The status of chiropractic maintenance care

The latest studies give insight into the followed yet ill-defined approach to chiropractic maintenance care

Many patients, and doctors of chiropractic, rely on chiropractic maintenance care to maintain holistic health — “a traditional chiropractic approach, whereby patients continue treatment after optimum benefit is reached,” according to the research paper “Chiropractic maintenance care — what’s new? A systematic review of the literature,” published in November 2019 by authors Iben Axén, Lise Hestbaek and Charlotte Leboeuf-Yde.

The paper followed two prior reviews in 1996 and 2008, both of which “concluded that evidence behind this therapeutic strategy was lacking.” But since then, a systematic research program in Nordic countries, involving some U.S. doctors of chiropractic, 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.”

Method and results

The team included 14 original research articles in their review, where 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.

“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.”

Defining maintenance care

The authors note that new evidence regarding the natural course of spinal pain should lead to a shift in treatment approaches from cure of the condition to management of pain trajectories with maintenance care.

“The acute episode of spinal pain, similarly to an episode of asthma, may be short-lived, but the condition is often, as for asthma, life-long,” the authors wrote, noting that chiropractors appear to have been in the forefront in this domain.

Some chiropractors recommend maintenance care as a form of precaution, the authors said, while other DCs “seem to have used it to ‘keep patients going,’ when they had chronic or recurring problems.” The authors note that the term “maintenance care” has been used for decades but remains without an official definition.

Based on recommendations for further study, a research project called “The Nordic Maintenance Care Program” was launched with the aim to increase knowledge regarding maintenance care, utilizing chiropractors in Denmark, Sweden, Finland and Norway.

Review objectives and data

The objectives of the systematic review of studies were:

1. To define the concept of maintenance care and the indications for its use.
2. To describe chiropractors’ belief in maintenance care and patients’ acceptance of it.
3. To establish the prevalence with which chiropractors use maintenance care and possible characteristics of the chiropractors associated with its use.
4. To determine its efficacy and cost-effectiveness for various types of conditions.

The 14 articles/studies included  were published between 2008-2018 and included ones from Canada, the U.S. and Egypt.

“There was a mixture of qualitative (focus groups and interviews) and quantitative studies (surveys, observational studies and randomized controlled trials),” the authors wrote. “One study was described as a structured workshop, but it was designed like a focus group discussion with a resulting qualitative summary. Eight studies collected their data from chiropractors who either estimated their responses or consulted their patient files, four studies collected their data from patients, in one study data were collected from both chiropractors and their patients, and one study used workers’ compensation claims data.”

Patients and DCs on maintenance care

One study specifically investigated the patient perspective of maintenance care; patients were interviewed and asked to explain why they would visit their chiropractor on a regular basis. Patients stated that:

• The purpose was to prevent recurrences (78%);
• The purpose was to remain pain-free (68%);
• The purpose was maintenance care as a wellness approach (17%).

By contrast, the prevalence with which chiropractors use maintenance care in studies saw that “some studies investigated the frequency of use of maintenance care from simply asking chiropractors to estimate their use of maintenance care the previous week (mean estimate 22%), to have them check the proportion on a typical clinic day (reported in two studies to be 28 and 35%, respectively), or actually observing in clinic and counting (reported in two studies to be 26 and 41%, respectively). Thus, the mean proportion of patients seen on a maintenance care regimen by Scandinavian chiropractors was around 22–41%, with large individual variations ranging from 0 to 100%.”

Regarding the spacing of maintenance care treatments, most visits were scheduled by patients within a range of 1-3 months.

American DCs and maintenance care

In one survey the majority of chiropractors from the given countries (98%) stated they believed that “maintenance care could be used as a preventive tool, at least sometimes.”

In an interview study it was found that some chiropractors “favored a universal approach, claiming that maintenance care was always beneficial and would prevent disease.”

In regard to American chiropractors, “One study conducted in Denmark investigated chiropractic factors associated with maintenance care use and found that it was more common among experienced chiropractors, clinic owners, and those who received their chiropractic degree in the U.S.”

At the time of the particular study, “the older chiropractors were almost all trained in the U.S., whereas the younger chiropractors were primarily educated in Denmark. Therefore, it is not known, if it is age (experience) or educational background that guided the use of maintenance care among these chiropractors.”

Further defining the term and use

Across the Nordic countries in the study, approximately 30% of chiropractic patients are maintenance care patients. Visits were usually between 1-3 months for these patients, with DCs emphasizing a full-spine approach.

As the authors note, “Clinical indications vary, but patients suitable for maintenance care are commonly thought to be those with persistent or episodic pain, who react well to the initial treatment.”

Three trials dealt with the clinical usefulness of maintenance care. “In one, patients who received maintenance care had better outcome than those who received short-term treatment or short-term sham treatment. The other two studies compared two types of maintenance care (with or without exercises, or different length of the follow-up treatments) and found no difference of outcomes between groups.”

The study concluded in part, “Presently, 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. However, these results should not be interpreted as an indication for maintenance care on all patients, who receive chiropractic treatment.”

The full study is available at chiromt.biomedcentral. com/articles/10.1186/s12998-019-0283-6#citeas.