Health Promotion and Wellness: A Paradigm Lost?
By Meridel I. Gatterman, MA, DC, MEd
Following completion of a book for patients titled Chiropractic, Health Promotion, and Wellness,1 I received a short description of the book from the publisher that stated, "Chiropractors have traditionally offered manipulation for neuromuscular skeletal problems.Today, many chiropractors are repositioning themselves as wellness providers." I promptly replied that chiropractors have traditionally counseled patients on health promotion and wellness. In mentioning this incident to a well-known research director, a non-chiropractor who has been involved with chiropractic for 14 years, he responded, with equal surprise, that practicing health promotion and wellness is not a new direction for chiropractors.1
This article and its companion, "Health Promotion and Wellness: Paradigm Lost, Gained or Maintained?" [to be published in a future issue of DC] are in response to this "apparent" paradigm loss. It is understandable that this perception is common, given the research focus on mechanical back pain during the past 25 years. Declaring the chiropractic identity as "spinal experts" does nothing to dispel this notion. This may be consistent with how chiropractors think the public seems to see chiropractic practice, but is this consistent with how chiropractors see themselves, or how those who have observed and documented how chiropractors practice view the profession?
How Do Others See Chiropractic Practice?
One of the earliest sociological studies2 of the chiropractic profession noted the holistic approach to practice that involved the patient's cooperation in preventing health problems by effecting change in his or her behavior. The authors also observed that chiropractors may go beyond the prevention of a particular problem and seek to modify behavior, so that major threats to health in general can be avoided.2 A study published in 1985 by a medical anthropologist examined the art of clinical chiropractic, noting chiropractors' holistic approach to healing.3 This included counseling on general health matters.
In 1991, Aspen published a book titled Health Promotion for Chiropractic Practice,4 authored by a medically trained chiropractic educator. This practical guide offered much useful information for practicing chiropractors, but was not widely used as a textbook in chiropractic colleges.
How Do Chiropractors See Themselves?
In 1992, Vear5 discussed the chiropractic scope of practice in Chiropractic Standards of Practice and Quality Care. He noted, "The chiropractic profession has always stressed patient counseling as an important component of patient care Counseling on diet, lifestyle, exercise, alcohol, tobacco, drugs, and ergonomics forms the basis for this interaction with patients." In the 1993 Job Analysis of Chiropractic, it was reported that encouragement of patients to change habits and lifestyle was routinely performed.6
Management of greater than 90% of the identified etiology of patient conditions named in the 2000 Job Analysis of Chiropractic7 is addressed in wellness practice, including: activities of daily living (18.9%), motor vehicle accident (14.2%), overuse/repetitive stress (12.9%), work (10.95) sports/exercise/recreation (9.5%), wellness and preventive care (9.3%), emotional stressors (7.9%) and environmental/dietary stressors (6.3%). This is consistent with the 2005 Job Analysis of Chiropractic: A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States.8
Responding to specific questions about health promotion and wellness, more than 90% of the chiropractors surveyed reported they routinely practice some strategies designed to promote healthy behavior. Advice on general fitness and exercise promotion is frequently given by greater than 98% of chiropractors to 65% of their patients. Ergonomic and postural advice is provided to 70% of patients by 97% of the chiropractors surveyed. Over 90% of the respondents reported they provide counseling on nutrition and give dietary recommendations to 52% of their patients; 97% reported counseling 55% of their patients on changing risky and unhealthy behaviors; and 96% percent teach self-care strategies to 60% of their patients. Relaxation and stress recommendations are made by 97% of chiropractors to half of their patients; and 91% present disease prevention and early screening advice to 40% of all patients.8
Health promotion and wellness counseling is given based on individual preferences and needs. Most patients come to chiropractors for musculoskeletal conditions, but as patients respond to therapeutic management, many doctors of chiropractic then begin counseling them on health promotion and wellness strategies.
Does Chiropractic Education Teach Health Promotion and Wellness Strategies?
