J Manipulative Physiol Ther 2000 (Jan); 23 (1): 10–19 ~ FULL TEXT
Ronald L. Rupert, MS, DC, Donna Manello, and Ruth Sandefur
Logan Chiropractic College,
St Louis, MO, USA.
OBJECTIVE: Health promotion and prevention services provided by the chiropractic profession historically have been referred to as maintenance care (MC). The primary objective of this investigation was to obtain information regarding multiple health issues of patients age 65 years and over who have had a long-term regimen of chiropractic health promotion and preventive care. The study also sought to explore the nature of the interventions and methods that were most commonly used by chiropractors when administering MC and to determine whether there were differences between patients who have had long-term exposure to these preventive services versus those who have not.
DESIGN: This descriptive study was accomplished by selecting chiropractic patients (age 65 years and over) who had received health-promotion and prevention services for at least 5 years, with a minimum of 4 visits per year. To enhance the probability of securing a more representative patient sample, selection was made through the participation of chiropractors from 6 diverse geographic locations across the United States. Doctors were asked to enroll the first 10 consenting patients who met the inclusion criteria. A battery of diverse assessment instruments were completed by each patient to provide a patient health profile. Information related to each patient included answers to the SF-36D survey, patient health habits, expenditures of health services, frequency of use of health providers, and perceived value of chiropractic prevention and health promotion services.
RESULTS: A total of 73 chiropractors participated in this investigation from the 6 study sites. In addition to an average 1.9 manual procedures used per patient, it was common to recommend stretching exercises (68.2%), aerobic exercises (55.6%), dietary advice (45.3%), and a host of other prevention strategies, including vitamins and relaxation. The patients investigated in this study reported making only half the annual number of visits to medical providers (4.76 visits per year) compared with the national average (9 visits per year) for individuals age 65 years and over.
CONCLUSIONS: On the basis of the response of participating chiropractors, this study describes the therapeutic components of MC for the elderly patient. For these patients, MC does not simply consist solely of periodic visits for joint manipulation, but it involves an eclectic host of interventions (e.g., exercise, nutrition, relaxation, physical therapy, and manipulation) that are directed at both musculoskeletal and visceral conditions.
From the Full-Text Article:
The definition and criteria for primary care established by the National Academy of Science included the need for the physician to “motivate and guide the patient to achieve and maintain a state of health with considerations of wellness and disease prevention.”  The need for these health-promotion and prevention services has not only been recognized by the medical profession but has long been embraced by chiropractors.  Also, there is a growing belief expressed by both professions that socioeconomic forces affecting health care in the United States are causing a paradigm shift that places less emphasis on treatment and more on prevention and wellness. [3-6] This will likely create a greater future need for effective preventive and health-promotion services.
Historically, chiropractors have advocated periodic office visits for the purpose of prevention and health promotion. These services have often been referred to as maintenance care (MC).  Previous studies confirm that chiropractors do engage in health-promotion activities, such as screenings and patient counseling related to issues, such as diet, smoking, exercise, and alcohol use. [8-11] Recent research has attempted to define more clearly the exact nature or therapeutic constituents of MC, particularly the role of manual procedures, such as spinal manipulation.  Despite the acceptance of MC by much of the chiropractic profession, [12-14] the value of these health maintenance services repeatedly has been questioned and criticized by the medical community and government agencies. [15, 16] As the New Zealand commission of inquiry noted, “…medical or dental check-ups may produce evidence of identifiable disorders whose results can be predicted with a reasonable degree of certainty. The Commission does not consider that the same can be said of chiropractic ‘preventative’ check-ups, at least in the present state of scientific knowledge.” 
Neither these criticisms nor the lack of research supporting the concept of chiropractic MC have deterred its widespread use. [12, 17, 18] In fact, chiropractors may administer more prevention and health-promotion services than any other health profession. The results of Part 1 of this study suggest that 79% of chiropractic patients receive the recommendation for MC, and 23% of all practice incomes relate to these services. 
