Chiropractic & Manual Therapies 2013 (Aug 20); 21: 27 ~ FULL TEXT
Corrie Myburgh, Dorthe Brandborg-Olsen, Hanne Albert and Lise Hestbaek
Institute of Sports Science and Clinical Biomechanics,
Nordic Institute for Chiropractic and Clinical Biomechanics,
University of Southern Denmark,
Objective To describe and interpret Danish Chiropractors' perspectives regarding the purpose and rationale for using MC (maintenance care), its content, course and patient characteristics.
Methods 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 analysed thematically.
Results 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.
Conclusions 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.
From the Full-Text Article:
Maintenance care (MC) is used by chiropractors to treat patients who are no longer in an
acute state of pain; the purpose being to prevent recurrence of episodic conditions (secondary
prevention) and/or maintain a desired level of function (tertiary prevention). The concept is
frequently used among chiropractors [1,2] and limited evidence suggests that, among workers
with work-related back pain, MC in chiropractic practice appears to decrease the recurrence
rate . However, according to two literature reviews, very limited evidence regarding the
definitions, purpose and content of MC is currently available [4,5].
As a result, several investigations aimed at increasing and clarifying information on MC have
been launched. Specifically, investigators involved with the Nordic Maintenance Care
Program have conducted a number of observational, questionnaire-based and qualitative
studies, in relation to MC practices for low back pain. The results, thus far, have proven
useful in increasing knowledge regarding issues such as usual time intervals between MC
treatments [2,6], treatment strategies for different back pain scenarios [1,7,8], the content of MC consultations  and patients perception regarding the purpose of MC .
Furthermore, the effect of MC has been investigated in clinical trials with varying results. A
pilot study included low back pain patients  and two randomized controlled trials (RCTs)
included chronic non-specific neck pain and chronic non-specific low back pain, respectively
[10,11]. However, in all three studies patients were included consecutively based on neck or
back pain alone, but apparently without taking into account the underlying rationale for MC
in the inclusion process.
An argument can be made that there is still a need for a more in-depth understanding of the
chiropractic professions’ own view on the concept of MC, before investigations progress to the level of RCTs. We therefore conducted a further qualitative investigation, in this instance
focusing on the care provider. Specifically, we focused on Danish chiropractors, in order to
develop a further understanding of their perspectives regarding the purpose and rationale for
using MC (maintenance care), its content, course and patient characteristics.
A phenomenological case study was deemed appropriate to observe the conceptualization of
MC in a private practice context.
Units of observation and sampling framework
Although MC practices can be observed from multiple perspectives, our focus was on the
perspective of the service provider (chiropractor).
A background/reference group was set up consisting of 6 chiropractors, all clinicians, who
were known by the research group to use MC in their everyday practice. This group
participated in the design of the present study and also, at a later stage, during the analysis of
Selection of study participants
Two chiropractors from each of the five regions in Denmark were contacted telephonically
and asked to give their opinion on whether peers, practicing in their region, used maintenance
care (MC) to a low (<20%), medium (20-50%), or high degree (>50%). The cut-points were
based on observations previously made regarding maintenance care practices in the
Scandinavian context . It was stressed that their opinions would anonymous. The sample
was furthermore stratified to take into account country of education as previous investigation
in the Danish context indicated that the MC utilization seems to relate to the country
chiropractor was educated in . Most chiropractors practicing locally are educated in the
USA, England or Denmark itself. Thus, we also included at least one chiropractor from each
of the three countries. Our target sample of nine respondents (n = 9) was also stratified to take
into account gender and to have an adequate geographical spread. Finally, we included a
tenth respondent to ensure that data saturation would be reached.
The targeted chiropractors were contacted by telephonically and given a brief introduction to
the project. They were also asked in which group – high, medium or low use of MC – they
would place themselves. If peer- and self-perception aligned, the individuals were asked to
join the study; non-alignment was therefore an exclusion criteria.
A semi-structured interview schedule was constructed based on the previous literature
[1,2,6,7,12,13] and input from the background group (see Additional file 1). The schedule
was designed to emphasize the collection of data relating to four overall domains:
Purpose: the rationale and the benefits of MC practices.
Patient characteristics: the type of patients believed to benefit from MC.
- Content: a description of the MC-consultations.
Course and development: Initiation and termination of MC as well as spacing between visits.
A semi-structured interview was deemed most appropriate, because it allowed for free and
open responses within the broad framework of MC already established.
