J Can Chiropr Assoc 2008 (Aug); 52 (3): 175–184 ~ FULL TEXT
Charles Blum, DC, Gary Globe, MBA, DC, PhD, Lisa Terre, PhD,
Timothy A. Mirtz, DC, PhD(c), CHES, Leon Greene, PhD, Denise Globe, DC, MHSA, PhD
Sacro Occipital Technique Organization - USA
INTRODUCTION: This study explores the extent to which consumers seek wellness care when choosing chiropractors whose practice methods are known to include periodic evaluative and interventional methods to maintain wellness and prevent illness.
METHODS: Using an international convenience sample of Sacro-Occipital Technique (SOT) practitioners, 1316 consecutive patients attending 27 different chiropractic clinics in the USA, Europe and Australia completed a one-page survey on intake to assess reason for seeking care. A forced choice response was obtained characterizing the patient's reason for seeking chiropractic care.
RESULTS: More than 40% of chiropractic patient visits were initiated for the purposes of health enhancement and/or disease prevention.
CONCLUSION: Although prudence dictates great caution when generalizing from this study, if confirmed by subsequent research among other similar cohorts, the present results may lend support to continued arguments of consumer demand for a more comprehensive paradigm of chiropractic care, beyond routine musculoskeletal complaints, that conceptualizes the systemic, nonspecific effects of the chiropractic encounter in much broader terms.
From the Full-Text Article:
In the emerging health care arena, the topic of wellness care has generated considerable interest. Consumers are seeking, alongside of conventional medical options, improved ways to prevent the onset of chronic diseases and even the common effects of aging by increasing their use of complementary and alternative (CAM) approaches to promoting health and preventing illness. [1, 2]
With regard to non-allopathic services, chiropractic is among the most commonly used modality. [3–5] Although prevalence estimates vary, it has been suggested that each year in the U.S. there may be more total visits to CAM providers (including homeopaths, acupuncturists, and chiropractors) than to more traditional primary care physicians.  Moreover, CAM use is predicted to rise with increasing third party reimbursement and managed care coverage. [5, 6] Research focused on patient motivations for seeking CAM suggest that this trend is not primarily rooted in patient dissatisfaction with conventional care but, instead, rests on more complex considerations including a “philosophical congruence” with alternative practitioners emphasizing a holistic approach to wellness. [5–7] Indeed, the growing popularity of wellness care has been described as a fundamental change in the “healthcare paradigm”8 that may reflect a “tipping point”  in the evolution from a purely biomedical to a more holistic, biopsychosocial perspective  that is reverberating throughout the healthcare system, affecting both allopathic as well as complementary and alternative (CAM) providers. 
Recently, chiropractic has expanded its longstanding spinal wellness emphasis by disseminating a widely adopted Model Course for Public Health Education in Chiropractic Colleges12 as well as specifying health promotion and wellness as key chiropractic competencies.  In support of these developments, Hawk and colleagues [3, 4] have advocated promoting “wellness concepts” in chiropractic student training, emphasizing national health targets (such as those found in Healthy People 201014) and evidence-based-practices for health promotion and disease prevention. [3, 4]
The recent formal inclusion of public health preventive measures within the scope of chiropractic practice has raised concerns about chiropractic’s evolving public identity and the potential public acceptance of chiropractors as wellness providers. For instance, the World Federation of Chiropractic’s Identity Consultation Task Force, in its 2005 final report,  emphasized the urgent need for a clear public identity in chiropractic. Indeed, in terms of public perception, chiropractic has long been synonymous with spinal manipulation and is characterized as “manual healing” (not “alternative systems”) in NC-CAM’s taxonomy.  Without a better understanding of the public’s willingness to seek out wellness care from chiropractic providers, the preparation of chiropractors as wellness providers may be a case of the cart leading the horse.
The World Federation of Chiropractic’s “Consultation on Identity” found that only 6% of patients seek wellness care from chiropractic providers.16 However, the fact that a minority of patients currently seek wellness care from chiropractic providers may have more to do with consumers’ current understanding of actual chiropractors’ scope of practice than with the acceptability of chiropractors as wellness practitioners. Indeed, practicing chiropractors currently differ substantially on whether they provide one therapeutic modality or a “complete system of healing.” 
Accordingly, as a first step effort, the present study explored the extent to which consumers seek wellness care when the provider is known to offer complementary approaches beyond standard manipulation to alleviate patient symptoms and enhance patient feelings of wellness.  Based on studies indicating that patients seek chiropractic care primarily for musculoskeletal complaints such as neck and low back pain,  the present study examined wellness preferences of patients visiting an international convenience sample of Sacro-Occipital Technique (SOT) practitioners utilizing a broad palate of holistic methods.
Using an international convenience sample, this study attempted
to identify patients’ specific wellness preferences
when seeking chiropractic care from a cohort of
chiropractors where wellness care is affirmatively promoted.
