A theoretical basis for maintenance spinal manipulative therapy for the chiropractic profession

Abstract

Object

The purpose of this article is to discuss a theoretical basis for wellness chiropractic manipulative care and to develop a hypothesis for further investigation.

Methods

A search of PubMed and of the Manual, Alternative, and Natural Therapy Index System was performed with a combination of key words: chiropractic, maintenance and wellness care, maintenance manipulative care, preventive spinal manipulation, hypomobility, immobility, adhesions, joint degeneration, and neuronal degeneration. Articles were collected, and trends were identified.

Results

The search revealed 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. Maintenance care optimizes the levels of function and provides a process of achieving the best possible health. It is proposed that this may be accomplished by including chiropractic manipulative therapy in addition to exercise therapy, diet and nutritional counseling, and lifestyle coaching.

Conclusions

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.

Introduction

The chiropractic profession continues to grow in collective thinking and progress in defining care rendered. In so doing, the profession participates in the investigation of the types of care rendered and in the translation of research into practice. Different types of care are developed from theories, clinical practice, and clinical observations and, ultimately, based on scientific evidence. However, certain types of chiropractic care are the subject of debate. This article considers the scientific basis of the commonly practiced procedure of chiropractic maintenance care and whether a hypothesis of a physiological basis can be generated to explain findings and practice.

Recent publications by the Council of Chiropractic Guidelines and Practice Parameters have summarized clinical best practices for chiropractic care and identified some of the changes that chiropractic clinicians need to make to improve care for their patient population.¹ Two articles2, 3 give us insight into the types of care rendered. Dehen et al² defined the stages of chiropractic care into care for acute and chronic/recurrent conditions, and wellness care. A distinction is made between the chronic/recurrent care and wellness or maintenance care. Care for chronic/recurrent conditions is defined as medically necessary care for conditions that are not expected to completely resolve, but in which one can provide documented improvement. According to Dehen et al, wellness or maintenance care may not be defined as being “medically necessary” for a current condition. However, this type of care optimizes the levels of function and provides a process of achieving the best possible function and health. This care includes chiropractic manipulative therapy in addition to exercise therapy, diet and nutritional counseling, and lifestyle coaching.² This concurred with surveys made by Danish and Swedish chiropractors who defined the purpose of chiropractic maintenance care as optimizing spinal function and decreasing the frequency of future episodes of back pain.⁴ Various definitions have been provided for maintenance care: (1) “Appropriate treatment directed toward maintaining optimal body function. This is treatment of the symptomatic patient who has reached pre-clinical status or maximum medical improvement, where condition is resolved or stable”; (2) “a regimen designed to provide for the patient's continued well-being or for maintaining the optimum state of health while minimizing recurrences of the clinical status”; and (3) “maintenance care was offered to patients that did not improve.”⁵

The current health care system more often focuses upon the doctors to fix problems that have developed over a number of years, instead of modifying patient behaviors to promote good health and prevent chronic illness.⁶ Musculoskeletal conditions may be prevented by years of appropriate diet and physical activities as wellness activities.⁶ Wellness is defined differently in the allopathic profession and in the retail industry. The allopathic profession defines wellness as the provision of diagnostic testing for early detection of disease processes. The retail industry often uses the term in marketing to sell products that may make the person feel better, look better, and function better, or prevent onset of aging or disease. Wellness has been defined as both a process and an outcome.⁷

Because of the multiple uses of the terms in the literature, for the purpose of this investigation, maintenance care and wellness care are used synonymously to represent the process of spinal manipulative therapy for an asymptomatic patient or a patient that has reached maximum therapeutic improvement after treatment of an acute condition, an acute exacerbation of a chronic condition, or an initial treatment regimen for a chronic condition. Some insurers have independently defined maintenance care as care provided for a stable condition without any functional improvement of the patient net health outcome over a 4-week period and further determine it as not being medically necessary.⁸ Jamison⁹ did a random survey of Australian and American doctors of chiropractic to obtain a global definition of maintenance care. She found that more than 90% opined that the purpose of maintenance care was to minimize recurrences or exacerbations, whereas greater than 80% responded that it would optimize the patients' health. This indicates some agreement of the opinions of the rationale for such care. Ninety-seven percent of the American and 85% of the Australian chiropractors report using manipulative therapy as a component of the maintenance care. A combined greater than 93% also used exercise as part of the maintenance care, whereas a great majority also used patient education in eating habits and other lifestyle choices. There was a greater than 91% agreement that the musculoskeletal system was most amenable to maintenance care, whereas many also felt that maintenance care was beneficial for stress; respiratory system; gastrointestinal system; and, to a lesser degree, cardiovascular system. This was all apparently based on clinical observation, personal philosophies, and experience because only 40% of the Americans and 22% of the Australians opined that the care was supported by adequate research.⁹ Rupert¹⁰ performed a similar study of US chiropractors in 2000 and had similar results showing that 95% of chiropractors recommended maintenance care to minimize recurrences or exacerbations of conditions and 90% recommended the care to optimize the health of the patient. Again, this was in the absence of known scientific support. A study that interviewed patients and doctors regarding maintenance care noted that 96% of elderly patients who received such care believed that it was either considerably or extremely valuable.¹¹ The prevalence of the rendering of this type of care is again noted by Rupert¹⁰ as contributing an average of 23% of the chiropractors' income. It is interesting to note that Sarnat and Winterstein¹² found substantial cost savings in an Independent Practice Association that used chiropractors as primary care providers despite the fact that 28% of the patients presented for wellness care and it was not uncommon for the patients to present twice a month for such care. Despite this, the US Preventive Task Force, which has been evaluating preventive health care measures for 27 years, fails to list this type of care as a preventive measure.¹³ If the chiropractic profession feels that maintenance care is important to our patients, then we need further evidence of a scientific basis of the physiological responses to this care. 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.¹⁰ The lack of third-party payment for such services in the US health care system may be a factor in how many patients elect to participate.

There are many questions surrounding maintenance care, and previous research has investigated some of these questions,14, 15 The object of this article is to look at the available evidence for a possible physiological basis that might allow development of a theory of the reported clinical benefits of such care. Given the positive clinical reports and the current state of knowledge of manipulative therapy, it is hypothesized that a theoretical physiological framework could be developed for future research. The purpose of this article is to provide the initial bridge from the clinical observations and theories to proposed hypotheses for further investigation into the clinical meaningfulness of maintenance care.