Prior to the study two test-interviews were conducted, to establish time duration requirements
and ensure the clarity of question posed. The information obtained was not analyzed as part
of the present study.
Trustworthiness of data
In order to establish and maintain trust between the interviewer and respondents three aspects
were considered, these being that both the interviewer and the rest of the research team were
chiropractors and thus part of the same profession as respondents, the explorative and neutral
nature of the project was emphasized and respondents were privy to the MC rating assigned
them by colleagues and were aligned to this (low, medium or high) and therefore their own
role in the project was clear and accepted.
As an introduction to each interview the interviewer made it clear that it was of great
importance that the chiropractor felt that he/she was given the opportunity to elaborate freely
on his view on MC. We used the systems CHILDES (Child Language Data Exchange
System, http://childes.spy.cmu.edu) and CLAN (Computerized Language Analysis) for
digitalized recording after which sound files were then exported for verbatim transcription.
The transcriptions were conducted by the interviewer (DO). This study was deemed exempt
from ethics approval, however, study was conducted in compliance with the stipulations of
the Danish Data Protection Agency with respect to the procurement and storage of
anonymous interview data.
Our conceptual framework for the categorization and synthesis of data is presented in Figure
1. It is important to note that a single quote can contribute several different codes. Codes may
be found to have a relationship with one another, either through shared quotes or inferred
meaning, thus resulting in the development of code families. Finally, several code families
may contribute to a theme or a single code may be raised to the level of a theme.
Manual coding was used throughout this study. Interview one was coded independently by
the primary interviewer (DO) and a naïve, second checker (HA); both used an inductive
approach and generated a code list, which was merged by means of discussion and consensus.
Using the merged code list, two further interviews were coded independently, during which
time code families were also generated. As with the codes, consensus was similarly reached
regarding the resulting code families. The remaining seven interviews were coded by the
Finally the code families (and the codes they contained) were related back to the domains of
MC in the form of a matrix, so that meaning could be extracted in the context of the MC
When saturation was reached, the chiropractors from the background group were invited to a
meeting in order to confirm saturation. All the extracted codes were presented and the
chiropractors were asked if they were able to recognize their own opinions among the
presented codes and whether they had anything to add.
All of the practitioners sampled agreed to participate in the study. The profile of our sample
is illustrated visually in Figure 2. Our tenth respondent was rated as a borderline low/medium
level MC practitioner, both by her peers and by herself. Interviews were conducted over a
two-month period, typically lasting between 20 and 50 minutes.
No new statements or points of views were noted after interview 10. Furthermore, the
chiropractors in the background group all felt that their points of views were covered and had
nothing further to add. We were therefore satisfied that data saturation had in fact been
reached and no further interviews were conducted.
As our analysis developed, it became apparent that the creation of code families would be an
unnecessary duplication. We consequently identified three main themes from the responses,
these being ‘The rationale and motivation of maintenance care’, ‘The maintenance care
model’ and ‘significant professional considerations’ (see Additional file 2).
The rationale and motivation for maintenance care
We observed two key conceptual frameworks motivating practitioners to provide MC.
The most dominant is the notion of MC as a preventative practice. Specifically, the provider
aims to stop/curb recurrence. This is considered achievable by combining treatments, such as
manipulation and other manual interventions with patient education regarding ergonomic
hygiene, exercise and healthy living:
“…if I can hit the point where as many as possible are functioning as good as
possible for as long as possible – that’s what makes me feel I’m doing
“…I actually think I experience a lot of cases where you can help patients who
used to have 3-4-5 cases of low back pain a year – they don’t have that when
they get MC…”
Aligned with this is the ‘lifelong chiropractic for all’ ideal of maintaining a certain level of
attained function for the patient:
…if we check them once, twice maybe three times a year – look, no problems!
My goal is to fix the initial problem and then attend to it regularly afterwards
to keep it working”
A less common perspective espoused is that MC represents the core motivation for providing
…if we use the degenerative joint disease model the aim is to keep those joints
as freely moving as possible, as [straightened out and well-functioning] as
possible, at as good a posture or position as possible and have as strong and
well-coordinated muscles as possible”
The body is built to heal itself if it is given good nutrition, good sleep,
exercise, clean air and water…it can manage all of this if we make sure that
the nervous system is working right
MC practices appear to be grounded in two key considerations, these being the maintenance
of an acquired improvement and/or the prevention of recurrence:
…there is the MC where the patient doesn’t have any symptoms, but out of
fear of getting symptoms…or because they wish to function optimally they
come in…so in this way it isn’t symptom based treatment”
…the other category is guided by symptoms, they feel that they are getting a
little more pain…it’s time for me to go and get a treatment… often this is a
person whom we can’t get a 100% on top”
However, there is also a perspective that the MC practices stop the occurrences of symptoms
stemming from sub-optimal nervous system function.
