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Research Update - 8/6/2004
Duration of Care for Correction of Vertebral Subluxation
Editor’s Note: The Council on Chiropractic
Practice Recently released the revised and updated clinical practice
guideline document: Vertebral Subluxation in Chiropractic Practice.
The 2003 guideline has been accepted for inclusion in the National
Guidelines Clearinghouse. In an effort to inform readers of some of
the changes in the updated document we are reproducing some of them
through the JVSR Research Update. Complete copies of the CCP
Guidelines are available on the CCP website: http://www.ccp-guidelines.org/
The following text is from Chapter 7 of the CCP
Guides and focuses on Frequency and Duration of
Dr. Matthew McCoy firstname.lastname@example.org Editor – Journal
of Vertebral Subluxation
7 Duration of Care for Correction of Vertebral
RECOMMENDATION – Unchanged
Chiropractors are encouraged to employ a clinically driven variable
length of care format in which the duration of care is determined by each
individual patient’s progress toward meeting measurable objectives, set in
individualized care plans and identified during individual assessment.
This application ensures that patients are not over- or underutilizing a
health-care resource and are currently receiving the best possible care.
When developing a care plan based on reduction, correction and
stabilization of the subluxation the attending chiropractor should take
into consideration many associated and aggravating factors. These will
include details about the extent and character of the patient's
subluxations. For example: How long have they been subluxated? How is this
subluxation affecting biomechanics, their nervous system, muscles,
ligaments and involved joints? The relationship between X-ray findings,
chiropractic and physical exam findings and instrumentation readings may
need to be correlated. It is important to consider the patient's age in
respect to their subluxations and how the age will impact the outcome.
Since physical trauma is one of the potential causes of subluxation it
is important to consider whether or not the patient had previous injuries,
traumas or accidents. This should not be limited to single instances of
trauma but also consider repetitive injuries, microtrauma on a daily basis
etc. These should all be considered in terms of how they will interfere
with subluxation correction and affect long term outcome. Other
co-existing health conditions may also affect the patient’s response to
care since if a patient is dealing with chronic health problems of any
sort this may impede progress. The patient’s work and home life demands
may also have a bearing on how much of a correction they attain and should
be considered in determining a care plan and prognosis.
The patient's sleeping habits may interfere with long-term correction
and stabilization of the subluxation and should be considered. A patient’s
ability to exercise or their lack of compliance to a prescribed exercise
regimen may impede their progress and diminish their response. And in some
cases, the patient’s weight may have a bearing on their recovery. Other
factors include smoking, alcohol, nutritional problems and socio-emotional
aspects of their life.
Justification for high frequency initial and extended wellness care
plans should be based on a combination of basic science, technique,
objective assessment of physiological function, structural changes and
quality of life issues. The practitioner should ideally choose from
several of these to develop their care plan and to justify its
No matter which of the various models of vertebral subluxation one
chooses to address in clinical practice there are two components that are
common to all models. These components are Kinesiopathology and
Kinesiopathology deals with issues related to misalignment and/or
abnormal motion and neuropathology deals with the neurological changes
related to the abnormal motion and/or misalignment. 
In discussing kinesiopathology the most significant basic science
information relative to this is Wolf’s Law, which states:
As bones are subjected to stress demands in weight bearing posture,
they will model or alter their shape accordingly. 
Wolf’s Law has a less well-known corollary for soft tissue called:
Davis’ Law that states:
Soft tissue will model according to imposed demands. 
These two Laws form the foundation of the rheology associated with
subluxation and these rheological properties are essential elements in the
epidemiology of vertebral subluxation, which must be considered with
regards to care plans that have as their goal to make structural changes.
Rheology is the study of the change in form and the flow of matter
including elasticity, viscosity and plasticity. The longer a subluxation
is allowed to set in the further along the path of immobilization
degeneration the subluxation is allowed to progress. 
The extent of immobilization degeneration and the patient’s individual
ability to reverse it may be a determining factor in the frequency of the
initial care plan and its duration. This will also affect long term care
whether from a palliative or wellness perspective once a substantial
correction has been made.
The other significant basic science issue related to frequency and
duration of care has to do with neuroplasticity. [5–14] This has to do with
the nervous system’s propensity to undergo “plastic” changes and learn to
habituate a response and is a fundamental aspect of the nature of
self-regulating repair processes that use the plasticity of the nervous
system as it's conduit. In order to overcome plastic neurological changes
that have set in secondary to subluxation the nervous system will need to
“rewire” in order to create new plastic changes for the better. This may
necessitate frequent adjustments and other inputs into the CNS over a long
duration in order to make these changes. This neuroplasticity and the
accompanying rheological changes discussed above secondary to subluxation
are what need to be overcome in order for the patient to have a reduction
in vertebral subluxation.
