the 12 months.

No studies evaluating the cost-effectiveness of maintenance care were found. However, a health-care register-based study showed that patients receiving maintenance care from a chiropractor had the smallest health care use when compared to patients receiving care from other health care professionals. However, there was no random allocation of patients and the groups were not compared for similarities/differences at baseline, so it is difficult to know how useful this data is.

Clinical Application & Conclusions:

Maintenance care is generally seen as a secondary or tertiary preventive approach, with visits usually scheduled between 1 and 3 months. Chiropractors seem to believe that this type of care is a public health approach, however, observations show that maintenance care sessions generally resemble ordinary consultations with an emphasis on a full spine approach. Patients who are generally considered good candidates for maintenance care include those with persistent or episodic pain, who reacted well to initial treatment.

As back pain is generally a chronic condition with episodes at short or long intervals, it seems logical to provide maintenance care to patients who initially get better with chiropractic care for as long as the patient finds it useful. As patient symptoms commonly change over time, it is important to remain alert to new developments and reassess symptoms when appropriate. We don’t currently know if maintenance care is of benefit because of the treatment provided or because of the clinical encounter itself (clinician attention or other contextual factors?). Therefore, further research is needed to determine which patients respond the best to maintenance care and which components of the treatment are of the most value.

Study Methods:

The authors repeated the search from the previous reviews, adding the term “manual therapy” to “chiropractic” AND “maintenance care” OR “prevention” and searched PubMed and Web of Science. PubMed was also searched for “The Nordic Maintenance Care Program”.

Only studies published after the 2007 review were included. Exclusion criteria included case studies, commentaries, and study protocols, and studies specifically referring to wellness (the authors wished to focus on studies related to symptoms).

Titles and abstracts were first reviewed independently by two authors, with disagreements settled by the third author. Full studies were then reviewed for their ability to answer the proposed research questions by all three authors independently.

Study Strengths / Weaknesses:

  • A thorough, systematic search was performed for this review.
  • Methodological quality of the studies included in this paper was not formally evaluated, rather the quality was narratively discussed.
  • Most of the studies included were from Northern Europe. Thus, there is a possibility this data may not be transferable to other populations.

Commentary from Dr. Iben Axén (lead author):

In the interest of evidence-based medicine, we have an obligation to scrutinize the methods that are utilized by chiropractors. If they are effective, we should promote them, if not, we should stop doing them. Sometimes the answer (to the question of effectiveness) may be less than crystal clear, as we are dealing with multifactorial conditions (such as pain) and very heterogeneous patient groups.

Maintenance Care is a management strategy that is commonly used by chiropractors world-wide. Still, a systematic review conducted in 2008 concluded that we knew very little about this way of treating patients: For whom is it recommended? For what conditions? What are the components of such a strategy and what is the frequency of care? How do chiropractors reason around this concept? Is it accepted by patients? Is it effective? Is it cost-effective?

We have now re-done the systematic review from 2008, and we found that the evidence-base of maintenance care has increased considerably. Through studies using many different methods (interviews, surveys, focus groups and randomized trials) we now have a clearer picture of what maintenance care is and how it is utilized. As is often the case, we cannot recommend this strategy for all, but there are some indications of effectiveness for a select group of patients.

Iben Axén, DC, PhD. Unit of Intervention and Implementation Research for Worker Health, The Institute of Environmental Medicine (IMM) Karolinska Institutet, Stockholm, Sweden. Research leader of the Norwegian Chiropractic Foundation ELiB (Et Liv I Bevegelse = a life in movement).

Additional References:

  1. da Silva T, Mills K, Brown BT, et al. Risk of recurrence of low back pain: a systematic review. J Orthop Sports Phys Ther 2017; 47(5): 305-313.
  2. Axén I, Leboeuf-Yde C. Trajectories of low back pain. Best Pract Res 2013; 27(5): 601-612.

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