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Maintenance Care

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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Prevention of Low Back Pain: Effect, Cost-effectiveness, and Cost-utility of Maintenance Care – Study Protocol for a Randomized Clinical Trial

By |June 8, 2014|Cost-Effectiveness, Low Back Pain, Maintenance Care, Randomized Controlled Trial|

Prevention of Low Back Pain: Effect, Cost-effectiveness, and Cost-utility of Maintenance Care – Study Protocol for a Randomized Clinical Trial

The Chiro.Org Blog

SOURCE:   Trials. 2014 (Apr 2);   15:   102

Andreas Eklund, Iben Axén, Alice Kongsted, Malin Lohela-Karlsson,
Charlotte Leboeuf-Yde, and Irene Jensen

Institute of Environmental Medicine,
Unit of Intervention and Implementation Research,
Karolinska Institutet, Nobels v13, S-171 77
Stockholm, Sweden. andreas.eklund@ki.se.

BACKGROUND:   Low back pain (LBP) is a prevalent condition and a socioeconomic problem in many countries. Due to its recurrent nature, the prevention of further episodes (secondary prevention), seems logical. Furthermore, when the condition is persistent, the minimization of symptoms and prevention of deterioration (tertiary prevention), is equally important. Research has largely focused on treatment methods for symptomatic episodes, and little is known about preventive treatment strategies.

METHODS/DESIGN:   This study protocol describes a randomized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care (chiropractic maintenance care) in a population of patients with recurrent or persistent LBP.Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden. The primary outcome is the number of days with bothersome pain over 12 months. Secondary measures are self-rated health (EQ-5D), function (the Roland Morris Disability Questionnaire), psychological profile (the Multidimensional Pain Inventory), pain intensity (the Numeric Rating Scale), and work absence.The primary utility measure of the study is quality-adjusted life years and will be calculated using the EQ-5D questionnaire. Direct medical costs as well as indirect costs will be considered.

Subjects are randomly allocated into two treatment arms:

1) Symptom-guided treatment (patient controlled), receiving care when patients feel a need.

2) Preventive treatment (clinician controlled), receiving care on a regular basis.

 

Eligibility screening takes place in two phases: first, when assessing the primary inclusion/exclusion criteria, and then to only include fast responders, i.e., subjects who respond well to initial treatment. Data are collected at baseline and at follow-up as well as weekly, using SMS text messages.

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The Nordic Maintenance Care Program: What Is Maintenance Care? Interview Based Survey of Danish Chiropractors

By |August 21, 2013|Maintenance Care, Medical Necessity, Uncategorized|

The Nordic Maintenance Care Program: What Is Maintenance Care? Interview Based Survey of Danish Chiropractors

The Chiro.Org Blog

SOURCE:   Chiropractic & Manual Therapies 2013 (Aug 20);   21:   27

Corrie Myburgh, Dorthe Brandborg-Olsen, Hanne Albert and
Lise Hestbaek

Institute of Sports Science and Clinical Biomechanics,
Nordic Institute for Chiropractic and Clinical Biomechanics,
University of Southern Denmark,
Odense, Denmark

Objective   To describe and interpret Danish Chiropractors’ perspectives regarding the purpose and rationale for using MC (maintenance care), its content, course and patient characteristics.

Methods   Semi-structured interviews were conducted with 10 chiropractors identified using a stratified, theoretical sampling framework. Interviews covered four domains relating to MC, namely: purpose, patient characteristics, content, and course and development. Data was analysed thematically.

Results   Practitioners regard MC primarily as a means of providing secondary or tertiary care and they primarily recommend it to patients with a history of recurrence. Initiating MC is often a shared decision between clinician and patient. The core elements of MC are examination and manipulation, but exercise and general lifestyle advice are often included. Typically, treatment intervals lie between 2 and 4 months. Clinician MC practices seem to evolve over time and are informed by individual practice experiences.

Chiropractors are more likely to offer MC to patients whose complaints include a significant muscular component. Furthermore, a successful transition to MC appears dependent on correctly matching complaint with management. A positive relationship between chiropractor and patient facilitates the initiation of MC. Finally; MC appears grounded in a patient-oriented approach to care rather than a market-oriented one.

Conclusions   MC is perceived as both a secondary and tertiary preventative measure and its practice appears grounded in the tenet of patient-oriented care. A positive personal relationship between chiropractor and patient facilitates the initiation of MC. The results from this and previous studies should be considered in the design of studies of efficacy.

