The Value of Maintenance Care
The primary reason that people go to chiropractors is for the management of spine pain. Sixty-three percent of chiropractic patients seek care for lower back pain. Thirty percent seek care for neck pain (1). Incredibly, surveys report that ninety-one percent of these patients report acceptable positive clinical outcomes to chiropractic care for these complaints (1).
Published clinical outcomes (as contrasted to surveys) are also supportive of the benefits of chiropractic for back and neck pain. As an example, a 1985 study involving 283 chronic, disabled, treatment resistant low back and leg-pain patients who were referred for chiropractic spinal manipulation showed that eighty-one percent of those without compressive neuropathology had their symptoms essentially resolve and they returned to full activity levels (2). Forty-eight percent of those with compressive neuropathology achieved similar outcomes (2).
In another series of patients with chronic neck and back pain of more than eight years duration, a nine-week trial of chiropractic spinal manipulation (two visits weekly) resulted in the resolution of all signs and symptoms in twenty-seven percent of the patients (3). Three additional observations were found from this study pertaining to the management of chronic back and neck pain:
- Chiropractic spinal adjusting was better than five time more effective in treating chronic back and neck pain as compared to the best prescription non-steroidal anti-inflammatory drugs (NSAIDs).
- Chiropractic spinal adjusting was about three times more effective in treating chronic back and neck pain as compared to needle acupuncture.
- Compared to prescription NSAIDs and needle acupuncture, chiropractic spinal manipulation was the only intervention that showed long-term (one year later) stable therapeutic benefit (4).
As a consequence of this, it is not surprising that modern clinical practice guidelines for the management of acute, subacute, and chronic back pain advocate the use of chiropractic spinal manipulation (5, 6, 7, 8).
An observed complication of the successful management of chronic spine pain, particularly chronic low back pain, is the recurrence rate (9, 10). Although it is commonly thought and claimed that about ninety percent of low back pain permanently resolved, this is not apparently the case.
A study on this topic was published in 1998 in the British Medical Journal and titled (9):
Outcome of Low Back Pain in General Practice:
A Prospective Study
This was a prospective study of 463 adult low back pain subjects who were followed for twelve months. The authors found that seventy-five percent of these subjects still had back problems a year later.
A related study was published in 2012 in the journal Physical Medicine and Rehabilitation, and titled (10):
Is It Time to Rethink the Typical Course of Low Back Pain?
These authors published an analysis of a survey administered to 590 subjects from 30 separate clinical practices pertaining to low back pain. Their findings include:
“Recurrent LBP episodes were common and numerous. Recurrences often worsened over time”
“Recurrences of back pain are widely recognized as common, reported as occurring in 60%-73% of individuals within 1 year after recovery from an acute episode.”
These authors suggest that there may be an underlying biomechanical cause for recurrences of low back pain that may be suboptimally managed. They also note that eighty-four percent of total costs for patients with low back pain are related to a recurrence.
A number of published investigations have assessed the potential for maintenance chiropractic spinal manipulation as an intervention that may reduce the incidence of recurrences of low back pain (11, 12, 13, 14). Maintenance care is the advising of the patient to return for more treatment even tough the initial signs and symptoms have either resolved or have achieved maximum improvement.
A theoretical academic basis for the use of maintenance chiropractic manipulation was published in 2011 in the Journal of Chiropractic Humanities and titled (11):
A Theoretical Basis for Maintenance
Spinal Manipulative Therapy
for the Chiropractic Profession
The author notes that the purpose of chiropractic maintenance care is to optimize spinal function and decrease the frequency of future episodes of back pain.