Furthermore, it appears that at least three determinants for initiating care are observable
namely; fear of recurrent symptoms, a perception of sub-optimal biomechanical and the
return of to self-reported patient outcomes, such as pain.
The maintenance care model
Who is a potential MC patient?
Our respondents identified seven factors that may help to profile a MC patient candidate. As
indicated in Table 1, these individuals are unlikely to be children presenting with a first
episode of back and/or neck pain.
Table 1: Who might be an MC candidate patient?
Unlikely Could be
The acute or ‘first A past history of chronicity and/or extended
episode’ patient courses of treatment
Pediatric patient More likely to be female
Patients complaining of ‘muscular’ trouble
Occupations where taxing physical labor form
a predictable part of the working day.
Biomechanical/structural variant (e.g. scoliosis)
Perhaps of more interest, however, was our observation that ‘more often than not it’s simply
a question of testing out which strategy seems to fit the single patient the best’. Thus, for
those practitioners who actively attempt to determine whether a patient is likely to benefit
from MC, considering the level of clinical interaction and the personality of the patient is
important. It is therefore more likely that the MC patient is one who has developed a
relationship with the chiropractor:
…we are not just machines…..it’s quite alright to have some personal relation
to a certain degree, and this is particularly the case with the MC patients.
In some instances, where patients are considered to be in process of developing a dependence
on treatment, MC is initiated as a strategy to control/limit the frequency of care:
[I am]…tired of those who think they are to come here once a month…they
are not allowed to do that
…I also have patients who come more often than I think they should…you try
to increase the interval between treatments all the time but…”
Profiling the MC patient was, however, not an important consideration for all respondents.
These were respondents who presented the poles of the MC spectrum, namely those who
considered MC universally beneficial to every patient:
…the majority of patients in the clinic, that’s what I aim for.
…everyone with a normal sensory capacity feels that this feels good…..and
that, I think, is what sells it.
and those who typically try to avoid it:
…[I only give it] if the patient directly asks for it.
Initiating and transitioning into MC
It appears that practitioner, patient or both initiate MC. Practitioners may use a suggestive
strategy to introduce the notion depending on the patient’s initial problem and history. For
…if your goal is to do the best possible for yourself (the patient) and get in as
good a shape as possible then we (the chiropractor) can help you to do so, and
if you want to be checked up upon once in a while we can do that too”…We
always let them sort of decide.
However, a concrete recommendation approach can be followed such as “now
listen we have to address this far more consequently as well with treatment as
Patients on the other hand appeal to the practitioner with statements such as “I
don’t think I can manage without some treatment, I would like to come on a
In instances where a joint decision to initiate MC is made agreement is
typically reached that “…it might be a good idea to try that strategy for a
Depending on the strategies mentioned above, the transition point to MC may vary, but
usually MC commences when treatment has been well established:
…if we get to the point where things are actually working, no or only limited
symptoms, ok let’s see how it works in a month, 2 months, 3 months and find
out what interval keeps you working.
… well, you can say it’s something I do straight away…to tell them what I
do….”now that my pain has gone why should I continue to come?” …I try to
tackle and address that straight away.
Whilst initiating and transitioning a patient into MC varied considerably depending on the
clinician’s individual circumstances and practice exposures, MC practices nevertheless
appear to evolve over time.
…I had no experience with MC whatsoever when I started.
…it was not at all on the schedule at school; we didn’t even talk about it!
…in the beginning it was probably the patients themselves who said – “can I
come on a regular basis?” – now it’s more me who suggests that it might be a
…I just found out myself that it works…
…the time spent in the same clinic for my part has been of essence…..to be
able to follow the same persons for years
…I took over a clinic where a lot of MC treatment was given; too much!
However, MC also appears to reflect individual perspectives relating to disease-oriented and
holistically oriented service provision:
…do you really want to do something about it [the cause of your problem] or
do you just want momentarily relief of your pain?
…it makes up a package. I don’t think it makes sense to only consider peoples
back problems, you have to take into consideration how they live, right?
