Clinical Guidelines for Chiropractic Practice in Canada
Chapter 14 - Preventative / Maintenance Care
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).
Some confusion arises from the use of various terms to describe such care - including supportive care, maintenance care, and preventative care. In this chapter a distinction is drawn between two kinds of long-term chiropractic care: supportive care, which has therapeutic necessity; and preventative/maintenance care, which is elective.
Long-term ongoing health management has been a significant component of the holistic chiropractic model of health. Surrounding this is a wellness paradigm that recognizes related influences on health, emphasizes drugless, non-surgical management, and takes a positive dynamic view of health. In addition to periodic passive care, the model looks to the whole individual and requires active patient participation.
Active care efforts emphasize patient responsibility and may include exercise programs, weight loss, other dietary counselling, lifestyle modifications, education on body postures and mechanics, coordination training, safety habits, modification of life stressors, etc.
This type of management program, which combines health promotion, preventative/maintenance care, and patient participation, is gaining much more widespread understanding and acceptance in today's more health conscious society.
For definitions see the Glossary at the end of this publication.
Preventative/Maintenance Care: Any management plan that seeks to prevent disease, prolong life, promote health and enhance the quality of life. A specific regimen is designed to provide for the patient's well-being or for maintaining the optimum state of health.
Supportive Care: Treatment for patients who have reached maximum therapeutic benefit, but who fail to sustain this benefit and progressively deteriorate when there are periodic trials of withdrawal of treatment. Supportive care follows appropriate application of active and passive care including rehabilitation and lifestyle modifications. It is appropriate when alternative care options, including home-based self-care, have been considered and attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when the risk of supportive care outweighs its benefits, i.e., physician dependence, somatization, illness behaviour, or secondary gain.
III. LIST OF SUB-TOPICS
IV LITERATURE REVIEW AND DISCUSSION
From the very beginning, the chiropractic model of health has had as its foundation the maxim that a human being is an ecologically and biologically unified organism. The relationship between a patient's internal and external environment must be understood. A major premise is that the inherent recuperative power of the body aids restoration and maintenance of health. These assumptions comprise a wellness paradigm embraced by the great majority of the chiropractic profession. The vertebral subluxation complex, along with other factors such as poor nutrition, stress, trauma, heredity, congenital weaknesses, fatigue, environmental stresses and sedentary lifestyles, is viewed as lowering resistance and creating physical disharmony (Shafer and Faye 1989, Gatterman 1990, Lantz 1989). The chiropractic model requires active patient participation (Coulter 1990, Jamison 1991, Coile 1990).
Patients presenting with a musculoskeletal problem often obtain a swift and favourable result. Then they may look to the practitioner for other health care needs (Shekelle, 1991).
Some patients require ongoing long-term care, others choose it. The effectiveness of chiropractic preventative/maintenance care unfortunately has not been thoroughly subjected to study by randomized trials, a process that presents major methodological and financial challenges, but is supported by evidence from case studies. (Stacey 1989, Yates et al. 1988). In one such study titled Functional Disturbances of the Spinal Column in Children and the Problems of Prevention of Vertebrogenic Lesions, Lewitt and Janda (1964) conclude that "the prime factor in the pathogenesis of vertebrogenic lesions is a disturbance of function which precedes morphological changes and which also closely corresponds to clinical symptoms". Manipulation of pain-free children with sacroiliac dysfunction produced positive short and long-term postural effects. In his most recent text Lewit, a neurologist, recommends preventative manipulative care, especially for children (Lewit 1991). However, the overall efficacy of preventative health care remains a subject of considerable debate (Hahn 1990, Kaplan 1990).
Preventative/maintenance care is elective care for patients without present disability or major symptoms. Therapeutic necessity is absent by definition. Clinically there is a need to distinguish for each patient when therapeutic and supportive care stops, and when preventative/maintenance care begins. The latter is considered safe and effective when used discriminately so as not to foster doctor dependence and chronicity.
Enhanced public awareness of environmental, psychosocial, and psychological issues through education and community action has forced preventative care onto the public health agenda as the number one priority. Smoking cessation, weight control, nutritional considerations, stress reductions and advice about exposure to environmental pollutants are examples of initiatives affecting the chiropractic patient population.
