J Canadian Chiropractic Association 2001 (Jun); 45 (2): 100–105 ~ FULL TEXT
Jennifer R Jamison, MB, BCh, PhD, EdD, AND Ronald L Rupert, MS, DC
Professor of Diagnostic Sciences,
Department of Chiropractic, Osteopathy & Complementary Medicine,
Faculty of Biomedical & Health Sciences,
RMIT, Bundoora Campus, Plenty Road,
Bundoora Vic Australia 3083.
Objective: To describe and compare maintenance care as practised in the United States and Australia.
Design: Postal surveys of randomly selected samples of American and Australian chiropractors was
Results: 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.
Conclusion: Description of a globally practised form of maintenance care helps to clarify scope of practice issues. More fundamental question of how and whether each of the elements described contributes to a wellness outcome can only be resolved with further research.
KEY WORDS: chiropractic, maintenance care, prevention.
From the Full-Text Article:
A random sample of US chiropractors found that although
two out of three respondents believed that chiropractic was
viewed as a therapeutic modality, eight out of ten believed
that it should be viewed as a complete system of health
care.  Most chiropractors certainly consider themselves
primary care practitioners  and the chiropractic profession
is legally permitted to and does offer a broad range of
diagnostic and treatment procedures.  A study involving
adult primary care physicians and members of a health
maintenance organisation furthermore found more interest
in having the HMO cover manipulative and behavioural
medicine therapies than other ‘alternative therapies’.  It is
consequently important that the nature of preventive services
provided by chiropractors is clarified.
One survey found the prevention practices most often
acknowledged by US chiropractors related directly to
musculoskeletal problems with counselling emphasising
lifting techniques, postural education, fitness exercise and
injury prevention.  Another found that chiropractic maintenance
care may be construed to provide a more comprehensive
description of the type of long term preventive
care patients may expect from the chiropractic profession.
 Until recently maintenance care has not been clearly
described. [5, 6] This study seeks to compare data from the US
and Australian surveys and offers a preliminary suggestion
for a global description of maintenance care.
The postal questionnaire is a well established means of
biomedical inquiry. The survey was initially designed after
a careful review of previously published work related
to maintenance care. Subsequent to that, a small pilot in
the USA consisting of a convenience sample of 24
practicing chiropractors was used to test and revise the
questionnaire. Chiropractors in the United States were randomly
selected by postal zip codes using the computerized
database of the National Directory of Chiropractic. This
database is updated continually in an attempt to include all
chiropractors in active practice. This sampling method insured
inclusion of chiropractors from all fifty states. In
addition to the survey, an addressed and postage paid return
envelope was included. Participants were advised that
their responses would be kept confidential.
A postal survey of members of the Chiropractors’ Association
of Australia was also undertaken. In an effort to
better ascertain the perceptions of mainline Australian
chiropractic, the Australian survey was restricted to
members of an Association that has traditionally been
regarded as representing chiropractic in this country.
Four hundred names were randomly selected from the
1999 directory of the Chiropractors’ Association of Australia.
Care was taken to ensure that chiropractors from
each of the states and territories were included. Each of
the chiropractors selected using random numbers was
mailed a covering letter, an informed consent form, a
questionnaire and a reply paid envelope. Potential participants
were asked to complete the questionnaire and
return it with the signed consent form. Participants were
given the option of remaining anonymous. No reminders
Because of the absence of previous research, the questionnaire
included 40 questions covering a broad range of
issues. The first five questions were fill-in and asked the
respondents for age, sex and other general demographic
information. This was followed by 28 questions related to
the following; the purpose of maintenance care, the types
of conditions or body systems that benefit most, which age
groups derive the most benefit, and what therapies or treatment
interventions are included. These 28 questions used a
5 point Likert scale format. The scale permitted a range of
responses from ‘strongly agree’ to ‘strongly disagree’. The
final 7 questions solicited a brief fill-in response. This concluding
part of the survey requested information about
how frequently maintenance care is recommended, how
many comply with the recommendations and the financial
impact of providing these services.
The pilot study identified diverse opinions related to
several issues. Most notable was the question of what was
the purpose of MC. Because of this, the survey permitted
chiropractors to select from a wide variety of possible responses
rather than the investigators attempting to impose
an arbritrary definition of the purpose of MC.
The response rate of the US sample was 44%, that of the
Australian case study was 35%.
Table 1 compares the
characteristics of the US and Australian chiropractic
Table 2 describes and compares the purposes for which
chiropractic respondents use maintenance care and
Table 3 identifies the therapeutic interventions used when practising
Table 4 outlines and compares clinical circumstances which respondents perceive as responsive
to maintenance care.
Table 5 compares the chiropractors perceptions about
how well maintenance care is supported by research, the
need for more research in this area and the desirability of
insurance health cover for this practice. It also identifies
the extent to which chiropractic respondents believe maintenance
care is used. It should be noted that although Australian
chiropractors believe only 6 in 10 chiropractors
practise maintenance care, 97% of Australian respondents
to this study indicated they were prepared to offer maintenance
care in their clinic.
