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Posted on 03-01-2017

~~ChiroACCESS Article

Medical Research Supports Chiropractic Maintenance Care


This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.
ChiroACCESS Editorial Staff
   

ChiroACCESS


Published on
April 19, 2011
Text Size:       
 
Share this:             

Two research studies generated by the medical profession this year add evidence in support of the value of chiropractic maintenance care. 

The first study published in January 2011 in Spine concluded that “SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.” 

The second study in April 2011, published in the Journal of Occupational and Environmental Medicine, provides additional support for the value of chiropractic maintenance care for post injury low back pain patients.  The study followed 894 injured workers for a period of one year.  During that year there were four different types of therapy available to the workers:  medical management, physical therapy, chiropractic, and no therapy.  Episodes of repeat disability were recorded during the year following the initial injury.  Physical therapy had the highest percentage of reinjured workers followed by those receiving medical management or no treatment at all.  The lowest incidence of repeat injury was found among those workers who had received chiropractic maintenance care. 

The results of published surveys given to chiropractors have documented the profession’s belief in the value of maintenance care.  Furthermore, during the last decade there have been a dozen peer reviewed papers on the subject.  There are far more questions to be answered, but it is heartening to see medical research corroborate the studies and beliefs of the chiropractic profession.

Note:  These mini-reviews are designed as updates and direct the reader to the full text of current research.  The abstracts presented here are no substitute for reading and critically reviewing the full text of the original research.  Where permitted we will direct the reader to that full text.
Health maintenance care in work-related low back pain and its association with disability recurrence.  [Link]

J Occup Environ Med. 2011 Apr;53(4):396-404.

Cifuentes M, Willetts J, Wasiak R.
From the Center for Disability Research at the Liberty Mutual Research Institute for Safety (Dr Cifuentes and Ms Willetts) and University of Massachusetts Lowell (Dr Cifuentes), Hopkinton, Mass; and Center for Health Economics & Science Policy at United BioSource Corporation, London, United Kingdom (Dr Wasiak).

OBJECTIVES: To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work-related low back pain (LBP).

METHOD: A total of 894 cases followed 1 year using workers' compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.

RESULTS: Controlling for demographics and severity, the hazard ratio [HR] of disability recurrence for patients of physical therapists (HR = 2.0; 95% confidence interval [CI] = 1.0 to 3.9) or physicians (HR = 1.6; 95% CI = 0.9 to 6.2) was higher than that of chiropractor (referent, HR = 1.0), which was similar to that of the patients non-treated after return to work (HR = 1.2; 95% CI = 0.4 to 3.8).

CONCLUSIONS: In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.

Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome? 

Spine (Phila Pa 1976). 2011 Jan 17. [Epub ahead of print]

Senna MK, Machaly SA.
Rheumatology and Rehabilitation Department, Mansoura Faculty of Medicine, Mansoura University.

Study Design:  A prospective single blinded placebo controlled study was conducted.

Objective:  To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic non-specific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low-back conditions after an initial phase of treatments.

Summary of background:  SMT is a common treatment option for low back pain. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic non-specific LBP has not been studied.

Subjects and Methods:  60 patients with chronic, nonspecific LBP lasting at least 6 months were randomized to receive either (1) 12 treatments of sham SMT over a one-month period, (2) 12 treatments, consisting of SMT over a one-month period, but no treatments for the subsequent nine months, or (3) 12 treatments over a one-month period, along with "maintenance spinal manipulation" every two weeks for the following nine months. To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-month, 4-month, 7-month and 10-month intervals.

Results:  Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029 respectively). However, only the third group that was given spinal manipulations during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the no maintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.

Conclusion:  SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.

The Nordic Maintenance Care Program: case management of chiropractic patients with low back pain - defining the patients suitable for various management strategies.   [Link]

CHIROPRACTIC & OSTEOPATHY. JUL Vol. 17(7) pp. 7-7

Malmqvist,S.;Leboeuf-Yde,C.

BACKGROUND: Maintenance care is a well known concept among chiropractors, although there is little knowledge about its exact definition, its indications and usefulness. As an initial step in a research program on this phenomenon, it was necessary to identify chiropractors' rationale for their use of maintenance care. Previous studies have identified chiropractors' choices of case management strategies in response to different case scenarios. However, the rationale for these management strategies is not known. In other words, when presented with both the case, and different management strategies, there was consensus on how to match these, but if only the management strategies were provided, would chiropractors be able to define the cases to fit these strategies? The objective with this study was to investigate if there is a common pattern in Finnish chiropractors' case management of patients with low back pain (LBP), with special emphasis on long-term treatment.

