In 1976, the first issue of the journal Spine was published. In this inaugural issue was a pioneering article by low back pain specialist Alf Nachemson, MD, titled (1):
The Lumbar Spine, An Orthopedic Challenge
In this article, without credible evidence, Dr. Nachemson states:
“Irrespective of treatment given, 70% of [back pain] patients get well within 3 weeks, 90% within 2 months.”
This statement implies that back pain is self-limiting, self-resolving, and treatment choices are largely irrelevant.
Fourteen years later, in 1990, the most authoritative reference text on spinal clinical biomechanics was published, titled Clinical Biomechanics of the Spine (2). The authors, Augustus White, MD, (Professor of Orthopedic Surgery at Harvard Medical School and Orthopedic Surgeon-in-Chief at Beth Israel Hospital in Boston), and Manohar Panjabi, PhD, (Professor of Orthopedics and Rehabilitation and Mechanical Engineering and Director of Biomechanics Research Yale University School of Medicine), have impressive resumes. In their text they comment on the 1976 article by Dr. Nachemson, noting that his study is:
“An outstanding, well-written review of all aspects of the state of knowledge [of low back pain] in 1976.”
In support of Nachemson, White and Panjabi state:
“There are few diseases [low back pain] in which one is assured improvement of 70% of the patients in 3 weeks and 90% of the patients in two months, regardless of the type of treatment employed.”
Therefore, “it is possible to build an argument for withholding treatment.”
This second reference also supports that back pain is self-limiting, self-resolving, and treatment choices are largely irrelevant, and perhaps therefore there should be no treatment given at all. Yet, these statements pertaining to the natural history of low back pain are unsupported by credible evidence. In spite of their lack of evidence, this optimistic view of low back pain became ingrained in the perspective of providers, insurance companies, and governmental agencies.
In 1994, low back pain recovery optimism was challenged in the journal Spine by Michael Von Korff, ScD, in a study titled (3):
Studying the Natural History of Back Pain
In contrast to Drs. Nachemson, White, and Panjabi, Von Korff notes:
“The course of back pain is highly variable, occurring in transient, recurrent, and chronic phases.”
“Recent longitudinal studies suggest that back pain is typically a recurrent condition and that chronic phases of back pain occur more often than previously believed.”
“It is widely believed that back pain typically runs an acute course among patients.”
“Studies that have followed patients for at least 6 months with follow-up interviews suggest that the course of back pain is typically recurrent and more often chronic than usually believed.”
“High rates of return to work immediately after back injury should not be interpreted as indicating that the back pain has necessarily resolved as many go back to work while still experiencing intermittent or chronic pain.”
“Confusion about the natural history of back pain may have arisen because of unwarranted assumptions that administrative data on return to work or care seeking provides an accurate reflection of the natural history of back pain.”
“Many persons with back pain return to work and do not continue to seek medical care, but may continue to experience moderate or even severe back pain.”
In 1998, a study was published in the British Medical Journal and titled (4):
Outcome of Low Back Pain in General Practice:
A Prospective Study
This was a prospective study of 463 adult low back pain subjects who were followed for 12 months. The authors found that 75% of these subjects still had back problems a year later. The authors note:
“It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month.”
“It is generally believed that most of these episodes will be short lived and that ‘80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment.’”
“While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability.”
“The findings of our interview study are in sharp contrast to the frequently repeated assumption that 90% of episodes of low back pain seen in primary care will have resolved within a month.”
“The inference that the patients have completely recovered [because they have stopped going to the doctor] is clearly not supported by our data.”
“Our study has shown that consulting a doctor is not a direct measure of the presence of pain and disability.”
“Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences.”
This prospective study of 463 patients with an acute episode of low back pain agrees with numerous other studies that indicate that approximately 90% of such patients will stop consulting their doctor about their back within three months. In this study the number was actually 92%. However, this study is adamant that NOT seeing a doctor for a back problem does NOT mean that the back problem has resolved. This study showed that 75% of the patients with a new episode of low back pain have continued pain and disability a year later, even though most are not continuing to go to the doctor. The belief that “90% of episodes of low back pain seen in general practice resolve within one month” is false.
