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The Nordic maintenance care program: What are the indications for maintenance care in patients with low back pain? A survey of the members of the Danish Chiropractors' Association

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  • 1. University of Southern Denmark.

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Maintenance care (MC) is relatively commonly used among chiropractors. However, factual information is needed on its indications for use. This study had two objectives: 1) to describe which role patients' past history and treatment outcome play in chiropractors' decision to use MC in patients with low back pain, 2) to investigate if the chiropractors' clinical/educational background has an effect on the frequency of using MC and their indications for use of MC. An anonymous questionnaire was sent to all 413 chiropractors practising in Denmark. Its main part consisted of 3 sets of 4 questions relating to one basic case of low back pain. For each case, the chiropractors were asked if they would use MC as they self-defined the term (no/perhaps/yes). There were questions also on gender, age, educational and clinical background, and on the number of MC patients seen by these chiropractors. Their decision to recommend MC was reported. Associations between the demographic variables and 1) the frequency of MC-use and 2) their indications for use of MC were tested through multivariate analysis. The response rate was 72%. Non-indications for MC were: 1) a good outcome combined with no previous events, or 2) a past history of LBP and gradual worsening with treatment. Indications for MC were a good outcome combined with a previous history of low back pain between once a month and once a year. The mean proportion of MC patients per week were 22% (SD 19), ranging from 0% to 100%. The use of MC was highest among experienced chiropractors, those who were educated in North America, and clinic owners. However, in Denmark most chiropractors graduated before 1999, are educated abroad, whereas most chiropractors thereafter are educated in Denmark. Therefore, we cannot conclude whether this difference relates to education or years of experience. There were no associations detected between demographic variables and the indications for MC. There is relatively high consensus on when MC should and should not be used. A history of prior low back pain combined with a positive response to treatment encourages the use of MC, whereas no previous history of back pain or a worsening of symptoms discourages the use of MC. There seems to be a difference in the proportional use of MC between chiropractors with more experience educated in North America and those with less experience educated in Denmark.
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RESEARC H Open Access
The Nordic maintenance care program: what are
the indications for maintenance care in patients
with low back pain? A survey of the members
of the Danish ChiropractorsAssociation
Signe F Hansen
1
, Anne L S Laursen
1
, Tue S Jensen
2
, Charlotte Leboeuf-Yde
1,3
, Lise Hestbæk
1,3*
Abstract
Background: Maintenance care (MC) is relatively commonly used among chiropractors. However, factual
information is needed on its indications for use.
Objectives: This study had two objectives: 1) to describe which role patientspast history and treatment outcome
play in chiropractorsdecision to use MC in patients with low back pain, 2) to investigate if the chiropractors
clinical/educational background has an effect on the frequency of using MC and their indications for use of MC.
Method: An anonymous questionnaire was sent to all 413 chiropractors practising in Denmark. Its main part
consisted of 3 sets of 4 questions relating to one basic case of low back pain. For each case, the chiropractors
were asked if they would use MC as they self-defined the term (no/perhaps/yes). There were questions also on
gender, age, educational and clinical background, and on the number of MC patients seen by these chiropractors.
Their decision to recommend MC was reported. Associations between the demographic variables and 1) the
frequency of MC-use and 2) their indications for use of MC were tested through multivariate analysis.
Results: The response rate was 72%. Non-indications for MC were: 1) a good outcome combined with no previous
events, or 2) a past history of LBP and gradual worsening with treatment. Indications for MC were a good outcome
combined with a previous history of low back pain between once a month and once a year. The mean proportion
of MC patients per week were 22% (SD 19), ranging from 0% to 100%. The use of MC was highest among
experienced chiropractors, those who were educated in North America, and clinic owners. However, in Denmark
most chiropractors graduated before 1999, are educated abroad, whereas most chiropractors thereafter are
educated in Denmark. Therefore, we cannot conclude whether this difference relates to education or years of
experience. There were no associations detected between demographic variables and the indications for MC.
Conclusions: There is relatively high consensus on when MC should and should not be used. A history of prior
low back pain combined with a positive response to treatment encourages the use of MC, whereas no previous
history of back pain or a worsening of symptoms discourages the use of MC. There seems to be a difference in
the proportional use of MC between chiropractors with more experience educated in North America and those
with less experience educated in Denmark.
* Correspondence: l.hestbaek@nikkb.dk
1
Institute of Clinical Biomechanics, University of Southern Denmark, Odense,
Denmark
Full list of author information is available at the end of the article
Hansen et al.Chiropractic & Osteopathy 2010, 18:25
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© 2010 Hansen et al; licensee Bi oMed Central Ltd. This is an Open Access ar ticle distributed under the terms of the Creative Commons
Attribution L icense (http://creati vecommons.org/licenses/by/2.0), which perm its unrestricted use, di stribution, and reproduction in
any medium, provided the original work is properly cited.
Background
Presently, it is not known if or how low back pain (LBP)
can be prevented from developing. Because LBP fre-
quently is a long-lasting or recurring problem, preven-
tion of recurrences is as relevant as primary prevention.
However, also this aspect is clouded in mystery.
Many patients with LBP will seek care from chiroprac-
tors [1,2]. Some patients will continue treatment after
the acute problem has been resolved or considerably
improved, because by then it appears logical to attempt
to attend to the underlying cause of the recurring LBP
complaint. Among chiropractors, this approach is called
maintenance care (MC).
The majority of patients with LBP who are treated by
chiropractors will receive spinal manipulation. Spinal
manipulative therapy has been tested in a number of
trials and found to be effective for LBP, at least in the
short term [3,4]. Whether such treatment can prevent
LBP from recurring or getting worse, however, appears
only to have been tested explicitly in one pilot study,
with inconclusive results [5]. Therefore, it is not known,
if MC is an effective method for preventing, delaying, or
mitigating recurrent episodes of LBP.
Nevertheless, this concept is fairly well accepted
among chiropractors. Chiropractors in various parts of
the world state that they use MC in about one third of
their patients [6-9]. However, the indications for MC, as
it is used today, have not been determined.
Presently, a research program is being conducted in
the Nordic countries trying to illuminate the use of, the
indications for, and the efficiency of MC. So far, it has
been determined, that there is a large degree of consen-
sus among Nordic chiropractors that the primary goal
of MC is prevention of new episodes of LBP, although
for some patients it can be prevention of deterioration
[10,11]. There is also general agreement, that the two
most important issues for recommending MC are fre-
quency of episodes in the past and effect of the treat-
ment. Thus, more previous episodes indicate a higher
risk of recurrence and therefore a larger need for treat-
ment,andtherehastobeapositiveresponsetotreat-
ment if a MC-strategy is to be recommended [7,10-12].
However, despite the large degree of consensus, there is
not total agreement and there are subgroups of chiro-
practors with different opinions.
Since prior history of LBP episodes, and positive
response to treatment have been identified as commonly
accepted indications for offering MC to patients, we
designed this current study to explore this finding in
more specific detail. We asked chiropractors in this
pragmatic cross-sectional survey about their use of MC,
as they self-defined the term, by presenting them with a
series of clinical case scenariosthatvariedastoprior
history (frequency and duration of the previous epi-
sodes) and response to treatment.
In addition we were curious to see, if there were other
factors that would influence chiropractorsuse of MC.