There has been a significant increase in the number of elderly persons in the United States,  and in the future, life expectancy is also projected to increase.  Currently, the population over age 65 years accounts for over one third of all health care expenses.  Elderly patients with chronic problems have a disproportionately higher cost associated with their care.  Chiropractors see a significant number of these elderly patients with chronic health problems.  These socioeconomic dynamics will create a greater potential patient pool for future chiropractic care. Although there appears to be a strong professional belief in MC,  some empirical support for its value,  and a significant amount of income derived from its administration,  there has never been an attempt to create a descriptive profile of the patient receiving MC or to study the benefits of any of these prevention programs. It is essential that the chiropractic profession evaluate the efficacy of its prevention and wellness efforts, particularly in the elderly who constitute the largest growing segment of the population and the most significant financial burden on the health care system.
The primary purpose of this research was to conduct a descriptive study of patients age 65 years and over who have received extended chiropractic preventive and health-promotion management (MC). Specific objectives included the following:
Evaluate and describe the overall health status of chiropractic patients receiving MC.
Describe the treatment patterns for patients receiving MC, including the type of chiropractic procedures used and the use of nutrition, exercise, physical therapy, and other protocols.
Describe the frequency and duration of chiropractic care, as well as medical care, received during the previous year.
Investigate the health habits of patients receiving MC related to exercise, smoking, drinking, use of drugs, use of vitamins, and related issues.
Describe the cost of health services for patients receiving MC.
Evaluate the perceived importance of MC treatment to the patient.
Investigate the possible relationship, if any, between the number of years of MC versus patient health status or health habits.
Caution must be exercised when reviewing some of the results of this investigation. A few questions required data to be supplied by patients receiving MC that was not verifiable, and errors in either overestimation or underestimation in their reporting may have occurred. The reported significant correlations and the correlations that approach significance suggest that a relationship exits between variables. However, correlations do not confirm that a cause-and-effect relationship exists. Although it is possible that MC provides benefit, it is also possible that significant differences may be due to the inherent differences in the population samples or other uncontrolled variables. For example, the reduced smoking seen with patients receiving long-term MC may be primarily due to the overall trend in society to reduce cigarette consumption. Future research will be required to explore and establish the possible cause-and-effect relationship that might exist between MC and improvements in patient health.
As other researchers have noted, the motivation of participating doctors and staff is difficult but imperative to the success of this type of study.  Great effort was expended to recruit and train chiropractors for this work; however, despite these efforts several difficulties arose. One problem involved doctors who initially expressed a desire to participate, were trained along with their staff, but dropped out as increased workloads prohibited their involvement. On several occasions doctors would lose staff, and retraining would have to be accomplished. Additionally, all sites had a few chiropractors who volunteered and were trained, but during the data collection period, had no patients meeting the inclusion criteria. These issues resulted in the need to train or dedicate efforts to retrain more doctors and staff than originally anticipated. These problems did not result in a degradation in the quality of data collected but did reduce the total number of subjects evaluated.
When initially contacted to participate in research, many chiropractors were either not eligible or expressed no desire to become involved. This same lack of cooperation by the chiropractic profession has been discussed previously by other researchers and most recently in another study involving chiropractic treatment of the elderly.  The majority of chiropractors who elected not to assist with this study did report providing various levels of MC services. The three most common reasons for not participating were that they were
(1) too busy,
(2) not in practice long enough to have patients under care for 5 years, or
(3) just did not have many elderly patients.
A larger sample size would provide a greater assurance that the patient sample was representative. This study did build in a measure of assurance that the doctors used in this work were representative of chiropractors nationally. Each participating chiropractor, as described earlier, completed the same questionnaire, which provided a profile of beliefs and practice patterns related to MC. With the exception of a greater participation of female chiropractors, the demographics were similar to those of the national survey. Most importantly, there were no significant differences in attitudes or practice patterns between the 73 doctors participating in this study and the doctors randomly selected for the national survey. The multicenter design, seeking geographic diversification of doctors and patients, also provided a greater likelihood of obtaining a representative sampling.