Findings indicate, overall, more than 40% of patients
seeking care reported doing so for the purpose of
“optimizing health” or “preventing illness” (including the
prevention and/or early intervention of potential risk factors). These findings differ from a previous World Federation
of Chiropractic survey, which indicated less than 5–
10% of patients seeking care for non-musculoskeletal
conditions. Indeed, the rates of patient-initiated wellness
visits in this convenience sample of wellness promoting
chiropractors is notable when compared to previous estimates
indicating lower consumer demand for chiropractic
wellness care. [16, 17] One obvious explanation for the outcomes
may be related to these patients’ awareness that
their chiropractors actually offer care other than solely
for pain reduction for musculoskeletal conditions such as
low back pain. Sacro-Occipital Technique practitioners
are trained to utilize a system of complex diagnostic and
treatment procedures focused upon systemic as well as
neuromusculosketal complaints. SOT practitioners educate
patients on the value of periodic (1–2 times per year)
examination/wellness check-ups to assess patient’s overall/
systemic health status by evaluating the spine and
nervous system through various mechanical and reflex
techniques. Treatment recommendations are then individualized
based upon the findings and typically involve
short-term, outcome-based interventions supported by
modification in patient lifestyles, diet, exercise, nutrition,
and other modifying behavioral and psychosocial factors.
Furthermore, the SOT model of care does not advocate
the unethical use of long-term, pre-paid maintenance
treatment programs developed outside of the normative
parameters of clinical indicators. While the authors clearly
believe that the frequency of maintenance/supportive
care should ethically be left strictly to individual patient
preferences, this tendentious aspect of chiropractic preventive
care is clearly beyond the focus of this paper.
Based on the public’s (and their chiropractors’) current
perceptions of chiropractic as primarily an NMS specialty,
19,16 the typical consumer responding to prior surveys
may not have been aware of the possibility that preventive/
wellness care is a chiropractic option and therefore
would have been less likely to express a desire for this
type of care. By contrast, patients in this cohort of SOT
practitioners, where preventive/wellness approaches to
health are emphasized in their practices (and presumably
transmitted through patient social and informal referral
networks), appeared to report higher rates of wellness
seeking preferences. This phenomenon might have important
implications for those chiropractic educators and
policy-makers who also continue to advocate a primary
healthcare role for chiropractors, particularly emphasizing
wellness/preventive care. A profession that does not regularly offer their patients primary care services nor educate
their patients as to their capabilities to serve as a
primary care provider will certainly find it challenging to
alter patient attitudes and behaviors in this regard.
Consistent with the broader literature on gender differences
in health attitudes and practices,20–25 women in the
present sample were more likely to express interest in
wellness, prevention, and self-care compared to men,
who were somewhat more prone to favor illness care,
which was most evident in the responses from the European
sample. Although explanations for these well-documented
gender differences are complex and remain a
focus of active research efforts, there are some empirical
hints in the broader literature that women’s socialization
experiences may sensitize them to identify incipient somatic
symptoms, and facilitate help-seeking sooner than
their male counterparts. By contrast, traditional male socialization
tends to reward risk-taking and a projected image
of strength, which often involves problem denial
(especially at sub threshold levels of severity such as
those associated with emerging health problems) and a
reluctance to seek help. [20–25] These socialization patterns
have direct implications for women’s greater propensity
to seek out health information and to utilize primary prevention
and early detection efforts. [26, 27] However, our
findings also resonate with extant research suggesting
that, despite well-documented gender differences, within
group variability also exists in men and women’s health
beliefs and practices,  highlighting the need to continue
efforts at unpacking the construct of gender with an eye
toward better tailoring of public health promotion messages.
 This need for more relevant public health communications
is especially pressing given that the health
behaviors of most adults still fall far short of public
health recommendations  and that these modifiable risk
factors significantly impact national health care costs. 
Interestingly, the geographic differences noted herein
are also consistent with the burgeoning literature highlighting
the importance of sociocultural and ethnic factors
in shaping symptom perceptions and motivations for
seeking health care. Although very little research has focused
specifically on chiropractic, numerous longitudinal
and cross-sectional studies have documented regional
variability in lifestyle, symptom perception, illness behavior, general health care utilization, and health outcomes as a function of complex combinations of
sociocultural, ethnic, and other local influences. [31–33]
Hence, in addition to being compatible with results from
the broader health care literature, our findings on regional
variability provide a preliminary foundation on which to
build subsequent research on consumer motivations for
seeking chiropractic care specifically.
Although international in scope, our convenience sample
of SOT practitioners certainly introduced selection bias,
thereby reducing the generalizability of the results.
The point was to demonstrate whether the previously reported
low rates of demand for wellness care were a
function of lack of interest on the part of patients or, perhaps,
a lack of understanding on the part of previous chiropractic
patients and their doctors that wellness/
preventive care was an option. The absence of information
on patient ethnicity, socioeconomic status, and other
potentially relevant background characteristics (which
was not collected in the present study) may have also
constrained our ability to examine some potentially important
influences on patient care preferences. Moreover,
the self-reported nature of responses may have been influenced
by a variety of potential response biases (including
social desirability and other demand characteristics).
