Maintenance Care,
Wellness and Chiropractic

This section was compiled by Frank M. Painter, D.C.
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Jump to:   What is Health? Maintenance & Wellness  

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Patient Satisfaction Cost-Effectiveness Safety of Chiropractic

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Headache Adverse Events Disc Herniation

Chronic Neck Pain Low Back Pain Whiplash Section

Conditions That Respond Alternative Medicine Approaches to Disease
What is Health?

A Chiro.Org Editorial

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.

Despite the historic emphasis on treatment, prevention and health promotion are receiving increased attention within the US health care system.   These same health promotion tasks are considered by the National Academy of Science and others as essential components of health services delivered by primary care providers.   Chiropractors are viewed by many as capable of and actively delivering prevention and health promotion in addition to providing other primary care services.

Prevention and health promotion activities administered by chiropractors
fall into 2 general categories:

those considered orthodox by the medical community
(eg, weight loss, exercise, smoking cessation)

and those that are not
(eg, soft-tissue and osseous manual procedures and some dietary supplementation).

Previous research demonstrates that the orthodox activities used by primary care medical providers are also used by chiropractors.   The concept that chiropractic care is of value in maintaining health and preventing disease began with the work of Palmer.

This preventive treatment is traditionally referred to as maintenance care (MC).
MC has been defined as:

“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.”

Many chiropractors believe that periodic patient visits permit the doctor to identify joint dysfunction or subluxations and make corrections with spinal manipulation or other manual procedures.   These treatments are believed to prevent disease of both neuromusculoskeletal and visceral origin.   [ 2 ]

  1. Re-defining ‘Health’
    Bulletin of the World Health Organization

  2. A Survey of Practice Patterns and the Health Promotion and Prevention Attitudes
    of US Chiropractors Maintenance Care: Part I

    J Manipulative Physiol Ther 2000 (Jan); 23 (1): 1–9 ~ FULL TEXT

Maintenance Care & Wellness Care ~ A Series of Articles

Clinical Indicators for Recommending Continued Care
to Patients with Neck Pain in Chiropractic Practice:
A Cohort Study

Chiropractic & Manual Therapies 2023 (Aug 31); 31: 33 ~ FULL TEXT

Receiving maintenance care (MC) (i.e. continued care as decided by the chiropractor) compared to receiving symptom-guided therapy (i.e. further care decided by the patient when they perceive a need) have been examined in patients with recurrent and persistent low back pain. [18] It was concluded that MC was more effective in reducing the total number of days with bothersome pain over a year’s time. [18] However, MC is currently being investigated and not included in clinical practice guidelines as a recommended evidence-based treatment strategy for prevention. Focus groups and surveys have systematically explored chiropractors’ indications for using MC in patients with low back pain. [13] According to these studies, MC is offered to patients who have experienced previous pain episodes, long pain duration, and have shown improvement after initial treatment. [19–21] These indicators for MC were confirmed in an observational study of patients with low back pain and previous pain episodes was found to be a strong predictor for recommending MC. [22] In addition, the recommendation of MC may also depend on the chiropractor and the clinical setting. Chiropractors who were trained in the US compared to Europe, as well as chiropractors with more experience and clinic ownership, tend to recommend MC more frequently and to a greater extent to their patients. [19]

Reducing Cervical Retrolisthesis With Long-Term Monthly
Chiropractic Maintenance Care: A Case Report

J Med Cases 2022 (Jul); 13 (7): 359–364 ~ FULL TEXT

The patient was diagnosed with right C5 radiculopathy associated with vertebral retrolisthesis. She was conservatively treated with multimodal chiropractic care comprising cervical manipulation applied to the affected segments, axial distraction, and isometric stretching. After 20 sessions over 3 months of therapy, the patient experienced complete relief of neck pain and radicular symptoms, and full cervical mobility. Because her complaints were characterized by relapsing episodes, she was enrolled in a monthly MC program to monitor and ensure the spine was functioning at its highest capacity. The MC program included disease monitoring, manipulation of dysfunctional segments, cervical strengthening exercises, and ergonomics coaching. Monthly care was shown to be successful in maintaining an asymptomatic status. Moreover, a gradual reduction in cervical retrolisthesis was observed during the 13–year MC period, and the ongoing MC ensured optimal spine functioning.

The Nordic Maintenance Care Program: A Series of Studies
17 studies published over a 15 year period.

Evidence-based Maintenance Care Among Chiropractors
in Norway: A Cross-sectional Survey in the
Nordic Maintenance Care Program

Chiropractic & Manual Therapies 2023 (Aug 10); 31 (1): 26 ~ FULL TEXT

The response rate was 41% (n = 312). Regarding attitudes towards evidence-based maintenance care, 26% agreed they needed tools to recommend this care to patients. Approximately half (57%) believed they had skills to identify suitable patients, and 45% had used published information in the past month. Strong alignment was observed between Norwegian chiropractors' attitudes, skills, and utilization of evidence-based maintenance care and general evidence-based practice. Maintenance care skills were significantly associated with age (those between 40 and 59 years being less likely to report having high skills), clinical setting (those working with conventional health care providers being less likely to report having high skills) and country of education (those educated in the US and Australia being more likely to report having high skills). Moreover, maintenance care use was significantly associated with country of education (those educated in Australia were less likely to have used published information regarding patient selection for maintenance care). Access to resources was a barrier, whereas knowledge of patient suitability facilitated evidence-based maintenance care.

