American Journal of Lifestyle Medicine 2008; 2 (6): 537–545 ~ FULL TEXT
Daniel Redwood, DC, and Gary Globe, MBA, DC, PhD
Cleveland Chiropractic College–Kansas City,
10850 Lowell Avenue,
Overland Park, KS 66210
Chiropractic care includes
a variety of minimally invasive
approaches, with both treatment and
prevention as essential elements of
clinical practice. Although chiropractic
adjustment (manipulation) is the signature
therapy and best-known identifier
of the profession, the practice of
chiropractic involves more than manual
therapeutics. In general, chiropractors
seek to bring a holistic worldview
to the doctor–patient encounter, seeking
not only to relieve pain and restore
neuromusculoskeletal function but also
to support the inherent self-healing
and self-regulating powers of the body.
Aside from applying their diagnostic
training to the evaluation of a variety
of physical disorders and delivering
manual adjustments and related therapeutic
interventions, many chiropractors
encourage patients to take an
active role in restoring and maintaining
health, with particular emphasis on
doctor-guided self-care through exercise
and nutrition. In this review, the
authors summarize the peer-reviewed
literature on chiropractic and prevention,
describe health promotion and
wellness approaches currently taught
at chiropractic colleges and used in
chiropractic clinical settings, discuss
duration of care, emphasize the importance
of interprofessional cooperation
and collaboration, and address
the hypothesis that chiropractic adjustments
yield preventive effects.
Keywords chiropractic; primary prevention; health promotion; complementary medicine; alternative medicine
When a niche in the health care
ecosystem remains unfilled by
medical physicians and their
associated paraprofessionals, in some
cases, a new profession emerges to fill
the gap. In the United States in late
19th century, the chiropractic profession
arose to meet a need for alternatives to
“heroic medicine,” the conventional care
of the time. This reflected a pragmatic
need for spine-focused manual therapeutics
coupled with a paradigmatic need
for a healing philosophy based on minimally
invasive (nonpharmaceutical, nonsurgical)
methods that included a strong
emphasis on preventive approaches. Over
the past century, chiropractic has grown
and evolved, gradually moving toward
mainstream status while largely maintaining
its original mission and tenets.
Preventive health care includes primary
prevention (averting illness before
it begins, chiefly through diet, exercise,
stress management, and avoiding
destructive behaviors such as smoking)
and secondary prevention (detecting
and treating disease in its early stages
to cure it or halt its progression or efforts
designed to prevent recurrence of illness
or injury). Historically, chiropractors
have recognized the importance of
both primary and secondary prevention,
but implementation has been inconsistent.
Although some chiropractors devote
a substantial part of their clinical efforts
to nutrition and/or therapeutic exercise
and rehabilitation and perform various
types of screenings and risk assessments,
others show less interest in these topics.
Similarly, although the biopsychosocial
model of health is now broadly accepted
and evidence-based prevention data on
problems such as smoking cessation,
overexposure to sunlight, and unprotected
sexual activity are widely available,
some chiropractors counsel patients
on such issues, whereas others address
them rarely or not at all.
At the heart of these choices by
individual practitioners lie fundamental
questions concerning the role of the
chiropractor in the health care system.
Within the profession, there is a broad
range of opinion and practice. At one
end of the spectrum are those who conceive
their role as primary care physicians
with a neuromusculoskeletal focus.
In a study of clinical and cost utilization
data, Sarnat and Winterstein  and
Sarnat et al  documented significantly
improved outcomes across a range of
parameters when patients under the care
of complementary/alternative medical
(CAM)–oriented primary care physicians
(including chiropractors) were compared
with usual non-CAM primary care physician
care. Although the care was primarily
therapeutic, it appears to have had
preventive effects as well. Over a 7-year
period, hospital admissions were 60.2%
lower, hospital days were 59.0% lower,
outpatient surgeries and procedures were
62.0% lower, and pharmaceutical costs
were 85% lower when compared with
conventional medicine performance for
the same health maintenance organization
product in the same geography and
At the opposite end of the spectrum
are chiropractors who define themselves
as “subluxation-based” practitioners,
who concentrate almost entirely on the
detection and reduction of the spinal
joint surface disrelationships and dysfunctions
that chiropractors call subluxation.
