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

By |November 22, 2019|Maintenance Care|

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

The Chiro.Org Blog


SOURCE:   Chiropractic & Osteopathy 2019 (Non 21); 27: 63

Axén Iben, Hestbaek Lise & Leboeuf-Yde Charlotte

Karolinska Institutet,
Institute of Environmental Medicine,
Unit of Intervention and Implementation Research for Worker Health,
Nobels väg 13, 171 77,
Stockholm, Sweden



Background   Maintenance Care is a traditional chiropractic approach, whereby patients continue treatment after optimum benefit is reached. A review conducted in 1996 concluded that evidence behind this therapeutic strategy was lacking, and a second review from 2008 reached the same conclusion. Since then, a systematic research program in the Nordic countries was undertaken to uncover the definition, indications, prevalence of use and beliefs regarding Maintenance Care to make it possible to investigate its clinical usefulness and cost-effectiveness. As a result, an evidence-based clinical study could be performed. It was therefore timely to review the evidence.

Method   Using the search terms “chiropractic OR manual therapy” AND “Maintenance Care OR prevention”, PubMed and Web of Science were searched, and the titles and abstracts reviewed for eligibility, starting from 2007. In addition, a search for “The Nordic Maintenance Care Program” was conducted. Because of the diversity of topics and study designs, a systematic review with narrative reporting was undertaken.

Results   Fourteen original research articles were included in the review. Maintenance Care was defined as a secondary/tertiary preventive approach, recommended to patients with previous pain episodes, who respond well to chiropractic care. Maintenance Care is applied to approximately 30% of Scandinavian chiropractic patients. Both chiropractors and patients believe in the efficacy of Maintenance Care. Four studies investigating the effect of chiropractic Maintenance Care were identified, with disparate results on pain and disability of neck and back pain. However, only one of these studies utilized all the existing evidence when selecting study subjects and found that Maintenance Care patients experienced fewer days with low back pain compared to patients invited to contact their chiropractor ‘when needed’. No studies were found on the cost-effectiveness of Maintenance Care.

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The Nordic Maintenance Care Program: Does Psychological Profile Modify the Treatment Effect of a Preventive Manual Therapy Intervention?

By |October 13, 2019|Maintenance Care|

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

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SOURCE:   PLoS One. 2019 (Oct 10); 14 (10): e0223349

Andreas Eklund ,Irene Jensen,Charlotte Leboeuf-Yde,Alice Kongsted,Mattias Jonsson, Peter Lövgren,Jakob Petersen-Klingberg,Christian Calvert,Iben Axén

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


A recent single blinded placebo controlled study, conducted by the Mansoura Faculty of Medicine, conclusively demonstrates that maintenance care provides significant benefits for those with chronic low back pain.

BACKGROUND:   Chiropractic maintenance care is effective as secondary/tertiary prevention of non-specific low back pain (LBP), but the potential effect moderation by psychological characteristics is unknown. The objective was to investigate whether patients in specific psychological sub-groups had different responses to MC with regard to the total number of days with bothersome pain and the number of treatments.

METHOD:   Data from a two-arm randomized pragmatic multicenter trial with a 12–month follow up, designed to investigate the effectiveness of maintenance care, was used. Consecutive patients, 18–65 years of age, with recurrent and persistent LBP seeking chiropractic care with a good effect of the initial treatment were included. Eligible subjects were randomized to either maintenance care (prescheduled care) or to the control intervention, symptom-guided care. The primary outcome of the trial was the total number of days with bothersome LBP collected weekly for 12 months using an automated SMS system. Data used to classify patients according to psychological subgroups defined by the West Haven-Yale Multidimensional Pain Inventory (adaptive copers, interpersonally distressed and dysfunctional) were collected at the screening visit.

RESULTS:   A total of 252 subjects were analyzed using a generalized estimating equations linear regression framework. Patients in the dysfunctional subgroup who received maintenance care reported fewer days with pain (–30.0; 95% CI: –36.6, –23.4) and equal number of treatments compared to the control intervention. In the adaptive coper subgroup, patients who received maintenance care reported more days with pain (10.7; 95% CI: 4.0, 17.5) and more treatments (3.9; 95% CI: 3.5, 4.2). Patients in the interpersonally distressed subgroup reported equal number of days with pain (–0.3; 95% CI: –8.7, 8.1) and more treatments (1.5; 95% CI: 0.9, 2.1) on maintenance care.

