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

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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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Conclusion   Knowledge of chiropractic Maintenance Care has advanced. 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, 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.

Keywords:   Maintenance care, Prevention, Chiropractic, Pain, Disease management, Systematic review

From the Full-Text Article:


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. Consequently, treatment, if at all required, was aimed at shortening the course of symptoms. However, gradually the fact that spinal pain is a recurring disorder, as stated by van Korff more than 20 years ago [1], is gaining acceptance. 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 [2], it might be wise to shift the focus of treatment from cure of the condition to management of pain trajectories. [3]

Chiropractors appear to have been in the forefront in this domain. ‘Maintenance Care’ is a well-known concept in the chiropractic profession, describing continued care beyond that of reducing symptoms. However, it has been used in different ways. Some chiropractors appear to have recommended Maintenance Care as a form of precaution to keep the patient healthy, regardless of symptoms and patient history. Others though, seem to have used it to ‘keep patients going’, when they had chronic or recurring problems.

The former approach has been criticized for lack of evidence and considered mainly a financial model to keep the practice busy. The second approach, although sensible in the light of spinal pain being a recurrent and persistent condition, did not have any scientific support and was also often frowned upon.

Interestingly, although the term ‘Maintenance Care’ has been used for many decades and by chiropractors all over the world, there seemed to be no official definition nor any knowledge regarding its clinical usefulness. A narrative review from 1996 [4] concluded that: “there is no scientific evidence to support the claim that Maintenance Care improves health status”. A second review, 12 years later, did not find that there was much more knowledge available on this topic. [5]

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