Content of MC
Our group of respondents provided a rather heterogeneous description of the content of MC;
these varied from so-called ‘pure chiropractic help’, consisting of examination and if
necessary manipulation to patient specific ‘packages’ including elements such as exercise
prescription and actual training, guidance on ergonomics, diet, weight loss and stress
management. The role of strength and conditioning training, in particular, appeared to be a
cause of disagreement, with respect to its inclusion as part of MC:
…those I consider to have a great risk of recurrence I would probably
recommend to work out on a regular basis instead of suggesting MC.
Despite the apparent incoherence of content, a fundamental part of MC appears to hinge on
providing the necessary attention and care for the patient, which is achieved by motivating
and helping patients maintain focus on beneficial habits and lifestyles:
…to help them remember what they can do themselves…that’s a big part of
the MC treatment
Frequency and termination of MC
Our observations suggest that treatment interval is determined on a case-by-case basis; with
factors such previous injuries, age, body-type, recurrence, and the presence of degenerative
joint disease informing the clinician’s ‘sixth sense’. Periodicity ranges between 2 to 4
months, typically evenly spaced over a calendar year.
When initiated by the patient, however, frequency coincides with the patient’s sense of
‘control’ of their particular problem:
…upon solution of their initial/acute problem I have told quite a few patients
that I find it beneficial for them to get into MC treatment, and they respond
that they feel confident that they can control it themselves and wish to call the
clinic when they get any of their well-known symptoms…
Respondents did not appear to experience tension with patient-determined
intervals ‘… if they are able to react on their symptoms before a regular
relapse.’ However, they were mindful that this mode could increase treatment
Our observations indicate that MC is terminated when symptomology is absent for extended
periods. Cost on the other hand may not be a primary driver for cessation:
…even if they get their treatments for free it is my experience that they don’t
want more treatment than they actually need.
…even though I have patients who get 100% insurance paid treatment ….. I
don’t think they would come here for no reason…
Significant professional considerations
Considering one’s professional ‘conscience’ whilst planning a course of treatment emerged
as an important theme associated with ‘the purpose and rationale of MC’. There was broad
agreement among the practitioners interviewed that MC should not be a standard choice and
that it should not be offered to or used for every patient:
…maintenance is an individual solution…this is part of our unique product.
…one should not pressure patients into MC treatment if they have no need and
I think that some people don’t have that need…
…we can’t just tell people to come back once a month. I know a lot of
chiropractors around the world [do this]… their maintenance programs are 3–4
Furthermore, patients who receive MC should have a real need and that they feel a benefit
from getting the treatment:
…it must not just be a convenient thing for me, that’s not right in an ethical
sense, not even if people ask for it themselves, there has to be an actual and
…coming in every three months on a regular basis without having
symptoms… I can’t make myself practice that way…
Interestingly the awareness that MC can potentially be misused as a strategy to justify over
servicing, appears to have resulted in some respondents declining MC even if their perception
was that the patient would benefit:
…clearly, some [DC’s] will do it [MC] out of economical reasons alone
,others will find that this is not okay and then they forget that there might be
other reasons than money to place patients on MC.
… it may very well be that I “cheat” some of my patients…. I can’t deny that
some of my patients might benefit from MC but don’t get it…
Our respondents were aware that positions vary with respect to MC and that it is a source of
tension for the profession. This position is best voiced in the following short discourse:
…some are kind of very much against the use of MC and some are very much
for it…but on the bottom line there are patients who wants one thing and
patients who wants another so it seems reasonable enough to offer different
…it’s very much those who don’t use MC… they are almost angry of those
who do….but on the other hand some of the MC chiropractors think that the
others simply let down their patients for instance when they don’t bother to
have training facilities . I for one find that absolutely wrong.
Regardless of individual position, our respondents considered it important that MC practices
be disassociated from a market-oriented strategy for building and maintaining a practice in
the Danish context. In this regard they state the following:
…it’s “un-Danish” this thing to plan long schematic treatment courses…
…I don’t want to be known as someone where it’s said that – “you have to
come here for the rest of your life” … I have seen Mr. XXX himself in
England… Completely unethical if you uncritically plan for every patient to
come back for many many treatments…
…it has to be based on the given situation….otherwise we risk ending up as in
USA where 60 treatments can easily be planned on your first visit…
Our investigation revealed clear themes confirming previous results from quantitative studies
[1,2,6-8,12,13]. In particular, as seen in other contexts, Danish chiropractors regard MC
primarily as a means of providing secondary or tertiary care, it is recommended to patients
with a history of recurrence, the initiation of MC is often a shared decision between
chiropractor and patient, the use of MC relates to the chiropractor’s education and clinical
experience, the core element of MC is examination and manipulation, but also commonly
includes exercise and general lifestyle advice and finally the typical interval between
consultations is 2–4 months.