Coile (1990) offers this historical perspective: "Thirty years ago, René Dubois, a research microbiologist, suggested in Mirage of Health that the advancement he and others had made in the development of antibiotics and therapeutics had less to do with the real health of populations than a variety of economic, social, nutritional, and behavioral factors. Five years later, the U.S. Surgeon-General's landmark report clearly revealed the links between smoking and diseases such as emphysema, chronic bronchitis, hypertension and lung cancer.
"A new awareness of the contribution of lifestyle, environment, and genetics infused medicine in the decade following. Sometimes called the `wellness movement', this new orientation broadened the paradigm of traditional biomedicine. Since Dubois' essay on health, a body of research findings has accumulated that demonstrates the validity of a more comprehensive approach to health, one which recognizes the many antecedents and co-factors in the disease and healing process.
"Although not fully accepted by all physicians, the holistic concept of health is gaining stature. Dozens of studies by employers have begun to quantify the beneficial impact of health promotion programs in terms of reduced health care utilization and lower health care costs".
The principles and practices of long-term care in chiropractic have been discussed by a number of authors (Coulter 1990, Jamison 1991A, Coile 1990, Jamison 1991A) offers a comprehensive overview of the current trends in chiropractic, and worksheets for health care assessment. McDowell and Newell (1987) describe general health care indicators and instruments. Jamison (1991B) reviews the improvement of basic health status by alteration of behaviour, especially through health education.
Some recent surveys focus upon musculoskeletal chiropractic practice (Phillips 1982, Wardwell 1989, Shekelle and Brook 1991) but other current literature takes a firm stance on the importance of maintaining a focus on prevention and health promotion (Coulter 1990, Sportelli 1985, Caplan 1991).
Areas with new significance for chiropractic long-term care include the management of osteoporosis (Stacey 1989), and hypertension and stress management (Yates et al. 1988).
No study yet addresses what specific impact preventative/maintenance care has on overall health care costs, or if preventative care enhances longevity or quality of life.
Today, however, research into such complex issues as these is becoming more feasible (Nyiendo 1991, Kassak 1991, Jose 1990).
Notwithstanding the challenges of research in the field of preventative care, there must be publication of valid clinical studies before chiropractic long-term preventative/maintenance care gains widespread recognition as an important component of health maintenance and wellness (Balduc 1988, Feinstein 1990)
V. ASSESSMENT CRITERIA
Rating Systems 2 assessment criteria are used in this chapter. For an explanation of this system see the Introduction and Guide to Use (p. xxiii).
VI. LIST OF RECOMMENDATIONS FOR EACH SUB-TOPIC
14.1 Preventative/maintenance care is discretionary and elective on the part of the patient. When recommended, it is necessary for the chiropractor to clearly identify the nature of this care.
Evidence: Class III
Consensus level: 1
14.2 The objectives of preventive/maintenance care in chiropractic practice are the prevention of ill health and the promotion of wellness or optimum health, as for example in the early detection and correction of neuromusculoskeletal disorders to prevent the onset of symptoms and disability.
Evidence: Class III
Consensus level: 1
14.3 Methods used in preventative/maintenance care must include periodic reassessment and may include treatment, education and counselling on topics such as exercise, spinal health, stress reduction, posture, lifestyle patterns and habits, and nutrition.
Evidence: Class III
Consensus level: 1
14.4 The frequency of preventative/maintenance care is determined on an individual basis, but generally should not exceed once per month. The frequency of care may vary if the patient's condition changes. In these circumstances there is a reassessment and conversion to appropriate therapeutic intervention, which may include initial and supportive care.
Evidence: Class III
Consensus level: 1
VII. COMMENTS, SUMMARY OR CONCLUSION
This chapter provides an analytical framework and specific interim guideline recommendations with respect to complications of and contraindications to manipulative thrust procedures. At present detailed systematic studies on this subject are lacking and the recommendations made are based on information from clinical reviews and case reports, as well as from expert and consensus methods. One objective of this chapter is to encourage productive debate leading to firmer commitment on risk management protocols.