A search of PubMed and of the Manual, Alternative, and Natural Therapy Index System was performed with a combination of key words: chiropractic, maintenance and wellness care, maintenance manipulative care, preventive spinal manipulation, hypomobility, immobility, adhesions, joint degeneration, and neuronal degeneration, 1970-2011. The search revealed surveys of doctors and patients, an initial clinical pilot study, randomized control trials, and laboratory studies that provided correlative information to provide a framework for development of a hypothesis for the basis of maintenance spinal manipulative therapy. The author states:
“It is hypothesized that because spinal manipulative therapy brings a joint to the end of the paraphysiological joint space to encourage normal range of motion, routine manipulation of asymptomatic patients may retard the progression of joint degeneration, neuronal changes, changes in muscular strength, and recruitment patterns, which may result in improved function, decreased episodes of injuries, and improved sense of well-being.”
The author cites published surveys indicating that over ninety percent of chiropractors opined that the purpose of maintenance care was to minimize recurrences or exacerbations. Ninety-five percent of chiropractors recommended maintenance care to minimize recurrences or exacerbations of conditions. In a study of ninety-six percent of elderly patients who received maintenance care believed that it was “either considerably or extremely valuable.”
This author further states:
“It has been reported that 79% of patients in chiropractic offices are recommended maintenance care and nearly half of those patients elect to receive these services.”
Evidence “clearly demonstrates that the clinical consensus of dosage of maintenance manipulative therapy has been found to be most beneficial at an average of once every 2 to 4 weeks.”
“Taking into account the neurological and biomechanical consequences of manipulative therapy, it is plausible to hypothesize that monthly manipulative therapy retards the progression of adhesion formation, joint degeneration, neuronal changes, and changes in muscular strength and recruitment patterns. This could result in improved function, decreased episodes of injuries, and improved sense of well-being.”
A 2004 chiropractic study of chronic low back pain showed that the group of patients who received 9 months of maintenance manipulation at the frequency of once per every 3 weeks maintained their initial clinical improvement while the control group returned to their previous levels of disability. The authors “concluded that there were positive effects of preventive maintenance chiropractic spinal manipulation in maintaining functional capacities and reducing the number and intensity of pain episodes after the acute phase of treatment of low back pain patients.”
“There is a common thread of the time dependency noted in all the laboratory and clinical studies. The periods of onset of the anatomical and physiological changes ranged from 2 to 4 weeks. The clinical studies also provided manipulation every 4 weeks and noted positive changes in the pain and disability measures. This time interval also correlates with the common recommendations found in the surveys of chiropractic physicians.”
Physician Manuel Cifuentes, MD, published another pertinent study on this topic in 2011. It was published in the Journal of Occupational and Environmental Medicine, and titled (12):
Health Maintenance Care in Work-Related Low Back Pain
and its Association With Disability Recurrence
The objective of this study was to compare occurrence of repeated disability episodes across types of health care providers (medical physician, physical therapists, chiropractor) who treat claimants with new episodes of work-related low back pain. A total of 894 cases were followed for 1-year using workers’ compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.
The authors note that an important component of the human and economic costs for low back pain are the recurrence rate. They state:
“Health maintenance care is a clinical intervention approach thought to prevent recurrent episodes of LBP. It conceptually refers to the utilization of health care services with the aim of improving health status and preventing recurrences of a previous health condition.” Health maintenance care is defined as “treatment. . . after optimum recorded benefit was reached.”
The authors note that chiropractors are the only group of providers who explicitly state that they have an effective treatment approach to maintain health with “maintenance “care. They also noted that chiropractic patients had “less expensive medical services and shorter initial periods of disability than cases treated by other providers.” Also, chiropractic patients had “fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups.”
These authors noted:
“After controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors.”
“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type.”
“After controlling for severity and demographics, no health maintenance care is generally as good as chiropractor care.”
“Our findings seem to support the use of chiropractor services, as chiropractor services generally cost less than services from other providers.”
In this study, the chiropractic patients who did suffer a recurrence did so 29 days later than the physical therapy or physician patients who suffered a recurrence. The authors speculate that the main advantage of chiropractors could be based on the dual nature of their practice, involving both regular care plus maintenance care. Chiropractic appears to be an “important advancement” in the treatment of work-related back injuries.
This study certainly supports the concept and value of chiropractic maintenance care.
