Dynamic Chiropractic for permission to reproduce this article!
by Meridel I. Gatterman, MA, DC, MEd,
ACA Wellness Subcommittee on Education; and
Joe Brimhall, DC,
president, Western States Chiropractic College
Council on Chiropractic Education (U.S.)
Following completion of a book for patients titled Chiropractic, Health Promotion, and Wellness,  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. 
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
studies  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.  A study published in 1985 by a medical
anthropologist examined the art of clinical chiropractic, noting chiropractors' holistic
approach to healing.  This included counseling on general health matters.
In 1991, Aspen published a book titled Health Promotion for
Chiropractic Practice,  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
How Do Chiropractors See Themselves?
In 1992, Vear  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
Management of greater than 90% of the identified etiology of patient
conditions named in the 2000 Job Analysis of
Chiropractic  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
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
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
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.  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.  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,  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.  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. 
The current ferment within the chiropractic profession stems largely from
a clash between the reductionistic and holistic
paradigms.  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.  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.  The current biomedical model
dominated by specialists is a legacy of the Cnidian
school.  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
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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