In 2012, a study was published in the journal Physical Medicine and Rehabilitation, and titled (5):
Is It Time to Rethink the Typical Course of Low Back Pain?
These authors published an analysis of a survey administered to 590 subjects from 30 separate clinical practices pertaining to low back pain. Their findings include:
“Recurrent LBP episodes were common and numerous. Recurrences often worsened over time”
“Recurrences of back pain are widely recognized as common, reported as occurring in 60%-73% of individuals within 1 year after recovery from an acute episode.”
These authors suggest that there may be an underlying biomechanical cause for recurrences of low back pain that may be sub-optimally managed. They also note that 84% of total costs for patients with low back pain are related to a recurrence.
Pain is a huge problem in America. In her 2014 book, A Nation in Pain, Judy Foreman claims, “Out of 238 million American adults, 100 million live in chronic pain.” (6) A conservative estimate of the direct costs and lost productivity resulting from this pain is up to $635 billion yearly (7).
Chronic pain affects every region of the body. The most significantly affected region is the lower back with a prevalence of 28%, followed by the knee at 19% (8). The Global Burden of Disease Study estimates that 632 million persons worldwide suffer from LBP (9) making it the leading cause of disability (10).
A recent review of the chiropractic profession was published in the journal Spine in December 2017, and titled (11):
The Prevalence, Patterns, and Predictors
of Chiropractic Use Among US Adults
Results From the 2012 National Health Interview Survey
The authors note:
“Chiropractic is one of the largest manual therapy professions in the United States and internationally.”
“There is a growing trend of chiropractic use among US adults from 2002 to 2012.”
“Back pain (63.0%) and neck pain (30.2%) were the most prevalent health problems for chiropractic consultations and the majority of users reported chiropractic helping a great deal with their health problem and improving overall health or well-being.”
“Back pain or back problems (63.2%) and neck pain or neck problems (30.2%) were by far the top specific health problems for which people consulted a chiropractor.”
“Around two in three users (64.5%) reported that chiropractic had helped a great deal to address these health problems.”
“Our analyses show that, among the US adult population, spinal pain and problems – specifically for back pain and neck pain – have positive associations with the use of chiropractic.”
“The most common complaints encountered by a chiropractor are back pain and neck pain and is in line with systematic reviews identifying emerging evidence on the efficacy of chiropractic for back pain and neck pain.”
“Chiropractic services are an important component of the healthcare provision for patients affected by musculoskeletal disorders (especially for back pain and neck pain) and/or for maintaining their overall well-being.”
There is a high level of satisfaction by patients who seek treatment for spinal and other pain syndromes from chiropractors. By a significant margin, the primary reason for adults in the US to seek chiropractic care is for back pain (63%), followed distantly by neck pain (30%).
Maintenance care is recommending to a patient to return for more treatment even though the initial signs and symptoms have either resolved or have achieved maximum improvement. It is argued that maintenance care may reduce the incidence of recurrences of back pain, and may even result in additional improvements in both symptoms and function of low back problems. The argument includes that the costs of maintenance care will significantly offset the costs of treating recurrences. Published investigations continue to assessed the potential for maintenance chiropractic spinal manipulation as an intervention that may reduce the incidence of recurrences and costs of low back pain (12, 13, 14, 15, 16).
A theoretical academic basis for the use of maintenance chiropractic manipulation was published in 2011 in the Journal of Chiropractic Humanities and titled (12):
A Theoretical Basis for Maintenance
Spinal Manipulative Therapy for the Chiropractic Profession
The author notes that the purpose of chiropractic maintenance care is to optimize spinal function and decrease the frequency of future episodes of back pain. He compiled a comprehensive search of the pertinent literature. The search located surveys of doctors and patients, an initial clinical pilot study, randomized control trials, and laboratory studies that provided correlative information to provide a framework for development of a hypothesis for the basis of maintenance spinal manipulative therapy. The author states:
“It is hypothesized that because spinal manipulative therapy brings a joint to the end of the paraphysiological joint space to encourage normal range of motion, routine manipulation of asymptomatic patients may retard the progression of joint degeneration, neuronal changes, changes in muscular strength, and recruitment patterns, which may result in improved function, decreased episodes of injuries, and improved sense of well-being.”