Development and Evaluation of the MAINTAIN Instrument,
Selecting Patients Suitable for Secondary or Tertiary
Preventive Manual Care: The Nordic
Maintenance Care Program
Chiropractic & Manual Therapies 2022 (Mar 17); 30 (1): 15~ FULL TEXT

The MAINTAIN instrument is a brief cinical tool with a simple scoring algorithm that has a very good to excellent diagnostic accuracy with regard to selecting dysfunctional patients in a clinical setting. By using 2 thresholds, patients can be categorized into “low probability”, “moderate probability” and “high probability” of having a good outcome from maintenance care for LBP. The diagnostic accuracy is similar and high across populations with minor differences in optimal thresholds for identifying dysfunctional individuals. Implementing the MAINTAIN instrument has the potential of improving outcomes by identifying dysfunctional high-risk patients early in the clinical course and stratifying them to appropriate interventions with a higher chance of treatment success.

The Nordic Maintenance Care Program: Patient Experience
of Maintenance Care- A Qualitative Study

Chiropractic & Manual Therapies 2021 (Aug 2); 29 (1): 28 ~ FULL TEXT

The current study addressed how patients experienced Maintenance Care. It focused on barriers to and facilitators of engaging in and maintaining this kind of care plan and it compared the experience of contrasting psychological subgroups, namely adaptive copers, interpersonally distressed, and dysfunctional. The findings reveal clear positive and negative experiences of MC as expressed by patients across the three psychological subgroups. The findings can contribute to a deeper understanding of MC and can help clinicians and researchers to identify care that patients perceive to have high value.

The Nordic Maintenance Care Program: Maintenance Care Reduces
the Number of Days With Pain in Acute Episodes and
Increases the Length of Pain Free Periods for
Dysfunctional Patients With Recurrent and
Persistent Low Back Pain - A Secondary
Analysis of a Pragmatic Randomized
Controlled Tial
Chiropractic & Manual Therapies 2020 (Apr 21); 28: 19 ~ FULL TEXT

Chiropractic Maintenance Care reduces the number of days of bothersome (activity-limiting) pain within each new LBP episode among patients classified as dysfunctional (by the MPI-S instrument). MC stabilizes the clinical course and increases the number of pain-free weeks between episodes. Understanding how subgroups of patients are likely to be affected by MC may help align patients’ and clinicians’ expectations with realistic outcomes and can be used as a framework in the selection and execution of appropriate care plans. MC is not a cure that prevents new episodes but rather a management strategy that reduces bothersome (activity-limiting) pain over time for a carefully selected group of patients with recurrent and persistent LBP.

The Nordic Maintenance Care Program: Does Psychological Profile
Modify the Treatment Effect of a Preventive Manual Therapy
Intervention? A Secondary Analysis of a
Pragmatic Randomized Controlled Trial
PLoS One. 2019 (Oct 10); 14 (10): e0223349 ~ FULL TEXT

Psychological characteristics appears to modify the effect of Maintenance Care (MC) and should be taken into consideration in the long-term management of patients with recurrent and persistent LBP. Patients who show a favorable response to an initial course of chiropractic care should be considered for MC if they report high pain severity, marked interference with everyday life due to pain, high affective distress, low perception of life control and low activity levels at baseline. Patients who, on the other hand, report low pain severity, low interference with everyday life due to pain, low life distress, high activity levels and a high perception of life control should probably not be recommended MC and instead only receive care when they experience a relapse of pain.

The Nordic Maintenance Care Program: Effectiveness of
Chiropractic Maintenance Care Versus Symptom-guided
Treatment for Recurrent and Persistent Low Back Pain
- A Pragmatic Randomized Controlled Trial
PLoS One. 2018 (Sep 12); 13 (9): e0203029 ~ FULL TEXT

In patients with recurrent and persistent LBP who responds well to an initial course of manual therapy, Maintenance Care resulted in a reduction in number of days with bothersome LBP per week, compared with symptom-guided treatment. In total, the Maintenance Care group had on average 12.8 fewer days with bothersome LBP over 12 months. The effect of the intervention was achieved at the cost of 1.7 additional visits to the chiropractor. For patients with recurrent and persistent LBP who are selected according to evidence-based criteria, MC should be considered as an option for tertiary prevention.

Prevention of Low Back Pain: Effect, Cost-effectiveness,
and Cost-utility of Maintenance Care - Study Protocol
for a Randomized Clinical Trial
Trials. 2014 (Apr 2); 15: 102 ~ FULL TEXT

This study protocol describes a randomized controlled clinical trial in a multicenter setting investigating the effect and cost-effectiveness of preventive manual care (chiropractic maintenance care) in a population of patients with recurrent or persistent LBP.Four hundred consecutive study subjects with recurrent or persistent LBP will be recruited from chiropractic clinics in Sweden.