METHOD: Information was obtained in a structured workshop. Fifteen chiropractors, members of the Finnish Chiropractors' Union, and present at the general assembly, participated throughout the entire workshop session. These were divided into five teams each consisting of 3 people. A basic case of a patient with low back pain was presented together with six different management strategies undertaken after one month of treatment. Each team was then asked to describe one (or several) suitable case(s) for each of the six strategies, based on the aspects of 1) symptoms/findings, 2) the low back pain history in the past year, and 3) other observations. After each session the people in the groups were changed. Responses were collected as key words on flip-over boards. These responses were grouped and counted.

RESULTS: There appeared to be consensus among the participants in relation to the rationale for at least four of the management strategies and partial consensus on the rationale for the remaining two. In relation to maintenance care, the patient's past history was important but also the doctor-patient relationship.

CONCLUSIONS: These results confirm that there is a pattern among Nordic chiropractors in how they manage patients with LBP. More information is needed to define the "cut-point" for the indication of prolonged care.

Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain and Related Disabilities: A Preliminary Study   [Link]

J MANIPULATIVE PHYSIOL THER. 2004 OCT; 27(8) pp. 509-15

Descarreaux M, Blouin J-S, Drolet M, Papadimitriou S, Teasdale N.

Objective:  To document the potential role of maintenance chiropractic spinal manipulation to reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments.

Methods:  Thirty patients with chronic nonspecific low-back pain were separated into 2 groups. The first group received 12 treatments in an intensive 1-month period but received no treatment in a subsequent 9-month period. For this group, a 4-week period preceding the initial phase of treatment was used as a control period to examine the sole effect of time on pain and disability levels. The second group received 12 treatments in an intensive 1-month period and also received maintenance spinal manipulation every 3 weeks for a 9-month follow-up period. Pain and disability levels were evaluated with a visual analog scale and a modified Oswestry questionnaire, respectively.

Results:  The 1-month control period did not modify the pain and disability levels. For both groups, the pain and disability levels decreased after the intensive phase of treatments. Both groups maintained their pain scores at levels similar to the postintensive treatments throughout the follow-up period. For the disability scores, however, only the group that was given spinal manipulations during the follow-up period maintained their postintensive treatment scores. The disability scores of the other group went back to their pretreatment levels.

Conclusions:  Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.

Upper Crossed Syndrome and Its Relationship to Cervicogenic Headache  [Link]

J MANIPULATIVE PHYSIOL THER. 2004 JUL-AUG; 27(6) pp. 414-20

Moore MK.

Objective:  To discuss the management of upper crossed syndrome and cervicogenic headache with chiropractic care, myofascial release, and exercise.

Clinical Features:  A 56-year-old male writer had been having constant 1-sided headaches radiating into the right eye twice weekly for the past 5 years. Tenderness to palpation was elicited from the occiput to T4 bilaterally. Trigger points were palpated in the pectoralis major, levator scapulae, upper trapezius, and supraspinatus muscles bilaterally. Range of motion in the cervical region was decreased in all ranges and was painful. Visual examination demonstrated severe forward translation of the head, rounded shoulders, and right cervical translation.

Intervention and Outcome:  The patient was adjusted using high-velocity, short-lever arm manipulation procedures (diversified technique) and was given interferential myofascial release and cryotherapy 3 times weekly for 2 weeks. He progressed to stretching and isometric exercise, McKenzie retraction exercises, and physioball for proprioception, among other therapies. The patient's initial headache lasted 4 days. He had a second headache for 1.5 days during his exercise training. During the next 7 months while returning to the clinic twice monthly for an elective chiropractic maintenance program, his headaches did not recur. He also had improvement on radiograph.

Conclusion:  The principles of upper crossed syndrome and the use of exercise, chiropractic care, and myofascial release in the treatment of cervicogenic headache are discussed. A review of the literature indicates that analyzing muscle imbalance as well as vertebral subluxation may increase the effectiveness of chiropractic treatment for cervicogenic headache.

A Survey of Practice Patterns and the Health Promotion and Prevention Attitudes of US Chiropractors, Maintenance Care: Part I  [Link]

J MANIPULATIVE PHYSIOL THER. 2000 JAN; 23(1) pp. 1-9

Rupert RL.

