title: The Nordic Maintenance Care Program: when do chiropractors recommend secondary and tertiary preventive care for low back pain?
abstract: BACKGROUND
  Among chiropractors the use of long-term treatment is common, often referred to as "maintenance care". Although no generally accepted definition exists, the term has a self-explanatory meaning to chiropractic clinicians. In public health terms, maintenance care can be considered as both secondary and tertiary preventive care. The objective of this study was to explore what factors chiropractors consider before recommending maintenance care to patients with low back pain (LBP).
  
  
  METHODS
  Structured focus group discussions with Swedish chiropractors were used to discuss pre-defined cases. A questionnaire was then designed on the basis of the information obtained. In the questionnaire, respondents were asked to grade the importance of several factors when considering recommending maintenance care to a patient. The grading was done on a straight line ranging from "Very important" to "Not at all important". All members of the Swedish Chiropractors' Association (SCA) were invited to participate in the discussions and in the questionnaire survey.
  
  
  RESULTS
  Thirty-six (22%) of SCA members participated in the group discussions and 129 (77%) returned the questionnaires. Ninety-eight percent of the questionnaire respondents claimed to believe that chiropractic care can prevent future relapses of back pain. According to the group discussions tertiary preventive care would be considered appropriate when a patient improves by 75% or more. According to the results of the questionnaire survey, two factors were considered as "very important" by more than 70% of the respondents in recommending secondary preventive care, namely frequency past year and frequency past 10 years of the low back pain problem. Eight other factors were considered "very important" by 50-69% of the respondents, namely duration (over the past year and of the present attack), treatment (effect and durability), lifestyle, work conditions, and psychosocial factors (including attitude).
  
  
  CONCLUSIONS
  The vast majority of our respondents believe that chiropractic treatment can prevent relapses of back pain. When recommending secondary preventive care, past frequency of the problem is considered. For tertiary preventive care, the patient needs to improve considerably before a recommendation of maintenance care is made.
authors.affiliation: The Karolinska Institute, Stockholm, Sweden. iben.axen@ki.se
authors.forename: Iben
authors.initials: I
authors.lastname: Axén
authors.forename: Irene B
authors.initials: IB
authors.lastname: Jensen
authors.forename: Andreas
authors.initials: A
authors.lastname: Eklund
authors.forename: Laszlo
authors.initials: L
authors.lastname: Halasz
authors.forename: Kristian
authors.initials: K
authors.lastname: Jørgensen
authors.forename: Fredrik
authors.initials: F
authors.lastname: Lange
authors.forename: Peter W
authors.initials: PW
authors.lastname: Lövgren
authors.forename: Annika
authors.initials: A
authors.lastname: Rosenbaum
authors.forename: Charlotte
authors.initials: C
authors.lastname: Leboeuf-Yde