Physician Mohammed K. Senna, MD, and colleague published another important study on this topic in 2011. It appeared in the journal Spine, and was titled (13):
Does Maintained Spinal Manipulation Therapy for
Chronic Nonspecific Low Back Pain
Result in Better Long-Term Outcome? Randomized Trial
This study is a prospective single blinded placebo controlled study that was conducted to assess the effectiveness of spinal manipulation therapy for the management of chronic nonspecific low back pain, and to determine the effectiveness of maintenance spinal manipulation in long-term reduction of pain and disability levels associated with chronic low back conditions.
Sixty patients with chronic, nonspecific low back pain lasting at least 6 months, were randomized to receive either:
- 12 treatments of sham spinal manipulation over a 1-month period
- 12 treatments consisting of spinal manipulation over a 1-month period
- 12 spinal manipulation treatments over a 1-month period plus maintenance spinal manipulation every two weeks for the following nine months
The spinal manipulation was defined as a “high velocity thrust to a joint beyond its restricted range of movement.”
Follow-up evaluations occurred at 1-, 4-, 7-, and 10-months. These assessments included:
- Pain, using the Visual Analog Scale (VAS)
- Disability, using the Oswestry Disability Questionnaire
- Generic health, using the 36-Item Short Form Health Survey (SF-36)
The authors made these observations:
The disability and pain scores in this study “are significantly reduced in the short-term evaluation—but not in long-term—when compared with the sham manipulation.”
Patients receiving real manipulation “experienced significantly lower pain and disability scores” than patients receiving sham manipulation at the end of 1-month.
“In the non-maintained spinal manipulation group, the mean pain and disability scores returned back near to their pretreatment level.”
“Spinal manipulation is effective for the treatment of chronic nonspecific of low back pain. To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative therapy.”
“One possible way to reduce the long-term effects of low back pain is maintenance care (or preventive care).”
“To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative.”
This study also supports the concept and value of chiropractic spinal manipulation maintenance care.
Pain (VAS) For The 3 Groups Over 10 Months
Disability (Oswestry) For The 3 Groups Over 10 Months
Most recently (September 2018), researchers from Sweden and Denmark published a study in the journal Public Library of Science (PLoS) One, titled (14):
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 aim of this trial was to investigate the effectiveness of chiropractic maintenance care on pain for patients with recurrent or persistent low back pain. It was an investigator-blinded, randomized controlled trial using 328 subjects aged 18-65 years, with non-specific low back pain, who had an early favorable response to chiropractic care.
If the initial course of chiropractic care (4 visits) resulted in substantial improvements in low back pain, the subjects were randomized to either maintenance chiropractic care (163 subjects) or not (control group, 158 subjects). The study used 35 chiropractic clinicians with mean number of years in practice of 17.9, ranging from 1 to 38 years.
The primary outcome was total number of days with bothersome low back pain during 52 weeks. The status was collected weekly via text messages.
The authors note that low back pain is often recurrent and has a large negative impact on society. Consequently, focusing on preventive strategies for recurrent low back pain is logical. “This is one of the first studies to test the effect of preventive manual care performed by chiropractors (maintenance care) for recurrent and persistent low back pain.”
The authors use two definitions for maintenance care:
- “. . .a regimen designed to provide for the patient’s continued well-being or for maintaining the optimum state of health while minimizing recurrences of the clinical status”
- “. . .treatment, either scheduled or elective, which occurred after optimum recorded benefit was reached, provided there was no evidence of relapse”
Chiropractors have traditionally used maintenance care as a prevention strategy against new episodes of low back pain, or in reducing the impact of a new episode of low back pain. Maintenance chiropractic care may improve biomechanical and neuromuscular function and address psychosocial issues, thereby reducing the risk of relapse into pain. “It is common for chiropractors to recommend maintenance care, i.e. preventive consultations/visits for recurrent and persistent musculoskeletal pain and dysfunction.”
