Chiropractors all over the world are consulted for spinal pain and dysfunction. Because many spinal pain complaints are chronic or recurrent in nature [1
], 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 [3
]. 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 [4
]. 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 [5
]. 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 [6
]. 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 [7
] 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 [8
]. Our continued monitoring of the literature revealed several additional studies since the time of their publication.