The vast majority of chiropractors
can be found in the broad middle of
this spectrum. A recent paper by
Nelson et al  made the case for this
middle-of-the-road definition of
“chiropractic as spine care,” which is
consistent with the World Federation
of Chiropractic’s consensus definition 
of the profession.
The degree to which evidence-based
prevention procedures are practiced by
individual chiropractors does not necessarily
correlate directly with one’s place
on this spectrum, but inclusion of these
procedures appears to be more likely
among those closer to the primary care
definition, which incorporates an evidence-based model to a greater degree.
As we demonstrate in this article, current
trends indicate that in the future, chiropractic
will include a more wide-ranging
and consistent emphasis on many areas
of evidence-based prevention.
Currently, chiropractors’ prevention
services focus primarily on physical activity
and exercise and, to a lesser extent,
on correction of poor nutritional habits.
Other areas where chiropractors could
potentially help their patients to pursue
healthier choices — most notably smoking
cessation — are addressed far less frequently.
The following is a summary of
studies evaluating chiropractors’ delivery
of preventive services as commonly
defined in the public health and health
Chiropractors Practicing Prevention: Survey of the Literature
Of the chiropractic academicians who
have written extensively on prevention,
the works of Jennifer Jamison,
Cheryl Hawk, and Will Evans stand out
for their high quality, depth of understanding,
and holistic orientation. Each of
these investigators has drawn from prevention
models and data from the public
health and health promotion communities
and generated original research
assessing chiropractors’ prevention practices
with the goal of increasing implementation
of evidence-based procedures.
To this end, each has framed these prevention
practices as means by which chiropractors
can more fully live up to their
professed ideals of holism, therapeutic
conservatism, active care, and patient
Jamison, a medical physician and educator
who taught at Australian university-based
chiropractic training programs for
nearly 3 decades, surveyed chiropractors
and 316 of their patients at 20 Australian
clinics to explore the health education
behaviors of the chiropractors, ascertain
their willingness to provide patient
counseling, and evaluate the congruence
of their responses vis-à-vis the interests
expressed by their patients.  Among her
key findings was that chiropractors most
often provide prevention information
in the form of printed brochures rather
than offering direct, interactive counseling
to their patients, apparently due in
large part to the additional unpaid time
required to pursue counseling in depth.
The conflicting imperatives of service to
patients versus increased income mirror
similar experiences in the private practices
of medical physicians.
The chiropractic clinics in Jamison’s
sample offered information on prevention
topics at the following rates: exercise,
91%; diet, 72%; nutritional supplements,
67%; smoking cessation, 35%; alcohol
abuse, 13%; and substance abuse, 12%.
Jamison expressed particular concern
at the low percentage of chiropractors
(23%) who offered patients information
on preventing osteoporosis, a condition
with clear relevance to chiropractic practice.
She also noted that although 78%
of chiropractors expressed a willingness
to counsel patients on injury prevention,
45% of the chiropractors had themselves
experienced a work-related injury
(most frequently the low back and wrist),
perhaps pointing to a lack of congruence
between their knowledge and their
behaviors. Regarding patients’ desires
and expectations for receiving health promotion
information from their chiropractors,
probably the most significant finding
was that patients desired information
from chiropractors at a higher rate than
what the chiropractors provided. The disparity
was most pronounced for information
on cancer, with patients desiring this
information from their chiropractors at
4 times the rate that chiropractic offices
provided it. There were also significant
differences between patient desires and
chiropractors’ delivery of information
about sleep, “social” drugs, heart attacks,
More recently, Jamison sought data on
the wellness perspectives and practices
of Australian chiropractors in a study 
involving 43 chiropractors and 347 chiropractic
patients (no less than 5 or no
more than 10 per chiropractic clinic).
Most patients reported that their chiropractors
had inquired about their occupation
(90%) and exercise (82%); many
reported inquiries about their tobacco
use (65%), weight (48%), alcohol (43%),
and fruit and vegetable consumption
(35%). Few chiropractors appeared to
inquire about blood pressure (27%),
cholesterol levels (17%), illicit drug use
(10%), or unsafe sex (.9%). In discussing
these results, Jamison noted the significant
health impacts of these risk factors
and concluded that “the chiropractic profession
lacks a shared comprehensive
approach to tackling this problem.”