In a previous study from Australia, it had been shown
that MC was more common among practitioners who
had only few new patients as compared to those who
had more new patients [13]. Other factors that we
thought could influence chiropractorsincentive to use
MC were: gender (women perhaps being more caring
than men), educational background (some chiropractic
institutions being reputed for encouraging the use of
MC), clinical experience (own experience might either
encourage or discourage its use), and whether
the respondent was a clinic owner or not (financial
incentives).
This study had two objectives: 1. to describe which
role patientspast history and treatment outcome play
in chiropractorsattitudes to the use of MC in patients
with LBP, and 2. to investigate if the chiropractors
demographic, clinical and educational background has
an influence on how many patients receive MC and
what type of patients are offered MC.
Method
The survey
A list of actively practising chiropractors was obtained
from the Danish ChiropractorsAssociation. These were
mailed a questionnaire plus a pre-stamped envelope in
February 2007. In order to encourage participation,
information on the study was given to participants at
local chiropractic meetings across the country by two
chiropractors and in the Danish chiropractorsprofes-
sional journal. The questionnaires were returned
anonymously.
The questionnaire
A questionnaire was designed specifically for the pur-
pose of this study (Additional file 1). The first page con-
sisted of demographic questions and information on the
number of MC patients as they self-defined the term.
The main part of the questionnaire consisted of three
separate pages each with 4 questions relating to one
basic case, in which an uncomplicated patient with LBP
was described. The basic case was:"A 40-year old man
consults you for low back pain of 2 days duration with
no additional spinal or musculoskeletal problems, and
with no other health problems. His x-rays are normal
for his age. There are no red flags and he seems to be
in good shape both physically and psychologically.
There are no aggravating factors at work or at home.
The questions about this patient were constructed such
that he was assumed to have received chiropractic
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treatment but that his past history could vary as could
the outcome of the treatment.
The second page of the questionnaire related to this
basic case, on this page presented as a patient who had
no previous history of back problems at all but here
were four different outcomes. On the third page, there
was a history of recurring problems but the outcomes
were the same as on the second page. On the fourth
page, there were four different past histories but the
outcomes were the same. Each of these 12 cases was fol-
lowed by the question:"Would you consider recom-
mending maintenance care? No/Perhaps/Yes.
The questionnaire was tested a number of times
among researchers and clinicians at the Back Research
Center, in Ringe, Denmark, and improved to ensure face
validity and user friendliness.
Scandinavian mainstream chiropractic practice
Based on previous studies [7,10-12] and in-depths inter-
views with 10 Danish chiropractors (not yet published)
we derived clinical parameters as operational definitions
for the term"Scandinavian mainstream chiropractic prac-
ticethat we applied during our analyses and presenta-
tion of data collected in this current study. Using these
operational definitions, we tried to identify those survey
responses, which were most likely to be expected as
answers to the 12 questions relating to the indications
for the use of MC. For example, within this definition, it
wasconsideredunsuitabletoofferMCtopatientswith
no previous history of back problems at all, whereas
patients with frequent past problems were considered
suitable, providing that they reacted well to treatment.
In 4 of the questions though (The exact wording can be
seen in Additional file 1: Appendix 1: page 2 scenario 3,
page 3 scenario 1 and 3, and page 4 scenario 2), the
information provided was not sufficiently succinct for a
clear cut decision, and therefore"mainstreamanswers
were based on the remaining 8 questions.
Quality of data
For validation purposes we obtained information on all
the members of the Danish ChiropractorsAssociation
on sex, age, college of graduation, and graduation year.
We compared this to the profile of our participants to
establish if our study sample was representative of its
target population.
The repeatability of the questionnaire was tested for
two of the clinical questions by asking them twice but
in different parts of the questionnaire: 1) the first sce-
nario on the second page and fourth page, and 2) the
first scenario on the third page and the third scenario
on the fourth page.
The self-reported use of MC was estimated by asking
for its proportional use both on the day of the study
and for the last working week. Both questions were
askedbecausethedataforthepresentdaywouldbe
easier collected (just counted) than data for the past
week. However, the week-data were there in case some
respondents on the day of the survey had an unusual
number of MC-patients.
Analysis and presentation of data
In the analyses, the variables age and clinical experience
were collapsed into fewer categories, based on the distri-
bution of data.
The distributions of MC use per day and per week
were analyzed with the help of frequency tables and
graphs and the mean value with standard deviations of
the weekly proportion of MC-patients were reported.
The number of"expectedanswers for each participant
was calculated based on the 8 predetermined"expected
answers. On the basis of the distribution of data this
variable was dichotomized into two groups, consisting
of"mainstream(giving the"expectedanswer for at least
7 of these 8 scenarios) vs."non-mainstreamanswers (all
the others).
Associations between the demographic variables and
the proportional use of MC and the proportion of"main-
streamanswers were tested with bivariate analyses, and
thereafter with multivariate linear regression analyses
for the variables found to be significant in the bivariate
analyses. Because of the possibility of strong correlations
between several of the demographic variables, we tested
these correlations using Pearsons r. The relationship
between the proportional use and the proportion
of"mainstreamanswers was tested using kappa statis-
tics. Data were analysed with STATA 8.2 (STATA Cor-
poration, 2000, Stata Statistical Software Release 8.2,
College Station, Tex., USA) and a p-level of 0.05 or less
was considered statistically significant.
Results
Description of the participants and their use of
maintenance care
In all, 296 out of 413 active members of the Danish
ChiropractorsAssociation (72%) returned their ques-
tionnaires, with an even distribution of men and
women. Two-thirds of the participants were aged 30-49
years and almost half had graduated in the USA or
Canada. The details are presented in Table 1 and a simi-
lar description of the members of the Danish Chiroprac-
torsAssociation is presented in the same table for
comparison.
The mean and median values of the self-reported pro-
portion of MC patients were almost identical for the last
full working week and the day of the survey. The
reported proportion of MC-patients the past week ranged
from 0% to 100%, with 15 missing replies and the mean
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value of MC patients per week was 22% (SD19). Based on
the distribution, three subgroups were determined. The
first group consisted of chiropractors who defined 0%
-25% of the patients seen that week as MC patients (n =
195). The second group reported that 26% -42% of their
patients were MC patients (n = 46), and the third group
reported their proportion of MC patients to be 43%-
100% (n = 40). For ease of reporting, these groups were
called"low,"medium, and"high, respectively.
Validity of data
The study sample closely resembled the target popula-
tion, i.e. all the members of the Danish Chiropractors
Association as seen in Table 1.
The internal consistency was good for one pair of
identical questions (an acute patient with no previous
history of LBP and good response to treatment: page 1,
scenario 1 and page 3, scenario1) with agreement in
94% of the cases. However, the second pair of identical
questions (a patient with recurrent LBP, one episode per
month for five years and good response to treatment:
page 2, scenario 1 and page 3, scenario 3) was less con-
vincing with 54% total agreement.
Indications for use of maintenance care
In relation to the indications for the use of MC, 40%
(n = 118) of the participants were classified as"main-
streampractitioners, giving the expected answer in at
Table 1 A comparison of the study sample in a survey of Danish chiropractors and the target population (%)
Compared variables Danish ChiropractorsAssociation
(N = 455, of which 413 are active members)
Study sample
(N = 296)
Gender
females 51 46
Males 49 45
missing 9
Age
20-29 6 4
30-39 31 35
40-49 38 38
50-59 18 20
60 or more 7 4
missing <1
Graduated in
Denmark 33 30
UK 22 24
USA/Canada 45 46
other < 1 0
missing <1
Clinical experience (yrs)
0-1 71
2-5 18 22
6-10 10 9
11-19 25 29
20 or more 38 39
missing 2 < 1
Where do you work (several answers possible)
general practice (data not available) 93
Falck health Care/Private hospital 16
Public hospital 4
Other 4
Are you (several answers possible)
clinic owner 62 65
employee 38 31
both (data not available) 3
missing 1
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least 7 of the 8 cases. For each of the 8 individual cases,
57% to 89% of the participants responded as expected.
