The Case For Maintenance Care, A Review of the Literature
Evidence Based Chiropractic Maintenance Care by Joe Siragusa, DC, FACO, M.Ed., CAE
It sounds like something out of an old chiropractic philosophy seminar but… chiropractic maintenance care has been shown to have clinical value. That is exactly the conclusion of a paper (literature review) published in the journal Chiropractic and Manual Therapies. In the November 2019 edition*, the Scandinavian authors conclude that chiropractic maintenance care:
• Is thought to have value by both chiropractors and their patients
• Is validated by this study only for patients with previous episodes of back pain (secondary care).
• Was most frequently recommended at intervals of 1-3 months • Most importantly, has the potential to reduce future episodes of pain.
Important quotes from the paper:
“New evidence regarding the natural course of spinal pain should lead to a shift in treatment approaches. Previously, low back pain (LBP) and neck pain (NP) were thought to be self-limiting ailments, hardly worthy of attention.”
“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. With this new understanding of spinal pain as a condition with exacerbations and remissions throughout life , it might be wise to shift the focus of treatment from cure of the condition to management of pain trajectories .”
“There is reasonable consensus among chiropractors on what Maintenance Care is, how it should be used, and its indications.”
“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 (emphasis mine), 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.”
“Maintenance Care can clearly be said to be used as a preventive therapeutic concept, although the exact interpretation varies somewhat between chiropractors. The logical approach would obviously be to provide this type of treatment on patients who initially get better with chiropractic care and to do so for as long as it seems useful from the patient’s perspective. However, trajectories vary between patients but also within subjects, with symptoms changing over time. It is therefore important to be vigilant regarding new developments and reassessments of patients’ symptoms. Chiropractors could obviously play an important role here as ‘back pain coaches’, as the long-term relationship would ensure knowledge of the patient and trust towards the chiropractor. This should ideally result in an individualized treatment approach to improve the long-term trajectories.”
“The 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.” “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.”
The authors clearly caution against an “everyone gets maintenance care” type of extrapolation from this paper. The clinical value (based on this study) is limited to patients with a previous episode of spine pain. The implications are significant. In one paper referenced in this review, patients selected for maintenance care experienced 13 fewer days of “bothersome” pain in the course of a year while under maintenance care. The authors did not make any assertions about cost effectiveness of maintenance care but recommend further study. Maintenance care (under the right circumstances) is actually evidence-based care. If your patient had good results with chiropractic care for their acute episode of spinal pain, it would be appropriate to recommend a trial of evidence-based maintenance care in an attempt to modify the trajectory of future episodes of spinal pain.
The key quote from this paper is repeated here: “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.”
*Iben, A., Lise, H. & Charlotte, L. Chiropractic maintenance care – what’s new? A systematic review of the literature. Chiropr Man Therap 27, 63 (2019) doi:10.1186/s12998-019-0283-6