Vertebral Subluxation and Well-Being
The 1996 Paradigm Statement by the Association of Chiropractic College
includes a section titled "Health Promotion" where it states that:
"Doctors of Chiropractic advise and educate patients and communities
in structural and spinal hygiene and healthful living
Another key aspect articulated in the ACC document concerns case
management issues. It outlines, in a generic way, how chiropractors
conduct themselves on a clinical level:
"Doctors of Chiropractic establish a doctor/patient relationship and
utilize adjustive and other clinical procedures unique to the
chiropractic discipline. Doctors of Chiropractic may also use other
conservative patient care procedures, and, when appropriate, collaborate
with and/or refer to other health care providers."
The CCP Guidelines address a distinct manner in which chiropractic
clinicians utilize the information, feedback and empirical results each
case accumulates. For this reason, the Guidelines are not linked to
various diseases or conditions the patient may or may not have, before or
after care has initiated. 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."  Given this broad
definition of health, epistemological constructs borrowed from the social
sciences may demonstrate health benefits not disclosed by randomized
clinical trials. Health benefits such as improvement in self-reported
quality-of-life, decreased health care costs, behaviors associated with
decreased morbidity, and patient satisfaction may be evaluated using such
This performance-based domain focuses the doctor-patient relationship
on the standards set by personal baselines and establishes guidelines for
the utility of various chiropractic techniques. This type of chiropractic
care is in a context with other non-invasive disciplines and is stratified
into discrete application-based domains across a spectrum of parameters
related to well-being.
Techniques and methods for correcting subluxation must be judged on
their intended outcome and most if not all chiropractic techniques have
some physiological and/or structural outcome that measures their results.
Further, some techniques have as their goals – improvement in quality of
life, an improved sense of well-being and a better sense of relationship
with the patient’s environment and society.
Several studies discussed previously warrant further discussion in this
context. Blanks, Schuster and Dobson  published the results of a
retrospective assessment of subluxation-based chiropractic care on
self-related health, wellness and quality of life. This is the largest
study of its kind ever undertaken regarding a chiropractic population.
After surveying 2,818 respondents in 156 clinics, a strong connection was
found between persons receiving chiropractic care and self-reported
improvement in health, wellness and quality-of-life. 95% of respondents
reported that their expectations had been met, and 99% wished to continue
Coulter et al  performed an analysis of an insurance database,
comparing persons receiving chiropractic care with non-chiropractic
patients. The study consisted of senior citizens over 75 years of age. It
was reported that the persons receiving 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
Rupert, Manello, and Sandefur  surveyed 311 chiropractic
patients, aged 65 years and older, who had received "maintenance care" for
five years or longer. 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. There was 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 decreased use of nonprescription
drugs. Furthermore, 95.8% believed the care to be either "considerably" or
Rupert  reports that 79% of chiropractic patients have maintenance
care recommended to them, and nearly half of those comply. In an online
survey with 3018 respondents by Miller,  62% responded affirmatively when
asked, "Although you feel healthy, would you follow your family member's
lead and visit a doctor who focuses on wellness and prevention just so you
can stay feeling that way?"
Three additional studies have addressed this issue since the
publication of the 1998 Guidelines. One of the studies consisted of a
three arm randomized clinical trial with two control groups (one of which
was placebo controlled). This was a single blind study utilizing
subluxation-centered chiropractic care implemented in a residential
addiction treatment setting.  A total of 98 subjects (14 female and 84
male) were enrolled in the year and a half study. 100% of the Active
(chiropractic) group completed the 30–day program, while only 24 (75%) of
the Placebo group and 19 (56%) of the Usual Care group completed 30 days.
The Active group showed a significant decrease in anxiety while the
Placebo group showed no decrease in anxiety. The frequency of visits to
the Nurse's station was monitored during the course of the study and among
the Active treatment group only 9% made one or more visits, while 56% of
the Placebo group and 48% in the Usual Care group made such visits. This
poor performance by the placebo group suggests that the chiropractic care
had no positive placebo effect.
Treatment was five days per week over a period of 30 days, for a total
of 20 treatment encounters. Therefore, a 100% retention rate was achieved
in a residential treatment setting using subluxation-centered
chiropractic. The possible mechanism for such a response is elaborated on
in an earlier paper by Holder et al, in which they describe the Brain
Reward Cascade in relationship to vertebral subluxation and its role in
resolving (RDS) Reward Deficiency Syndrome. 
A third study by Blanks et al. looked at the degree to which
chiropractic intervention affected a change in a healthy lifestyle. The
study found that chiropractic care users do tend towards the practice of a
positive health lifestyle, which also has a direct effect on reported
improvements in wellness. These empirical links are relative to the
sociodemographic characteristics of this population and show that use of
chiropractic care is an aspect of a wellness lifestyle. 
Chiropractors have historically recommended initial care plans that
involve a high frequency of visits as well as extended care plans of long
duration to encompass corrective care and wellness based care. Care plans
that do not base care solely on the presence or absence of symptoms have
as their basis some very fundamental scientific laws that govern the
connective tissue and neurological responses to abnormal biomechanical
loads and neurological interference while also addressing the quality of
life issues discussed above. The goal of care becomes the reversal of
these insidious processes and an enhanced sense of well-being so that any
judgment of that care must take into consideration those outcomes as well
as outcomes related to the technique being applied.
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