Over the years I have had the opportunity to talk to doctors of chiropractic about health promotion, wellness and preventive care in chiropractic practice. These opportunities have come from postgraduate teaching, homecomings at various colleges, and at times, an invitation to speak to a group of alumni or members of a distinguished state or national organization.
Inevitably, while I am discussing the need for all health care providers to take vital signs on each new patient visit or reactivation visit, some practitioner wants to argue the point about the doctor of chiropractic's role in this sort of evaluation. On other occasions, the practitioner suggests prevention is the primary-care doctor's responsibility and that as chiropractors, one only need to care for spine and or musculoskeletal conditions.
There is only one problem with this suggestion: Patients who have chronic spine conditions have significantly more comorbid conditions (health issues) than people who don't suffer from chronic spine conditions.1-2 They have more hypertension, more cardiovascular issues, are more likely to smoke, and likely have the same poor dietary issues most Americans have.
Barriers to Wellness Practices
Two distinct, but dysfunctional paradigms seem to emerge from discussions about chiropractic and whether we have a role to play in prevention or wellness. These paradigms are barriers to actual wellness practices – in spite of the fact that many a chiropractic office has "wellness" in the name of the clinic and/or on the business card or sign.
First, some hold to a notion that they only adjust after analyzing the spine for subluxations and that this is what chiropractors are all about. Second, at the other end of the spectrum, some suggest chiropractors are musculoskeletal specialists who should only deal with the conditions patients most commonly present to the chiropractor for: back pain, neck pain and headaches.
That may be fine and well to have as a paradigm, but the literature I outlined earlier suggests the thing we treat the most – spine problems – is more likely to be accompanied with lifestyle-related health issues if allowed to become chronic. Why wouldn't all spine practitioners want to address the root causes of those comorbid conditions as part of their practice?
The U.S. Centers for Disease Control and Prevention stresses that every health care provider talk to patients about tobacco use.3 Yes, this means you. There have been calls to action for all providers, including chiropractors, to address the escalating pandemics of overweight, obesity and other preventable health conditions.4-5 And those primary-care doctors? How can we count on them to be successful when a patient, on average, will see them 1.9 times per year?6
Chiropractors and other complementary providers have a unique opportunity primary care does not have: dose-response. This dose-response is related to messaging and advising patients on how to be healthy. While the average primary-care patient is seen by the doctor less than two times a year, the average chiropractic patient will likely be seen at least several more times a year. This provides multiple opportunities to engage them on lifestyle / healthy behavior modification.
In addition, studies show primary-care doctors don't engage the majority of patients on prevention, anyway.4,7-8 Some chiropractors have stated that patients do not want to hear a preventive message in the first place and are not likely to listen to advice. That may be the case in some instances, but research indicates that when either a chiropractor or other provider suggests lifestyle changes, more than 85 percent of patients try to comply.9
What if we offered serious resources in our offices – or at least referred patients toward those resources? What if those resources truly focused on wellness and prevention? What if we stressed advising every patient who uses tobacco to stop; and advised every patient on the 2008 Guidelines for Physical Activity?10 What if we at least offered patients information on what to eat as a routine part of what we do? What if we networked with other like-minded providers and truly had a patient-centered, wellness-focused practice instead of a "subluxation-centered" or "pain-centered" practice?
The Consequence of Inaction
Unfortunately, a true wellness-centered practice is just a buzzword for most chiropractors to use as a tag line in marketing. Actually working to assess and advise patients on lifestyle change doesn't appear to be the route many chiropractors are willing to take.
So what happens to the patient? Well, it could be argued that for those lifestyle-related behavior changes they could make – if only we would offer them the opportunity – won't happen. In its place, they are likely to end up in a chronic, pharmaco-medical management program for the rest of their life; simply because we want to focus exclusively on correction of subluxation or back pain.
Either way, we do a tremendous disservice to our community and contribute to poor health outcomes in our "well-adjusted" clientele by using wellness as a tag line, but never delivering the goods.
Most of the leading causes of premature morbidity and mortality could be positively impacted by chiropractic if practitioners simply chose to participate in the efforts.11 Why not choose to join the fight against the 21st century's latest pandemic – lifestyle-related disease? We could cut the profits of Big Pharma in the process. Sounds like fun to me!
Author's note: I invite you to join the chiropractic public health community. If you are already a member of the American Public Health Association's Chiropractic Health Care section, you know how important the relationship is between public health and chiropractic. At APHA, prevention is paramount and you'll network with multidisciplinary colleagues of like minds. To learn more, click here.
- Fanuele JC, Birkmeyer NJO, Abdu WA, Tosteson T, Weinstein JN. The impact of spinal problems on the health status of patients: have we underestimated the effect? Spine, 2000;25(12):1509-1514.
- Von Korff M, Crance P, Lane M, et al. Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication. Pain, 2005;113:331-339.
- Fiore MC, Jaén CR, Baker TB, et al. "Treating Tobacco Use and Dependence: 2008 Update. Quick Update for Clinicians." U.S. Department of Health & Human Services, Public Health Service, April 2009.
- Manson JE, Skerrett PJ, Greenland P, VanItallie TB. The escalating pandemics of obesity and sedentary lifestyle. Arch Intern Med, 2004;164:249-258.
- Evans MW, Rupert R. The Council on Chiropractic Education's new wellness standard: a call to action for the chiropractic profession. Chiropr and Osteop, 2006;14(1):23.
- Woolf SH, Jonas S, Kaplan-Liss E. Health Promotion and Disease Prevention in Clinical Practice. 2nd Edition. Philadelphia, PA. Wolters Kluwer-Lippincott, Williams & Wilkins; 2008; 533-535.
- Morrato EH, Hill JO, Wyatt HR, Ghushchyan V, Sullivan PW. Are health care professionals advising patients with diabetes or at risk for developing diabetes to exercise more? Diabetes Care, 2006;29(3):543-548.
- Evans MW, Ndetan H, Singh KP. Primary prevention: what are we missing in primary care? Am J Health Stud, 2012;27(2):82-96.
- Ndetan, HT, Sejong, B, Evans, M, Rupert, R, Singh KP. Characterization of health status and modifiable risk behavior - United States adults using chiropractic care as compared to general medical care. J Manipul Physiol Ther, 2009;32(6):414-422.
- 2008 Physical Activity Guidelines for Americans. Be Active, Healthy, and Happy. U.S. Department of Health and Human Services: www.health.gov/paguidelines.
- Hawk C, Evans W. Health Promotion and Wellness: An Evidence-Based Guide to Clinical Preventive Services. Philadelphia, PA. Wolters Kluwer-Lippincott, Williams & Wilkins; 2013;1-3.
Click here for previous articles by Rand Baird, DC, MPH, FICA, FICC.
Dr. Will Evans is the associate provost of the University of Western States. A graduate of Logan College, he also holds a master's degree in health studies and a doctorate degree in health education and health promotion with a concentration in epidemiology. Before joining Western States, Dr. Evans previously served in a variety of high-level educational roles including director of research at the Center for Health Promotion and Human Performance, Texas Chiropractic College; director of wellness initiatives at Parker University; and dean of graduate studies and director of the health promotion degree at Cleveland College of Chiropractic.