1. Maintenance care in patients with no previous history of
back problems but with different outcomes
Overall, the results of the first set of cases were in
accordance with the expectations of the research group,
as the majority of respondents found it unsuitable to
provide MC to patients with no previous history of LBP
at all. There was only one possible exception. In sce-
nario 3, depicting a patient who does not improve over
two months of treatment ("some days are good, some
are bad), 54% of the chiropractors responded either"-
perhapsor"yesto the consideration of MC. For this
scenario, the research team expected the majority to
reply"no(Table 2).
2. Maintenance care in patients with monthly episodes of
LBP but with different outcomes
Information collected in this part of the questionnaire
did not always agree with the expectations of the
research group (Table 3). In the first two scenarios, in
which the patient is getting better in relation to the
treatment, the"expectedanswer would be to consider
MC. However, in the patient who improves directly on
the first visit and whose pain does not recur within two
months, only 41% would offer MC, whereas 58% would
offer MC to the other person who had a recurrence
after one month. If the patient does not improve after
two months ("some days are good some are bad), 54%
of the chiropractors answer"yesor"perhapsto offering
MC. In this case the research team had expected a
response of"no. For the patient who gradually gets
worse, the research team had also anticipated a majority
response of"noand 88% of the respondents agreed with
that concept.
3. Maintenance care in patients with good outcome but
different past histories
As expected, 87% would not offer MC to a patient with
immediate and lasting positive response and no previous
history of back pain. The opinions were mixed if there
had been 1-2 episodes of LBP a year, with 46% answer-
ing"perhaps, whereas the research teamsexpected
answer was"yes. The majority, however, agreed that
MC would be suitable for more frequent past episodes.
For monthly episodes, 70% were in favour, and 69% for
weekly episodes. This was in line with the"expected
answers (Table 4).
Associations between the demographic background and
the proportional use of maintenance care
There were no statistically differences in the use of MC
between men and women or between age groups. How-
ever, there were statistically significant differences
between the proportion of MC-patients per week and
the other factors investigated: 1) graduates from USA/
Canada had the highest use of MC and graduates from
Denmark the lowest, 2) more years in practice was asso-
ciated with a higher use of MC, and 3) clinic owners
used MC more often than employees, see Tables 5, 6, 7.
However, these three factors are closely interrelated.
Almost all chiropractors in Denmark with less than 11
years of experience are graduates from Denmark.
Because of the strong correlation between graduation
Table 2 The use of maintenance care in patients with no previous history of low back pain and different outcomes of
treatment
Would you consider recommending MC to
this patient?
No Perhaps Yes Missing
Follow-up scenarios Frequency
(%)
Frequency
(%)
Frequency
(%)
Frequency
(%)
You treat him once and the symptoms disappear directly after you manipulated the painful area.
You follow for him two months and the pain does not reappear, the movement pattern is
normal, and you cannot provoke any symptoms by palpation or other tests.
264
(89%)
16
(5%)
12
(4%)
4
(1%)
You treat him once and the symptoms disappear directly after you manipulated the painful area.
You follow him for two months and after one month there is a recurrence. But after one more
treatment the pain does not reappear, the movement pattern is normal, and you cannot
provoke any symptoms by palpation or other tests.
169
(57%)
82
(28%)
39
(13%)
6
(2%)
You treat him for two months and you can see from his file that some days are good some are
bad, but in all there is no difference really.
132
(45%)
92
(31%)
67
(23%)
5
(2%)
You treat him for 2 months and he is getting gradually worse. 260
(88%)
18
(6%)
13
(4%)
5
(2%)
The following basic case was given:"A 40-year old man consults you for low back pain of 2 days duration with no additional spinal or musculoskeletal problems,
and with no other health problems. His x-rays are normal for his age. There are no red flags and he seems to in good shape both psychically and
psychologically. There are no aggravating factors at work or at home.The expected answers are written in bold, and where the majority of the practitioners
agree with the research team, the answer is also in italics.
The use of maintenance care based on patients with a history of one episode of LBP per month the last 5 years lasting 5-6 days resolving spontaneously and
different outcomes.
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and experience (Pearsons r = 0.82, p < 0.001), gradua-
tion and employment (Pearsons r = -0.54, p < 0.001),
and between experience and employment (Pearsonsr=
-0.57, p < 0.001) we did not perform a multi-variate
analysis. It is therefore not possible to determine
whether high use of MC is determined by educational
background or experience.
Associations between the demographic background,
care and"mainstreamuse of MC
Neither the demographic data nor the use of MC was
associated with the"mainstreamanswers in the analyses.
Discussion
Theresultsofthisstudyindicatethatourstudysample
was representative of the membership of the Danish
ChiropractorsAssociation. Among Danish chiropractors
there is a wide variation in the use of MC; some not
usingitatallandothersalways.Astrongdeterminant
for this was, not surprisingly, their educational back-
ground, with the American-educated chiropractors being
more likely to have more MC patients than those edu-
cated in the UK or Denmark. It is possible that the use of
MC is a major differential factor between European-style
and American-style chiropractic. One should therefore
be careful when interpreting data on this topic from dif-
ferent parts of the world. However, since there is a strong
correlation between country of graduation and years of
clinical experience among Danish chiropractors, this dif-
ference could also be related to experience.
Whether MC is a useful approach or not, is not
known, but assuming that it does have an effect, it
Table 3 The use of maintenance care based on patients with a history of one episode of LBP per month the last 5
years lasting 5-6 days resolving spontaneously and different outcomes
Would you consider recommending MC to
this patient?
No Perhaps Yes Missing
Follow-up scenarios Frequency
(%)
Frequency
(%)
Frequency
(%)
Frequency
(%)
You treat him once and the symptoms disappear directly after you manipulated the painful area.
You follow him for two months and the pain does not reappear, the movement pattern is
normal, and you cannot provoke any symptoms by palpation or other tests.
83
(28%)
88
(30%)
120
(41%)
5
(2%)
You treat him once and the symptoms disappear directly after you manipulated the painful area.
You follow him for two months and after one month there is a recurrence. But after one more
treatment the pain does not reappear, the movement pattern is normal, and you cannot
provoke any symptoms by palpation or other tests.
27
(9%)
94
(32%)
171
(58%)
4
(1%)
You treat him for two months and you can see from his file that some days are good some are
bad, but in all there is no difference really.
129
(44%)
90
(30%)
71
(24%)
6
(2%)
You treat him for 2 months and he is gradually getting worse. 259
(88%)
21
(7%)
10
(3%)
6
(2%)
The following basic case was given:"A 40-year old man consults you for low back pain of 2 days duration with no additional spinal or musculoskeletal problems,
and with no other health problems. His x-rays are normal for his age. There are no red flags and he seems to in good shape both psychically and
psychologically. There are no aggravating factors at work or at home.The expected answers are written in bold, and where the majority of the practitioners
agree with the research team, the answer is also in italics.
Table 4 The use of maintenance care in patients with different past histories but identical outcomes
Would you consider recommending MC to
this patient?