Table 1: The Study Sample
CHARACTERISTIC USA SAMPLE (n = 658) AUSTRALIAN (n = 138)
Males 83% 80%*
Females 17% 17%*
Age 76% under 45 years 60% 40 years old or under
Years In Practice 57% 10 years of less 47% 10 years or less
* 3% unknown
Table 2: The Purpose of Maintenance Care
FUNCTION OF MAINTENANCE CARE USA SAMPLE (n = 658) AUSTRALIAN (n = 138)
Minimise recurrence/exacerbations 95% 92%
Maintain/optimize health 88% 80%
Provide palliative care for 85% 78%
Determine and treat subluxations 80% 83%
Table: 3 Important Therapeutic Components of Maintenance Care
OF MAINTENANCE CARE USA SAMPLE (n = 658) AUSTRALIAN (n = 138)
Adjustments/manipulation 97% 85%
Exercise 96% 93%
Proper eating habits 93% 81%
Patient education eg 84% 72%
Use of vitamin and 67% 49%
Table 4: Conditions/Systems Amenable to Maintenance Care
DISORDERS/ORGAN SYSTEMS THAT
BENEFIT FROM MAINTENANCE CARE USA SAMPLE (n = 658) AUSTRALIAN (n = 138)
Musculoskeletal system 94% 91%
Stress 91% 83%
Respiratory system 79% 76%
Gastro-intestinal system 75% 72%
Cardiovascular system 58% 46%
Reproductive system 56% 57%
Table 5: Perceptions About the Status of Maintenance Care
MAINTENANCE CARE USA SAMPLE (n = 658) AUSTRALIAN (n = 138)
Is supported by adequate research 40% 22%
Requires more research 93% 97%
Should be paid for by insurance 72% 69%
Is performed by most chiropractors 82% 60%
There appears to be a marked similarity in the perceptions
of American and Australian chiropractors with respect to
the purpose, the organ system responsiveness to care and
the therapeutic composition of maintenance care. Maintenance
care is certainly perceived to reduce recurrences
(U.S. 95%, Australia 92%), to maintain optimal health
(U.S. 88%, Australia 80%) and provide relief for persistent
or irreversible conditions (U.S. 85%, Australia 83%).
These health benefits are achieved by providing chiropractic
adjustments (U.S. 97%, Australia 85%) and exercise
(U.S. 96%, Australia 93%) and dietary counseling (U.S.
93%, Australia 81%). A large number of chiropractors
also include patient education to quit unhealthy habits
(U.S. 84%, Australia 72%) and some may offer advise on
nutritional supplementation (U.S. 67%, Australia 49%).
While this study suggests that American chiropractors may offer more comprehensive health intervention than a
number of their Australian counterparts, maintenance care
in both countries does involve both manual therapy and
Maintenance care is seen to be particularly effective for
managing musculoskeletal problems and for stress management.
It is also seen to be reasonably effective for conditions
affecting the respiratory and gastro-intestinal
systems and less effective for cardiovascular and reproductive
system problems. The response rate to the respiratory
questions reflects the all-inclusive nature of the
question. Respondents may have interpreted the questions
as including both a functional and/or structural components.
In hindsight it may have been better to differentiate
between functional disorders characterised by muscle
spasm eg bronchospasm as in asthma, and structural
changes as in emphysema and chronic bronchitis. The tendency
for Americans to be marginally more enthusiastic
about the various aspects of maintenance care investigated
may derive from a number of factors including; differences
in educational systems, attitudes of patients towards
health promotion, the growing but limited reimbursement
for wellness related services, or many other socioeconomic
factors. These marginal differences may not reflect
any real difference in the perceptions of chiropractors
about the nature and function of maintenance care.
While there is consensus that more research into maintenance
care is required, a major discrepancy that emerged
between the two samples related to the adequacy of the
research basis of maintenance care. The Australian chiropractic
sample proved more sceptical. Such scepticism is
not misplaced. Studies have repeatedly shown that “Even
chiropractors trained in the same technique seem to show
little consensus on the indications for the necessity to adjust
specific segments of the spine”.  Others found their
“study of commonly used chiropractic diagnostic methods
in patients with chronic mechanical low-back pain to detect
manipulable lesions in the lower thoracic spine, lumbar
spine, and the sacroiliac joints has revealed that the
measures are not reproducible”.  Even researchers who
consider “Many of the clinical tests of passive general
motion range were shown to be reliable.” suggested the
need for further studies to establish reliability. 