The Council on Chiropractic Education (CCE) considers that doctors of chiropractic must be able to provide wellness care and to promote health maintenance, as well as to perform common screening procedures and wellness assessments in different age groups. The CCE Standards state that a doctor of chiropractic should be trained to help meet the health needs of individuals and of the public, including wellness promotion, by assessing health risks and providing general health information and lifestyle counseling.9
Undergraduate courses in nutrition include the biochemistry of proteins, enzymes, carbohydrates, lipids, vitamins and trace elements. Clinical nutrition courses discuss nutrient metabolism and nutritional needs throughout life. Nutritional management of common conditions encountered in chiropractic practice is emphasized. Pediatric, maternal and infant, and geriatric courses discuss the specific needs of these different age groups.
Public health information is included for leading health indicators (tobacco use, substance abuse, responsible sex behavior, injury and violence, immunization, and access to health care). Screening and risk assessment, along with counseling for lifestyle modification and injury prevention, are also a part of the curriculum.
A patient-centered partnership for promoting wellness is an important part of traditional chiropractic care.10 The strong emphasis on the relationship between structure and function and the neuromusculoskeletal system provides a background in the assessment and management of posture and spinal health. Enhancement of function through physical activity and exercise is approached with consideration to individual variations and needs. Occupational health is considered in terms of work safety, environmental quality, and ergonomics. Mental fitness that is dependent on sleep, rest and recreation, in addition to stress management, is discussed relative to individual patient needs.
Are Doctors of Chiropractic Suitable as Health Promotion and Wellness Practitioners?
The chiropractic preference for conservative methods of care makes the profession philosophically well suited for the practice of health and wellness.10 The understanding of the relationship between the mind and the body and the nature of functional conditions is essential for the promotion of health and wellness. Doctors of chiropractic are readily accessible with offices located in most communities that provide easy access to chiropractic services. Jurisdictionally, doctors of chiropractic are primary contact practitioners and may serve as primary care doctors, making them ideally suited to solve health problems. They offer conservative care with a preference for natural, minimally invasive and drugless interventions. They are committed to promoting health and they facilitate wellness by considering the many factors that contribute to well-being.
Is Health Promotion and Wellness a Paradigm Lost?
With the current health care crisis,11 health promotion and wellness is a paradigm whose time has come. The reductionistic paradigm that has dominated our health care culture for the past several hundred years has served well to direct the treatment of disease, but fails in the promotion of health and wellness.12 The preoccupation with disease and its prevention has tended to equate health with the absence of disease. If we truly wish to promote health, we need to direct our attention to a paradigm more suited to health promotion and wellness.13
The current ferment within the chiropractic profession stems largely from a clash between the reductionistic and holistic paradigms.10 This conflict can be traced back to ancient Greece, where the Coans, led by Hippocrates, adhered to a holistic world view in which the patient was viewed as a whole. In contrast, the Cnidian school focused on diseases of parts located in organs or organ systems.14 The Coan school held that disease had a natural basis which was the result of an imbalance within the person. Coan decision-making was person-oriented, emphasizing the structure-function relationships. Promotion of health included diet, exercise and a balanced life. The Cnidian tradition saw disease as real entities with an existence distinct from the person.14 The current biomedical model dominated by specialists is a legacy of the Cnidian school.15 The most useful paradigm to meet the health promotion and wellness needs of society follows the Coan tradition of Hippocrates. This is emphasized in the following definition of wellness quoted by Ian Coulter, PhD:
"Wellness is more than a concept. It is a way of life, an integrated enjoyable approach to living that emphasizes the importance of achieving harmony in all parts of the person: mind, body, spirit. It is a lifestyle that creates the greatest potential for personal well being. More than an absence of illness, it is balance among all of the aspects of the person."16
The appropriate paradigm for health promotion and wellness may be abandoned and lost by some in the profession, while others continue to follow a model that traditionally has been as much a part of chiropractic care as the problems of the spine. While patients most commonly are brought to the chiropractor's office by back pain, as they recover from their disorder, many chiropractors begin the process of serving as health educators and wellness practitioners. To them, the paradigm is not lost.
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