The author cites published surveys indicating that over 90% of chiropractors believe that the purpose of maintenance care is to minimize recurrences or exacerbations. In a study, 96% of elderly patients who received maintenance care believed that it was “either considerably or extremely valuable.”
This author further states:
“It has been reported that 79% of patients in chiropractic offices are recommended maintenance care and nearly half of those patients elect to receive these services.”
Evidence “clearly demonstrates that the clinical consensus of dosage of maintenance manipulative therapy has been found to be most beneficial at an average of once every 2 to 4 weeks.”
“Taking into account the neurological and biomechanical consequences of manipulative therapy, it is plausible to hypothesize that monthly manipulative therapy retards the progression of adhesion formation, joint degeneration, neuronal changes, and changes in muscular strength and recruitment patterns. This could result in improved function, decreased episodes of injuries, and improved sense of well-being.”
A 2004 chiropractic study of chronic low back pain showed that the group of patients who received 9 months of maintenance manipulation at the frequency of once per every 3 weeks maintained their initial clinical improvement while the control group returned to their previous levels of disability. The authors “concluded that there were positive effects of preventive maintenance chiropractic spinal manipulation in maintaining functional capacities and reducing the number and intensity of pain episodes after the acute phase of treatment of low back pain patients.”
“There is a common thread of the time dependency noted in all the laboratory and clinical studies. The periods of onset of the anatomical and physiological changes ranged from 2 to 4 weeks. The clinical studies also provided manipulation every 4 weeks and noted positive changes in the pain and disability measures. This time interval also correlates with the common recommendations found in the surveys of chiropractic physicians.”
Also, in 2011, physician Manuel Cifuentes, MD, published a study in the Journal of Occupational and Environmental Medicine, titled (13):
Health Maintenance Care in Work-Related Low Back Pain
and its Association with Disability Recurrence
The objective of this study was to compare occurrence of repeated disability episodes across types of health care providers (medical physician, physical therapist, chiropractor) who treat claimants with new episodes of work-related low back pain. A total of 894 cases were followed for 1-year.
The authors note that an important component of the human and economic costs for low back pain are the recurrence rate. They state:
“Health maintenance care is a clinical intervention approach thought to prevent recurrent episodes of LBP. It conceptually refers to the utilization of health care services with the aim of improving health status and preventing recurrences of a previous health condition.” Health maintenance care is defined as “treatment. . . after optimum recorded benefit was reached.”
The authors note that chiropractors are the only providers who explicitly state that they have an effective treatment approach to maintain health with “maintenance” care. They also noted that chiropractic patients had “less expensive medical services and shorter initial periods of disability than cases treated by other providers.” Chiropractic patients also had “fewer surgeries, used fewer opioids, and had lower costs for medical care than the other provider groups.” These authors note:
“After controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors.”
“After controlling for demographic factors and multiple severity indicators, patients suffering nonspecific work-related LBP who received health services mostly or only from a chiropractor had a lower risk of recurrent disability than the risk of any other provider type.”
“After controlling for severity and demographics, no health maintenance care is generally as good as chiropractor care.”
“Our findings seem to support the use of chiropractor services, as chiropractor services generally cost less than services from other providers.”
The authors speculate that the main advantage of chiropractic could be based on the dual nature of their practice, involving both regular care plus maintenance care. Chiropractic appears to be an “important advancement” in the treatment of work-related back injuries.
