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
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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:
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 articles [ 2, 3] give us insight into the types of care rendered. Dehen et al [2] 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]
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OA is not a discrete disease entity, it is joint failure, akin to cardiac or kidney failure; and, like heart or kidney failure, it can be asymptomatic. Furthermore, just as the heart can fail as a result of primary problems in the endocardium, myocardium or epicardium, joint failure can result from problems in subchondral bone, cartilage, ligaments, periarticular muscles, nerves or synovium, and OA can originate in any of these or other tissues.[11]
The joint is a mechanical structure, and the key to understanding OA is abnormal mechanical stress: joint failure is the pathophysiological response of a synovial joint to mechanical insult, and the attempt of the joint to repair the damage caused by local abnormalities in force/unit area. The abnormalities in cytokines, degradative enzymes, toxic radicals and the like, which are being studied as the cause of OA, are rather the result of this attempted repair.[9, 11] Therefore, thinking about OA is moving from biochemistry of the articular cartilage to the mechanobiology of the whole joint.
OA is joint failure rather than a disease.
Joint failure is driven by abnormal joint loading.
This is part of an article I read and bookmarked I received from MedScape. The article is entitled Developments in Osteoarthritis: Perception is Everything. (NOTE: Registration at Medscape is free)
It’s about an article from the Rheumatology 2011 Journal. Good opinion article. I feel it offers some logic foe “maintenance” care.
Future Management of Osteoarthritis
What of the future? It seems to me that after years in the doldrums, we are now in a position to move forward in OA, and find new approaches to the control of the disease process and of pain and disability. But these advances will not come if we only use the biological approaches that have so successfully led to the control of inflammatory arthritis. The OA process is driven by abnormal mechanical forces on a joint, so the answer must come from biomechanics as much as biology.
Proof-of concept studies are already available, through, for example, the improvements that can occur in both symptoms and joint pathology following osteotomy or joint distraction to unload damaged areas of the joint.[19] Pain and disability require a biopsychosocial and holistic approach to the multiple problems of older people. As with any chronic disease, management of OA is complex and needs individualizing.[20]
This is another section of this opinion article in Rheumatology 2011 journal. I find it interesting and very (modern) chiropractic . Providing optimal biomechanics to the kinetic chain may reduce/slow down this process (even when asymptomatic). Of course this is not even close to an easy sale if you will. More often then not in our culture it has to be very very broken before attempted to be fixed. This is why I’m personally frustrated when a person comes in with a condition that I can treat but will really require 8-10 visits but the insurance chiropractor wants me to perform yet another miracle of doing it in 2 visits.
Very nice piece Frank. The articles cited seem to show an advantage to those who receive regular adjustments. It is tough however, to tease out the benefits of manipulation alone in these studies. As Coulter points out, causality is difficult to establish. It sounds like those seeking maintenance care are a cohort that is more pro-active regarding their health. They exercise more, probably eat healthier and seem to have a better over-all outlook. Of course, chiropractic is more than manipulation. Practiced properly, it is a Doctor-patient encounter that includes a wide variety of health care advice. A few well-chosen words can do much.
Regarding the originating article I think as chiropractors we have always believed that impaired motion can lead to pathological changes in the joint but, at this point it remains a hypothesis. A stepping stone. To be convincing, more work is needed.
Hi John!!!
I believe the Heisenberg Uncertainty Principle has a dramatic effect on any observation.
We can NEVER know how those people would have been IF they never received chiropractic care. All we can do is *try* to compare people with similar complaints who either saw a DC, or saw an MD. Even so, the statistics for those who DO receive chiropractic care is quite compelling.
There is also what is referred to as the “non-specific effects of care“, including that fuzzy-warm feeling you may have for your doctor, and the advice and attention they bestow.
Satisfaction surveys certainly rate DCs MUCH higher than their MD counterparts. Researchers are now placing much higher value on that “placebo-effect” than ever before.
Finally, regarding your comment about the “pathological changes in the joint“, I recently re-worked the What is The Chiropractic Subluxation? page, to make it much easier to review the neurologic and degenerative effects of joint fixation, and how chiropractic can help.
I am living proof that chiropractic manipulation makes a difference. As a gymnast in my teens, I suffered a severe neck injury and started experiencing neck and arm pain. After going to my medical doctor for several weeks I was referred to a chiropractor. Within a short time I was back feeling great, but after I started chiropractic school my symptoms started to exacerbate. I had cervical films taken which demonstrated degenerative changes and I was only 22 years of age. Since that time I have received regular care that has been able to help keep my joint changes in check. After 33 years of practice I have never missed a day of work because of illness or injury. I don’t think that is a coincidence.
Chiropractors have been and currently the leaders/experts to address the “mechanobiology” of a joint under undue stress. Like the article I posted says OA osteoarthritis is a joint failure rather than a disease. Joint failure is driven by abnormal joint loading. Lastly, in the Rheumatology article( I posted portions of the article above) as with any chronic disease management of OA is complex and needs individualizing. Wow sounds like chiropractic. We need to continue to educate the public but I wonder will health care insurance companies allow us to treat these individuals and reimburse us for it?
Hi Karl,
Thanks for the suggested materials.
I hope you don’t mind, but I added links in your fists submission, so people could review the materials you mentioned.
As an FYI, you can add URLs (or bolding, etc) in your posts by clicking on the link icon
Hey Frank, I don’t mind at all. I appreciate this web site and your input. Thanks.