In another survey of wellness practices
in Australian chiropractic clinics, 
Jamison gathered data on the effects of
providing health brochures to patients.
Of 757 participants, 275 requested brochures.
Women were more likely to
request brochures than men, with
nearly half of older (ages 46 and above)
women taking 1 or more brochures.
The “Better Sleep” brochure was chosen
most often, with “Eating to Prevent
Cancer,” “Prevent Osteoporosis,” and
“Prevent Hypertension” as the next most
frequently chosen topics. Of course,
picking up a brochure, although a positive
step, is no guarantee of changed
health behaviors. In this study, of those
who had taken brochures, less than 25%
implemented changes within 3 weeks of
receiving the information. However, with
the exception of brochures for preventing
skin and genital cancers, at least 2 of
3 patients who did initiate changes were
continuing with their health improvement
initiatives at 3 months. For many of
the changed behaviors, adherence had
declined substantially at the 12-month
follow-up. After 12 months, the behavioral
changes most likely to persist were
increased exercise, maintaining a relaxing
bedtime routine, and eating less fat
and more fruits and vegetables. Perhaps
the most hopeful sign was that more than
three quarters of those making dietary
changes to prevent cancer sustained their
changes at the 12-month follow-up.
Because all of Jamison’s research was
performed in Australia, it is unclear to
what extent her findings can be generalized
to the United States and other nations.
Hawk, a chiropractor with a PhD in
preventive medicine who practiced for
12 years prior to embarking on a research
career, was the lead author of 2 studies
a decade apart dealing with primary care
and prevention issues. [8–10] Taken together,
these studies offer insight into the status
and trajectory of prevention efforts by
chiropractors in the United States, where
a majority of the world’s approximately
100,000 chiropractors practice.
In the earlier survey, [9, 10] a nationwide
random sample of 753 chiropractors,
Hawk and Dusio inquired as to whether
chiropractors considered themselves to
be primary care practitioners (PCPs), in
part because it is widely understood that
PCPs have a fundamental responsibility
to provide preventive health services and
information. Hawk and Dusio found that
90% of chiropractors consider themselves
to be PCPs. In further defining their roles,
63% said chiropractors should be general
primary care, portal-of-entry practitioners;
25% said chiropractors should be
the chief portal of entry for musculoskeletal
conditions but not general primary
care; and 4% endorsed an arrangement
where chiropractors serve as the designated
specialists for musculoskeletal spinal
conditions, rather than portal-of-entry
Because chiropractors in North America
and many other nations are unarguably
portal-of-entry practitioners (ie, patients
can legally access chiropractic care without
medical referral), a status no chiropractor
seeks to relinquish, it is likely
that at least some respondents in the
Hawk and Dusio study were unclear as
to what constitutes primary care and portal
of entry. The question of whether chiropractic
practice is or should be primary
care has at times been a source of heated
debate within the profession. Whatever
the eventual resolution, it is unclear what
practical effects, if any, would ensue
from a determination that chiropractors
do or should practice primary care. [1, 11] It
may be that the issue is mainly one of
Regarding comprehensiveness of
overall services, Hawk and Dusio’s earlier
study [9, 10] found that more than (58%)
of respondents did a regional physical
exam on every patient, 29% did a complete
physical examination (PE) on every
patient (chiropractic training requires
demonstrating proficiency at PE), and
71% performed a complete health history
(HH) on every patient. Conversely,
2% never did a complete HH, 12.5%
never did a complete PE, and 3.8% never
checked blood pressure. Lab tests, either
in-office or referred out, were the least
frequently employed procedure, with
1.5% performing them on every patient;
however, 63% did them occasionally.
Nearly one fourth never did lab tests.
These findings appear inconsistent with
the PCP role. On the other side of the
equation, nearly 1 in 10 of the chiropractors
had hospital privileges.