The Nordic Maintenance Care Program: What Is
Maintenance Care? Interview Based Survey
of Danish Chiropractors

Chiropractic & Manual Therapies 2013 (Aug 20); 21: 27 ~ FULL TEXT

Chiropractors are more likely to offer MC to patients whose complaints include a significant muscular component. Furthermore, a successful transition to MC appears dependent on correctly matching complaint with management. A positive relationship between chiropractor and patient facilitates the initiation of MC. Finally; MC appears grounded in a patient-oriented approach to care rather than a market-oriented one.

The Nordic Maintenance Care Program: The Clinical
Use of Identified Indications for Preventive Care

Chiropractic & Manual Therapies 2013 (Mar 6); 21: 10 ~ FULL TEXT

The results showed that “previous episodes” with LBP was the strongest predictor for recommending MC, and that the presence of all predictors strengthens the frequency of this recommendation. However, there was considerable heterogeneity among the participating chiropractors concerning the recommendation of MC. The study largely confirms the clinical use of the previously identified indications for recommending MC for recurrent and persistent LBP. Previous episodes of LBP was the strongest indicator.

The Nordic Maintenance Care Program: Maintenance Care
- What Happens During the Consultation?
Observations and Patient Questionnaires

Chiropractic & Manual Therapies 2012 (Aug 10); 20 (1): 25 ~ FULL TEXT

The results from these two studies indicate that MC consultations commonly take place with around two months intervals, and that history taking, examination and treatment are as important components in MC as in non-MC consultations. Further, the results demonstrate that most patients consider the goal to be secondary or tertiary prevention.

The Nordic Maintenance Care Program: What Are The
Indications For Maintenance Care In Patients With
Low Back Pain? A Survey of the Members of the
Danish Chiropractors' Association

Chiropractic & Osteopathy 2010 (Sep 1); 18: 25 ~ FULL TEXT

Non-indications for MC were: 1) a good outcome combined with no previous events, or 2) a past history of LBP and gradual worsening with treatment. Indications for MC were a good outcome combined with a previous history of low back pain between once a month and once a year.

The Nordic Maintenance Care Program - Time Intervals
Between Treatments of Patients With Low Back Pain:
How Close and Who Decides?

Chiropractic & Osteopathy 2010 (Mar 8); 18: 5 ~ FULL TEXT

There were two distinctly different patterns for the time period between visits for MC patients and non-MC patients. For non-MC patients, the most frequent interval between visits was one week and for MC patients, the period was typically between two weeks and three months.

The Nordic Maintenance Care Program: Case Management
of Chiropractic Patients With Low Back Pain
– Defining the Patients Suitable for
Various Management Strategies

Chiropractic & Osteopathy 2009 (Jul 12); 17: 7 ~ FULL TEXT

There appeared to be consensus among the participants in relation to the rationale for at least four of the management strategies and partial consensus on the rationale for the remaining two. These results confirm that there is a pattern among Nordic chiropractors in how they manage patients with LBP.

The Nordic Maintenance Care Program – An Interview Study
on the Use of Maintenance Care in a Selected Group
of Danish Chiropractors

Chiropractic & Osteopathy 2009 (Jun 17); 17: 5 ~ FULL TEXT

The results from the questionnaire in the Danish survey showed that the response pattern for the nine scenarios was similar to that obtained in the Swedish survey. There seems to be relative agreement between chiropractors working in different countries and sampled through different methods in relation to their choice of management strategies in patients with low back pain.

The Nordic Maintenance Care Program: When Do
Chiropractors Recommend Secondary and Tertiary
Preventive Care For Low Back Pain?

Chiropractic & Osteopathy 2009 (Jan 22); 17: 1 ~ FULL TEXT

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.

The Nordic Maintenance Care Program – Case Management
of Chiropractic Patients With Low Back Pain:
A Survey of Swedish Chiropractors

Chiropractic & Osteopathy 2008 (Jun 18); 16: 6 ~ FULL TEXT

In general, patients of concern would be referred out for a second opinion, cases with early recovery and without a history of previous low back pain would be quickly closed, and cases with quick recovery and a history of recurring events would be considered for maintenance care.

Maintenance Care In Chiropractic – What Do We Know?
Chiropractic & Osteopathy 2008 (May 8); 16: 3 ~ FULL TEXT

It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown.

Other Key Studies/Guidelines Regarding Maintenance Care

Maintenance Care Recommendations from the Mercy Conference
Guidelines for Chiropractic Quality Assurance and Practice Parameters
1993 • Aspen Publishers, Inc.

Preventive orientation to health through health promotion is well established. Health promotion provides the opportunity for chiropractic practitioners to promote health through assessment, education, and counseling on topics such as nutrition, exercise, stress reduction, life style patterns, weight reduction, smoking cessation, and ergonomics, among others.

