”Maintenance Care” in chiropractic practice

From 2009 to 2013, several Scandinavian studies described the use of ‘maintenance care’ (MC) in chiropractic practice. Based on this, Iben Axén, Andreas Eklund, Charlotte Yde and others designed a randomised clinical study in Stockholm to study the effect of MC.

319 patients aged 18 to 65 years with persistent or episodic low back pain, who responded well to chiropractic treatment, were included in the study. They were randomised into either an MC group or a control group for their continued care. In the MC group, the aim was to organize treatment before recurrence of the back pain, based on the opinion of the chiropractor, but with maximum intervals of 3-months. The control group was instructed to make an appointment if the pain returned. During the following 52 weeks, the patients responded to a text message asking, ‘How many days during the last week have you experienced disabling low back pain?’

On average, the MC group experienced 85.2 days with disabling low back pain (DLBP) during the 52 weeks, while the control group experienced 98.0 days, a statistically significant difference of 12.8 days in favour of the MC procedure. The detailed courses of pain can be seen in figure 11https://journals.plos.org/plosone/article/figure?id=10.1371/journal.pone.0203029.g002

The next step was to investigate whether the difference was dependent on personality profiles. Here, the patients were divided into three groups: ‘Adaptive copers’ (low pain, high activity, life control, n=93); ‘Interpersonally distressed’ (it is someone else’s fault, ‘distrust’, n=62) and ‘Dysfunctional’ (High pain, reduced activity, mentally affected, low sense of control, n=97). It turned out that the effect of MC was very different in the three groups. In the strongest group (adaptive copers) the patients in the MC groups had 10.7 more days with DLBP than the control group, while the patients in the weakest group (dysfunctional) had 30 fewer days with DLBP if they were in the MC group. There was no difference between the groups in the middle group (interpersonally distressed). This is illustrated in figure 2: https://journals.plos.org/plosone/article/figure?id=10.1371/journal.pone.0223349.g002
In other words, it is very important to consider the patient’s personality  when deciding if MC should be offered to the patient or not2.

The latest paper, published in 2020, shows the course of pain three weeks before and three weeks after consultation. The results confirm that the control group had a bigger increase in days with DLBP up to a consultation (because they call when they need a consultation) followed by a decrease, whereas the MC group had a rather even procedure with only little variation. However, the difference is clearly driven by the weakest personality profile (dysfunctional). The average course for this personality group is illustrated in figure 3: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7171853/figure/Fig4/.

The three articles combined support the idea that it is indeed possible to prevent relapse by planning treatment before the anticipated return of the pain, however only for those with the weakest personality profile3.


  1. The Nordic Maintenance Care program: Effectiveness of chiropractic maintenance care versus symptom-guided for recurrent and persistent low back pain—A pragmatic randomized controlled trialAndreas Eklund, Irene Jensen, Malin Lohela-Karlsson, Jan Hagberg, Charlotte Leboeuf-Yde, Alice Kongsted, Lennart Bodin, Iben Axén. PLoS One. 2018; 13(9): e0203029. Published online 2018 Sep 12. doi: 10.1371/journal.pone.0203029 
  2. The Nordic Maintenance Care Program: Does psychological profile modify the treatment effect of a preventive manual therapy intervention? A secondary analysis of a pragmatic randomized controlled trial. Andreas Eklund, Irene Jensen, Charlotte Leboeuf-Yde, Alice Kongsted, Mattias Jonsson, Peter Lövgren, Jakob Petersen-Klingberg, Christian Calvert, Iben Axén. PLoS One. 2019; 14(10): e0223349. Published online 2019 Oct 10. doi: 10.1371/journal.pone.0223349
  3. The Nordic maintenance care program: maintenance care reduces the number of days with pain in acute episodes and increases the length of pain free periods for dysfunctional patients with recurrent and persistent low back pain - a secondary analysis of a pragmatic randomized controlled trial. Andreas Eklund, Jan Hagberg, Irene Jensen, Charlotte Leboeuf-Yde, Alice Kongsted, Peter Lövgren, Mattias Jonsson, Jakob Petersen-Klingberg, Christian Calvert, Iben Axén. Chiropr Man Therap. 2020; 28: 19. Published online 2020 Apr 21. doi: 10.1186/s12998-020-00309-6