This was a study of a small group of Danish chiropractors and their theoretical approach to the long-term management of low back pain. They could choose between 6 management strategies for 9 different scenarios. Two of these strategies consisted of different types of maintenance care. We noted that there was a fair amount of concordance in their choices of strategies.
The participants in the Danish study had been selected because they were known to use maintenance care, so we would have expected them to have a higher usage of maintenance care, as compared to a larger group of Swedish chiropractors, who had been selected on other inclusion criteria for participation in a previous questionnaire survey [4]. This was true, as their median number of maintenance care patients was about twice as high as that of the Swedish participants (42% vs. 20%).
Despite this difference, the overall results of the present study mirrored those of the previous Swedish study because, in both study groups, the majority of participants selected the same management strategies. For example, the two groups largely agreed on when to refer patients for a second opinion, when to consider the treatment completed, when to continue the treatment a few times more, and when maintenance care would be their strategy of choice. Hence maintenance care was not more often the predominant answer for the Danish than for the Swedish respondents. Nor was clinical findings-guided maintenance care generally more commonly selected in the Danish than in the Swedish study. Although we could find no specific information in other studies on this topic, this could indicate that the chiropractic clinical approach to this type of patient is fairly universal.
As in the Swedish study, maintenance care was never thought to be relevant for patients who obviously should be referred out for a second opinion. It would therefore appear that also these chiropractors have a safe approach to the long-term management.
The strongest support (100%) for maintenance care was found for the fourth scenario, a patient with recurring back problems and good recovery. On condition that one believes in the usefulness of this approach, for us, we considered this case to be the most suitable indication for maintenance care.
However, there was one response that surprised us. Although the most common single answer to scenario 5 (a patient who failed to improve after six visits) was to "try again" (45%), there was an equally strong preference for some sort of maintenance care. We would have expected that improvement would have been a prerequisite for maintenance care. Also in the Swedish survey the combined result for the two types of maintenance care exceeded the most commonly selected choice ("try again"). We therefore conclude that it would be necessary to study more closely the short-term outcome criteria for patients considered suitable for maintenance care.
We were curious to see, if the use of clinical findings-guided maintenance care would be more commonly considered in this group of practitioners than in the more diversified group surveyed in Sweden. In other words, would these chiropractors ignore patients' symptoms and base their treatment on clinical findings only, such as palpation? Interestingly, this was the case in only 1 of the 9 scenarios. It therefore looks as if the group of Danish chiropractors took notice of their patients' symptoms and not only their own examination findings.
Interview vs. mail survey – validation of the questionnaire
In a short questionnaire, it can be difficult to convey meaningful clinical information to be understood by a wide variety of individuals. By using the same questionnaire as in the Swedish study but collecting the information through a structured interview, it would be possible to pick up any misunderstandings or comments that could shed light on problems of interpretation in the original questionnaire. Fortunately, the interview revealed no difficulties for the chiropractors to understand or relate to the questionnaire.
Open-ended question-results
The present study included also an open-ended question that was meant to shed some more light on the definition of maintenance care. However, with one exception, the chiropractors in the present study did not provide distinct definitions of maintenance care but approached the question indirectly, by describing some clinical aspects thereof.
In doing so, they did not describe any conditions or profiles or any standard management programs. Rather, their responses indicated that maintenance care can be used for any type of low back pain with the intent of improving spinal function in order to avoid a relapse of the condition. In fact, this corresponds to the definition of secondary prevention, and none of the respondents discussed a tertiary prevention scenario.
What people think that they do and what really happens, do not always concur. According to a recent Norwegian multi-center outcome study of patients with more persistent or chronic low back pain, at the one-year follow-up, maintenance care was shown to have been given mainly to patients who did not have a good short-term outcome [5]. In other words, absence of symptoms in the short term did not seem to incite further treatment (secondary prevention) but continued symptoms did (i.e. tertiary prevention). Whether this was the chiropractors' preferred choice or whether patients with quick recovery were uninterested in secondary prevention, is of course not known.
Some of the interviewed chiropractors considered it irrelevant, if the patient had symptoms or not, at the time of the consultation ("clinical-findings guided maintenance care"). If patients' symptoms are thought to be irrelevant, the chiropractor would have to trust his own examination findings entirely. This is a big responsibility, in the absence of evidence for the validity of the tests used to determine the presence of the treatable spinal lesion or without much knowledge of other factors that precipitate the recurrence of low back pain. Obviously, this concept requires further study.
Further, almost all of the interviewees were of the opinion that chiropractic treatment can improve spinal function and that optimal spinal function will reduce the risk for recurring problems of low back pain. This may be a commonly held belief. According to Rupert, it was commonly thought among North American chiropractors that one of the purposes of maintenance care is to "determine and treat subluxation" [6], confirmed in a similar study in Australia [7].
Judging from our results, there is no commonly agreed standard frequency of scheduled treatments but it would vary with the needs of the patient. This differs from the impression one gets when reading the case-report of one maintenance care patient by Wenban [8]. According to his report a pre-determined, hence probably rigid, treatment schedule was offered to the patient. We were unable to find other descriptions of this aspect in the literature but such a standardized approach appears unreasonable. How can one predict in advance the future clinical development and consequential treatment needs of an individual patient?