Chapter 14 – Preventative/Maintenance Care from
Chiropractic in Canada

Clinical Guidelines for Chiropractic Practice in Canada (1994) ~ FULL TEXT

The practice of chiropractic usually deals with acute therapeutic intervention and long-term care plans. This chapter focuses on the latter, which includes wellness or preventative care (designed to reduce the future incidence of illness or impairment) and health promotion (based upon optimal function).

Visit Frequency and Outcomes for Patients Using Ongoing
Chiropractic Care for Chronic Low-Back and Neck Pain:
An Observational Longitudinal Study
Pain Physician 2021 (Jan); 24 (1): E61–E74 ~ FULL TEXT

This 3-month window on chiropractic patients with CLBP and/or CNP revealed that they were improving, although slowly; may have reached maximum therapeutic improvement; and are possibly successfully managing their chronic pain using a variety of chiropractic visit frequencies. These results may inform payers when building coverage policies for ongoing chiropractic care for patients with chronic pain.

Chiropractic Maintenance Care - What’s New?
A Systematic Review of the Literature

Chiropractic & Osteopathy 2019 (Nov 21); 27: 63 ~ FULL TEXT

Knowledge of chiropractic Maintenance Care has advanced. There is reasonable consensus among chiropractors on what Maintenance Care is, how it should be used, and its indications. Presently, Maintenance Care can be considered an evidence-based method to perform secondary or tertiary prevention in patients with previous episodes of low back pain, who report a good outcome from the initial treatments. However, these results should not be interpreted as an indication for Maintenance Care on all patients, who receive chiropractic treatment.

Short or Long-term Treatment of Spinal Disability in
Older Adults with Manipulation and Exercise
Arthritis Care Res (Hoboken). 2019 (Nov); 71 (11): 1516–1524 ~ FULL TEXT

182 participants were randomized. The short-term and long-term groups demonstrated significant improvements in back (–3.9, 95% confidence interval (CI) –5.8 to –2.0 versus –6.3, 95% CI –8.2 to –4.4) and neck disability (–7.3, 95% CI –9.1 to –5.5 versus –9.0, 95% CI = –10.8 to –7.2) after 36 weeks, with no difference between groups (back 2.4, 95% CI –0.3 to 5.1; neck 1.7, 95% CI –0.8 to 4.2). The long-term management group experienced greater improvement in neck pain at week 36, self-efficacy at week 36 and 52, functional ability and balance.

Ratings of Perceived Effectiveness, Patient Satisfaction
and Adverse Events Experienced by Wellness Chiropractic
Patients in a Practice-based Research Network

Complement Ther Clin Pract. 2019 (Aug); 36: 82–87 ~ FULL TEXT

Wellness patients are predominantly female, rating their care as effective/very effective and with high satisfaction. Adverse events reported were minor (i.e., self-limiting) with a prevalence ranging from 6.3% to 11.3%. Experiencing an AE and the chiropractor providing care had a significant effect on patient satisfaction ratings. We support continued research in characterizing the patterns and utilization of chiropractic services for wellness chiropractic patients.

Community-based Free Clinics: Opportunities for
Interprofessional Collaboration, Health Promotion,
and Complex Care Management

J Chiropractic Education 2016 (Mar); 30 (1): 25–29 ~ FULL TEXT

This patient population is demographically diverse. A high proportion of patients who used tobacco, or were overweight or obese expressed interest in information on those topics. A substantial proportion reported being under care with a mental health professional. This clinic provides opportunities for students to work with diverse populations, collaborate with other professions, and practice health promotion.

Wellness-related Use of Common Complementary Health
Approaches Among Adults: United States, 2012

National Health Statistics Report 2015 (Nov 4); (85): 1–12 ~ FULL TEXT

This 12 page National Institutes of Health report presents national estimates of selected wellness-related reasons for the use of natural product supplements, yoga, and spinal manipulation among U.S. adults in 2012. Self-reported perceived health outcomes were also examined.

The Comparative Effect of Episodes of Chiropractic
and Medical Treatment on the Health of Older Adults

J Manipulative Physiol Ther 2014 (Mar); 37 (3): 143–154 ~ FULL TEXT

This study provides evidence of the comparative effectiveness of chiropractic care relative to medical-only services on the functional health of older adults during acute episodes of back care. Our results are the first to show the importance of examining chiropractic use within an episode of care in traditional practice settings, rather than focusing on visit frequency alone. Moreover, we evaluated the effects of the treatments received during the episodes on ADLs, IADLs, and LBFs, which are critically important measures that inform patients, clinicians, and payers about the benefits and harms of certain treatments relative to others. Given the literature supporting a minimally effective chiropractic treatment level for back problems, this research provides additional support that such therapeutic levels are indeed beneficial in terms of protecting older persons from functional declines and self-rated health over as much as 2 years.

