This week from Dr. Cerami and Utah Sports and Wellness

From: Public Library of Science, 2018


Quick Summary:

The aim of this trial was to investigate the effectiveness of chiropractic maintenance care on pain for patients with recurrent or persistent low back pain.  It was an investigator-blinded, randomized controlled trial using 328 subjects aged 18-65 years, with non-specific low back pain, who had an early favorable response to chiropractic care. This study found that patients who used a maintenance style of care  had almost 2 full weeks less of back pain per year than those using a symptom-based program of care, with an average difference of less than 2 more appointments per year for those utilizing a maintenance style of care. The idea behind maintenance care is that maintenance (or asymptomatic) care can improve movement and neuromuscular function. Additionally, it may address psychosocial issues – meaning people are less worried about falling back into pain and are less cautious about their back in their activities of daily living. When it comes to treating chronic low back pain, maintenance care can be a good option for preventing back pain as well as treating it when it does pop up.


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

These authors also note:

  • “Non-specific low back pain (LBP) is one of the most common and costly healthcare problems in society today.”
  • “The burden of disabling low back pain on individuals, families, communities, industries and societies is substantial and is now the leading cause of activity limitation and work absence in the world.”
  • Low back pain is often recurrent and has a large negative impact on society.
  • Focusing on preventive strategies for recurrent low back pain is logical.
  • “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 are trained to assess and treat disorders of the musculoskeletal system, of which LBP is the most common.”
  • “The majority of patients seeking chiropractic care receive some form of manual therapy, of which spinal manipulation and mobilization are the most common, often along with advice on exercise.”
  • Chiropractors have traditionally used Maintenance Care (MC), as secondary and tertiary prevention strategies against new episodes of low back pain, or in reducing the impact of a new episode of low back pain. “It is common for chiropractors to recommend maintenance care, i.e. preventive consultations/visits for recurrent and persistent musculoskeletal pain and dysfunction.”
  • Maintenance chiropractic care may improve biomechanical and neuromuscular function and address psychosocial issues, thereby reducing the risk of relapse into pain.
  • About one fifth of all visits to Scandinavian chiropractors are maintenance care visits and 98% of Swedish chiropractors use the approach to some extent.
  • “Chiropractic maintenance care resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment.”
  • Results: the chiropractic maintenance care group (n = 163) had 12.8 fewer days in total with bothersome low back pain.
  • “The total number of days with bothersome low back pain over the 12 months was 85.2 for the maintenance group and 98.0 for the control group.”
  • The maintenance group had a faster reduction in days with bothersome low back pain and reached a lower steady state earlier.
  • “No serious adverse events were recorded.”
  • Maintenance chiropractic care was more effective than symptom-guided treatment in reducing the total number of days over 52 weeks with bothersome non-specific LBP by about 13 days, but it resulted in a higher number of treatments (by 1.7).
  • Maintenance chiropractic care should be considered an option for tertiary prevention of low back pain. 17) Maintenance chiropractic care “resulted in a reduction in the total number of days per week with bothersome LBP compared with symptom-guided treatment.”
  • Yet, “the maintenance group required only a slightly higher number of visits [1.7 visits] to the chiropractor than the control group.”
  • The maintenance chiropractic care group “improved faster and achieved the steady state phase earlier with a lower mean number of days with LBP per week.”
  • “The treatment was not reported as being linked to any serious harm and both the intervention and the control regimes must be considered safe treatments.”
  • There were minor transient reactions to the treatment, such as local soreness for 1-2 days.
  • “The results of this study support the findings of the only other sufficiently powered RCT to have investigated preventive manual care. They found that patients who continued to receive spinal manipulation after an initial course of care had lower pain and disability scores at a 10-month follow-up.”
  • The authors note that the maintenance care in this study was between 1 and 3 months, which may be an inadequate frequency for best outcomes.
  • “Some clinicians suggested that some patients (the ones with more persistent pain) would have benefited from shorter intervals than 1 month to be able to prevent future episodes.”