No Perhaps Yes Missing
Past history Frequency
(%)
Frequency
(%)
Frequency
(%)
Frequency
(%)
He has never previously had any back pain at all. 257
(87%)
19
(6%)
12
(4%)
8
(3%)
Over the past 5 years he has had 1-2 episodes of LBP a year, each event lasting 5-6 days and
resolving spontaneously.
67
(23%)
135
(46%)
86
(29%)
8
(3%)
Over the past 5 years he has had 1 episode of LBP per month, each event lasting 5-6 days
and resolving spontaneously.
20
(7%)
61
(21%)
207
(70%)
8
(3%)
Over the past 5 years he had about 1 episode per week, each event lasting 2-3 days and
resolving spontaneously.
29
(10%)
54
(18%)
205
(69%)
8
(3%)
The following course of treatment was given: You treat him once and the symptoms disappear directly after a manipulation to the painful area. You followhim
for two months and the pain does not reappear, the movement pattern is normal and you cannot provoke any symptoms by palpation or other tests. The
expected answers are written in bold, and where the majority of the practitioners agree with the research team, the answer is also in italics.
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should be used in such a way as to be cost-effective for
the patient. Therefore it seemed logical that good out-
come should be a major prerequisite, as should a con-
siderable risk of future LBP. This was also the result in
this study as well as in previous studies.
Interestingly, respondents who provided the unex-
pected answers could do this in both directions, i.e. not
offering MC to a case with a profile assumed to be sui-
table or offering MC to those assumed to be unsuitable.
This shows there is some diversity in the chiropractic
profession regarding MC. If such a thing as"correct
answers exists to these survey questions, some chiro-
practors will offer MC more frequently and others less
frequently. On that note, it must be remembered that
the clinical scenarios presented in the survey have very
limited information and many other factors (e.g. the
psychological profile of the patient, various types of
spinal problems, etiology of the back pain etc.) might
influence the chiropractorschoice[11].Despitethese
shortcomingsofthesurvey,thereisalargedegreeof
consensus among the chiropractors.
There seems to be a general agreement that MC
should be used in patients at risk for future problems
and that the past history is a predictor of that. Further,
the patient should improve with treatment. As for the
cut-off point for past LBP events, it lies somewhere
between one episode per year and one per month, but
probably closer to the latter.
For clinicians, also the non-indications for MC treat-
ment are important. Almost 90% agreed that patients
who recovered very quickly, remained stable over two
months, and who had no past history of LBP should not
have MC. And about as many of our participants would
not consider MC for patients who got gradually worse.
Curiously, there was no majority"no"- response for the
patients who"oscillated(some days good some days
bad) with no real improvement. Also according to pre-
vious Swedish and Danish studies, subgroups of respon-
dents who would recommend MC also in patients who
do not report a clinically relevant amount of improve-
ment were noted [7,10,11]. Further, in a Finnish study,
some argued that lack of treatment success could also
be an indication for MC [12]. We had hoped for some
clear indications on this issue, but some confusion
remains. Perhaps such answers arise because some chir-
opractors consider chiropractic treatment always to be
of benefit, regardless the reporting of symptoms. This
was neither the opinion of the research team, nor of the
majority of respondents, but until the value of MC has
been tested in a number of randomized controlled clini-
cal trials, nobody can tell who is right.
Conclusions
We were able to reach four distinct conclusions:
About 2/3 of the Danish chiropractors reported to
use MC on between 0 and 25% of their patients.
The most frequent use of MC was reported by
chiropractors who were graduates from North
America, experienced chiropractors and clinic
owners.
For Danish chiropractors in general, the indica-
tions for MC in patients with LBP were: good short-
term outcome and at least 1-2 previous episodes per
year.
There were no associations between the demo-
graphic background and the indications for the use
of MC.
Conflict of interests
The authors declare that they have no competing
interests.
Table 5 The weekly use of MC among Danish
chiropractors in relation to clinical experience.
Use of MC per week
Clinical experience (years) Low Medium High Total
0-1 3 (100) 0 0 3 (100)
2-5 54 (86) 5 (8) 4 (6) 63 (100)
6-10 19 (73) 4 (15) 3 (12) 26 (100)
11-19 49 (58) 23 (27) 12 (14) 84 (100)
20 or more 69 (66) 14 (13) 21 (20) 104 (100)
Total 194 (69) 46 (16) 40 (14) 280 (100)
Test for linear trend, p < 0.005
Table 6 The weekly use of MC among Danish
chiropractors in relation to country of graduation.
Use of MC per week
Graduated in Low Medium High Total
Denmark 73 (84) 8 (9) 6 (7) 87 (100)
UK 46 (71) 14 (22) 5 (8) 65 (100)
USA/Canada 76 (59) 24 (19) 29 (22) 129 (100)
Total 195 (69) 46 (16) 40 (14) 281 (100)
Pearson chi2(4) = 20.2974 Pr = 0.000
Table 7 The weekly use of MC among Danish
chiropractors in relation to employment.
Use of MC per week
Employement Low Medium High Total
Clinic owner 116 (63) 34 (19) 33 (18) 183 (100)
Employee 72 (81) 10 (11) 7 (8) 89 (100)
Both 6 (75) 2 (25) 0 8 (100)
Total 194 (69) 46 (16) 40 (14) 280 (100)
Pearson chi2(4) = 10.5322 Pr = 0.032
Hansen et al.Chiropractic & Osteopathy 2010, 18:25
http://www.chiroandosteo.com/content/18/1/25
Page 7 of 8
Additional material
Additional file 1: Questionnaire. A copy of the questionnaire used in
the survey about the use of maintenance care in Danish chiropractic
practice.
Author details
1
Institute of Clinical Biomechanics, University of Southern Denmark, Odense,
Denmark.
2
The Back Research Center, Ringe, University of Southern Denmark,
Odense, Denmark.
3
Nordic Institute for Chiropractic and Clinical
Biomechanics, University of Southern Denmark, Odense, Denmark.
Authorscontributions
SHF and ALSH designed the study, collected and analyzed the preliminary
data and wrote a report on part of the results as a part requirement for
their masters degree in Health Sciences (Biomechanics), supervised by CLY
and LH. TSJ supervised and assisted with the data analysis. CLY and LH were
responsible for the final manuscript. All authors read and approved the final
manuscript.
Received: 30 September 2009 Accepted: 1 September 2010
Published: 1 September 2010
References
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doi:10.1186/1746-1340-18-25
Cite this article as: Hansen et al.: The Nordic maintenance care
program: what are the indications for maintenance care in patients
with low back pain? A survey of the members of the Danish
ChiropractorsAssociation. Chiropractic & Osteopathy 2010 18:25.
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Hansen et al.Chiropractic & Osteopathy 2010, 18:25
http://www.chiroandosteo.com/content/18/1/25
Page 8 of 8
... Eight studies collected their data from chiropractors [8][9][10][11][12][13][14][15], who either estimated their responses or consulted their patient files, four studies collected their data from patients [16][17][18][19], in one study data were collected from both chiropractors and their patients [20], and one study used workers' compensation claims data [21]. Please see Table 1 for a description of the included studies. ...
... The indications for the use of Maintenance Care had been studied in different ways, from focus groups [10,12] to surveys [8,10,15]. Only the most common findings are aggregated here. ...
... Only the most common findings are aggregated here. Studies, including specific hypothetical cases, found that Maintenance Care was offered, particularly, if the patient had had previous episodes and had improved with treatment [8,15]. When clinicians were asked to identify suitable cases, the patient's past history was also acknowledged [12]. ...
Article
Full-text available
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. 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.