Evidence-based Classification Of Low Back Pain In
the General Population: One-year Data Collected
With SMS Track

Chiropractic & Manual Therapies 2013 (Sep 2); 21: 30

In all, 261 study subjects were included in the analyses, for which 7 distinct LBP subsets could be identified. These could be grouped into three major clusters; those mainly without LBP (35%), those with episodic LBP (30%) and those with persistent LBP (35%). There was a positive association between number of episodes and their duration.

The Impact of Chiropractic Care On Health:
Why Maintenance Care Makes Sense

A Chiro.Org Editorial ~ March 10, 2013

Coulter and researchers at the RAND Corporation [1] performed an analysis of an insurance database, comparing persons receiving chiropractic care with non-chiropractic 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 non-chiropractic patients.

Consensus Process to Develop a Best-Practice Document
on the Role of Chiropractic Care in Health Promotion,
Disease Prevention, and Wellness

J Manipulative Physiol Ther. 2012 (Sep); 35 (7): 556–567 ~ FULL TEXT

Chiropractic wellness care (sometimes referred to as maintenance care [MC]) is accepted by the profession as an integral part of chiropractic practice. [1–6] The theory of MC suggests that ongoing chiropractic care may have value in maintaining and promoting health, as well as preventing disease. [7] In the late 1990s, a survey of a small sample of US doctors of chiropractic (DCs) (n = 658) self-reported that they recommended MC to 79% of their patients but that only 34% of those patients elected to pursue this type of care. [3]

Zen and the Art of Chiropractic Maintenance:
An Inquiry Into Health Care Values

Dynamic Chiropractic (January 1, 2012)

The same might be said of chiropractic's own journey, in this case seeking proper recognition. In particular, chiropractic from the point of view of a variety of third-party payers has been repeatedly turned down for reimbursement when it comes to matters of maintenance or preventive therapy. Completely counterintuitive, you might say, in light of the repeated and sometimes urgent declarations that we hear to the effect that the only way to control the runaway costs and inefficiency of American health care is to emphasize preventive care, placing it at the highest rather than lowest priority of interventions. [2]   The evidence from recent research clearly demonstrates that the provision of maintenance or preventive measures from chiropractors appears to deliver tangible benefits, with major impacts upon our health care system:

A Theoretical Basis For Maintenance Spinal Manipulative
Therapy For The Chiropractic Profession

J Chiropractic Humanities 2011 (Dec); 18 (1): 74–85 ~ FULL TEXT

In summary, this narrative literature review manifested progressive physiological consequences as a result of joint immobility. When this is correlated with the biomechanical and neurological research finding of manipulative therapy, a line of reasoning arises that generates a theoretical framework for a physiological hypothesis of the basis of MMT. There appears to be a correlation of time intervals of immobility and the onset of joint adhesions, spinal joint degeneration, aberrant Ia neurological input, degeneration of the a-motor neuronal pool, motor end plate degenerative changes, and onset of muscular weakness and atrophy. This correlates with the usual clinical dosage of MMT as shown in clinician surveys in numerous countries and patient satisfaction (Fig 2). The graphic depiction clearly demonstrates that the clinical consensus of dosage of MMT has been found to be most beneficial at an average of once every 2 to 4 weeks. We also see here that it closely correlates with the studies that show onset of facet joint degeneration, neural degeneration, neuroplastic changes, and muscular atrophy and weakness at an average of 2 to 4 weeks.

Does Maintained Spinal Manipulation Therapy for
Chronic Non-specific Low Back Pain Result in
Better Long Term Outcome?

Spine (Phila Pa 1976) 2011 (Aug 15); 36 (18): 1427–1437

This new, single blinded placebo controlled study, conducted by Mansoura Faculty of Medicine at Mansoura University, conclusively demonstrates that maintenance care (aka Preventive Care) provides significant benefits for those with chronic low back pain.
This study also re-confirms the findings of a virtually identical study by Descarreaux (JMPT 2004)
Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain and Related Disabilities:
A Preliminary Study

and Ronald L. Rupert's (JMPT 2000)  
Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65.

The Trials of Evidence:
Interpreting Research and the Case for Chiropractic
The Chiropractic Report ~ July 2011 ~ FULL TEXT

For the great majority of patients with both acute and chronic low-back pain, namely those without diagnostic red flags, spinal manipulation is recommended by evidence-informed guidelines from many authoritative sources – whether chiropractic (the UK Evidence Report from Bronfort, Haas et al. [1]), medical (the 2007 Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society [2]) or interdisciplinary (the European Back Pain Guidelines [3]).

Health Maintenance Care in Work-Related Low Back Pain
and Its Association With Disability Recurrence

J Occupational and Environmental Medicine 2011 (Apr); 53 (4): 396–404 ~ FULL TEXT

This study found that you are twice as likely to end up disabled if you get your care from a Physical Therapist, rather than from a DC, and that patients were 60% more likely to be disabled if they choose an MD to manage their care, rather than a DC.

A Randomised Controlled Trial of Preventive Spinal
Manipulation With and Without a Home Exercise
Program For Patients With Chronic Neck Pain

BMC Musculoskelet Disord. 2011 (Feb 8); 12: 41 ~ FULL TEXT

This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.