In addition, the cross sectional nature of the data certainly
precludes any inferences about causality.
Further study should include more controlled research
that systematically examines chiropractic preferences,
perhaps utilizing an expanded survey administered in a
variety of chiropractic settings (beyond SOT) where wellness/
preventive care is normatively, ethically practiced,
including questions targeting patient interest in receiving
wellness/preventive care from their chiropractors.
This study was an attempt to determine patients’ specific
wellness preferences when seeking chiropractic care.
Based on an international convenience sample of Sacro-
Occipital technique (SOT) practitioners utilizing a broad
palate of holistic methods, more than 40% of patients
agreeing to participate in this study self-reported a preference
for care targeted at health enhancement and/or disease
prevention. Although generalizations from these
preliminary data cannot be made, the findings from this
study suggest there may be a sector of chiropractic patients
who seek out a more comprehensive paradigm of
chiropractic care that conceptualizes health broadly, beyond
the simple absence of disease or disability.  Indeed,
the Final Report of the Identity Consultation Task
Force of the World Federation of Chiropractic includes
the following foundational statement: “A patient-centered
and biopsychosocial approach, emphasizing the mind/
body relationship in health, the self-healing powers of the
individual, individual responsibility for health, and encouraging
patient independence” (page ii).  In order for
chiropractors to optimally serve their patients, there appears
to be a need for greater clarity and more well-developed
understanding of actual consumers’ health care
preferences. While the research literature indicates that
there is a substantial demand for complementary and alternative
care in the United States, [1, 2, 35] further research is
warranted to evaluate how chiropractors may ethically
and productively serve various subpopulations who exhibit
a preference for including access to some chiropractic
wellness approaches to health promotion and disease
Appendix: Patient Health Preference Categories*
Activity undertaken by a person, who believes himself to be healthy, for the
purpose of attaining a greater level of health.
Activity, undertaken by a person, who perceives himself to be healthy, for the
purpose of preventing illness or detecting it in an asymptomatic state.
Activity undertaken by a person, who believes himself to be healthy, but at
greater risk of developing a specific health condition, for the purpose of
preventing that condition or detecting it in an asymptomatic state.
Activity undertaken by a person, who perceives himself to be ill, to define the
state of his health and discover a suitable remedy.
Activity undertaken by a person, who considers himself to be ill, for the
purposes of getting well. It includes receiving treatments, involves few
dependent behaviors, and leads to some degree of neglect of ones’ usual duties.
Activity undertaken by a person, who considers himself to be ill, for the
purpose of getting well. It includes minimal reliance on therapists, involves
a few dependent behaviors, and leads to little neglect of one’s duties.
*Handbook of Clinical Chiropractic Care, 2005: Jones and Barlett Publishers,
Sudbury, MA. www.jbpub.com, Reprinted with permission
Form Sent to Participating SOT Clinicians
Health Behaviors [1, 2]
Wellness behavior — Are you here today because although you feel healthy you want to even have a
greater level of health?
Preventive health behavior — Are you here today because although you feel healthy you want to help prevent an illness or possible injury?
At-risk behavior — Are you here today because although you feel healthy you have a tendency to be at risk for injuring yourself and want to prevent that from happening?
Sick role Behavior — Are you here today because you are injured or ill and want help so that you will feel better, without having to do any home therapies or modifying activities out of this office?
Self role Behavior — Are you here today because you are injured or ill and want help so that you will feel better, and want to have home therapies and activities that I can do to help myself outside this office? 
It is questionable whether one can “motivate someone
sufficiently to affect their lifestyle behaviors which play a
large role in many of today’s disease states.”  If effective
health promotion is based upon the person’s willingness
to change for something better and wellness is a
behavior, then understanding various health behaviors
will help gain insight into the types of patients and what
they are seeking in a chiropractor’s office. 
As chiropractors “acknowledge that patients may
present with various health behaviors the clinical encounter
will become more exacting as well as educational.
The knowledge of such behaviors will aid in identifying
patients to help meet their unique individual needs.” 
Few if any studies have been performed in the chiropractic
profession evaluating patients’ health behaviors relating
to their reason for seeking chiropractic care. While
it might not seem all that important to a typical practitioner
it is essential for those in the research and epidemiological
community to understand the thought processes of a typical
chiropractic patient. This pilot study will help gain insight
and greater understanding into the nature of the
presenting health behavior of patients in a sacro occipital
technique (SOT) chiropractic office.
1. Green LW, Kreuter MW
Health Promotion Planning
Mayfield Publishing Company, Mountain
View, CA. 1999
2. Mirtz TA
Health Promotions in Clinical Practice
in Handbook of Clinical Chiropractic Care
LH) 2nd edition, Jones and Bartlett Publishers: Sudbury,
MA, 2005: 8–9
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