Chiropractic research is evolving. Rather than chiropractors
continuing to view ‘science and research as
marketing strategies’,  a national meeting to develop a
research agenda for the chiropractic profession that targets
the need to increase chiropractic’s research capacity was
convened in 1996 in Washington.  While this American
ferment in chiropractic research demonstrates a laudable
trend, the scientific basis for correction and prevention of
subluxations, the unique characteristic of chiropractic
maintenance care, remains suspect. After concluding that
none of the tests they had studied had been sufficiently
evaluated in relation to reliability and validity, Hestoek
and Leboeuf-Yde suggested that: “The detection of the
manipulative lesion in the lumbo-pelvic spine depends on
valid and reliable tests. Because such tests have not been
established, the presence of the manipulative lesion remains
hypothetical”.  Eight out of 10 chiropractors perceive
one of the functions of maintenance care is to
determine and treat subluxations and about 9 in 10 perceive
adjustments to be an important therapeutic component
of maintenance care. Given this context, it is not
realistic for the chiropractic profession to expect health
insurance agencies to fund its preventive efforts within the
health care system until dysfunctions can be reliably detected
and corrected with a consistently predictable improvement
Despite progress and commitment to chiropractic research
and chiropractors holding firmly to the belief that
maintenance care will enhance health, the absence of research
to validate this belief still makes it impossible to
answer the question posed almost a decade ago: “Preventive
chiropractic: what justification?”.  Furthermore, the
current research agenda to investigate barriers to usage of
chiropractic; develop models to explain chiropractic usage;
determine cost-effectiveness of different chiropractic
procedures; develop valid measures and predictors of
quality of chiropractic care; and examine satisfaction with
chiropractic services may not necessarily address this issue.
 The wider research community is being challenged
to change its framework. The potency of the ‘placebo’ has
been acknowledged [15, 16] and maximising placebo benefits
are to be encouraged.  A research agenda to establish the
effective elements of interventions, placebo and otherwise,
needs to be formulated.  As chronic low back pain is
persistent once it is established, research that emphasise
maintenance of employment and function is likely to be
most productive.  It is within this evolving framework
that chiropractic maintenance care may achieve validation
as a valuable therapy.
Description of a globally practised form of maintenance
care helps to clarify scope of practice issues but fails to
address the more fundamental question of how and
whether each of the elements described contributes to a
wellness outcome. More research is urgently required.
This project was funded in part by a grant from the Foundation
for Chiropractic Education and Research with funds
from the National Chiropractic Mutual Insurance Company.
Support was also provided by Parker College of
Chiropractic. This Australian component of this study was
supported by the Australian Spinal Research Foundation.
Hawk C, Byrd L, Jansen RD, Long CR.
Use of complementary healthcare practices among chiropractors in the United States: a survey.
Altern Ther Health Med 1999; 5 (1): 56–62
Gordon NP, Sobel DS, Tarazona EZ.
Use of and interest inalternative therapies among adult primary care clinicians and adult
members in a large health maintenance organization.
West J Med 1998; 169 (3): 153–161
Lamm LC, Wegner E, Collord D.
Chiropractic scope ofpractice: what the law allows—update 1993.
J Manipulative Physiol Ther 1995 (Jan); 18 (1): 16–20
Hawk C, Dusio ME.
Survey of 492 U.S. chiropractors onprimary care and prevention-related issues.
J ManipulativePhysiol Ther 1995; 18 (2): 57–64
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
Maintenance care: an Australian case study.
Hawk C, Phongphua C, Bleecker J, Swank L, Lopez D, Rubley T.
Preliminary study of the reliability of assessment procedures for indications for chiropractic
adjustments of the lumbar spine.
J Manipulative Physiol Ther 1999; 22 (6): 382–389
French SD, Green S, Forbes A.
Reliability of chiropractic methods commonly used to detect manipulable lesions
in patients with chronic low-back pain.
J ManipulativePhysiol Ther 2000; 23 (4): 231–238
Fjellner A, Bexander C, Faleij R, Strender LE.
Interexaminer reliability in physical examination of the cervical spine.
J Manipulative Physiol Ther 1999; 22 (8): 511–516
Keating JC Jr, Green BN, Johnson CD.
“Research” and“science” in the first half of the chiropractic century.
J Manipulative Physiol Ther 1995; 18 (6): 357–378
Hawk C, Meeker W, Hansen D.
The National Workshop to Develop the Chiropractic Research Agenda.
J Manipulative Physiol Ther 1997; 20 (3): 147–149
Hestoek L, Leboeuf-Yde C.
Are chiropractic tests for the lumbo-pelvic spine reliable and valid?
A systematic critical literature review.
J Manipulative Physiol Ther 2000; 23 (4): 258–275
Preventive chiropractic: what justification?
Chiropr J Aust 1991; 21: 10–12
Mootz RD, Coulter ID, Hansen DT.
Health Services Research Related to Chiropractic: Review and Recommendations for
Research Prioritization by the Chiropractic Profession
J Manipulative Physiol Ther. 1997 (Mar); 20 (3): 201–217
Turner JA, Deyo RA, Loeser JD, Von Korff M, Fordyce WE.
The importance of placebo effects in pain treatment and research.
JAMA 1994; 271 (20): 1609–1614
Harnessing the placebo effect.
Hosp Pract 1998; 33 (7): 107–116
Moerman DE, Jonas WB.
Toward a research agenda on placebo.
Adv Mind Body Med 2000 (Winter); 16 (1): 33–46
Researching healing: a psychologist’s perspective.
J Altern Complement Med 2000 Apr; 6 (2): 181–186
Carey TS, Garrett JM, Jackman AM.
Beyond the good prognosis. Examination of an inception cohort of patients with chronic low back pain.
Spine 2000 Jan; 25 (1): 115–120
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