Regarding prevention counseling opinions
and practices, Hawk and Dusio
inquired on more than 20 topics, asking
whether the respondents believed these to
be topics that all chiropractors should discuss
with patients and whether they had
personally discussed them with patients in
the preceding 3 months. The prevention
practices most frequently discussed with
patients were fitness and exercise, 68.1%;
nutritional supplements, 65.8%, lifting techniques,
64.0%; and postural education,
59.8%. The data on belief versus practice
included lifting techniques, which 78% said
that all chiropractors should discuss with
patients and 64% had actually discussed
with a patient in the previous 3 months;
smoking, where the respective figures
were 53% and 53%; nutritional supplements,
51.6% and 65.8%; cancer detection,
54.5% and 32.9%; weight loss programs,
38.2% and 55.8%; and sexually transmitted
disease, 48.6% and 19.2%. These figures
reflect varying levels of individual commitment
to different aspects of prevention and
also an appreciation by chiropractors of a
diversity of legitimate choices on how
others should conduct their practices
(ie, there need not be a single standardized
answer to these questions).
The 2004 Hawk et al  study assessed
attitudes of chiropractic students, public
health faculty, and practitioners concerning
clinical preventive and health promotion
services. A total of 582 students, 45 faculty,
and 496 practitioners were surveyed. More
than 80% of practitioners reported providing
information to patients on musculoskeletal
risk reduction, exercise, diet, stress
reduction, and injury prevention. More
than 80% also reported obtaining information
from patients on physical activity,
stress, dietary habits, obesity, medication
use, and occupational hazards. In general,
female, younger, and more recently graduated
practitioners appeared to be somewhat
more likely to agree that chiropractors
should provide prevention counseling and
to report providing it. Concerning immunization
information, a much higher proportion
of faculty (91%) and students (80%)
than practitioners (62%) felt chiropractors
should provide both pro and con information
to patients. This reflects a longstanding
concern among chiropractors about potential
adverse effects of vaccinations. Because
the chiropractor’s legal scope of practice
specifically excludes prescription medicines
and implicitly excludes telling patients to
reject or discontinue their use, the vaccination
issue should be a moot point for chiropractors
who adhere to their legal scope
In addition, an association was seen
between attitudes toward health indicator
counseling and respondent education.
Practitioners with at least a bachelor’s
degree (as of 2003, 67.5% of practicing
chiropractors were 4-year college
graduates)  were statistically significantly
more likely to report providing counseling
for physical activity, to agree that chiropractors
should provide counseling,
and to report actually providing counseling
within the last month for substance
abuse, responsible sexual behavior, mental
health, and injury and violence prevention.
Preprofessional education levels
have risen steadily over the past several
decades, and this may be indicative of
Educating Chiropractic Students in Prevention
For many years, public health education
in chiropractic colleges focused on
topics such as microbiology, sewage
treatment, potable water, and pasteurization
that were only minimally relevant
to chiropractic practice. In 1998,
the Chiropractic Health Care Section of
the American Public Health Association
formed the Public Health Curriculum
Task Force with the goal of improving
the quality of public health training for
chiropractic students. One year later, this
report by interdisciplinary researchers
was disseminated to all chiropractic colleges.
It included a detailed list of topics
and resources (developed by the task
force with input from all faculty teaching
public health in US chiropractic colleges)
for inclusion in their public health
courses. By 2001, a Model Course for
Public Health Education in Chiropractic
with greater relevance to health promotion
and clinical preventive services, such
as physical exercise, safe lifting, weight
loss strategies, and smoking cessation,
was recommended. [13–16]
Major changes have been under way
since that time. As one example, Cleveland
Chiropractic College–Los Angeles implemented
a fully revamped public health
curriculum that includes a modernized
classroom syllabus along with policy
changes that require interns in the college’s
public clinic to elicit information from their
patients and provide appropriate prevention
Globe et al  evaluated the impact of
these changes, measuring the frequency
with which chiropractic interns provided
appropriate prevention recommendations
to patients. A standardized data abstraction
form was developed, which was
used for chart reviews before and after
the curriculum change took effect. The
primary purpose of this tool was to collect
factors from each chart that would
establish the need for preventive health
services that could be provided by chiropractic
interns (tobacco cessation,
physical activity, obesity, nutrition, hypertension,
reduction in dietary fat intake,
blood cholesterol levels, and recommendations
for screening for cervical, breast,
and colorectal cancer). Guidelines from
the US Preventive Services Task Force’s
Guide to Clinical Preventive Services
were used to operationally define when
a patient was a candidate for a preventive
health service recommendation. The
investigators then evaluated the frequency
with which interns actually delivered
evidence-based preventive care advice to
their patients when factors indicating such
a need were present.
