RECOMMENDATION – Unchanged

Additional Commentary

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 implementation.

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 Neuropathology.

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.¹

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. ²

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. ³

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.⁴

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 practices."¹⁵

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."16 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 methods.

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 Dobson17 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 care.

Coulter et al18 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 patients.
Rupert, Manello, and Sandefur19 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 "extremely" valuable.

Rupert20 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,21 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.22 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.23

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.24

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.

Additional References

1. Kent, C. Models of vertebral subluxation. Journal of Vert. Subluxation Res. Vol. 1, No. 1. August 1996.
2. Wolff J; Maquet P, Furlong R, trans. The Law of Bone Remodelling. Berlin, Germany: Springer-Verlag; 1986.
3. Functional Progressions for Sport Rehabilitation by Steven R. Tippett, MS,PT,SCS,ATC, and Michael L. Voight, MED,PT,SCS,OCS,ATC. Published by Human Kinetics, Champlain, IL. Copyright 1995.
4. Lantz, C.A. Immobilization Degeneration and the Fixation Hypothesis of the Chiropractic Subluxation. Chiropractic Research Journal. Vol. 1 No. 1. 1988.
5. Peterson-Felix S, Curatola M. Neuroplasticity-an important factor in acute and chronic pain. Swiss Med Wkly, Jun 2002; 132(21-22): 273-278.
6. Munte TF, Altenmuller E, Jancke L. The musician’s brain as a model of neuroplasticity. Nat Rev Neurosci., Jun 2002; 3(6): 473-478.
7. Melzack R, Coderre TJ, Katz J, Vaccarino AL. Central neuroplasticity and pathological pain. Ann N Y Acad Sci., Mar 2001; 933: 157-174
8. Corner MA, van Pelt J, Wolters PS, Baker RE, Nuytinck RH. Physiological effects of sustained blockade of excitatory synaptic transmission on spontaneously active developing neuronal networks-an inquiry into the reciprocal linkage between intrinsic biorhythms and neuroplasticity in early ontogeny. Neurosci Biobehav Rev., Mar 2002; 26(2): 127-185
9. Bergado-Rosado JA, Almaguer-Melian W. Cellular mechanisms of neuroplasticity. Rev Neurol., Dec 2000; 1-15; 31(11): 1074-1095.
10. Carli G. Neuroplasticity and clinical pain. Prog Brain Res., 2000; 129: 325-330.
11. Grafman J. Conceptualizing functional neuroplasticity. J Common Disord., Jul-Aug 2000; 33(4): 345-355; quiz 355-356.
12. Trojan S, Pokorny J. Theoretical aspects of neuroplasticity. Physiol Res., 1999; 48(2): 87-97.
13. Azmitia EC. Serotonin neurons, neuroplasticity, and homeostasis of neural tissue. Neuropsychopharmacology, Aug 1999; 21(2 Suppl): 33A-45S.
14. Goldman S, Plum F. Compensatory regeneration of the damaged adult human brain: neuroplasticity in a clinical perspective. Adv Neurol. 1997;73:99-107.
15. Association of Chiropractic Colleges Paradigm Statement http://www.chirocolleges.org/paradigm_scope.html
16. World Health Organization: The first ten years of the World Health Organization. Geneva: WHO, 1958.
17. Blanks RHI, Schuster TL, Dobson M: A retrospective assessment of Network care using a survey of self-reported health, wellness and quality of life. J. of Vertebral Subluxation Res. 1997;1(4):15.
18. Coulter ID, Hurwitz EL, Aronow HU, et al: Chiropractic patients in a comprehensive home-based geriatric assessment, follow-up and health promotion program. Topics in Clinical Chiropractic 1996;3(2):46.
19. Rupert RL, Manello D, Sandefur R: Maintenance care: health promotion services administered to US chiropractic patients aged 65 or older, Part II. J. of Manipulative and Phys. Ther. 2000;23(1):10.
20. Rupert RL: A survey of practice patterns and the health promotion and prevention Attitudes of US chiropractors. Maintenance care: Part I. J. of Manipulative and Phys. Ther. 2000;23(1):1.
21. Miller S: chiroviewpresents.com. Survey says? 2/6/02.
22. Holder JM, Duncan Robert C, Gissen M, Miller M, Blum K. Increasing retention rates among the chemically dependent in residential treatment: Auriculotherapy and (in a separate study) subluxation-based chiropractic care. Journal of Molecular Psychiatry. Vol 6, Supplement No. 1. March 2001. http://www.naturesj.com/mp/
23. Blum K, et al. Reward Deficiency Syndrome (RDS): A Biogenetic Model for the Diagnosis and Treatment of Impulsive, Addictive and Compulsive Behaviors. Vol 32 Supplement. November 2000. Haight Ashbury Publications. Journal of Psychoactive Drugs. http://www.hafci.org/journal/index.html
24. Schuster TL, Dobson M, Blanks RH. Wellness Lifestyles. 10th Annual Meeting of the International Society for Quality of Life Research. Prague, Czech Republic. November 2003.