Objective:  To investigate the primary care, health promotion activities associated with what has historically been called "maintenance care" (MC) as used in the practice of chiropractic in the United States. This includes issues such as investigating the purpose of MC, what conditions and patient populations it best serves, how frequently it is required, what therapeutic interventions constitute MC, how often it is recommended, and what percent of patient visits are for prevention and health promotion services. It also investigates the economic impact of these services.

Design:  Postal survey of a randomized sample of practicing US chiropractors. The questionnaire was structured with a 5-point ordinal Likert scale (28 questions) and brief fill-in questionnaire (12 questions). The 40-question survey was mailed to 1500 chiropractors selected at random from a pool of chiropractors with active practices in the United States. The National Directory of Chiropractic database was the source of actively practicing chiropractors from which doctor selection was made. The sample was derived by using the last numbers composing the zip codes assigned by the US Postal Service. This sampling method assured potential inclusion of chiropractors from all 50 states, from rural areas and large cities, and assured a sample weighting based on population density that might not have been afforded by a simple random sample.

Results:  Six hundred and fifty-eight (44%) of the questionnaires were completed and returned. US chiropractors agreed or strongly agreed that the purpose of MC was to optimize health (90%), prevent conditions from developing (88%), provide palliative care (86%), and minimize recurrence or exacerbations (95%). MC was viewed as helpful in preventing both musculoskeletal and visceral health problems. There was strong agreement that the therapeutic composition of MC placed virtually equal weight on exercise (96%) and adjustments/manipulation (97%) and that other interventions, including dietary recommendations (93%) and patient education about lifestyle changes (84%), shared a high level of importance. Seventy-nine percent of chiropractic patients have MC recommended to them and nearly half of those (34%) comply. The average number of recommended MC visits was 14.4 visits per year, and the total revenue represents an estimated 23% of practice income.

Conclusions:  Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.

~~ChiroACCESS Article

Medical Research Supports Chiropractic Maintenance Care


This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.
ChiroACCESS Editorial Staff
   

ChiroACCESS


Published on
April 19, 2011
Text Size:       
 
Share this:             

Two research studies generated by the medical profession this year add evidence in support of the value of chiropractic maintenance care. 

The first study published in January 2011 in Spine concluded that “SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.” 

The second study in April 2011, published in the Journal of Occupational and Environmental Medicine, provides additional support for the value of chiropractic maintenance care for post injury low back pain patients.  The study followed 894 injured workers for a period of one year.  During that year there were four different types of therapy available to the workers:  medical management, physical therapy, chiropractic, and no therapy.  Episodes of repeat disability were recorded during the year following the initial injury.  Physical therapy had the highest percentage of reinjured workers followed by those receiving medical management or no treatment at all.  The lowest incidence of repeat injury was found among those workers who had received chiropractic maintenance care. 

The results of published surveys given to chiropractors have documented the profession’s belief in the value of maintenance care.  Furthermore, during the last decade there have been a dozen peer reviewed papers on the subject.  There are far more questions to be answered, but it is heartening to see medical research corroborate the studies and beliefs of the chiropractic profession.

Note:  These mini-reviews are designed as updates and direct the reader to the full text of current research.  The abstracts presented here are no substitute for reading and critically reviewing the full text of the original research.  Where permitted we will direct the reader to that full text.
Health maintenance care in work-related low back pain and its association with disability recurrence.  [Link]

J Occup Environ Med. 2011 Apr;53(4):396-404.

Cifuentes M, Willetts J, Wasiak R.
From the Center for Disability Research at the Liberty Mutual Research Institute for Safety (Dr Cifuentes and Ms Willetts) and University of Massachusetts Lowell (Dr Cifuentes), Hopkinton, Mass; and Center for Health Economics & Science Policy at United BioSource Corporation, London, United Kingdom (Dr Wasiak).

OBJECTIVES: To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work-related low back pain (LBP).

METHOD: A total of 894 cases followed 1 year using workers' compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.

RESULTS: Controlling for demographics and severity, the hazard ratio [HR] of disability recurrence for patients of physical therapists (HR = 2.0; 95% confidence interval [CI] = 1.0 to 3.9) or physicians (HR = 1.6; 95% CI = 0.9 to 6.2) was higher than that of chiropractor (referent, HR = 1.0), which was similar to that of the patients non-treated after return to work (HR = 1.2; 95% CI = 0.4 to 3.8).

CONCLUSIONS: In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.

Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome? 

Spine (Phila Pa 1976). 2011 Jan 17. [Epub ahead of print]

Senna MK, Machaly SA.
Rheumatology and Rehabilitation Department, Mansoura Faculty of Medicine, Mansoura University.