... MC has traditionally been used by chiropractors and is described as a long-term management strategy, introduced when treatment benefit has been recorded after an initial care plan, with the aim of preventing future episodes and deterioration by treating the patient regularly irrespective of symptoms [9][10][11][12][13][14]. Ninety-eight percent of all Swedish chiropractors support the concept of MC and consider it to be a useful clinical procedure, at least in some circumstances [9]. MC is mainly used as a form of secondary or tertiary prevention aimed at recurrent and persistent conditions [9,12,[15][16][17]. There seems to be a common patient-oriented management concept among chiropractors according to which patients are selected for MC mainly on the basis of their previous history of pain and the effectiveness of the initial care plan [10,12,[15][16][17][18][19][20]. ...
... MC is mainly used as a form of secondary or tertiary prevention aimed at recurrent and persistent conditions [9,12,[15][16][17]. There seems to be a common patient-oriented management concept among chiropractors according to which patients are selected for MC mainly on the basis of their previous history of pain and the effectiveness of the initial care plan [10,12,[15][16][17][18][19][20]. In previous studies, the proportion of chiropractic MC visits ranged between 14% and 41%. ...
... In a comprehensive program starting 2008, the Nordic Maintenance Care Program, indications, content and frequency of MC have been systematically investigated by Scandinavian researchers [10,12,[15][16][17][18][19][20]. Based on this knowledge, a randomized pragmatic clinical trial was designed to investigate the effectiveness of MC for recurrent and persistent LBP [27]. ...
Article
Full-text available
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. The primary outcome of the trial was the total number of days with bothersome LBP collected weekly for 12 months using an automated SMS system. Data used to classify patients according to psychological subgroups defined by the West Haven-Yale Multidimensional Pain Inventory (adaptive copers, interpersonally distressed and dysfunctional) were collected at the screening visit. Results A total of 252 subjects were analyzed using a generalized estimating equations linear regression framework. Patients in the dysfunctional subgroup who received maintenance care reported fewer days with pain (-30.0; 95% CI: -36.6, -23.4) and equal number of treatments compared to the control intervention. In the adaptive coper subgroup, patients who received maintenance care reported more days with pain (10.7; 95% CI: 4.0, 17.5) and more treatments (3.9; 95% CI: 3.5, 4.2). Patients in the interpersonally distressed subgroup reported equal number of days with pain (-0.3; 95% CI: -8.7, 8.1) and more treatments (1.5; 95% CI: 0.9, 2.1) on maintenance care. Conclusions Psychological and behavioral characteristics modify the effect of MC and should be considered when recommending long-term preventive management of patients with recurrent and persistent LBP.
... Chiropractic MC is described as a long-term management strategy for musculoskeletal disorders, introduced when optimum treatment bene t has been reached after an initial care plan. The aim is to prevent future episodes and deterioration by treating the patient at regular intervals, regardless of symptoms (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). In an ambitious effort, researchers across the Scandinavian countries have systematically explored and investigated indications, content, and frequency of MC in a series of research projects (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). ...
... The aim is to prevent future episodes and deterioration by treating the patient at regular intervals, regardless of symptoms (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). In an ambitious effort, researchers across the Scandinavian countries have systematically explored and investigated indications, content, and frequency of MC in a series of research projects (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Commonly, MC patients are selected based on their previous history of pain and the effectiveness of the initial care plan. ...
Preprint
Full-text available
Background Chiropractic Maintenance Care (MC) has been found to be effective for patients classified as dysfunctional (high pain severity, marked interference with everyday life due to pain, high affective distress, low perception of life control, and low activity levels) by the Swedish equivalent of the West Haven-Yale Multidimensional Pain Inventory (MPI-S). Although displaying good psychometric properties such as validity and reliability, the instrument was not designed to be used in clinical practice to screen patients for stratified care pathways. To effectively be able to screen for individuals suitable for MC, the aim was to develop a clinical instrument with the intent of identifying dysfunctional patients with acceptable sensitivity, specificity, and discriminant ability. Methods Data from 249 patients with a complete MPI dataset from an RCT that investigated the effect and cost-effectiveness of MC with a 12-month follow-up was used in this cross-sectional analysis. The MPI’s data was used to develop a short screening instrument to identify dysfunctional patients, with a summary measure, based on the original instrument. Different cutoffs were considered with regards to sensitivity, specificity, and discriminant ability and compared to the original instrument’s classification of dysfunctional patients. The instrument was then tested in 3 other existing datasets to assess validity across populations. Results Using an explorative approach, the MAINTAIN instrument with 10 questions (0-6 Likert responses) with 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. Discriminant ability (area under the curve (AUC)) was estimated to 0.87 (95% CI: 0.83, 0.92; p <0.001) and Youden’s index was highest (0.70) at a score of 20. The discriminant ability is similar and acceptable across populations with minor differences in optimal thresholds for identifying dysfunctional individuals. Conclusion The MAINTAIN instrument had an acceptable performance with regards to identifying dysfunctional patients and may be used as a decision aid in clinical practice. By using 2 thresholds, patients can be categorized into “low probability (-12 to 17)”, “moderate probability (18 to 21)”, and “high probability (22 to 48)” of having a good outcome from maintenance care for Low Back Pain (LBP). Trial registration Clinical trials.gov; NCT01539863; registered February 28, 2012; https://clinicaltrials.gov/ct2/show/NCT01539863
... MC is a secondary/tertiary treatment strategy where patients are treated at regular intervals over a lengthy period of time with the aim of preventing future episodes (secondary prevention) or managing persistent pain (tertiary prevention) [11,12]. In a joint initiative, researchers in Sweden, Denmark and Finland have investigated the frequency, indications and content of MC [13][14][15][16][17][18][19][20][21]. Based on their findings a multicenter pragmatic randomized clinical trial was conducted in Sweden from 2012 to 2016 [22,23]. ...
... This study is a secondary analysis of data from a pragmatic, multicenter, investigator-and assessor-blinded randomized controlled trial with a two-arm parallel design [22][23][24]. The trial was based on the findings of the Nordic Maintenance Care program and made use of all the current evidence in the field [13][14][15][16][17][18][19][20][21]. The primary aim of the trial was to measure the differences in outcome of MC on patients with recurrent or persistent LBP. ...
Article
Full-text available
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 and total number of pain-free weeks, for all study participants as well as for each psychological subgroup. Methods A secondary analysis of data from a randomized controlled trial of patients (n = 319) seeking chiropractic care for recurrent or persistent LBP used 52 weekly estimates of days with bothersome (activity-limiting) LBP. First, a generalized estimating equations analysis was used to compare the pain trajectory before and after the initial treatment in every new treatment period. Thereafter, a time-to-event analysis (using Cox regression) estimated time to/risk of a new LBP episode. The analyses were performed on i) all study participants and ii) separately for each psychological sub-group (named adaptive copers, interpersonally distressed and dysfunctional) classified by the West Haven-Yale Multidimensional Pain Inventory. Results Patients receiving MC had flat pain trajectories around each new treatment period and reported fewer days with pain compared to patients receiving the control intervention. The entire effect was attributed to the dysfunctional subgroup who reported fewer days with activity limiting pain within each new LBP episode as well as longer total pain-free periods between episodes with a difference of 9.8 weeks (CI 95% 3.3, 16.3) compared to the control group. There were no differences in the time to/risk of a new episode of LBP in either of the subgroups. Conclusion Data support the use of MC in a stratified care model targeting dysfunctional patients for MC. For a carefully selected group of patients with recurrent and persistent LBP the clinical course becomes more stable and the number of pain-free weeks between episodes increases when receiving MC. Understanding how subgroups of patients are likely to be affected by MC may help align patients’ and clinicians’ expectations based on realistic outcomes. Trial registration Clinical trials.gov; NCT01539863; February 22, 2012.