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The Nordic Maintenance Care Program: Effectiveness of Chiropractic Maintenance Care Versus Symptom-guided Treatment for Recurrent and Persistent Low Back Pain

By |September 17, 2018|Maintenance Care|

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 Chiro.Org Blog


SOURCE:   PLoS One. 2018 (Sep 12); 13 (9): e0203029

Andreas Eklund, Irene Jensen, Malin Lohela-Karlsson, Jan Hagberg, Charlotte Leboeuf-Yde, Alice Kongsted, Lennart Bodin, Iben Axén

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


BACKGROUND:   For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP.

METHOD:   This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18-65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model.

RESULTS:   Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded.

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Prevention of Low Back Pain: Effect, Cost-effectiveness, and Cost-utility of Maintenance Care – Study Protocol for a Randomized Clinical Trial

By |June 8, 2014|Cost-Effectiveness, Low Back Pain, Maintenance Care, Randomized Controlled Trial|

Prevention of Low Back Pain: Effect, Cost-effectiveness, and Cost-utility of Maintenance Care – Study Protocol for a Randomized Clinical Trial

The Chiro.Org Blog


SOURCE:   Trials. 2014 (Apr 2);   15:   102

Andreas Eklund, Iben Axén, Alice Kongsted, Malin Lohela-Karlsson,
Charlotte Leboeuf-Yde, and Irene Jensen

Institute of Environmental Medicine,
Unit of Intervention and Implementation Research,
Karolinska Institutet, Nobels v13, S-171 77
Stockholm, Sweden. andreas.eklund@ki.se.


BACKGROUND:   Low back pain (LBP) is a prevalent condition and a socioeconomic problem in many countries. Due to its recurrent nature, the prevention of further episodes (secondary prevention), seems logical. Furthermore, when the condition is persistent, the minimization of symptoms and prevention of deterioration (tertiary prevention), is equally important. Research has largely focused on treatment methods for symptomatic episodes, and little is known about preventive treatment strategies.

METHODS/DESIGN:   This study protocol describes a randomized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care (chiropractic maintenance care) in a population of patients with recurrent or persistent LBP.Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden. The primary outcome is the number of days with bothersome pain over 12 months. Secondary measures are self-rated health (EQ-5D), function (the Roland Morris Disability Questionnaire), psychological profile (the Multidimensional Pain Inventory), pain intensity (the Numeric Rating Scale), and work absence.The primary utility measure of the study is quality-adjusted life years and will be calculated using the EQ-5D questionnaire. Direct medical costs as well as indirect costs will be considered.

Subjects are randomly allocated into two treatment arms:

1) Symptom-guided treatment (patient controlled), receiving care when patients feel a need.

2) Preventive treatment (clinician controlled), receiving care on a regular basis.

Eligibility screening takes place in two phases: first, when assessing the primary inclusion/exclusion criteria, and then to only include fast responders, i.e., subjects who respond well to initial treatment. Data are collected at baseline and at follow-up as well as weekly, using SMS text messages.

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The Nordic Maintenance Care Program: What Is Maintenance Care? Interview Based Survey of Danish Chiropractors

By |August 21, 2013|Maintenance Care, Medical Necessity, Uncategorized|

The Nordic Maintenance Care Program:
What Is Maintenance Care? Interview Based Survey of Danish Chiropractors

The Chiro.Org Blog


SOURCE:   Chiropractic & Manual Therapies 2013 (Aug 20);   21:   27

Corrie Myburgh, Dorthe Brandborg-Olsen, Hanne Albert and
Lise Hestbaek

Institute of Sports Science and Clinical Biomechanics,
Nordic Institute for Chiropractic and Clinical Biomechanics,
University of Southern Denmark,
Odense, Denmark


Objective   To describe and interpret Danish Chiropractors’ perspectives regarding the purpose and rationale for using MC (maintenance care), its content, course and patient characteristics.