Consensus Terminology for Stages of Care:
Acute, Chronic, Recurrent, and Wellness

J Manipulative Physiol Ther 2010 (Jul); 33 (6): 458–463 ~ FULL TEXT

As the chiropractic profession pursues its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic case management is clearly delineated. To ensure equitable inclusion in the health care arena, it is imperative that the terms used in our interprofessional discussions are common to all health care providers. Therefore, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), at the behest of the American Chiropractic Association (ACA) Insurance Relations Committee, engaged in a multidisciplinary consensus process to address the terminology related to “levels of care.”
You may also enjoy this ACA Press release titled:
Chiropractic Reaches Consensus On Terminology For Stages Of Care

Process Versus Outcome:
Challenges of the Chiropractic Wellness Paradigm

J Chiropractic Humanities 2009 (Dec); 16 (1): 50–53 ~ FULL TEXT

The term wellness is ubiquitous and is not a term that is unique to the chiropractic profession. Almost every profession including chiropractic, medicine, dentistry, optometry, physical therapy, podiatry, psychiatry, and veterinary medicine have incorporated this buzzword into its discipline. According to Pilzer, wellness in 2007 was expected to be a $500 billion industry; this is an increase of $300 billion from 2002. [1]

Pilot Study of the Effect of a Limited and Extended Course
of Chiropractic Care on Balance, Chronic Pain, and
Dizziness in Older Adults

J Manipulative Physiol Ther. 2009 (Jul); 32 (6): 438–447 ~ FULL TEXT

Falls are one of the chief public health concerns for older adults, being the leading cause of nonfatal injury and comprising two thirds of all unintentional injury deaths in this population. [1] Direct medical costs of falls are estimated to be $6 to $8 billion per year. [2] Not only is the number of older adults increasing, but also the fall death rates have increased significantly from 1988 to 2000 for both men and women. [3]

Public Health, Wellness, Prevention, and Health Promotion:
Considering the Role of Chiropractic and Determinants of Health

J Manipulative Physiol Ther. 2009 (Jul); 32 (6): 405–412 ~ FULL TEXT

Prevention, wellness, and health promotion are often neglected when compared to short-term care treatments (eg, antibiotics) and disease prevention (eg, vaccinations). Unfortunately, many people presently rely upon the health care system to fix their health problems that may have developed over a period of years rather than modifying their behaviors to promote good health and prevent chronic illnesses. Chiropractic's historical approach to patient health has focused on the patient's innate, homeostatic powers of the body to heal, which include physical, psychosocial, emotional, and/or spiritual components. [9] As stated by Palmer, [12] chiropractic's founder, “Functions performed in a normal manner and amount result in health. Diseases are conditions resulting from either an excess or deficiency of functioning.” Thus, the chiropractic profession embraced a broad definition of health years before the World Health Organization adopted its 1946 definition that health is, [13] “[a] state of complete physical, mental, and social well-being and not merely the absence of disease.”

Psychological Response in Spinal Manipulation: A Systematic
Review of Psychological Outcomes in
Randomised Controlled Trials

Complementary Therapies in Medicine 2007 (Dec); 15 (4): 271–283

One hundred and twenty nine RCTs of spinal manipulation were identified; 12 had adequately reported psychological outcomes. Six trials with a verbal intervention comparator were combined in a meta-analysis, and found a mean benefit from spinal manipulation equivalent to 0.34 of the population standard deviation (S.D.) [95% confidence interval (CI) 0.23–0.45] at 1–5 months; 0.27 of the S.D. [95% CI 0.14–0.40] at 6–12 months. There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.

Chiropractic Care of Musculoskeletal Disorders in a Unique
Population Within Canadian Community Health Centers

J Manipulative Physiol Ther 2007 (Mar); 30 (3): 165–170 ~ FULL TEXT

Patients of low socioeconomic status face barriers to accessing chiropractic services. This study suggests that chiropractic care reduces pain and disability as well as improves general health status in patients with MSK conditions. Further studies using a more robust methodology are needed to investigate the efficacy and cost-effectiveness of introducing chiropractic care into publicly funded health care facilities.

Fostering Critical Thinking Skills:
A Strategy for Enhancing Evidence Based Wellness Care

Chiropractic & Osteopathy 2005 (Sep 8) Volume 13 (1): 19 ~ FULL TEXT

Chiropractic has traditionally regarded itself a wellness profession. As wellness care is postulated to play a central role in the future growth of chiropractic, the development of a wellness ethos acceptable within conventional health care is desirable. This paper describes a unit which prepares chiropractic students for the role of "wellness coaches". Emphasis is placed on providing students with exercises in critical thinking in an effort to prepare them for the challenge of interfacing with an increasingly evidence based health care system.