... Chiropractors have described the procedure as "a type of prolonged care delivered at regular intervals" or as "a preventive approach, aimed at preventing new episodes and maintaining improvement" (5). In a strategic research program, the Nordic Maintenance care program has been investigated in a series of projects with the aim of understanding the procedure and establishing effectiveness and costeffectiveness (4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18). Patients de ned as "Dysfunctional" by the West-Haven Multidimensional Pain Inventory (19,20), with high pain severity, marked interference with everyday life, high affective distress, low perception of life control and low activity levels, report clinically signi cant improvements from MC with no or little additional cost (4,6,7). ...
Preprint
Full-text available
Background: Low back pain is one of the major causes of disability world-wide. Most back pain sufferers experience pain that is recurrent or persistent, making management of this condition a priority. In a series of previous studies, chiropractic maintenance care has been found to be an effective way of reducing the number of days with pain, particularly for patients with a certain psychological profile. However, little is known about patients’ experience of this kind of management plan. This study aimed to explore patient experiences and preferences by looking at barriers to and facilitators of engaging in and maintaining a care plan, and to contrast the data using psychological sub-groups. Methods: In this qualitative study we performed semi-structured interviews with 24 patients who had previously participated in a Swedish trial evaluating maintenance care. They were purposefully selected to obtain richness, variation and breadth of data. The data were analyzed using inductive qualitative manifest and latent content analysis. We used the theory of planned behavior to deepen our understanding of the constructed themes. Results: The analysis resulted in two overarching dimensions: “when maintenance care is of high value” and “when maintenance care is of low value”. Four factors were jointly identified as obstacles to maintenance care by patients in all the psychological subgroups. These factors were: Cost demanding, A sense of low value, Perceived as unavailable and Fear of treatment. The one factor seen as facilitating maintenance care by patients in all the subgroups was Care that is patient-centered. Conclusions: The findings reveal a variance of both positive and negative experiences of MC in the psychological subgroups. These findings can deepen our understanding of how patients experience MC and can help clinicians to understand when patients might regard maintenance care as being of high value.
... Chiropractic maintenance care (MC) is described as a long-term management strategy for musculoskeletal disorders, introduced when optimum treatment benefit has been reached after an initial care plan. The aim of MC is to prevent future episodes, progression, and consequences of LBP by treating the patient at regular intervals, regardless of symptoms [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. In an ambitious effort, researchers across the Nordic countries have systematically explored and investigated indications, content, and frequency of MC in a series of research projects [18]. ...
Article
Full-text available
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. Conclusion The MAINTAIN instrument has very good diagnostic accuracy with regards to identifying dysfunctional patients and may be used as a decision aid in clinical practice. By using 2 thresholds, patients can be categorized into “low probability (− 12 to 17)”, “moderate probability (18 to 21)”, and “high probability (22 to 48)” of having a good outcome from maintenance care for low back pain. Trial registration Clinical trials.gov; NCT01539863; registered February 28, 2012; https://clinicaltrials.gov/ct2/show/NCT01539863 .
... Chiropractors have described the procedure as "a type of prolonged care delivered at regular intervals" or as "a preventive approach, aimed at preventing new episodes and maintaining improvement" [5]. In a strategic research program, the Nordic Maintenance care program has been investigated in a series of projects with the aim of understanding the procedure and establishing effectiveness and cost-effectiveness [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Patients defined as "Dysfunctional" by the West-Haven Multidimensional Pain Inventory [19,20], with high pain severity, marked interference with everyday life, high affective distress, low perception of life control and low activity levels, report clinically significant improvements from MC with no or little additional cost [4,6,7]. ...
Article
Full-text available
Background Low back pain is one of the major causes of disability world-wide. Most back pain sufferers experience pain that is recurrent or persistent, making management of this condition a priority. In a series of previous studies, chiropractic maintenance care has been found to be an effective way of reducing the number of days with pain, particularly for patients with a certain psychological profile. However, little is known about patients’ experience of this kind of management plan. This study aimed to explore patient experiences and preferences by looking at barriers to and facilitators of engaging in and maintaining a care plan, and to contrast the data using psychological sub-groups. Methods In this qualitative study we performed semi-structured interviews with 24 patients who had previously participated in a Swedish trial evaluating maintenance care. They were purposefully selected to obtain richness, variation and breadth of data. The data were analyzed using inductive qualitative manifest and latent content analysis. We used the theory of planned behavior to deepen our understanding of the constructed themes. Results The analysis resulted in two overarching dimensions: “when maintenance care is of high value” and “when maintenance care is of low value”. Four factors were jointly identified as obstacles to maintenance care by patients in all the psychological subgroups. These factors were: Cost demanding, A sense of low value, Perceived as unavailable and Fear of treatment. The one factor seen as facilitating maintenance care by patients in all the subgroups was Care that is patient-centered. Conclusions The findings reveal a variance of both positive and negative experiences of MC in the psychological subgroups. These findings can deepen our understanding of how patients experience MC and can help clinicians to understand when patients might regard maintenance care as being of high value.
... Nevertheless, previous studies of chiropractors in other countries have resulted in better response rates. For example; Denmark 72% [38], Finland 88% [39], Norway 61% [40], Sweden 60% [25] and 77% [41]. These studies were all conducted in Scandinavia. ...
Article
Full-text available
Background Recent studies have shown that psychological factors, attitudes and beliefs impact on the quality of chiropractic student clinical decisions. This association has not been studied among qualified chiropractors. Our objective was to investigate if personality, psychological factors and/or unorthodox beliefs among chiropractors are related to choices of management in specific clinical scenarios. Method In February 2018, a subsample of chiropractors (N = 700) from a practitioner-based research network in Australia known as ACORN (N = 1680), were invited to respond to an on-line anonymous questionnaire. Questions included items relating to management of specific clinical scenarios, intolerance of uncertainty (IU) and the ‘Big-5’ personality score, adoption of a prescriptive technique system, self-rating of chiropractic abilities, and the level of importance of subluxation and chiropractic philosophy in the delivery of care. Descriptive analysis was to be reported and associations examined between i) personality and psychology factors, unorthodox beliefs and ii) scores obtained for management of specific clinical scenarios, numbers of interdisciplinary referrals, and guideline-based X-ray use. Results The number of respondents was 141 (20%) and 33 of their responses were largely incomplete resulting in a final response rate of 108 (15.4%). In addition, some questions were left unanswered. These related mainly to IU and Big-5 personality measurements. Some sample characteristics (age, number of patients per week, hours worked per week) were similar to the larger ACORN project sample. However, the low response rate indicated that the final study sample was unlikely to be truly representative of the study population and the low number of participants made association testing unsuitable. Conclusion and recommendations The low response rate and small study sample in this study made any substantive analysis inappropriate. For these reasons, the study was not concluded. However, the potential reasons for the low response from this large database of volunteer research participants are of interest and need to be investigated. Clearly, it is necessary to engage this population better to explore sensitive issues such as personality inventories and different practice profiles in the interest of effective health care delivery and patient safety. Electronic supplementary material The online version of this article (10.1186/s12998-019-0236-0) contains supplementary material, which is available to authorized users.