Another limitation of this work was the selection and design of assessment instruments. Because there had been no previous attempt to evaluate patients receiving MC, it was not possible to know which assessment instruments would most likely demonstrate potential differences if indeed differences in these patients compared with other population samples did exist. The authors attempted to use a brief and diverse range of measurements for a broad sampling of areas in which distinctive characteristics of patients receiving MC might be identified. It is quite possible that other instruments might have been more suitable or that, as others suggest, new assessment instruments might be necessary to evaluate these patients.  It was believed that although the development and validation of new measuring devices may indeed demonstrate greater differences or potential value from MC care, there were a number of accepted instruments that should be explored before the expensive and time-consuming process of new test development is undertaken. There were also some limitations in survey design of some of the test instruments. To not discourage participation by either doctors or patients, the length of questionnaires had to be kept reasonably brief. This necessitated limiting fields and choices (eg. the number of chiropractic techniques listed or the list of other interventions that might have been used in patient care). The need for brevity also limited the use of other instruments that, in retrospect, may have been superior to those used. For example, the SF-36D data suggest a low level of depression among patients receiving MC; future studies should explore this finding with some of the many instruments available for that purpose.
It is not known how long a regimen of MC is required before differences, if any, could be measured. Clearly, the very nature of MC requires an ongoing doctor-patient relationship. Patients who are newly enrolled in an MC regimen would not have had time for any changes to have occurred resulting from MC treatment. Five years of care was considered a reasonable starting point for patients in this study. However, it is possible that because of the advanced age of the patient population targeted for this study and the often chronic, long-standing problems they encounter, that 5 years would not be a sufficient amount of time for MC to make changes in the patient's overall health status. Five years of care cannot remove 65 or 70 years of health abuse, and there may have been more substantial changes observed if more data could have been obtained for patients who had a longer regimen of MC management. However, considering the substantial problems that the investigators had in recruiting doctors and patients meeting the various existing inclusion-exclusion criteria, additional patients receiving long-term MC would have been extremely difficult to obtain.
There were weaknesses in the design of some of the 7 supplemental questions related to health habits. Question design could have been improved if an operational definition or a more specific grounding had been given for terms like “relax.” Also, it would have been more useful to ask patients how much alcohol they drank in a specific period of time rather than how often they drank alcohol. An important financial issue is whether chiropractic care for the elderly simply adds to or reduces the total cost of health care. This is certainly a significant matter for both those who argue that chiropractic services may serve to augment the insufficient number of primary care medical providers, as well as those who argue that chiropractic complements and adds to the cost of health services. Several medical reports suggest that chiropractic visits do not replace nonavailable medical services. [40-42]
One such article reviews patient patterns in Manitoba, Canada (1983). Manitoba is a province that fully insures the elderly for medical services but only provides a limited number of chiropractic services. The study concluded that “chiropractic services do not substitute for physician services among the elderly.”  In addition to chiropractic visits, patients with chronic conditions also made more medical visits.  The work of Coulter et al  with chiropractic patients over 65 years of age had essentially the same finding: visits to the chiropractor are not associated with a reduction of the number of visits to the medical physician. All of these previous investigations evaluated all chiropractic patients 65 years of age and older, whereas this study focused on only those patients who had been enrolled in a long-term health promotion and prevention doctor-patient relationship of at least 5 years. The findings of this study contrast with those of these previous works.
One explanation of this difference is that there may be a distinct profile and dynamic involving elderly patients who supplement medical care with chiropractic visits (which may add to and not reduce medical management) versus the patient who relies heavily on chiropractic treatment for long-term primary care services. The former category of patient continues to maintain the same level of medical management, whereas the second (like the patients receiving MC in this study) may supplant half of the medical management with chiropractic care. The chiropractors who participated in this study had many patients over 65 years of age who were being seen for management of an acute condition and therefore did not meet the inclusion criteria. For these acute care patients, the chiropractor may serve as a specialist and complements the health management of the patients' primary care provider. On the other hand, there are patients, such as the patients receiving MC reported in this study, who rely on the chiropractor for prevention, health promotion, and other primary care services. It appears that these patients receiving MC require far less medical intervention. This study did not investigate the extent to which medical visits made by patients receiving MC might have been the result of referral from the chiropractor or from the medical provider to the chiropractor.
