Chiropractic and Maintenance Care

Bed Of Chiropractic,Image via Wikipedia
“Do I need to keep coming back for treatment to prevent this from happening again?”

This method of chiropractic care is known as Maintenance care. I have always struggled with answering this question.  Even though I was told that maintaining a healthy spine is a good thing and that chiropractic care helps to prevent injuries, I had trouble accepting this approach since I have not seen any supporting literature.


What is Maintenance Chiropractic Care?

Maintenance Chiropractic care is elective care.  By definition it is long term care, that is not therapeutically necessary, but performed at regular intervals to help prevent injury and enhance quality of life.  This form of care is provided after maximal therapeutic benefit is achieved, without a trial of treatment withdrawal, to prevent symptoms from returning or for those without symptoms to promote health or prevent future problems.

The problem I have with this form of care is that we do not know how a patient will respond without treatment. Will they improve or will they worsen if care is stopped?  At what point in time does this treatment method end; is it indefinite? Who dictates how frequently the treatment should be? Should the treatment frequency be the same for every patient?

Since I believe evidence helps guide my treatments for my patients I asked, “Does treating a chiropractic patients beyond their lower back pain result in better outcomes or prevent injury??

Here is the evidence that I could find (If you find other information please share it with me):


Maintenance care in chiropractic – what do we know? (2008)
Charlotte Leboeuf-Yde and Lise Hestbæk

Research Type: A review of Literature
Quoted findings I felt were interesting:

  • 13 articles were reviewed in this article (This isn’t that many)
  • 79% of patients are recommended for maintenance care and that 34% of those “elect to receive these services”
  • There was only sparse information in the literature on the indications for maintenance care and there was no information on specific indications for particular conditions.
  • According to the Mercy Guidelines [7], spinal adjustments are central in maintenance care. However, the research literature is vague on the contents of a maintenance care consultation and the frequency of treatments required for different types of patients.
  • Rupert [11] asked his North-American study subjects to describe the therapeutic components of maintenance care and concluded that they were adjustments/spinal manipulation, exercises, proper eating habits, patient education, and vitamin supplementation.
  • According to one of Rupert’s studies, North American patients who agree to receive maintenance care, average 14 visits per year [11], and in another study, elderly maintenance care patients (65+ years of age) average 17 visits per year [12]. This amounts to a little more than one visit per month.
  • This literature review reveals that more than 30 years of ad hoc research into maintenance care does not provide much information. In fact, the relative paucity of studies, the obvious biases in many of these, the lack of exhaustive information, and the diversity of findings made it impossible to answer any of our questions.
  • [It] would be relevant to test the cost-effectiveness for patients who choose to be treated regularly vs. those who receive treatment only when symptoms arise.

The above paper cited the following research article:

Efficacy of preventive spinal manipulation for chronic low-back pain and related disabilities: A preliminary study (2004)
Martin Descarreaux,a Jean-Se´bastien Blouin,a Marc Drolet,b Stanislas Papadimitriou,b and Normand Teasdalea

Groups: Group 1 (12 treatments in a month, n=10), Group 2 (12 treatments in a month followed by one treatment every 3 weeks for 9 months, n=10)
Compared: Compared groups’ subjective levels of  pain and disability.
Results: Both groups had similar pain and disability at the end of the first month. At the end of the 10 months Group 2 had lower disability scores. For Group 1 the disability scores went back to pre-treatment levels.

Associated with this article is a more recent article that will soon be printed in the journal, Spine.  I discovered a review of this article through the website, Research Review Service. This article was the reason for my review of this subject.  Here are the basics of this study.

Does maintained spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome?(2011)
Senna M & Machaly S

Groups: Total of 93 subjects.  Control group, Non-maintained spinal manipulation group (Spinal manipulation for 1 month, 3 times a week), Maintained spinal manipulation group (Spinal manipulation for 1 month, followed by every 3 weeks for 9 months)
Compared: Each group filled out questionnaires for subjective pain and disability.
Results:  The two manipulation groups had lower pain and disability scores compared to the control group after one month. At the end of the research study the non-maintained spinal manipulation group returned to pre-treatment levels while the maintained spinal manipulation group had significantly lower pain and disability scores.

Dr Notley’s thoughts on the research:

  • The last two articles show merit for continued care beyond an intensive month treatment plan. Based on this information if someone asked me if it was necessary I would be able to quote these two studies.  The decision to continue on with care would be up to them
  • I am curious if the subjects in these studies were without pain after the 4 week period or were they still experiencing signs and symptoms.
  • I am curious what the effects would be if a more comprehensive treatment protocol was performed (the use of rehabilitation exercises, Active Release Techniques, acupuncture/dry needling and/or conditioning programs, etc)?
  • I would be interested in seeing what the results would be if they added in a group that received the one month of care followed by and a home based exercise program and maintaining proper spinal mechanics during the remainder of the 10 months
  • I had difficulty finding any research papers regarding prevention of injury with chiropractic spinal manipulation.  This question still remains to be unanswered at this time.
  • So if a patient continues with maintenance care when does the treatment end?  If they only get better to a certain degree and just maintain where they are at then does continuing with care make sense?
  • If a doctor has you on a maintenance program of once every two weeks for the next year how do you know if once a month does not result in the same effect?

Support care may be the answer to this last question.  In my chiropractic practise I prefer to treat my patients with this form of care.

What is Supportive Chiropractic Care?

Supportive Chiropractic care is a long-term treatment plan that is therapeutically necessary. The patient has reached maximum therapeutic benefits but fails to maintain that improvement over a period of time.  Supportive care follows appropriate use of active and passive care including rehabilitation and lifestyle modifications.

To determine the need for supportive care a period of no treatment is required.  This point of no treatment is usually done when the patient has no signs or symptoms and appears to be fully functional.  If the patient does not worsen during the time off then no further care is necessary.  If the patient worsens then further treatment is justified.  Your doctor should be willing refer out for other treatment options to ensure that no other treatment method would help you more.

Though the above articles show some promise for maintenance care I feel there are more questions than answers and more assumptions than facts to confidently say that a person needs continued care beyond being pain free.

I suggest to my patients that they should always be proactive in their care.  If they are not improving then they should ask their Chiropractor/Doctor for alternative forms of care.

Until next week

Dr Notley

Winnipeg’s only Chiropractor and Athletic Therapist.

P.S. I should note, most of my patients receive a trial treatment plan of 6 to 8 treatments.  Some get better before this while others might take longer.  I expect patients to be at least 50% better at this time.  If not, I put it upon myself, for my patients, to seek out alternative forms of care.  This might mean, trying a different method of care or referring to a sports medicine doctor, a physiotherapist, a massage therapist, an athletic therapist, nutritionist, etc.

Reference:
http://www.nationalinjurydiagnostics.com/Maintenence_Care_vs_Supportive_Care.pdf  Link broken as of March 2017

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