Again, in 2011, physician Mohammed Senna, MD, and colleagues published a study in the journal Spine, titled (14):
Does Maintained Spinal Manipulation Therapy
for Chronic Nonspecific Low Back Pain Result
in Better Long-Term Outcome?
This study is a prospective single blinded placebo-controlled study that was conducted to assess the effectiveness of spinal manipulation therapy for the management of chronic nonspecific low back pain, and to determine the effectiveness of maintenance spinal manipulation in long-term reduction of pain and disability levels associated with chronic low back conditions.
Sixty patients with chronic, nonspecific low back pain lasting at least 6 months, were randomized to receive either:
- 12 treatments of sham spinal manipulation over a 1-month period
- 12 treatments consisting of spinal manipulation over a 1-month period
- 12 spinal manipulation treatments over a 1-month period plus maintenance spinal manipulation every two weeks for the following nine months
The spinal manipulation was a “high velocity thrust to a joint beyond its restricted range of movement.”
Follow-up evaluations occurred at 1-, 4-, 7-, and 10-months, using:
- Pain with the Visual Analog Scale (VAS)
- Disability with the Oswestry Disability Questionnaire
- Generic health with the 36-Item Short Form Health Survey (SF-36)
The authors made these observations:
Patients receiving real manipulation “experienced significantly lower pain and disability scores” than patients receiving sham manipulation at the end of 1-month.
“In the non-maintained spinal manipulation group, the mean pain and disability scores returned back near to their pretreatment level.”
“Spinal manipulation is effective for the treatment of chronic nonspecific low back pain. To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative therapy.”
“One possible way to reduce the long-term effects of low back pain is maintenance care (or preventive care).”
“To obtain long-term benefit, this study suggests maintenance spinal manipulation after the initial intensive manipulative.”
In 2018, researchers from Sweden and Denmark published a study in the journal Public Library of Science (PLoS) One, titled (15):
The Nordic Maintenance Care program:
Effectiveness of Chiropractic Maintenance Care
Versus Symptom-Guided Treatment for Recurrent
and Persistent Low Back Pain:
A Pragmatic Randomized Controlled Trial
The aim of this trial was to investigate the effectiveness of chiropractic maintenance care on pain for patients with recurrent or persistent low back pain. It was an investigator-blinded, randomized controlled trial using 328 subjects aged 18-65 years, with non-specific low back pain.
If the initial course of chiropractic care (4 visits) resulted in substantial improvements in low back pain, the subjects were randomized to either maintenance chiropractic care (163 subjects) or not (control group, 158 subjects). The study used 35 chiropractic clinicians with mean number of years in practice of 17.9, ranging from 1 to 38 years. The primary outcome was total number of days with bothersome low back pain during 52 weeks.
The authors note that low back pain is often recurrent and has a large negative impact on society. Consequently, focusing on preventive strategies for recurrent low back pain is logical. “This is one of the first studies to test the effect of preventive manual care performed by chiropractors (maintenance care) for recurrent and persistent low back pain.”
Chiropractors have traditionally used maintenance care as a prevention strategy against new episodes of low back pain, or in reducing the impact of a new episode of low back pain. Maintenance chiropractic care may improve biomechanical and neuromuscular function and address psychosocial issues, thereby reducing the risk of relapse into pain. “It is common for chiropractors to recommend maintenance care, i.e. preventive consultations/visits for recurrent and persistent musculoskeletal pain and dysfunction.” The authors note:
“Non-specific low back pain is one of the most common and costly healthcare problems in society today.”
“The burden of disabling low back pain on individuals, families, communities, industries and societies is substantial and is now the leading cause of activity limitation and work absence in the world.”
“Chiropractors are trained to assess and treat disorders of the musculoskeletal system, of which low back pain is the most common.”
“The majority of patients seeking chiropractic care receive some form of manual therapy, of which spinal manipulation and mobilization are the most common, often along with advice on exercise.”
“Chiropractic maintenance care resulted in a reduction in the total number of days per week with bothersome low back pain compared with symptom-guided treatment.”