About one fifth of all visits to Scandinavian chiropractors are maintenance care visits and 98% of Swedish chiropractors use the approach to some extent. The authors make these comments:
“Non -specific low back pain is one of the most common and costly healthcare problems in society today.”
“The burden of disabling low back pain on individuals, families, communities, industries and societies is substantial and is now the leading cause of activity limitation and work absence in the world.”
“Chiropractors are trained to assess and treat disorders of the musculoskeletal system, of which low back pain is the most common.”
“The majority of patients seeking chiropractic care receive some form of manual therapy, of which spinal manipulation and mobilization are the most common, often along with advice on exercise.”
“Chiropractic maintenance care resulted in a reduction in the total number of days per week with bothersome low back pain compared with symptom-guided treatment.”
The maintenance group had a faster reduction in days with bothersome low back pain and reached a lower steady state earlier.
Maintenance chiropractic care was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific low back pain, and it only resulted in a higher number of treatments by 1.7. (less than two visits)
Maintenance chiropractic care should be considered an option for tertiary prevention of low back pain.
The maintenance chiropractic care group “improved faster and achieved the steady state phase earlier with a lower mean number of days with low back pain per week.”
“The treatment was not reported as being linked to any serious harm and both the intervention and the control regimes must be considered safe treatments.”
The increasing range of published studies supporting chiropractic manipulation for the management of musculoskeletal pain complaints, especially for low back and neck pain, is gaining global notice and acceptance. This review adds that perhaps there is also mounting support for the use of chiropractic manipulation for maintenance care as well.
- Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
- Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.
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- Chou R, Huffman LH; Non-pharmacologic Therapies for Acute and Chronic Low Back Pain; Annals of Internal Medicine; October 2007; Vol. 147; No. 7; pp. 492-504.
- Globe G, Farabaugh RJ, Hawk C, Morris CE, Baker G, DC, Whalen WM, Walters S, Kaeser M, Dehen M, DC, Augat T; Clinical Practice Guideline: Chiropractic Care for Low Back Pain; Journal of Manipulative and Physiological Therapeutics; January 2016; Vol. 39; No. 1; pp. 1-22.
- Wong JJ, Cote P, Sutton DA, Randhawa K, Yu H, Varatharajan S, Goldgrub R, Nordin M, Gross DP, Shearer HM, Carroll LJ, Stern PJ, Ameis A, Southerst D, Mior S, Stupar M, Varatharajan T, Taylor-Vaisey A; Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration; European Journal of Pain; Vol. 21; No. 2 (February); 2017; pp. 201-216.
- Qaseem A, Wilt TJ, McLean RM, Forciea MA; Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians; For the Clinical Guidelines Committee of the American College of Physicians; Annals of Internal Medicine; April 4, 2017; Vol. 166; No. 7; pp. 514-530.
- Croft PR, Macfarlane GF, Papageorgiou AC, Thomas E, Silman AJ; Outcome of low back pain in general practice: A prospective study; British Medical Journal; May 2, 1998; Vol. 31; pp. 1356-1359.
- Donelson R, McIntosh G; Hall H; Is It Time to Rethink the Typical Course of Low Back Pain? Physical Medicine and Rehabilitation (PM&R); June 2012; Vol. 4; No. 6; pp. 394–401.
- Taylor DN; A theoretical basis for maintenance spinal manipulative therapy for the chiropractic profession; Journal of Chiropractic Humanities December 2011; Vol. 1; No. 1; pp. 74-85.
- Cifuentes M, Willetts J, Wasiak R; Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence; Journal of Occupational and Environmental Medicine; April, 2011; Vol. 53; No. 4; pp. 396-404.
- Senna MK, Shereen A, Machaly SA; Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome? Randomized Trial; SPINE; August 15, 2011; Vol. 36; No. 18; pp. 1427–1437.
- Eklund A, Jensen I, Lohela-Karlsson M, Hagberg J, Leboeuf-Yde C, Kongsted A, Bodin L, Axen I; 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; Public Library of Science (PLoS) One; September 12, 2018; Vol. 13; No. 9; e0203029
“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”