Self-reported Nonmusculoskeletal Responses to
Chiropractic Intervention: A Multination Survey

J Manipulative Physiol Ther 2005 (Jun); 28 (5): 294–302 ~ FULL TEXT

Positive reactions were reported by 2% to 10% of all patients and by 3% to 27% of those who reported to have such problems. Most common were improved breathing (27%), digestion (26%), and circulation (21%).

Quality of Life Changes in a Disadvantaged, Underserved
Chiropractic Patient Population: A Retrospective
Case Series Report

J Vertebral Subluxation Research 2005 (Apr 15): 1–3

SF-36 mean scores of patients from the shelter increased in each of the scales and summary scores. Results must be interpreted cautiously because of the small number of participants, but it is interesting to note that the vitality scale (VT) score improved 22 points. This increase was enough to achieve statistical significance (p equals 0.02) despite the small numbers of patients involved. It appears that chiropractic care holds promise and merits further investigation as one means of enhancing the quality of life in the homeless population studied in this case series report.

Chiropractic Maintenance Care and Quality of Life of a
Patient Presenting with Chronic Low Back Pain

J Manipulative Physiol Ther 2005 (Feb); 28 (2): 136–142 ~ FULL TEXT

The patient appeared to experience improvement in quality of life while showing signs suggestive of improved spinal function. The relationship between indicators of vertebral subluxation and quality of life deserves further investigation using a research design that allows for exploration of possible causal relationships.

Efficacy of Preventive Spinal Manipulation for Chronic
Low-Back Pain and Related Disabilities:
A Preliminary Study

J Manipulative Physiol Ther 2004 (Oct); 27 (8): 509–514 ~ FULL TEXT

This study demonstrated two important points:

(1) Chiropractic is effective for chronic low back pain (LBP), and
(2) that ongoing supportive care can reduce disability levels, as measured by the Oswestry Low Back Pain Disability questionnaire.

Objective Physiologic Changes and Associated Health Benefits
of Chiropractic Adjustments in Asymptomatic Subjects:
A Review of the Literature

J Vertebral Subluxation Research 2004 (Apr 26): 1–9

The data reviewed lend support to the contention that chiropractic adjustments, often for the purpose of correcting vertebral subluxation, confer measurable health benefits to people regardless of the presence or absence of symptoms. A significant amount of preliminary evidence supports that people without symptoms can benefit from chiropractic care. Improved function can be objectively measured in asymptomatic individuals following chiropractic care in a number of body systems often by relatively non-invasive means. It is plausible that chiropractic care may be of benefit to every function of the body and have the potential for long-term, overall health benefit to those receiving chiropractic care.

Chronic Pediatric Asthma and Chiropractic Spinal Manipulation:
A Prospective Clinical Series and Randomized Clinical Pilot Study

J Manipulative Physiol Ther 2001 (July); 24 (6): 369–377 ~ FULL TEXT

After 3 months of combining chiropractic SMT with optimal medical management for pediatric asthma, the children rated their quality of life substantially higher and their asthma severity substantially lower. These improvements were maintained at the 1-year follow-up assessment.
You may review many other articles about chiropractic and Asthma.

Maintenance Care: Towards A Global Description
J Canadian Chiropractic Association 2001 (Jun); 45 (2): 100–105 ~ FULL TEXT

Six hundred and fifty eight American (44%) and 138 Australian (35%) chiropractors returned completed questionnaires. Maintenance care is perceived to reduce recurrences, to maintain optimal health and provide relief for irreversible conditions. Health benefits are largely achieved by providing chiropractic adjustments, exercise and dietary counselling. Maintenance care is perceived to be particularly effective for managing musculoskeletal problems and stress but is also effective for conditions affecting the respiratory, gastro-intestinal, and to a lesser extent cardiovascular and reproductive systems. Respondents believe that maintenance care should be funded by insurance but recognise the need for further research.

Chiropractic Care of the Older Patient: Developing an
Evidence-based Approach

Proceedings of the World Federation of Chiropractic Congress 2001 (May); 6: 245–246

This study indicated that, as a profession, chiropractic has recognized the importance of geriatric education. Several articles indicate that the utilization of chiropractic services of older patients is increasing, and other articles indicate that many different conditions have been successfully resolved by chiropractic care. Although the results of this article are encouraging, continued research is necessary to further develop an evidence-based approach to chiropractic geriatric care, especially in the areas of maintenance care and the management of non-musculoskeletal conditions.

A Survey of Practice Patterns and the Health Promotion
and Prevention Attitudes of US Chiropractors.
Maintenance Care: Part I

J Manipulative Physiol Ther 2000 (Jan); 23 (1): 1–9 ~ FULL TEXT

Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.

Maintenance Care: Health Promotion Services Administered to
US Chiropractic Patients Aged 65 and Older, Part II

J Manipulative Physiol Ther 2000 (Jan); 23 (1): 10–19 ~ FULL TEXT

Rupert, Manello, and Sandefur surveyed 311 chiropractic patients, aged 65 years, who had received “maintenance care” for 5 years. Chiropractic patients receiving maintenance care, when compared with US citizens of the same age, spent only 31% of the national average for health care services and reported a 50% reduction in medical provider visits. The health habits of patients receiving maintenance care were better overall than the general population, including decreased use of cigarettes and nonprescription drugs. Furthermore, 95.8% believed the care to be either “considerably” or “extremely” valuable.

