Maintenance care in chiropractic
Maintenance care in chiropractic - what do we know?
From: Chiropractic & Osteopathy. 2008 May 8;16(1):3 [Epub ahead of print]
Back problems are often recurring or chronic. It is therefore not surprising that chiropractors wish to prevent their return or reduce their impact. This is often attempted with a long-term treatment strategy, commonly called maintenance care. However, some aspects of maintenance care are considered controversial. It is therefore relevant to investigate the scientific evidence forming the basis for its use.
A review of the literature was performed in order to obtain answers to the following questions: What is the exact definition of maintenance care, what are its indications for use, and how is it practised? How common is it that chiropractors support the concept of maintenance care, and how well accepted is it by patients? How frequently is maintenance care used, and what factors are associated with its use? Is maintenance care a clinically valid method of approach, and is it cost-effective for the patient?
Thirteen original studies were found, in which maintenance care was investigated. The relative paucity of studies, the obvious bias in many of these, the lack of exhaustive information, and the diversity of findings made it impossible to answer any of the questions.
There is no evidence-based definition of maintenance care and the indications for and nature of its use remain to be clearly stated. It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. Therefore, our conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial.
Chiropractors all over the world are consulted for spinal pain and dysfunction. Because many spinal pain complaints are chronic or recurrent in nature, it is understandable that, once improvement has been achieved, chiropractors attempt to prevent new events or maintain patients at their optimal level. This is usually done by scheduling additional visits over a prolonged period of time but at longer time intervals than during the acute event. Among chiropractors, this approach is named “maintenance care”, whereas in public health terms it is described as secondary or tertiary prevention. Secondary prevention is aimed at preventing new events, whereas tertiary prevention means that improved patients with incurable conditions are maintained at the best possible level.
Although it appears perfectly logical to use maintenance care in chronic and recurrent conditions, when informally discussing this phenomenon with chiropractors, we have often detected either a disinclination to discuss, or an ardour of arguments, often resulting in an embarrassing change of subject. In other words, maintenance care appears to be, for some, a politically incorrect topic.
This might be because the indications for treatment in asymptomatic patients depend solely on tests and observations, such as palpation findings, none of which has been shown to be clearly valid. When treating an acute problem, however, this lack of valid examination tests is of little or no concern, as the patient’s reaction to the treatment will provide feedback on the construct validity of the various treatment procedures. Therefore, there appears to be disagreement among chiropractors as to whether chiropractic treatment is mainly effective in the acute phase or whether it is possible also to prevent the underlying disorder, regardless of whether the patient is symptomatic at the time of examination and treatment.
Jamison has discussed the preventive aspect of maintenance care, when encompassing other than the musculoskeletal conditions. She points out that some chiropractors believe “that subluxations can cause, and spinal adjustments correct, diverse problems ranging from pain to more subtle endocrine, visceral and autonomic dysfunctions” and warns that this scientifically untested theory has considerable ill effects in the scientific and medical communities. In general, if chiropractors believe that “spinal health” equals good health, it is understandable that they would try to convince patients to have regular preventive chiropractic treatments. Jamison discusses this in a second paper, where she also mentions the negative repercussions of such practice. It could also be that the overzealous use of maintenance care has resulted in problems with various reimbursement systems, as Mitchell warned already in 1980. Some individuals’ short-term financial gains could be seen as having negative long-term repercussions for the whole profession.
The concept of maintenance care, therefore, seems to be associated with the very core of disagreement between chiropractors and their styles of practice; those who treat mainly musculoskeletal conditions and those who attempt to treat also other conditions. In addition, it may divide those who believe that their examination method is objective and valid and those who depend (also) on patients’ signs and symptoms for their diagnosis and treatment.
Nevertheless, maintenance care seems to be commonly employed, and if it is a useful model of preventive treatment, it should be recognized as such; but if it is ineffective, it should not be part of the chiropractic patient management strategy. Maintenance care therefore, merits being taken seriously and to be subjected to scientific scrutiny.
In 1993, the Mercy Guidelines attempted to perform a literature review on this subject but ended up making its recommendations largely on clinical experience “of nearly 100 years”. The report suggested that the use of chiropractic adjustments in a regiment of preventive/maintenance care has merit. There are no statements in the guideline in relation to indications, type of treatment, duration and frequency of treatment, nor on effectiveness. It is merely written that maintenance care is “discretionary and elective on the part of the patient” and that when recommended, “it is necessary for the practitioner to clearly identify the type and nature of this care and to give proper patient disclosure”.
Aker and Martel, three years later, performed a narrative review and concluded on the basis of the sparse literature that “there is no scientific evidence to support the claim that maintenance care improves health status” and went on to recommend a series of research actions to be taken. Our continued monitoring of the literature revealed several additional studies since the time of their publication.
This is an interesting article which also seeks definitions of maintenance care. Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary. Their definition is “Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.”
It is interesting to note the term “supportive”. Supportive care (Mercy 1993): Treatment/care for patients having reached MMI, in whom periodic trials of withdrawal from care fail to sustain previous therapeutic gains that would otherwise progressively deteriorate. Supportive care follows appropriate application of active and passive care including lifestyle modifications, it is appropriate when rehabilitative and/or functional restorative and alternative care options including home-based self-care and lifestyle modifications have been considered and attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when the risk of supportive care outweighs its benefits, i.e., physician dependence, somatization, illness behavior, and secondary gain.
Furthermore, a study published in the Journal of Manipulative and Physiological Therapeutics, Volume 27, Issue 8, Pages 509-514 (October 2004) - Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain and Related Disabilities: A Preliminary Study indicates “This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels”.
It seems plausible that supportive care, when documented, is reasonable and necessary. Additionally, the terms supportive and maintenance should not be used interchangeably and seem to be intentionally confused by some. Furthermore, the reference to financial gain sounds like an attack on practice management groups instead of reasonable efforts by sound practitioners.