Study Design:  A prospective single blinded placebo controlled study was conducted.

Objective:  To assess the effectiveness of spinal manipulation therapy (SMT) for the management of chronic non-specific low back pain (LBP) and to determine the effectiveness of maintenance SMT in long-term reduction of pain and disability levels associated with chronic low-back conditions after an initial phase of treatments.

Summary of background:  SMT is a common treatment option for low back pain. Numerous clinical trials have attempted to evaluate its effectiveness for different subgroups of acute and chronic LBP but the efficacy of maintenance SMT in chronic non-specific LBP has not been studied.

Subjects and Methods:  60 patients with chronic, nonspecific LBP lasting at least 6 months were randomized to receive either (1) 12 treatments of sham SMT over a one-month period, (2) 12 treatments, consisting of SMT over a one-month period, but no treatments for the subsequent nine months, or (3) 12 treatments over a one-month period, along with "maintenance spinal manipulation" every two weeks for the following nine months. To determine any difference among therapies, we measured pain and disability scores, generic health status, and back-specific patient satisfaction at baseline and at 1-month, 4-month, 7-month and 10-month intervals.

Results:  Patients in second and third groups experienced significantly lower pain and disability scores than first group at the end of 1-month period (P = 0.0027 and 0.0029 respectively). However, only the third group that was given spinal manipulations during the follow-up period showed more improvement in pain and disability scores at the 10-month evaluation. In the no maintained SMT group, however, the mean pain and disability scores returned back near to their pretreatment level.

Conclusion:  SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.

The Nordic Maintenance Care Program: case management of chiropractic patients with low back pain - defining the patients suitable for various management strategies.   [Link]

CHIROPRACTIC & OSTEOPATHY. JUL Vol. 17(7) pp. 7-7

Malmqvist,S.;Leboeuf-Yde,C.

BACKGROUND: Maintenance care is a well known concept among chiropractors, although there is little knowledge about its exact definition, its indications and usefulness. As an initial step in a research program on this phenomenon, it was necessary to identify chiropractors' rationale for their use of maintenance care. Previous studies have identified chiropractors' choices of case management strategies in response to different case scenarios. However, the rationale for these management strategies is not known. In other words, when presented with both the case, and different management strategies, there was consensus on how to match these, but if only the management strategies were provided, would chiropractors be able to define the cases to fit these strategies? The objective with this study was to investigate if there is a common pattern in Finnish chiropractors' case management of patients with low back pain (LBP), with special emphasis on long-term treatment.

METHOD: Information was obtained in a structured workshop. Fifteen chiropractors, members of the Finnish Chiropractors' Union, and present at the general assembly, participated throughout the entire workshop session. These were divided into five teams each consisting of 3 people. A basic case of a patient with low back pain was presented together with six different management strategies undertaken after one month of treatment. Each team was then asked to describe one (or several) suitable case(s) for each of the six strategies, based on the aspects of 1) symptoms/findings, 2) the low back pain history in the past year, and 3) other observations. After each session the people in the groups were changed. Responses were collected as key words on flip-over boards. These responses were grouped and counted.

RESULTS: There appeared to be consensus among the participants in relation to the rationale for at least four of the management strategies and partial consensus on the rationale for the remaining two. In relation to maintenance care, the patient's past history was important but also the doctor-patient relationship.

CONCLUSIONS: These results confirm that there is a pattern among Nordic chiropractors in how they manage patients with LBP. More information is needed to define the "cut-point" for the indication of prolonged care.

Efficacy of Preventive Spinal Manipulation for Chronic Low-Back Pain and Related Disabilities: A Preliminary Study   [Link]

J MANIPULATIVE PHYSIOL THER. 2004 OCT; 27(8) pp. 509-15

Descarreaux M, Blouin J-S, Drolet M, Papadimitriou S, Teasdale N.

Objective:  To document the potential role of maintenance chiropractic spinal manipulation to reduce overall pain and disability levels associated with chronic low-back conditions after an initial phase of intensive chiropractic treatments.

Methods:  Thirty patients with chronic nonspecific low-back pain were separated into 2 groups. The first group received 12 treatments in an intensive 1-month period but received no treatment in a subsequent 9-month period. For this group, a 4-week period preceding the initial phase of treatment was used as a control period to examine the sole effect of time on pain and disability levels. The second group received 12 treatments in an intensive 1-month period and also received maintenance spinal manipulation every 3 weeks for a 9-month follow-up period. Pain and disability levels were evaluated with a visual analog scale and a modified Oswestry questionnaire, respectively.