Unfortunately, Globe et al’s initial data 
indicated a near-total failure to change
intern behaviors. Of 408 charts examined
(204 before and 204 after the curriculum
change), there were only 4 documented
instances (1%) of recommendations for
any of the 9 preventive health service
categories. Two of these recommendations
occurred in the precurriculum
Theorizing that this disappointing
response may have resulted from a prevention
services learning module that
relied too heavily on didactic presentations
and provided only minimal experiential
learning opportunities, along with
an inefficient system of audit by faculty
clinicians, the college changed its pattern
of instruction and accountability, instituting
policies, including normative behavior
feedback and guideline compliance
prompts. Administratively enforced policies
required both student interns and
faculty clinicians to confirm that lifestyle
and disease risk information is elicited
from patients and evaluated by interns
and their supervising clinicians to determine
In addition, a series of required audit
steps was put into place to ascertain that
these recommendations are presented to
patients and that each patient’s compliance
is monitored periodically during his
or her course of care.
Posters were affixed to the walls of the
college’s community clinic as reminders.
Materials were provided for patients
to facilitate self-efficacy concerns along
with related patient/clinician prompts
and brochures. Academic detailing procedures
were amended to ensure continual
clinician review via chart audits with
Perhaps most important, 2 new screening
forms were created, using evidence-based
materials from Healthy People
2010 and the US Preventive Services Task
Force. These forms, the Physical Activity
and Nutrition Behaviors Monitoring Form
(PAN)  and the Adult Health Risk Profile
(AHRP),  are now an integral part of the
intake paperwork for every new patient
seen at the Cleveland Chiropractic College
clinics in Los Angeles and Kansas City.
The PAN form quantifies more than
a dozen aspects of physical activity
and nutrition, including exercise, hours
watching television, and amounts of
sweet drinks and sodas, fast food, fatty
snacks, milk and other calcium sources,
fruits, and vegetables. The AHRP screens
for risk factors related to injury prevention,
tobacco use, sun exposure, oral
health, tuberculosis, cholesterol, blood
pressure, diabetes, colorectal cancer,
sexually transmitted diseases/HIV,
multivitamin/folic acid use, Pap smears,
mammograms, osteoporosis, nutrition,
physical activity, and body mass index.
The revamped prevention program,
including educational intervention and
clinical implementation, was instituted
in the fall of 2005. In the spring of 2006,
data were collected from randomly
selected new patient files (n = 159).
These revealed 636 prevention counseling
opportunities among 159 patients. Of
these, 201 counseling recommendations
were documented. This represents a 33%
improvement secondary to the clinically
relevant intervention. The typical success
rate in program intervention is approximately
a 5% change in the target cohort’s
Follow-up 1 year later demonstrated
that PAN and AHRP forms were now
introduced during preclinical coursework,
without complaints from interns
about completing these screening forms.
In a dramatic sign of improvement, an
October 2007 file audit found that 87%
of files (n = 156) demonstrated that the
AHRP screening forms translated into
appropriate patient counseling recommendations
as documented in the diagnosis
and treatment progress notes. 
In an example of an effort by a chiropractic
college to implement a prevention
strategy targeted at one specific behavior,
Evans, a chiropractor with a PhD in
health promotion (with a concentration
in epidemiology), and colleagues studied
chiropractic interns’ interventions for
smoking cessation, [21, 22] seeking to develop
a research-based training program for
interns that could also be applicable to
practicing chiropractors. The program,
initially implemented at Parker College of
Chiropractic in Texas, had 7 components:
a lecture aimed at clinic interns, a card
describing the Surgeon General’s 5 As, 
a lapel button, treatment room posters, a
smoking cessation information brochure
rack, a list of area cessation programs,
and a paperwork stamp to track interns’
Within 1 month of the delivery of the
campaign, there was a 25% increase in
the number of patients reporting receipt
of smoking cessation information from
interns. As noted by Evans et al,  “this
campaign was inexpensive and was
well received. . . . It has been integrated
into the curriculum as part of the wellness
class required . . . before interns
see patients in student or outpatient clinics.”