Methods   Semi-structured interviews were conducted with 10 chiropractors identified using a stratified, theoretical sampling framework. Interviews covered four domains relating to MC, namely: purpose, patient characteristics, content, and course and development. Data was analysed thematically.

Results   Practitioners regard MC primarily as a means of providing secondary or tertiary care and they primarily recommend it to patients with a history of recurrence. Initiating MC is often a shared decision between clinician and patient. The core elements of MC are examination and manipulation, but exercise and general lifestyle advice are often included. Typically, treatment intervals lie between 2 and 4 months. Clinician MC practices seem to evolve over time and are informed by individual practice experiences.

Chiropractors are more likely to offer MC to patients whose complaints include a significant muscular component. Furthermore, a successful transition to MC appears dependent on correctly matching complaint with management. A positive relationship between chiropractor and patient facilitates the initiation of MC. Finally; MC appears grounded in a patient-oriented approach to care rather than a market-oriented one.

Conclusions   MC is perceived as both a secondary and tertiary preventative measure and its practice appears grounded in the tenet of patient-oriented care. A positive personal relationship between chiropractor and patient facilitates the initiation of MC. The results from this and previous studies should be considered in the design of studies of efficacy.

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From the Full-Text Article:

Background

Maintenance care (MC) is used by chiropractors to treat patients who are no longer in an acute state of pain; the purpose being to prevent recurrence of episodic conditions (secondary prevention) and/or maintain a desired level of function (tertiary prevention). The concept is frequently used among chiropractors [1,2] and limited evidence suggests that, among workers with work-related back pain, MC in chiropractic practice appears to decrease the recurrence rate [3]. However, according to two literature reviews, very limited evidence regarding the definitions, purpose and content of MC is currently available [4,5].

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Participate in a Wellness Care/ Maintenance Care Research Project

By |April 18, 2013|Announcement, Chiropractic Care, Maintenance Care, Wellness Care|

Participate in a Wellness Care/
Maintenance Care Research Project

The Chiro.Org Blog


Wellness care, or “maintenance care,” is widely accepted by the profession as an integral part of chiropractic practice. However, to date, a cause-and-effect relationship between wellness care and improved long-term health outcomes has yet to be clearly demonstrated. This proposed study is designed to add to the evidence base about this important topic.

Purpose of this Study

The purpose of this study is to assess changes in Health-Related Quality of Life over a 12 month period for chiropractic patients who do, or do not participate in wellness care. It is being conducted in the offices of U.S. chiropractors who are members of the Integrated Chiropractic Outcomes Network (ICON).

For this study, we define chiropractic wellness care as a course of long-term care provided to a patient who is either asymptomatic or whose original presenting complaint has been resolved or stabilized, and is provided for the purpose of preventing disease, optimizing function, and supporting the patient’s wellness-related activities and/or minimizing recurrences of previous complaints.

Cheryl Hawk, DC, PhD, Michael Schneider, DC, PhD, Marion Willard Evans Jr., DC, PhD, MCHES, Daniel Redwood, DC
Consensus Process to Develop a Best-Practice Document on the Role of Chiropractic Care in Health Promotion, Disease Prevention, and Wellness

J Manipulative Physiol Ther. 2012 (Sep); 35 (7): 556-567

Study Design

Baseline data are collected in practitioners’ offices; follow-up is conducted by the central office at Logan, by phone and email. Each doctor enrolls 5 consecutive new patients. New patients of any age are eligible! Data are collected at 4 points: first visit and 1, 6 and 12 months later. Outcomes are assessed primarily via questions from the CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Patients are entered in a drawing for a $100 gift card when they complete the follow-up.

Would You Like to Join Our Study?


We have rolling enrollment so you can still join!

Simply email or call Program Coordinator
Michelle Anderson:

michelle.anderson@logan.edu or call her at: (636) 230-1946


Principal Investigator: Cheryl Hawk, DC, PhD
Coinvestigators: Katherine Pohlman, DC, MS, U of Alberta
Jay Greenstein, DC, CCSP, private practice
Program Coordinator: Michelle Anderson

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