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From the Full-Text Article:

Background

Maintenance care (MC) is used by chiropractors to treat patients who are no longer in an acute state of pain; the purpose being to prevent recurrence of episodic conditions (secondary prevention) and/or maintain a desired level of function (tertiary prevention). The concept is frequently used among chiropractors [1,2] and limited evidence suggests that, among workers with work-related back pain, MC in chiropractic practice appears to decrease the recurrence rate [3]. However, according to two literature reviews, very limited evidence regarding the definitions, purpose and content of MC is currently available [4,5].

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The Impact of Chiropractic Care On Health ~ Why Maintenance Care Makes Sense

By |March 10, 2013|Maintenance Care, Prevention, Wellness Care|

The Impact of Chiropractic Care On Health
Why Maintenance Care Makes Sense

The Chiro.Org Blog

SOURCE:   A Chiro.Org Editorial

Coulter and researchers at the RAND Corporation [1] performed an analysis of an insurance database, comparing persons receiving chiropractic care with non-chiropractic patients. The study consisted of senior citizens >75 years of age.

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 non-chiropractic patients.

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%].

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

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In another study, Van Breda et al [2] interviewed 200 pediatricians and 200 chiropractors, to determine what, if any, differences were to be found in the health status of their respective children, since their families were being raised under 2 very different health care models.

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The Nordic Maintenance Care Program: The Clinical Use of Identified Indications for Preventive Care

By |March 7, 2013|Chiropractic Care, Guidelines, Low Back Pain, Maintenance Care|

The Nordic Maintenance Care Program: The Clinical Use of Identified Indications for Preventive Care

The Chiro.Org Blog

Chiropractic & Manual Therapies 2013 (Mar 6); 21: 10

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:

Background

In the past few decades, the prevalence of low back pain, LBP, has been found to be extremely high [1] and the resulting costs of the condition are substantial [2] . 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.

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The Nordic Maintenance Care Program: Maintenance Care – What Happens During the Consultation? Observations andPatient Questionnaires

By |August 11, 2012|Chiropractic Care, Maintenance Care, Spinal Manipulation|

The Nordic Maintenance Care Program: Maintenance Care –
What Happens During the Consultation? Observations and Patient Questionnaires

The Chiro.Org Blog

Chiropractic & Manual Therapies 2012 (Aug 10); 20 (1): 25

Marita Bringsli, Aurora Berntzen, Dorthe B Olsen, Charlotte Leboeuf-Yde and Lise Hestbaek

Background:   Because maintenance care (MC) is frequently used by chiropractors in the management of patients with back pain, it is necessary to define the rationale, frequency and indications for MC consultations, and the contents of such consultations. The objectives of the two studies described in this article are: i) to determine the typical spacing between visits for MC patients and to compare MC and non-MC patients, ii) to describe the content of the MC consultation and to compare MC and non-MC patients and iii) to investigate the purposes of the MC program.

Method:   In two studies, chiropractors who accepted the MC paradigm were invited to assist with the data collection. In study 1, patients seen by seven different chiropractors were observed by two chiropractic students. They noted the contents of the observed consultations. In study 2, ten chiropractors invited their MC patients to participate in an anonymous survey. Participants filled in a one page questionnaire containing questions on their view of the purposes and contents of their MC consultations. In addition, information was obtained on the duration between appointments in both studies.

Results:   There were 178 valid records in study 1, and in study 2 the number of questionnaires received was 373. The time interval between MC visits was close to nine weeks and for non-MC consultations it was two weeks. The content of the consultations in study 1 was similar for MC and non-MC patients with treatment being the most time-consuming element followed by history taking/examination. MC consultations were slightly shorter than non-MC consultations. In study 2, the most common activities reported to have taken place were history taking and manipulative therapy. The most commonly reported purposes were to prevent recurring problems, to maintain best possible function and /or to stay as pain free as possible.

Conclusions:   The results from these two studies indicate that MC consultations commonly take place with around two months intervals, and that history taking, examination and treatment are as important components in MC as in non-MC consultations. Further, the results demonstrate that most patients consider the goal to be secondary or tertiary prevention.

 

The FULL TEXT Article

Background:

Present level of evidence

Maintenance care (MC) is a concept well known among chiropractors, although it is poorly defined and rarely studied. A literature review published in 1996 concluded that there was no scientific evidence to support the claim that MC improves health status and recommended that a series of research actions should be taken [1]. (more…)

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