Article
Objectives: The treatment goals of patients successfully using ongoing provider-based care for chronic spinal pain can help inform health policy related to this care. Design: Multinomial logistical hierarchical linear models were used to examine the characteristics of patients with different treatment goals for their ongoing care. Settings/Location: Observational data from a large national sample of patients from 125 chiropractic clinics clustered in 6 U.S. regions. Subjects: Patients with nonwork-injury-related nonspecific chronic low-back pain (CLBP) and chronic neck pain (CNP). Interventions: All were receiving ongoing chiropractic care. Outcome measures: Primary outcomes were patient endorsement of one of four goals for their treatment. Explanatory variables included pain characteristics, pain beliefs, goals for mobility/flexibility, demographics, and other psychological variables. Results: Across our sample of 1614 patients (885 with CLBP and 729 with CNP) just under one-third endorsed a treatment goal of having their pain go away permanently (cure). The rest had goals of preventing their pain from coming back (22% CLBP, 16% CNP); preventing their pain from getting worse (14% CLBP, 12% CNP); or temporarily relieving their pain (31% CLBP, 41% CNP). In univariate analysis across these goals, patients differed significantly on almost all variables. In the multinomial logistic models, a goal of cure was associated with shorter pain duration and more belief in a medical cure; a goal of preventing pain from coming back was associated with lower pain levels; and those with goals of preventing their pain from getting worse or temporarily relieving pain were similar, including in having their pain longer. Conclusions: Although much of health policy follows a curative model, the majority of these CLBP and CNP patients have goals of pain management (using ongoing care) rather than "cure" (care with a specific end) for their chiropractic care. This information could be useful in crafting policy for patients facing provider-based nonpharmacologic care for chronic pain.
Thesis
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La chiropraxie est une thérapie manuelle fondée à la fin de XIXème siècle aux Etats-Unis. Au cours du XXème siècle, cette profession a su, dans certains pays, s’insérer progressivement au sein du système de santé et académique. Aujourd’hui, en France, la chiropraxie est définie comme une profession de la santé visant à la prévention et au traitement des troubles neuro-musculo-squelettiques.En marge de cette évolution, certains chiropracteurs adoptent une approche thérapeutique conservatrice, en accord avec les principes fondateurs de la chiropraxie. C’est particulièrement le cas dans le domaine de la prévention, où les soins de wellness sont parfois utilisés en chiropraxie. Les soins de wellness peuvent notamment être composés d’ajustements chiropratiques, visant à prévenir primairement les troubles neuro-musculo-squelettiques, mais aussi les troubles non neuro-musculo-squelettiques.Les travaux constitutifs de cette thèse ont pour but d’étudier la prévention en chiropraxie, principalement chez des patients asymptomatiques. La première revue systématique de la littérature a mis en évidence le fait que les chiropracteurs souhaitent effectuer des actes de prévention primaire auprès de leurs patients, y compris des soins de wellness. Cependant, les patients chiropratiques ne souhaitent pas consulter pour ces motifs. La deuxième revue systématique a montré que la prévention primaire/secondaire précoce des troubles non neuro-musculo-squelettiques n’est pas soutenue par l’évidence scientifique. Enfin, l’enquête effectuée auprès des étudiants en chiropraxie a montré que ces derniers ont des difficultés à identifier les cas de non-indications au traitement chiropratique préventif chez les patients asymptomatiques. Il a également été montré que ces difficultés sont associées à leurs opinions conservatrices envers la chiropraxie.
Article
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Maintenance care is a well known concept among chiropractors, although there is little knowledge about its exact definition, its indications and usefulness. As an initial step in a research program on this phenomenon, it was necessary to identify chiropractors' rationale for their use of maintenance care. Previous studies have identified chiropractors' choices of case management strategies in response to different case scenarios. However, the rationale for these management strategies is not known. In other words, when presented with both the case, and different management strategies, there was consensus on how to match these, but if only the management strategies were provided, would chiropractors be able to define the cases to fit these strategies? The objective with this study was to investigate if there is a common pattern in Finnish chiropractors' case management of patients with low back pain (LBP), with special emphasis on long-term treatment. Information was obtained in a structured workshop. Fifteen chiropractors, members of the Finnish Chiropractors' Union, and present at the general assembly, participated throughout the entire workshop session. These were divided into five teams each consisting of 3 people. A basic case of a patient with low back pain was presented together with six different management strategies undertaken after one month of treatment. Each team was then asked to describe one (or several) suitable case(s) for each of the six strategies, based on the aspects of 1) symptoms/findings, 2) the low back pain history in the past year, and 3) other observations. After each session the people in the groups were changed. Responses were collected as key words on flip-over boards. These responses were grouped and counted. There appeared to be consensus among the participants in relation to the rationale for at least four of the management strategies and partial consensus on the rationale for the remaining two. In relation to maintenance care, the patient's past history was important but also the doctor-patient relationship. These results confirm that there is a pattern among Nordic chiropractors in how they manage patients with LBP. More information is needed to define the "cut-point" for the indication of prolonged care.
Article
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Although maintenance care appears to be relatively commonly used among chiropractors, the indications for its use are incompletely understood. A questionnaire survey was recently carried out among Swedish chiropractors in order to identify their choice of various management strategies, including maintenance care. That study revealed a common pattern of choice of strategies. However, it would be necessary to verify these findings in another study population and to obtain some additional information best collected through an interview. The main aim of the present study was to attempt to reproduce the findings in the Swedish study and to obtain more information on the use of maintenance care. A group of 11 chiropractors were selected because they used maintenance care. They were interviewed using the questionnaire from the previous Swedish survey. The questionnaire consisted of a simple description of a hypothetical patient with low back pain and nine possible ways in which the case could develop ("scenarios"). They could choose between six different management strategies for each scenario. In addition, the chiropractors were encouraged to provide their own definition of maintenance care in an open-ended question. Interviews were taped, transcribed and analyzed. For the open-ended question, statements were identified relating to six pre hoc defined topics on the inclusion criteria/rationale for maintenance care, the frequency of treatments, and the duration of the maintenance care program. The open-ended question revealed that in patients with low back pain, maintenance care appears to be offered to prevent new events. The rationale was to obtain optimal spinal function. There appears to be no common convention on the frequency of treatments and duration of the treatment program was not mentioned by any of the interviewees. The results from the questionnaire in the Danish survey showed that the response pattern for the nine scenarios was similar to that obtained in the Swedish survey. There seems to be relative agreement between chiropractors working in different countries and sampled through different methods in relation to their choice of management strategies in patients with low back pain. However, more precise information is needed on the indications for maintenance care and its treatment program, before proceeding to studying its clinical validity.
Article
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Among chiropractors the use of long-term treatment is common, often referred to as "maintenance care". Although no generally accepted definition exists, the term has a self-explanatory meaning to chiropractic clinicians. In public health terms, maintenance care can be considered as both secondary and tertiary preventive care. The objective of this study was to explore what factors chiropractors consider before recommending maintenance care to patients with low back pain (LBP). Structured focus group discussions with Swedish chiropractors were used to discuss pre-defined cases. A questionnaire was then designed on the basis of the information obtained. In the questionnaire, respondents were asked to grade the importance of several factors when considering recommending maintenance care to a patient. The grading was done on a straight line ranging from "Very important" to "Not at all important". All members of the Swedish Chiropractors' Association (SCA) were invited to participate in the discussions and in the questionnaire survey. Thirty-six (22%) of SCA members participated in the group discussions and 129 (77%) returned the questionnaires. Ninety-eight percent of the questionnaire respondents claimed to believe that chiropractic care can prevent future relapses of back pain. According to the group discussions tertiary preventive care would be considered appropriate when a patient improves by 75% or more. According to the results of the questionnaire survey, two factors were considered as "very important" by more than 70% of the respondents in recommending secondary preventive care, namely frequency past year and frequency past 10 years of the low back pain problem. Eight other factors were considered "very important" by 50-69% of the respondents, namely duration (over the past year and of the present attack), treatment (effect and durability), lifestyle, work conditions, and psychosocial factors (including attitude). The vast majority of our respondents believe that chiropractic treatment can prevent relapses of back pain. When recommending secondary preventive care, past frequency of the problem is considered. For tertiary preventive care, the patient needs to improve considerably before a recommendation of maintenance care is made.