Viewing these results as a possible
springboard to profession-wide changes,
the authors continue, “Chiropractic has
long been seen as a holistic profession
that says it emphasizes wellness and better
health for patients. We see no reason
why advising smoking patients on cessation
should not be a part of routine clinical
chiropractic practice. We feel this
should be made a requirement in all
Broadening Implementation of Health and Wellness Strategies
The World Health Organization (WHO)
defines health as “a state of complete
physical, mental and social well-being and
not merely the absence of disease or
infirmity.”  This profoundly affirmative
biopsychosocial perspective, first enunciated
by representatives of 61 nations at
the International Health Conference in
New York in 1946 and enshrined in the
preamble of the WHO constitution, set a
clear benchmark that health professionals
and all who seek the greater well-being
of the public have sought to employ
for the past 6 decades. A contemporary
wellness movement worthy of the
name must be as broadly based as possible,
drawing on the skills and energy
of all individuals and groups who share
its high ideals and seek to contribute to
In 2001, the American Chiropractic
Association endorsed a consensus document
outlining a detailed wellness
model for the chiropractic profession. 
This active care model strongly encourages
patient participation, seeking to lay
the groundwork for a profession-wide
effort to pursue evidence-based evaluation
and assessment of patients, provision
of educational information to
patients, intervention and monitoring,
and coordination with other community
Probably the single most important
elaboration of the burgeoning evidencebased
wellness movement within chiropractic
was the mandate  from the
profession’s accrediting agency, the
Council on Chiropractic Education (CCE),
that requires all students graduating
from chiropractic colleges after January
2007 to demonstrate knowledge of evidence-based prevention approaches and
mastery of methods for applying these
approaches in the clinical setting. The
CCE wellness mandate grants individual
institutions leeway to craft their own
wellness training programs, but all institutions
will be audited for compliance
with the key markers spelled out in the
mandate. Thus, all future chiropractic
graduates will be required to demonstrate
evidence-based wellness assessment and
intervention skills, which presumably will
carry over into their careers as practicing
Suitability of Chiropractic Practice for Health Promotion Counseling
Hawk  has aptly noted, “Chiropractors
are in an excellent position to reinforce
health promotion messages at
each visit, because chiropractic care
requires multiple visits, and chiropractors
usually establish long-term relationships
with patients.” Moreover, Harvard
medical educators Kaptchuk (an acupuncture
and Chinese medicine practitioner)
and Eisenberg (a medical physician)
concluded that, in general, the ability of
chiropractors to develop rapport and connection
with their patients is among the
greatest strengths of the profession.  The
combination of strong rapport plus ongoing
opportunities for presentation and
reinforcement of health promotion messages
seems tailor-made for success, as
long as chiropractors are properly trained
and willing to make the effort.
Regarding the reasons (aside from
chronic neuromusculoskeletal disorders)
that patients pursue ongoing, multiple-visit
care with chiropractors, it is worth
noting that many patients initially come
to chiropractors for back pain or other
neuromusculoskeletal complaints and
then discover that chiropractic offers
more than they expected — a holistic
philosophy of natural healing, based on
principles asserting that structure and
function are intimately related, that manual
methods are a key means for achieving
structural and functional integrity, that
diet and exercise are crucial determinants
of health, and that stopping illness before
it starts (or in its early stages) is always
better than intervening when illness or
dysfunction has rooted deeply.
Ongoing Care: Does Adjustment/Manipulation Yield Preventive Effects?
Chiropractors have long hypothesized
that manual adjustments have a protective
or preventive influence on human physiology
and that these effects are mediated
by the nervous system. This has led many
chiropractors to recommend ongoing
care (known as maintenance, wellness, or
preventive care) even in the absence of
problematic symptoms. Observers have
questioned whether this is legitimate.
The answer is not simple because there
is supporting evidence, but it falls short
of being clearly persuasive. Adjustment/
manipulation is most frequently justified
by the presence of palpably restricted
joint mobility and, in some cases, radiographically
demonstrable joint surface
disrelationships at 1 or more spinal
levels. These findings often coincide with
pain or other symptoms but may also
appear as a precursor to such symptoms.
