From the very beginning, the chiropractic model of health has had as its foundation the maxim that a human being is an ecologically and biologically unified organism. The relationship between a patient's internal and external environment must be understood. A major premise is that the inherent recuperative power of the body aids restoration and maintenance of health. These assumptions comprise a wellness paradigm embraced by the great majority of the chiropractic profession. The vertebral subluxation complex, along with other factors such as poor nutrition, stress, trauma, heredity, congenital weaknesses, fatigue, environmental stresses and sedentary lifestyles, is viewed as lowering resistance and creating physical disharmony (Shafer and Faye 1989, Gatterman 1990, Lantz 1989). The chiropractic model requires active patient participation (Coulter 1990, Jamison 1991, Coile 1990).
Patients presenting with a musculoskeletal problem often obtain a swift and favourable result. Then they may look to the practitioner for other health care needs (Shekelle, 1991).
Some patients require ongoing long-term care, others choose it. The effectiveness of chiropractic preventative/maintenance care unfortunately has not been thoroughly subjected to study by randomized trials, a process that presents major methodological and financial challenges, but is supported by evidence from case studies. (Stacey 1989, Yates et al. 1988). In one such study titled Functional Disturbances of the Spinal Column in Children and the Problems of Prevention of Vertebrogenic Lesions, Lewitt and Janda (1964) conclude that "the prime factor in the pathogenesis of vertebrogenic lesions is a disturbance of function which precedes morphological changes and which also closely corresponds to clinical symptoms". Manipulation of pain-free children with sacroiliac dysfunction produced positive short and long-term postural effects. In his most recent text Lewit, a neurologist, recommends preventative manipulative care, especially for children (Lewit 1991). However, the overall efficacy of preventative health care remains a subject of considerable debate (Hahn 1990, Kaplan 1990).
Preventative/maintenance care is elective care for patients without present disability or major symptoms. Therapeutic necessity is absent by definition. Clinically there is a need to distinguish for each patient when therapeutic and supportive care stops, and when preventative/maintenance care begins. The latter is considered safe and effective when used discriminately so as not to foster doctor dependence and chronicity.
Enhanced public awareness of environmental, psychosocial, and psychological issues through education and community action has forced preventative care onto the public health agenda as the number one priority. Smoking cessation, weight control, nutritional considerations, stress reductions and advice about exposure to environmental pollutants are examples of initiatives affecting the chiropractic patient population.
Coile (1990) offers this historical perspective: "Thirty years ago, René Dubois, a research microbiologist, suggested in Mirage of Health that the advancement he and others had made in the development of antibiotics and therapeutics had less to do with the real health of populations than a variety of economic, social, nutritional, and behavioral factors. Five years later, the U.S. Surgeon-General's landmark report clearly revealed the links between smoking and diseases such as emphysema, chronic bronchitis, hypertension and lung cancer.
"A new awareness of the contribution of lifestyle, environment, and genetics infused medicine in the decade following. Sometimes called the `wellness movement', this new orientation broadened the paradigm of traditional biomedicine. Since Dubois' essay on health, a body of research findings has accumulated that demonstrates the validity of a more comprehensive approach to health, one which recognizes the many antecedents and co-factors in the disease and healing process.
"Although not fully accepted by all physicians, the holistic concept of health is gaining stature. Dozens of studies by employers have begun to quantify the beneficial impact of health promotion programs in terms of reduced health care utilization and lower health care costs".
The principles and practices of long-term care in chiropractic have been discussed by a number of authors (Coulter 1990, Jamison 1991A, Coile 1990, Jamison 1991A) offers a comprehensive overview of the current trends in chiropractic, and worksheets for health care assessment. McDowell and Newell (1987) describe general health care indicators and instruments. Jamison (1991B) reviews the improvement of basic health status by alteration of behaviour, especially through health education.
Some recent surveys focus upon musculoskeletal chiropractic practice (Phillips 1982, Wardwell 1989, Shekelle and Brook 1991) but other current literature takes a firm stance on the importance of maintaining a focus on prevention and health promotion (Coulter 1990, Sportelli 1985, Caplan 1991).
Areas with new significance for chiropractic long-term care include the management of osteoporosis (Stacey 1989), and hypertension and stress management (Yates et al. 1988).
No study yet addresses what specific impact preventative/maintenance care has on overall health care costs, or if preventative care enhances longevity or quality of life.
Today, however, research into such complex issues as these is becoming more feasible (Nyiendo 1991, Kassak 1991, Jose 1990).
Notwithstanding the challenges of research in the field of preventative care, there must be publication of valid clinical studies before chiropractic long-term preventative/maintenance care gains widespread recognition as an important component of health maintenance and wellness (Balduc 1988, Feinstein 1990)