There is normally an association between the number of physician visits and the total cost of health services. However, this might not be true if the office visits were part of an effective prevention and health-promotion program that reduced other more costly health care services. The cost of health care for patients receiving MC in this study was far less than that for patients of similar age in the general population despite the doubling of physician visits (medical plus chiropractic). The greatest difference in health care costs with patients receiving MC was in the areas of nursing care and, especially, hospital care. This reduced need for hospital and nursing home services has recently been corroborated by the research of Coulter et al.
Because of limitations in both the objectives and design of this study, it is not possible to establish a causal relationship between the use of MC and the overall difference between health expenses of patients receiving MC and those of patients not receiving MC. This study describes several improved health variables associated with increased years of chiropractic MC management. These include improved perception of overall health status, improved health habits, and improved mental status. Several factors beside MC (eg, patient self-selection) could account for this finding. If MC is responsible for these changes, it is not clear which therapeutic interventions or other elements of this care fostered the patients' improved health. Some of the important elements of MC include the long-term chiropractic doctor-patient relationship, which embodies much of the relationship-oriented holism discussed by other authors. [43, 44] MC incorporates an eclectic variety of components, which include a high number of doctor-patient encounters over an extended period of time and a variety of therapeutic interventions.
The doctor-patient relationship itself has many dynamics that may combine to account for the apparent benefits of MC; these include the validation of the patient complaint, the effects of human touch, the placebo effect, the increased opportunity for patient education, and counseling and other factors. [45-47] In this regard chiropractic MC is a unique patient experience and quite different from the typical medical encounter. The extended duration of the doctor-patient relationship much more closely resembles that with the primary care provider than the limited number of visits common with medical specialists. MC treatment differs from orthodox medicine; it relies on multiple manual procedures for each patient, an emphasis on exercise and diet, and a variety of other interventions.
Along with health status questionnaires like the SF-36D, other existing assessment instruments will need to be used or perhaps developed and tested to more thoroughly investigate long-term chiropractic preventive management. Because of the findings that significantly correlate reduced nervousness with years of MC, as well as possible reduced symptoms of depression, additional psychologic instruments would be of particular interest for future research. Another general research problem that must be addressed is the reluctance of practicing chiropractors to become part of research efforts. This study required a minimal contribution in the doctor's time, yet few were willing to participate. On the basis of the degree of difficulty experienced in recruiting chiropractors for this and other studies, better strategies to recruit, educate, and perhaps reward chiropractors need to be explored before more demanding investigations of MC will be feasible.
On the basis of clinical information provided by the treating chiropractor, most patients receiving MC receive an eclectic variety of therapeutic interventions, which usually include manipulation, exercises, and patient education relative to diet, vitamins, and other health issues. In addition to prevention and health promotion, MC visits are directed at a variety of musculoskeletal, as well as visceral, conditions.
The responses of the 311 patients involved in this study demonstrated a significant positive correlation associated with the patients' perception of health status and the number of years of MC. Where data related to the health habits of US citizens 65 years of age and over existed, the health habits of patients receiving MC were similar to or better than those of the general population. There were positive correlations with both the decreased use of cigarettes and decreased use of nonprescription drugs and the number of years of MC.
There appears to be a subtle difference in the nature of the doctor-patient relationship that exists between chiropractic patients who receive MC management and chiropractic patients who do not, as well as differences between patients receiving MC and those elderly patients who receive no chiropractic care at all. These differences in patients receiving MC included the number and mix of office visits to various health providers. Patients receiving MC had twice as many contacts with a physician during the year than patients who receive no chiropractic care at all. These doctor-patient contacts are primarily for chiropractic MC care and result in a 50% reduction in medical provider visits. Therefore for these patients receiving MC, chiropractic management appeared to replace medical management rather than be complementary to medical treatment. This contrasts with previous work, which demonstrated that elderly chiropractic patients, including both those who do and those who do not receive MC, actually made more visits to medical providers in addition to their chiropractic visits. The need for hospitalization and the high costs associated with that service were markedly reduced for the patient receiving MC. The total annual cost of health care services for the patient receiving MC was conservatively estimated at only a third of the expenses made by US citizens of the same age. Patients also perceived MC services as highly beneficial to prevention and health promotion. Future research will need to determine whether the positive relationships that are associated with patients receiving MC and extended duration of MC care are directly related to the chiropractic services provided, population differences, or other variables.