A Theoretical Basis for Maintenance Spinal Manipulative Therapy for the Chiropractic Profession
SOURCE: J Chiropractic Humanities 2011 (Dec)
David N. Taylor
Director, Multimed Center, Inc., Greenfield, MA
The World Health Organization defines health as being “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity”. [ 1 ]
Given this broad definition of health, epistemological constructs borrowed from the social sciences may demonstrate health benefits not disclosed by randomized controlled trials.
Health benefits, such as improvement in self-reported quality-of-life (QOL), behaviors associated with decreased morbidity, patient satisfaction, and decreased health care costs, are reported in the following articles, and they make a compelling statement about the effects of chiropractic on general health.
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.
The Full-Text Article:
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.  Two articles [ 2, 3] give us insight into the types of care rendered. Dehen et al  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.  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.  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.” 
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.  Musculoskeletal conditions may be prevented by years of appropriate diet and physical activities as wellness activities.  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. 
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.  Jamison  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. 
Rupert  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.  The prevalence of the rendering of this type of care is again noted by Rupert  as contributing an average of 23% of the chiropractors’ income. It is interesting to note that Sarnat and Winterstein  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.  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.  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.
There is still ambiguity in the literature regarding the clinical benefits of maintenance or wellness manipulative care. A previous report by LeBoeuf-Yde and Hestabek  concluded that there was no evidence base for the indications or the nature of the use of maintenance care based on a 2008 literature review. They also point out the lack of an objective measure of the benefits. In addition, Aker and Martel  in their qualitative literature review concurred that there was no scientific evidence to support the claim that maintenance care improves one’s health status, although anecdotal evidence from both doctors and patients is strong. A recent randomized controlled trial of monthly preventive spinal manipulation of more than 10 months’ duration showed no difference in functional measures, range of motion, or visual analogue pain scales when compared with a control group of bimonthly reassurance or a combination of manipulation and home exercise. This author concluded that the premise of stating that regular treatments, designed to preserve optimum health and minimize the recurrence of clinical problems, was more likely due to interventions of reassurance, patient education, help with self-management, and active care strategies.  In contrast, a different study looked at the pain levels and functional Oswestry disability measures of 2 chronic low back pain groups.  Both received an initial 12 spinal treatments over 4 weeks. Then the maintenance care was provided to one group at a frequency of every 3 weeks for a 9-month follow-up, but not to the second group. This study found that disability remained at the lowered post 4-week level for the maintenance group but returned to the previous levels for the control group. They 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.  This seemed to concur with the Swedish surveys of chiropractors who found consensus on providing such care to prevent relapses. 
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 MMT 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. Although there have been physiological measures to assess the results of manipulative therapy, studies of these measures applied to preventive manipulation have not been conducted; nor has there been any testing of physiological vs psychological contributions to the reported clinical benefits. Further investigatory studies in these areas would be able to tie together some of the laboratory and clinical findings.
In the first conference on spinal manipulation in 1977 sponsored by the National Institute of Neurological and Communicative Disorders and Stroke, Haldeman  presented the criteria for investigating the clinical basis of the mechanisms of manipulative therapy. These still apply today and can be paraphrased to apply to MMT:
- That the application of MMT must demonstrate consistent clinical results under controlled conditions in the treatment of a specific pathologic process, organ dysfunction, or symptom complex.
- That MMT demonstrates a specific effect on the musculoskeletal system to which it is applied.
- That the musculoskeletal effect caused by MMT must be shown to have a specific influence on the nervous system.
- That the influence on the nervous system brought about by the manipulation must demonstrate a beneficial influence on abnormal function of an organ, tissue pathology, or symptom complex. But we must be careful about presenting theory as fact. 
As science starts with a theory, the theory must then be investigated for validity. Currently, the theories involving MMT are evolving; and there are initial investigations that may apply to this care. In response to the beliefs, positive anecdotal findings, patient satisfaction, and historical clinical reports, the following is a response to those directives.
One cannot attribute MMT as a preventive cure-all. We must therefore look at specific conditions in which MMT may effect. It appears that the clinical opinions and the research to date have looked at the effect on low back conditions. This would be a good starting point to research the efficacy of MMT in reducing the incidence of low back injuries or the severity of the episodes. It has been theorized that there is a neurological response to the manipulation. This has included the increase in population of proprioception, stimulation of α-motor neuronal pool, and reflexogenic responses through the stretch reflex. There is now increasing research available that is confirming much of this; but further research is still warranted, especially in regard to these effects under MMT. There is initial evidence of the effect of immobility on the Ia afferent nerves, the α-motor neuronal pool, the motor end plates, and the muscular end organs.
Further research should be aimed at confirming these findings in human subjects and the reversal of these effects with the application of MMT procedures. The influence on the nervous system from the manipulative therapy has been shown in the studies outlined in our literature search. Future research should look at the beneficial influence of MMT on patients with chronic musculoskeletal conditions before looking at healthy individuals. Population studies similar to those performed by Senna and Machaly  and by Hawk et al  with larger populations should give us further insight into the clinical value of MMT. In vivo assessment of neurological and musculoskeletal changes would be beneficial in providing further physiological evidence to support the recommendations of MMT.
This study is limited in scope because it is not a quantitative analysis of the literature, nor does it qualitatively evaluate the literature reviewed. This was a narrative review to provoke thought, further debate and discussion on the topic, generate theories, and challenge future research directions.
The value of maintenance care must be demonstrated to substantiate use of this service and for it to be a covered service on par with other preventive care services such as annual physical examinations, colonoscopic examinations, prostate examinations in men, and mammograms in women. The purpose of this discussion was to address MMT, its clinical care, and the body of evidence and to generate theories that might further investigate evidence on the same basis as other common preventive services. Therefore, a theoretical framework was developed based on the grounded theory of the common clinical practice of MMT and its common dosage. This review suggests that there may be a correlation between clinical dosages with the time of onset of pathologies. This article aimed to enlighten the debate between the clinical theories and the scientific evidence, and between the philosophy and science of MMT, while providing a physiological hypothesis of the benefits of and direction for future MMT research.
This study is supported by Descarreaux’s 2004 JMPT study, which concluded that:
“This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective post-intensive treatment disability levels”.
It also confirms the findings of Dr. Ron L. Rupert, in his ground-breaking 2000 JMPT article, titled: Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65 and Older, Part II which found that:
“The cost of health care for patients receiving MC in this study was far less than that for patients of similar age in the general population, despite the doubling of physician visits (medical plus chiropractic). The greatest difference in health care costs with patients receiving MC was in the areas of nursing care and, especially, hospital care. This reduced need for hospital and nursing home services has recently been corroborated by the research of Coulter et al.”
Coulter et al (Topics In Clinical Chiropractic 1996) performed an analysis of an insurance database, comparing persons receiving chiropractic care with nonchiropractic patients. The study consisted of senior citizens >75 years of age. Recipients of chiropractic care reported better overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and were more active than the nonchiropractic patients.
As part of a comprehensive geriatric assessment program, the RAND Corporation studied a subpopulation of patients who were under chiropractic care compared to those who were not and found that the individuals under continuing chiropractic care were:
- Free from the use of a nursing home
[95.7% vs 80.8%];
Free from hospitalizations for the past 23 years
[73.9% vs 52.4%];
More likely to report a better health status; More likely to exercise vigorously; More likely to be mobile in the community
[69.6% vs 46.8%].
Although it is impossible to clearly establish causality, it is clear that continuing chiropractic care is among the attributes of the cohort of patients experiencing substantially fewer costly healthcare interventions.
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