Article
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This study explores the extent to which consumers seek wellness care when choosing chiropractors whose practice methods are known to include periodic evaluative and interventional methods to maintain wellness and prevent illness. Using an international convenience sample of Sacro-Occipital Technique (SOT) practitioners, 1316 consecutive patients attending 27 different chiropractic clinics in the USA, Europe and Australia completed a one-page survey on intake to assess reason for seeking care. A forced choice response was obtained characterizing the patient's reason for seeking chiropractic care. More than 40% of chiropractic patient visits were initiated for the purposes of health enhancement and/or disease prevention. Although prudence dictates great caution when generalizing from this study, if confirmed by subsequent research among other similar cohorts, the present results may lend support to continued arguments of consumer demand for a more comprehensive paradigm of chiropractic care, beyond routine musculoskeletal complaints, that conceptualizes the systemic, nonspecific effects of the chiropractic encounter in much broader terms.
Article
The purpose of this project was to review the literature for the use of spinal manipulation for low back pain (LBP). A search strategy modified from the Cochrane Collaboration review for LBP was conducted through the following databases: PubMed, Mantis, and the Cochrane Database. Invitations to submit relevant articles were extended to the profession via widely distributed professional news and association media. The Scientific Commission of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) was charged with developing literature syntheses, organized by anatomical region, to evaluate and report on the evidence base for chiropractic care. This article is the outcome of this charge. As part of the CCGPP process, preliminary drafts of these articles were posted on the CCGPP Web site www.ccgpp.org (2006-8) to allow for an open process and the broadest possible mechanism for stakeholder input. A total of 887 source documents were obtained. Search results were sorted into related topic groups as follows: randomized controlled trials (RCTs) of LBP and manipulation; randomized trials of other interventions for LBP; guidelines; systematic reviews and meta-analyses; basic science; diagnostic-related articles, methodology; cognitive therapy and psychosocial issues; cohort and outcome studies; and others. Each group was subdivided by topic so that team members received approximately equal numbers of articles from each group, chosen randomly for distribution. The team elected to limit consideration in this first iteration to guidelines, systematic reviews, meta-analyses, RCTs, and coh ort studies. This yielded a total of 12 guidelines, 64 RCTs, 13 systematic reviews/meta-analyses, and 11 cohort studies. As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
Article
In a survey of British chiropractors and their practices, it was found that the majority of their patients attended for back pain. The average age of patients was 47 years, the sex ratio was equal, and most had had their complaints for longer than three months and had access to the chiropractor within a few days. They were largely housewives and persons from the executive and managerial occupations. The main investigative procedures used were static and motion palpation of the spine, and vital systems, orthopaedic, neurological, and radiological examination. Treatment was mostly manual and directed at the spinal column, and the benefit obtained, as assessed by the chiropractors, was comparable to that reported in other studies. Maximum benefit was usually recorded within seven attendances, although 39 % of patients made further visits for maintenance treatment. The chiropractors are seen to be a young, growing, and largely male group, and their new patient numbers are at present likely to be at least one-twentieth that of hospital out-patient departments which deal with back pain.
Article
Two surveys of 121 preselected Victorian and South Australian chiropractors were conducted during the period of December 1986 to February 1987 in order to investigate whether practice location (metropolitan area and country town) and chiropractor/population ratio (number of chiropractors per 10,000 inhabitants) have any effect on patient numbers, practice procedures and practitioner attitudes. Practitioners' response rates to the first and second questionnaires were 82% and 61%, respectively. Analysis of data revealed that metropolitan chiropractors utilized more adjunctive therapies than their country town colleagues. Most chiropractors felt that the number of chiropractors in their area was sufficient. However, there appeared to be no difference in patient numbers (patient visits and new patients) and ratio of new patients to patient visits as related to practitioner density or practice location. Patient volume appeared to be practitioner-induced; fewer new patients corresponded to a higher number of revisiting patients, and maintenance care corresponded to a higher number of patient visits.
Article
To investigate the primary care, health promotion activities associated with what has historically been called "maintenance care" (MC) as used in the practice of chiropractic in the United States. This includes issues such as investigating the purpose of MC, what conditions and patient populations it best serves, how frequently it is required, what therapeutic interventions constitute MC, how often it is recommended, and what percent of patient visits are for prevention and health promotion services. It also investigates the economic impact of these services. Postal survey of a randomized sample of practicing US chiropractors. The questionnaire was structured with a 5-point ordinal Likert scale (28 questions) and brief fill-in questionnaire (12 questions). The 40-question survey was mailed to 1500 chiropractors selected at random from a pool of chiropractors with active practices in the United States. The National Directory of Chiropractic database was the source of actively practicing chiropractors from which doctor selection was made. The sample was derived by using the last numbers composing the zip codes assigned by the US Postal Service. This sampling method assured potential inclusion of chiropractors from all 50 states, from rural areas and large cities, and assured a sample weighting based on population density that might not have been afforded by a simple random sample. Six hundred and fifty-eight (44%) of the questionnaires were completed and returned. US chiropractors agreed or strongly agreed that the purpose of MC was to optimize health (90%), prevent conditions from developing (88%), provide palliative care (86%), and minimize recurrence or exacerbations (95%). MC was viewed as helpful in preventing both musculoskeletal and visceral health problems. There was strong agreement that the therapeutic composition of MC placed virtually equal weight on exercise (96%) and adjustments/manipulation (97%) and that other interventions, including dietary recommendations (93%) and patient education about lifestyle changes (84%), shared a high level of importance. Seventy-nine percent of chiropractic patients have MC recommended to them and nearly half of those (34%) comply. The average number of recommended MC visits was 14.4 visits per year, and the total revenue represents an estimated 23% of practice income. Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.
Article
To document the potential role of maintenance chiropractic spinal manipulation to reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments. Thirty patients with chronic nonspecific low-back pain were separated into 2 groups. The first group received 12 treatments in an intensive 1-month period but received no treatment in a subsequent 9-month period. For this group, a 4-week period preceding the initial phase of treatment was used as a control period to examine the sole effect of time on pain and disability levels. The second group received 12 treatments in an intensive 1-month period and also received maintenance spinal manipulation every 3 weeks for a 9-month follow-up period. Pain and disability levels were evaluated with a visual analog scale and a modified Oswestry questionnaire, respectively. The 1-month control period did not modify the pain and disability levels. For both groups, the pain and disability levels decreased after the intensive phase of treatments. Both groups maintained their pain scores at levels similar to the postintensive treatments throughout the follow-up period. For the disability scores, however, only the group that was given spinal manipulations during the follow-up period maintained their postintensive treatment scores. The disability scores of the other group went back to their pretreatment levels. Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.