The maintenance group had a faster reduction in days with bothersome low back pain and reached a lower steady state earlier.
Maintenance chiropractic care should be considered an option for tertiary prevention of low back pain.
The maintenance chiropractic care group “improved faster and achieved the steady state phase earlier with a lower mean number of days with low back pain per week.”
In 2019, a study was published in the journal Chiropractic & Manual Therapies and titled (16):
Chiropractic Maintenance Care – What’s New?
A Systematic Review of the Literature
These authors performed a systematic review of the literature using the search terms “chiropractic OR manual therapy” AND “Maintenance Care OR prevention”, using PubMed and Web of Science, starting from 2007. Fourteen identified studies were included in their review. The authors note:
It is now accepted fact that “spinal pain is a recurring disorder.”
Because “spinal pain is a condition with exacerbations and remissions throughout life, it might be wise to shift the focus of treatment from cure of the condition to management of pain trajectories.”
“Maintenance Care is a traditional chiropractic approach, whereby patients continue treatment after optimum benefit is reached.”
“Both chiropractors and patients believe in the efficacy of Maintenance Care.”
“Maintenance Care patients experienced fewer days with low back pain compared to patients invited to contact their chiropractor ‘when needed’.”
“Maintenance Care can be considered an evidence-based method to perform secondary or tertiary prevention in patients with previous episodes of low back pain, who report a good outcome from the initial treatments.”
“The majority of chiropractors (98%) stated that they believed that Maintenance Care could be used as a preventive tool, at least sometimes.”
“Maintenance Care sessions included a range of treatment modalities, from the ordinary examination/manual treatment to packages including exercise prescriptions, advice on ergonomics, diet, weight loss, and stress management, i.e. it included a program meant to motivate patients to maintain healthy lifestyle habits through empowerment.”
“Patients who received Maintenance Care had better outcome than those who received short-term treatment or short-term sham treatment.”
“Chiropractors could obviously play an important role here as ‘back pain coaches’, as the long-term relationship would ensure knowledge of the patient and trust towards the chiropractor.”
“Back pain is a chronic disease for most, with episodes at short or long intervals. A preventive approach such as Maintenance Care, therefore, makes sense.”
The increasing range of published studies supporting chiropractic manipulation for the management of spinal pain complaints is helping the global acceptance of chiropractic care. This review adds that there is mounting support for the use of chiropractic manipulation for maintenance care as well.
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- Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C et al (2013); Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010; Lancet; Vol. 380; pp. 2163–2196.
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- Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults: Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; Vol. 42; No. 23; pp. 1810–1816.
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December 2011; Vol. 1; No. 1; pp. 74-85.
- Cifuentes M, Willetts J, Wasiak R; Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence; Journal of Occupational and Environmental Medicine; April, 2011; Vol. 53; No. 4; pp. 396-404.
- Senna MK, Shereen A, Machaly SA; Does Maintained Spinal Manipulation Therapy for Chronic Nonspecific Low Back Pain Result in Better Long-Term Outcome? Randomized Trial; Spine; August 15, 2011; Vol. 36; No. 18; pp. 1427–1437.
- Eklund A, Jensen I, Lohela-Karlsson M, Hagberg J, Leboeuf-Yde C, Kongsted A, Bodin L, Axen I; The Nordic Maintenance Care program: Effectiveness of Chiropractic Maintenance Care Versus Symptom-Guided Treatment for Recurrent and Persistent Low Back Pain: A Pragmatic Randomized Controlled Trial; Public Library of Science (PLoS) One; September 12, 2018; Vol. 13; No. 9; e0203029.
- Iben A, Lise H, Charlotte LY: Chiropractic Maintenance Care – What’s New? A Systematic Review of the Literature; Chiropractic & Manual Therapies; November 21, 2019; Vol. 27:63.
“Authored by Dan Murphy, D.C.. Published by ChiroTrust® – This publication is not meant to offer treatment advice or protocols. Cited material is not necessarily the opinion of the author or publisher.”