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Development and Evaluation of the MAINTAIN Instrument, Selecting Patients Suitable for Secondary or Tertiary Preventive Manual Care: The Nordic Maintenance Care Program

By |March 24, 2022|Chiropractic Management, Maintenance Care|

Development and Evaluation of the MAINTAIN Instrument, Selecting Patients Suitable for Secondary or Tertiary Preventive Manual Care: The Nordic Maintenance Care Program

The Chiro.Org Blog


SOURCE:   Chiropractic & Manual Therapies 2022 (Mar 17)

Andreas Eklund, Per J Palmgren, Ulf Jakobsson, Iben Axén

Unit of Intervention and Implementation Research for Worker Health,
The Institute of Environmental Medicine (IMM),
Karolinska Institutet,
Stockholm, Sweden



Background:   Chiropractic maintenance care (MC) has been found to be effective for patients classified as dysfunctional by the West Haven-Yale Multidimensional Pain Inventory (MPI). Although displaying good psychometric properties, the instrument was not designed to be used in clinical practice to screen patients for stratified care pathways. The aim was to develop a brief clinical instrument with the intent of identifying dysfunctional patients with acceptable diagnostic accuracy.

Methods:   Data from 249 patients with a complete MPI dataset from a randomized clinical trial that investigated the effect and cost-effectiveness of MC with a 12-month follow-up was used in this cross-sectional analysis. A brief screening instrument was developed to identify dysfunctional patients, with a summary measure. Different cut-offs were considered with regards to diagnostic accuracy using the original instrument’s classification of dysfunctional patients as a reference. Very good diagnostic accuracy was defined as an area under the curve (AUC) metric between 0.8 and 0.9. The instrument was then externally validated in 3 other existing datasets to assess model transportability across populations and medical settings.

Results:   Using an explorative approach, the MAINTAIN instrument with 10 questions (0-6 Likert responses) capturing 5 dimensions (pain severity, interference, life control, affective distress, and support) was developed, generating an algorithm-based score ranging from – 12 to 48. Reporting a MAINTAIN score of 18 or higher, 146 out of the 249 patients were classified as dysfunctional with 95.8% sensitivity and 64.3% specificity. At a score of 22 or higher, 109/249 were classified as dysfunctional with 81.1% sensitivity and 79.2% specificity. AUC was estimated to 0.87 (95% CI 0.83, 0.92) and Youden’s index was highest (0.70) at a score of 20. The diagnostic accuracy was similar and high across populations with minor differences in optimal thresholds for identifying dysfunctional individuals.

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Maintenance Care Reduces the Number of Days

By |April 23, 2020|Maintenance Care|

The Nordic Maintenance Care Program: Maintenance Care Reduces the Number of Days With Pain in Acute Episodes and Increases the Length of Pain Free Periods for Dysfunctional Patients With Recurrent and Persistent Low Back Pain – A Secondary Analysis of a Pragmatic Randomized Controlled Trial

The Chiro.Org Blog


SOURCE:   Chiropractic & Manual Therapies 2020 (Apr 21); 28: 19

Andreas Eklund, Jan Hagberg, Irene Jensen, Charlotte Leboeuf-Yde, Alice Kongsted, Peter Lövgren, Mattias Jonsson, Jakob Petersen-Klingberg, Christian Calvert & Iben Axén

Karolinska Institutet,
Institute of Environmental Medicine,
Unit of Intervention and Implementation Research for Worker Health,
Stockholm, Sweden.


BACKGROUND:   A recent study showed that chiropractic patients had fewer days with bothersome (activity-limiting) low back pain (LBP) when receiving care at regular pre-planned intervals regardless of symptoms (‘maintenance care’, MC) compared to receiving treatment only with a new episode of LBP. Benefit varied across psychological subgroups. The aims of this study were to investigate 1) pain trajectories around treatments, 2) recurrence of new episodes of LBP, and 3) length of consecutive pain-free periods

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Documentation Supporting Chiropractic Maintenance Care

By |March 20, 2020|Maintenance Care|

Documentation Supporting Chiropractic Maintenance Care

The Chiro.Org Blog


SOURCE:   Our Maintenance Care Page

Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC



As part of a comprehensive geriatric assessment program, the RAND Corporation studied a subpopulation of patients who were under chiropractic care compared to those who were not and found that the individuals under continuing chiropractic care were:

  • Free from the use of a nursing home   [95.7% vs 80.8%];
  • Free from hospitalizations for the past 23 years   [73.9% vs 52.4%];
  • More likely to report a better health status;
  • More likely to exercise vigorously;
  • More likely to be mobile in the community   [69.6% vs 46.8%].