Unexpected Positive Nonmusculoskeletal Side Effects
of Chiropractic Care

J Manipulative Physiol Ther 1999 (Nov); 22 (9): 559–564 ~ FULL TEXT

A retrospective study conducted in Sweden [1] has determined that about one in four chiropractic patients experiences some form of "positive nonmusculoskeletal side effect" after spinal manipulative therapy (SMT). In addition, the percentage of patients who experience positive side effects increases with the number of spinal regions adjusted. The Swedish researchers asked all members of the Swedish Chiropractors Association (SCA) to participate in the study. Eighty-one percent of the SCA membership complied. Each doctor of chiropractic gathered data from 20 patients over a three-week period for a total of 1,504 valid patient questionnaires. Patients were included if they had been previously adjusted within the last two weeks for musculoskeletal complaints. The patients were asked if after their previous visit they ìexperienced any positive changes that do not seem to have anything to do with your back problem?

Stress: The Chiropractic Patients Self-perceptions
J Manipulative Physiol Ther 1999 (Jul); 22 (6): 395–398 ~ FULL TEXT

Of the 138 patients attending 1 of 10 participating chiropractic clinics, more than 30% regarded themselves as moderately to severely stressed, and over 50% felt that stress had a moderate or greater effect on their current problem. Some 71% of patients felt it would be helpful if their chiropractic care included strategies to help them cope with stress, and 44% were interested in taking a self-development program to enhance their stress management skills. Patient perceptions are known to be important in health care. A number of chiropractic patients perceive they are moderately or severely stressed. Interventions that reduce stress, or even the patient's perception of being stressed, may be construed as valid, non-specific clinical interventions. It may be timely for chiropractors to actively contemplate including stress management routinely in their clinical care protocols.

Maintenance Care
Topics In Clinical Chiropractic 1996; 3 (4): 32–35 ~ FULL TEXT

Complementary and alternative medicine strategies often offer patients more holistic approaches to health care than traditional disease-specific allopathic models. Chiropractic has historically offered a similar approach to improved health through the use of regular spinal manipulation or adjustments, often termed maintenance care. There is strong anecdotal support of regular spinal manipulation, both from chiropractors and their patients that invites further research to substantiate these claims.

Chiropractic Patients in a Comprehensive Home-Based
Geriatric Assessment, Follow-up and
Health Promotion Program

Topics In Clinical Chriopractic 1996 (Jun): 3 (2): 46–55

Coulter et al 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.

A Comparative Study of the Health Status of Children
Raised Under the Health Care Models of
Chiropractic and Allopathic Medicine

J Chiropractic Research 1989 (Summer); 5: 101–103

This 1989 study compared the health of two hundred children under chiropractic care and two hundred children under medical care. The chiropractic children had fewer ear infections, fewer allergies, fewer cases of tonsillitis, and needed less medical treatment (antibiotics and other medications). The authors noted that there is a “definite correlation between chiropractic care and superior health.” In fact, this study “has shown that children raised under chiropractic care are less prone to infectious processes such as otitis media and tonsillitis, and that their immune systems are better able to cope with allergens such as pollen,weeds, grasses, etc. compared to children raised under allopathic care. There is also a significant decreased history of antibiotic use among the ‘Chiropractic’ children, indicating a lower susceptibility to bacterial infections as a result of their greater immune system response.”

Changes in Wellness and Quality of Life During
Subluxation-Centered Chiropractic Care

Most studies of chiropractic efficacy have been limited to low back pain, neck pain or headaches. The notion that chiropractic may enhance one's life experience if used on an ongoing basis has been largely ignored in the literature. In that sense, chiropractic care, aimed at the removal of vertebral subluxation, may be of benefit to a wider proportion of the population, besides those complaining of specific illness or pain. Evidence is needed to justify the use of long-term chiropractic care in a population in which the main goals of care are the advancement of health and human potential rather than the treatment of disease or the alleviation of pain.

Reference Materials

Chiropractors as the Spinal Health Care Experts
A Chiro.Org article collection

Enjoy these learned articles about chiropractors as first-contact Spinal Health Care Experts.

Health Promotion & Wellness Articles
A Chiro.Org article collection

Enjoy this series of articles (mostly by by Meridel I. Gatterman, MA, DC, MEd) as they review how DCs have traditionally counseled patients on health promotion and wellness.   You will find these articles most informative!

Immune Function and Chiropractic
A Chiro.Org article collection

This page reviews the impact of the chiropractic adjustment on immune function.

Nutrition Section @ Chiro.Org
A Chiro.Org article collection

Review how proper diet and supplementation can support a healthy lifestyle.

Documentation Supporting Maintenance Care
Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC
Enjoy this fascinating mini-review of 10 different studies that discuss the improvements that occur when patients receive supportive Maintenance Care.


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