A theoretical basis for maintenance spinal manipulative therapy for the chiropractic profession

1) The purpose of this article is to discuss a theoretical basis for wellnesschiropractic manipulative care. 2) A search of PubMed and of the Manual, Alternative, and Natural TherapyIndex System was performed with a combination of key words: chiropractic,maintenance and wellness care, maintenance manipulative care, preventive spinalmanipulation, hypomobility, immobility, adhesions, joint degeneration, andneuronal degeneration, 1970-2011. 3) The search revealed surveys of doctors and patients, an initial clinical pilotstudy, randomized control trials, and laboratory studies that provided correlativeinformation to provide a framework for development of a hypothesis for the basis ofmaintenance spinal manipulative therapy. 4) Maintenance care optimizes the levels of function and provides a process ofachieving the best possible health. It is proposed that this may be accomplished byincluding chiropractic manipulative therapy in addition to exercise therapy, diet andnutritional counseling, and lifestyle coaching. 5) It is hypothesized that because spinal manipulative therapy brings a joint tothe 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 recruitmentpatterns, which may result in improved function, decreased episodes of injuries,and improved sense of well-being. 6) This article considers the scientific basis of the commonly practicedprocedure of chiropractic maintenance care and whether a hypothesis of aphysiological basis can be generated to explain findings and practice.Dr. Taylor cites studies to support these concepts: A)) Acute chiropractic care for the management of acute conditions. B)) Care for chronic/recurrent conditions is defined as medically necessary carefor conditions that are not expected to completely resolve, but in which one canprovide documented improvement. 2 [Chronic/recurrent care is medically necessary, even though the condition is notexpected to completely resolve] [Use measurement outcomes to document improvements] C)) Wellness or maintenance care may not be defined as being medicallynecessary for a current condition.However, this type of care optimizes the levels of function and provides a processof achieving the best possible function and health. This care includes chiropracticmanipulative therapy in addition to exercise therapy, diet and nutritionalcounseling, and lifestyle coaching.[Use measurement outcomes to show functional improvement which may qualifysuch care as being medically necessary] 7) The purpose of chiropractic maintenance care is to optimize spinal functionand decrease the frequency of future episodes of back pain. 8) Other definitions for chiropractic maintenance care include: A)) Appropriate treatment directed toward maintaining optimal body function.This is treatment of the symptomatic patient who has reached pre-clinical status ormaximum medical improvement, where condition is resolved or stable. B)) A regimen designed to provide for the patient’s continued wellbeing or formaintaining the optimum state of health while minimizing recurrences of the clinicalstatus. 9) The medical profession uses wellness as providing diagnostic tests for earlydetection of disease processes. 10) For this article, maintenance care and wellness care are used synonymouslyto represent the process of spinal manipulative therapy for an asymptomatic patientor a patient that has reached maximum therapeutic improvement. 11) Some insurance companies have defined maintenance care as care providedfor a stable condition without any functional improvement of the patient net healthoutcome over a 4-week period and further determine it as not being medicallynecessary. 12) In published surveys, 90+% of chiropractors opined that the purpose ofmaintenance care was to minimize recurrences or exacerbations; 80+% ofchiropractors responded that it would optimize the patients’ health. 13) 97% of American and 85% of the Australian chiropractors use manipulativetherapy as a component of the maintenance care. 14) 95% of chiropractors recommended maintenance care to minimizerecurrences or exacerbations of conditions and 90% recommended the care tooptimize the health of the patient. 15) In a study 96% of elderly patients who received maintenance care believedthat it was either considerably or extremely valuable. 16) It has been reported that 79% of patients in chiropractic offices arerecommended maintenance care and nearly half of those patients elect to receivethese services. 17) In animal studies, fixation of facet joints for 4-8 weeks causes degenerativechanges and osteophyte formation of the articular surfaces. These findings mayprovide an explanation to the anecdotal findings reported in clinical practice inwhich patients report increased well-being and decreased incidence of spinalcomplaints with once per month preventive wellness manipulation. 18) Sadly, facet articular surface degeneration began at less than 1 week. Thecommon clinical treatment frequency at every 4 weeks correlates with the findingsof the threshold of 4 weeks for irreversible degenerative osteophyte formation.This finding correlates with the common practice pattern of progressive decreasingof the frequency of manipulation as the patients progress in recovery from an acuteincident. It also indicates that even when patients present for once per monthasymptomatic preventive manipulation, the process of degeneration of the articularsurfaces may have already begun. 19) Facet joint fixation also resulted in synovial fold fibrotic adhesions thatprogressed to mild adhesions in 4 weeks, moderate adhesions in 8 weeks, andsevere adhesions after 12 weeks. In humans, it can be hypothesized that there isa period where the adhesions are forming without clinical symptoms. This wouldalso support the common once per month maintenance spinal manipulation. 20) It has also been demonstrated that lumbar spinal manipulation gaps the facetjoints which may break up adhesions. This would lend additional support for theonce per month clinically recommended spinal manipulative therapy. 21) Four weeks of joint immobilization has been found to cause a time dependentloss of neurons that becomes progressively worse thereafter. An increase inneurons occurs after release of the fixation. 22) Such immobilization also causes time dependent muscle weakness, atrophyand fatty deposition of the multifidi muscles. The time-dependent factor progressedfrom normal muscles to mild, moderate, and severe muscular atrophy. 23) There may also be a possibility of reversal of the neuronal degeneration andmuscular weakness through manipulation and remobilization of the joint.4 24) These progressive adverse physiological consequences of joint immobility,create a line of reasoning arises that generates a theoretical framework for aphysiological hypothesis of the basis of maintenance manipulative therapy. 25) Evidence clearly demonstrates that the clinical consensus of dosage ofmaintenance manipulative therapy has been found to be most beneficial at anaverage of once every 2 to 4 weeks. We also see here that it closely correlates withthe studies that show onset of facet joint degeneration, neural degeneration,neuroplastic changes, and muscular atrophy and weakness at an average of 2 to 4weeks. 26) Taking into account the neurological and biomechanical consequences ofmanipulative therapy, it is plausible to hypothesize that monthly manipulativetherapy retards the progression of adhesion formation, joint degeneration, neuronalchanges, and changes in muscular strength and recruitment patterns. This couldresult in improved function, decreased episodes of injuries, and improved sense ofwell-being. 27) A 2004 chiropractic study of chronic low back pain showed that the group ofpatients who received 9 months of maintenance manipulation at the frequency ofonce per every 3 weeks maintained their initial clinical improvement while thecontrol group returned to their previous levels of disability. The authors concludedthat there were positive effects of preventive maintenance chiropractic spinalmanipulation in maintaining functional capacities and reducing the number andintensity of pain episodes after the acute phase of treatment of low back painpatients. 28) Swedish surveys of chiropractors find consensus on providing maintenancecare to prevent disability relapses. 29) There is a common thread of the time dependency noted in all the laboratoryand clinical studies. The periods of onset of the anatomical and physiologicalchanges ranged from 2 to 4 weeks. The clinical studies also provided MMT every 4weeks and noted positive changes in the pain and disability measures. This timeinterval also correlates with the common recommendations found in the surveys ofchiropractic physicians.