In addition to these confirmatory observations our investigation also revealed that in the local
context chiropractors were more likely to offer MC to patients whose complaints included a
significant muscular component, that a successful transition to MC appears dependent on a
correct matching of complaint and management, that a positive relationship between
chiropractor and patient facilitates the initiation of MC, and finally that MC rests in the tenet
patient-oriented care rather than market-oriented. Previous studies have indicated that the
patient needs to respond positively to chiropractic care before MC is offered, but this issue
did not emerge in the present study. Whether this is because the interviewed chiropractors did
not find it important, or whether they considered it obvious and therefore didn’t mention it, is
We selected as broad a range of Danish chiropractors and conducted enough interviews to
reach the point of saturation. We also believe our data to be trustworthy due to the nature of
the interviews and the apparent trust between the interviewees and the research team.
However, the nature of this type of investigation precludes us from inferring a generalizable
truth about MC in Denmark. Nevertheless, these results are synergistic to other investigations
on this topic and as such it seems fair to consider results from the present study as relevant
indicators for the Danish chiropractors’ view on MC.
The concept of MC as secondary or tertiary prophylaxis varies somewhat from the most
common perception of prophylaxis, which focuses on primary prevention, i.e. to prevent
disease from occurring. Typical examples of the latter include vaccines for communicable
diseases or condoms to avoid sexually transmitted diseases (STDs), where the purpose is
primary prevention. However, in public health, many initiatives aimed at primary prophylaxis
also function as secondary or tertiary prophylactics. For example physical exercise may
prevent cardiovascular disease; however, it also serves to regulate blood pressure after the
onset of the disease.
MC practices are not unique to the chiropractic profession. In dentistry, MC is intended to
avoid caries and periodontal disease through fluoride therapy and improved dental hygiene.
However, if such disease occurs despite the primary prevention strategy, secondary
preventative treatment takes effect to avoid exacerbation. Thus, the concept is generally
recognized in society in other health domains and the implicit overall aim is to decrease the
burden of disease and thereby also reduce the cost of health care.
Low back pain is now the leading cause of disability globally measured in years lived with
disability (YLD) with 1206 YLD per 100,000 in 2010 and neck pain is number four with 488
YLD per 100.000 (GBD 2013). This represents an increase of 33.3% since 1990, largely
driven by population growth and ageing . Thus, these figures are likely to continue to
increase. Parallel to this, there has been a significant increase in the consumption of
painkillers, i.e. the sale of opioid analgesics has quadrupled between 1999 and 2010 .
Considering that more than 100.000 deaths per year can be attributed to adverse effects of
medication in the US alone  as well as non-quantifiable morbidity, non-pharmaceutical
prophylactic strategies deserve attention and for the musculoskeletal system chiropractic care
might be an option. Limited evidence is currently available with respect to the effectiveness
of MC strategies initiated by chiropractors. As stated previously, the RCTs available have
included consecutive patients without consideration of either factors qualifying patients for
MC in practice or individual care requirements. Therefore, these RCTs are unlikely to reflect
clinical reality, and we suggest that investigators consider such factors and requirements in
future studies, especially when planning RCTs.
MC is a common phenomenon in Danish chiropractic practice, considered 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. However, successful transition to MC appears to be
dependent on a correct matching of complaint and management strategy. Interestingly,
chiropractors in this study were more likely to offer MC to patients whose complaints include
a significant muscular component.
It remains to be investigated whether MC is actually effective, both for the individual patient
and in a societal/economic perspective. This is necessary in order to establish the appropriate
role of MC in modern healthcare. The results from this and previous studies should be
considered in the design of such studies.
The authors declare that they have no competing interests.
DBO and LH contributed to conception and design of the study, DBO conducted the
interviews, DBO, HA and CM did the analyses. LH and CM were responsible for the
interpretation of the data. CM and LH drafted the manuscript. All authors read and approved
the final manuscript.
We would like to acknowledge the chiropractors that participated in the interviews.
The study was made possible by a grant from the Foundation for Chiropractic research and
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