The Nordic Maintenance Care Program: The Clinical Use of Identified Indications for Preventive Care
Iben Axén and Lennart Bodin
Intervention & Implementation Research, Institute of Environmental Medicine, Karolinska Institutet, Nobels väg 13, Stockholm 171 77, Sweden
Background Low back pain (LBP) is a prevalent condition and has been found to be recurrent and persistent in a majority of cases. Chiropractors have a preventive strategy, maintenance care (MC), aimed towards minimizing recurrence and progression of such conditions. The indications for recommending MC have been identified in the Nordic countries from hypothetical cases. This study aims to investigate whether these indications are indeed used in the clinical encounter.
Methods Data were collected in a multi-center observational study in which patients consulted a chiropractor for their non-specific LBP. Patient baseline information was a) previous duration of the LBP, b) the presence of previous episodes of LBP and c) early improvement with treatment. The chiropractors were asked if they deemed each individual patient an MC candidate. Logistic regression analyses (uni– and multi-level) were used to investigate the association of the patient variables with the chiropractor’s decision.
Results The results showed that “previous episodes” with LBP was the strongest predictor for recommending MC, and that the presence of all predictors strengthens the frequency of this recommendation. However, there was considerable heterogeneity among the participating chiropractors concerning the recommendation of MC.
Conclusions The study largely confirms the clinical use of the previously identified indications for recommending MC for recurrent and persistent LBP. Previous episodes of LBP was the strongest indicator.
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From the Full-Text Article:
In the past few decades, the prevalence of low back pain, LBP, has been found to be extremely high  and the resulting costs of the condition are substantial  . Upon further scrutiny, the condition has been found to be recurrent in most cases and persistent in some [3-5] . These facts invite preventive approaches, both from a personal and societal perspective. Secondary prevention, to minimize the recurrences or the impact of episodic LBP, and tertiary prevention, to minimize the effects of persistent LBP, seem warranted.
In the chiropractic profession, there is a traditional preventive approach named Maintenance Care, MC. It has been defined as: “…treatment, either scheduled or elective, which occurred after optimum recorded benefit was reached”  and “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”  . However, a review concluded that there is no evidence-based definition, no identified indications for use nor evidence of effect of MC  . During the past decade, efforts have been made in the Nordic countries to describe the intent [9,10] , content [9,10] and frequency [10,11] of this approach. In the US, efforts have been made to develop consensus definitions regarding this practice. 
The indications for MC have also been studied in a series of studies through a process of triangulation. In short, the indications were identified in qualitative focus group discussions  , and then tested in questionnaires across the Nordic countries [11,13,14] . As a third step, case management strategies were explored to investigate chiropractors’ decisions using hypothetical but clinically relevant cases in a questionnaire  as well as in an interview study  . During the process, clinicians argued that it was difficult for them to identify the most important indicator, as several factors will always be considered in the clinical encounter. However, when asked to grade the suggested factors, the chiropractors in Sweden, Finland and Denmark agreed that secondary prevention would be recommended to a patient who reported previous episodes of the condition, and that the indication for tertiary care was improvement with treatment  . Further, the practice of using preventive strategies seemed similar in the Nordic countries, albeit there seemed to be a group of clinicians who seemed to use MC to a larger extent than most. 
As these indications have been identified through hypothetical cases they are, in that sense, theoretical constructs. Whether they represent clinical reality is still unknown. This study aimed to test if these theoretically defined indications are really in use in a clinical setting/situation. To test the efficacy of MC in future studies in the clinical setting, it is important to know what indications are actually used. This will ensure that the relevant subgroups of patients are included, i.e. the subgroups that chiropractors usually recommend MC to. It will then be possible to study if the outcome of the MC treatment is associated with these criteria.
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