Recipients of chiropractic care reported better overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and were more active than the nonchiropractic patients.

Although it is impossible to clearly establish causality, it is clear that continuing chiropractic care is among the attributes of the cohort of patients experiencing substantially fewer costly healthcare interventions. [1]


A second review of a larger cohort of elderly patients across the United States compared direct expenditures [hospital care, physicians’ services, nursing home] between groups of patients who were under maintenance chiropractic care and those who were not.

Nearly a threefold savings of mean annual expenditures was reported as follows:

  • $ 3,105 : Maintenance care
  • $10,041 : No maintenance care [2]

One study involving elderly populations reviewed the consequences of implementing an on-site industrial chiropractic program which included the early detection, treatment, prevention and occupational management of musculoskeletal injuries 2 days per week.

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Chiropractic Maintenance Care – What’s New?

By |November 22, 2019|Maintenance Care|

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

The Chiro.Org Blog


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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The Nordic Maintenance Care Program: Does Psychological Profile

By |October 13, 2019|Maintenance Care|

The Nordic Maintenance Care Program: Does Psychological Profile Modify the Treatment Effect of a Preventive Manual Therapy Intervention? A Secondary Analysis of a Pragmatic Randomized Controlled Trial

The Chiro.Org Blog


SOURCE:   PLoS One. 2019 (Oct 10); 14 (10): e0223349

Andreas Eklund ,Irene Jensen,Charlotte Leboeuf-Yde,Alice Kongsted,Mattias Jonsson, Peter Lövgren,Jakob Petersen-Klingberg,Christian Calvert,Iben Axén

Karolinska Institutet,
Institute of Environmental Medicine,
Unit of Intervention and Implementation Research for Worker Health,
Stockholm, Sweden.


 

A recent single blinded placebo controlled study, conducted by the Mansoura Faculty of Medicine, conclusively demonstrates that maintenance care provides significant benefits for those with chronic low back pain.

BACKGROUND:   Chiropractic maintenance care is effective as secondary/tertiary prevention of non-specific low back pain (LBP), but the potential effect moderation by psychological characteristics is unknown. The objective was to investigate whether patients in specific psychological sub-groups had different responses to MC with regard to the total number of days with bothersome pain and the number of treatments.

METHOD:   Data from a two-arm randomized pragmatic multicenter trial with a 12–month follow up, designed to investigate the effectiveness of maintenance care, was used. Consecutive patients, 18–65 years of age, with recurrent and persistent LBP seeking chiropractic care with a good effect of the initial treatment were included. Eligible subjects were randomized to either maintenance care (prescheduled care) or to the control intervention, symptom-guided care.

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The Nordic Maintenance Care Program: Effectiveness of Chiropractic

By |September 17, 2018|Maintenance Care|

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 Chiro.Org Blog


SOURCE:   PLoS One. 2018 (Sep 12); 13 (9): e0203029

Andreas Eklund, Irene Jensen, Malin Lohela-Karlsson, Jan Hagberg, Charlotte Leboeuf-Yde, Alice Kongsted, Lennart Bodin, Iben Axén

Karolinska Institutet,
Institute of Environmental Medicine,
Unit of Intervention and Implementation Research for Worker Health,
Stockholm, Sweden.


BACKGROUND:   For individuals with recurrent or persistent non-specific low back pain (LBP), exercise and exercise combined with education have been shown to be effective in preventing new episodes or in reducing the impact of the condition. Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies. The aim of this trial was to investigate the effectiveness of MC on pain trajectories for patients with recurrent or persistent LBP.

METHOD:   This pragmatic, investigator-blinded, two arm randomized controlled trial included consecutive patients (18-65 years old) with non-specific LBP, who had an early favorable response to chiropractic care. After an initial course of treatment, eligible subjects were randomized to either MC or control (symptom-guided treatment). The primary outcome was total number of days with bothersome LBP during 52 weeks collected weekly with text-messages (SMS) and estimated by a GEE model.

RESULTS:   Three hundred and twenty-eight subjects were randomly allocated to one of the two treatment groups. MC resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment. During the 12 month study period, the MC group (n = 163, 3 dropouts) reported 12.8 (95% CI = 10.1, 15.5; p = <0.001) fewer days in total with bothersome LBP compared to the control group (n = 158, 4 dropouts) and received 1.7 (95% CI = 1.8, 2.1; p = <0.001) more treatments. Numbers presented are means. No serious adverse events were recorded.

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