Results:  The 1-month control period did not modify the pain and disability levels. For both groups, the pain and disability levels decreased after the intensive phase of treatments. Both groups maintained their pain scores at levels similar to the postintensive treatments throughout the follow-up period. For the disability scores, however, only the group that was given spinal manipulations during the follow-up period maintained their postintensive treatment scores. The disability scores of the other group went back to their pretreatment levels.

Conclusions:  Intensive spinal manipulation is effective for the treatment of chronic low back pain. This experiment suggests that maintenance spinal manipulations after intensive manipulative care may be beneficial to patients to maintain subjective postintensive treatment disability levels. Future studies, however, are needed to confirm the finding in a larger group of patients with chronic low-back pain.

Upper Crossed Syndrome and Its Relationship to Cervicogenic Headache  [Link]

J MANIPULATIVE PHYSIOL THER. 2004 JUL-AUG; 27(6) pp. 414-20

Moore MK.

Objective:  To discuss the management of upper crossed syndrome and cervicogenic headache with chiropractic care, myofascial release, and exercise.

Clinical Features:  A 56-year-old male writer had been having constant 1-sided headaches radiating into the right eye twice weekly for the past 5 years. Tenderness to palpation was elicited from the occiput to T4 bilaterally. Trigger points were palpated in the pectoralis major, levator scapulae, upper trapezius, and supraspinatus muscles bilaterally. Range of motion in the cervical region was decreased in all ranges and was painful. Visual examination demonstrated severe forward translation of the head, rounded shoulders, and right cervical translation.

Intervention and Outcome:  The patient was adjusted using high-velocity, short-lever arm manipulation procedures (diversified technique) and was given interferential myofascial release and cryotherapy 3 times weekly for 2 weeks. He progressed to stretching and isometric exercise, McKenzie retraction exercises, and physioball for proprioception, among other therapies. The patient's initial headache lasted 4 days. He had a second headache for 1.5 days during his exercise training. During the next 7 months while returning to the clinic twice monthly for an elective chiropractic maintenance program, his headaches did not recur. He also had improvement on radiograph.

Conclusion:  The principles of upper crossed syndrome and the use of exercise, chiropractic care, and myofascial release in the treatment of cervicogenic headache are discussed. A review of the literature indicates that analyzing muscle imbalance as well as vertebral subluxation may increase the effectiveness of chiropractic treatment for cervicogenic headache.

A Survey of Practice Patterns and the Health Promotion and Prevention Attitudes of US Chiropractors, Maintenance Care: Part I  [Link]

J MANIPULATIVE PHYSIOL THER. 2000 JAN; 23(1) pp. 1-9

Rupert RL.

Objective:  To investigate the primary care, health promotion activities associated with what has historically been called "maintenance care" (MC) as used in the practice of chiropractic in the United States. This includes issues such as investigating the purpose of MC, what conditions and patient populations it best serves, how frequently it is required, what therapeutic interventions constitute MC, how often it is recommended, and what percent of patient visits are for prevention and health promotion services. It also investigates the economic impact of these services.

Design:  Postal survey of a randomized sample of practicing US chiropractors. The questionnaire was structured with a 5-point ordinal Likert scale (28 questions) and brief fill-in questionnaire (12 questions). The 40-question survey was mailed to 1500 chiropractors selected at random from a pool of chiropractors with active practices in the United States. The National Directory of Chiropractic database was the source of actively practicing chiropractors from which doctor selection was made. The sample was derived by using the last numbers composing the zip codes assigned by the US Postal Service. This sampling method assured potential inclusion of chiropractors from all 50 states, from rural areas and large cities, and assured a sample weighting based on population density that might not have been afforded by a simple random sample.

Results:  Six hundred and fifty-eight (44%) of the questionnaires were completed and returned. US chiropractors agreed or strongly agreed that the purpose of MC was to optimize health (90%), prevent conditions from developing (88%), provide palliative care (86%), and minimize recurrence or exacerbations (95%). MC was viewed as helpful in preventing both musculoskeletal and visceral health problems. There was strong agreement that the therapeutic composition of MC placed virtually equal weight on exercise (96%) and adjustments/manipulation (97%) and that other interventions, including dietary recommendations (93%) and patient education about lifestyle changes (84%), shared a high level of importance. Seventy-nine percent of chiropractic patients have MC recommended to them and nearly half of those (34%) comply. The average number of recommended MC visits was 14.4 visits per year, and the total revenue represents an estimated 23% of practice income.

Conclusions:  Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.

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