Recommendations made must be continuously re-evaluated in light of ongoing research and clinical experience. Co-operative intradisciplinary and interdisciplinary research will be necessary to determine the true extent of the nature and incidence of iatrogenic complications in chiropractic practice. The development of a central registry system capable of generating comprehensive research data would be valuable, and would facilitate the establishment of more detailed and refined guideline recommendations in the future.
Balduc H. How chiropractic care can promote wellness (Northwestern College of Chiropractic).
Caplan RL. Health care reform and chiropractic in the 1990s. J Manipulative Physiol Ther 1991; 14(6):341-354.
Coile JR, Russell C. Promoting health, the new medicine: reshaping medical practice and health care management. Rockville: Aspen Publishers, 1990; 151-166.
Coulter ID. The patient, the practioner, and wellness: paradigm lost, paradigm gained. J Manipulative Physiol Ther 1990; 13(2):107-111.
Feinstein AR. Problems, pitfalls, and opportunites in long-term randomized trials. Drug Res 1989; 39:980-985.
Gatterman MI. Chiropractic management of spinal related disorders. Baltimore: Williams & Wilkins, 1990; 3.
Hahn DL, Berger MG. Implementation of a systematic health maintenance protocol in a private practice. J Family Practice 1990; 31(5).
Jamison JR. The chiropractor as health information resource, health promotion for chiropractic practice. Gaithersburg: Aspen Publishers Inc, 1991:35-36.
Jamison J. Preventive chiropractic and the chiropractic management of visceral conditions: Is the cost to chiropractic acceptance justified by the benefits to health care? Chiropr J Aust 1991; 9(3):95-101.
Jose WS. Health objectives of the year 2000: a challange to the chiropractic profession. Proceedings: American Public Health Association, Atlanta, 1991.
Kaplan RM. Behaviour as the central outcome in health care. American Psychologist 1990; 45:1211-1220.
Karl SV. The detection and modification of psychosocial and behavioral risk factors. Applications of social science to clinical medicine and health policy. New Brunswick: Rutgers University Press, 1986: chapter 17.
Kassak K. Outcomes measurement assessment: the experience NWCC. Proceedings: American Public Health Association. Atlanta, 1991.
Lantz CA. The vertebral subluxation complex. International Review of Chiropractic, 1989.
Lewit K, Janda V. Functional disturbances of the spinal column in childhood and the problem of prevention of vertebrogenic lesions. Acta Uiv Carol Med Suppl 1964; 19.
Lewit K, Manipulative Therapy. In: Lewit K, ed. Rehabilitation of the locomotive system, 2nd ed. London: Butterworth Heinman, 1991.
McDowell I, Newell C. Measuring health: a guide to rating scales and questionnaires. New York: Oxford University Press, 1987.
Nyiendo J, Jaas M, Jones R. Using the SF-36D (General Health Status Questionnaire) in a pilot study of outcome assessment for low-back (chiropractic) patients. Proceedings: International Conference on Spinal Manipulation. Arlington, VA., 1991.
Phillips RB, Butler R. Survey of chiropractic in Dade County, Florida. J Manipulative Physiol Ther 1982; 5(2):83-89.
Schafer RC, Faye LJ. Motion palpation and chiropractic technique, 2nd ed. Huntington Beach: Motion Palpation Institute, 1989.
Shekelle PG, Brook RH. A community-based study of the use of chiropractic services. Amer J Public Health 1991; 81(4):437-442.
Sportelli L. The future of health and health care: contradictions and dilemmas. J Manipulative Physiol Ther 1985; 8(4):271-282.
Stacey TA: Osteoporosis: exercise therapy, pre- and post-diagnosis. J Manipulative Physiol Ther 1989; 12(3):211-219.
Wardwell WI: The Connecticut survey of public attitudes toward chiropractic. J Manipulative Physiol Ther 1989; 12(3):167-173.
Yates RG, Lamping DL, Abram NL, Wright C. Effects of chiropractic treatment on blood pressure and anxiety. A randomized, controlled trial. J Manipulative Physiol Ther 1988; 11(6):484-488.
IX. MINORITY OPINIONS