Thus, if joint restriction is noted even in
the absence of symptoms, this may serve
as a rationale for the application of
As Hawk  frames the issue, “People
unfamiliar with chiropractic might only
think of chiropractic adjustments . . . as
a sort of ‘aspirin,’ that is, a treatment to
reduce pain, and so would not seek care
if they did not have any symptoms. This
use of chiropractic care would be seen as
curative care or possibly tertiary or secondary
prevention. . . . However, conceptually,
if adjustments remove or reduce a
risk factor (subluxation) and prevent disease
or disability from occurring, this
would be primary prevention. . . . In this
view, screening for subluxations in asymptomatic
people would therefore be more
akin to doing a health risk appraisal than
it would be to screening for early manifestations
of disease, such as mammography
does.” Hawk continues, “This conceptual
framework is as yet undocumented,
due in part to the difficulty of designing
and conducting studies to investigate
it. However, it has served as the theoretical
basis for much of chiropractic practice
for more than 100 years, and thus has the
considerable weight of clinical experience
to support it, if not yet the support of scientific
As for evidence that might be considered
supportive, in a landmark, wideranging
article on chiropractic in the
Annals of Internal Medicine, Meeker and
Haldeman  proposed a series of mechanical
and neurologic mechanisms to explain
the effects of spinal manipulation. Some of
these clearly involve symptomatic presentations,
whereas others also apply to minimally
symptomatic or even asymptomatic
cases where they may exert either primary
or secondary preventive effects:
Alleviation of an entrapped facet joint
inclusion or meniscoid that has been
shown to be heavily innervated [30, 31]
Repositioning of a fragment of posterior
annular material from the intervertebral
disk [31, 32]
Alleviation of stiffness induced by
fibrotic tissue from previous injury
or degenerative changes that may
include adaptive shortening of fascial
tissue [33, 34]
Inhibition of excessive reflex activity
in the intrinsic spinal musculature or
limbs and/or facilitation of inhibited
muscle activity [35–37]
Reduction of compressive or irritative
insults to neural tissues 
The one survey in the Medline-indexed,
peer-reviewed literature that directly
addresses the possible effects of ongoing
care is the study by Rupert  and Rupert
et al  on Medicare patients. These investigators
surveyed a randomized sample
of practicing US chiropractors and a representative
sample of chiropractic maintenance
care (MC) patients, age 65 and
older, seeking information on health
promotion activities associated with MC
visits. Exclusion criteria required that
patients must have been under MC for
at least 5 years, with a minimum of
4 visits per year.
The chiropractors judged that the
purpose of MC was to optimize health
(90%), prevent conditions from developing
(88%), provide palliative care (86%),
and minimize recurrence or exacerbations
(95%). The therapeutic composition
of MC placed virtually equal weight
on exercise (96%) and adjustment/
manipulation (97%), whereas other interventions,
including dietary recommendations
(93%) and patient education about
lifestyle changes (84%), shared a high
level of importance.
Information elicited from patients
included the SF-36D survey, patient health
habits, expenditures on health services,
frequency of use of health providers, and
perceived value of chiropractic prevention
and health promotion services. Key
findings were that, in addition to manual
procedures, it was common to recommend
stretching exercises (68.2%),
aerobic exercises (55.6%), dietary advice
(45.3%), and a host of other prevention
strategies, including nutritional supplements
and relaxation. Perhaps the most
intriguing finding was that the patients
investigated in this study reported making
only half the annual number of visits
to medical providers (4.76 visits per
year) compared with the national average
(9 visits per year) for individuals age
65 years and older. The methodology
used by Rupert39 and Rupert et al  does
not justify conclusions regarding cause
and effect, but the possibility of a health
benefit from MC remains an open and
potentially important question for future
Opportunities for Collaboration and Integration
As chiropractors equipped with
evidence-based health promotion training
(along with their highly developed
skills in manual manipulation and related
methods) gradually enter a health care
mainstream that itself is changing, significant
opportunities are emerging for
interprofessional cooperation, collaboration,
and integration. The degree of
mainstreaming and integration seen over
the past generation has exceeded the
expectations of all but the most optimistic
observers and participants. Much
has been accomplished, but there is still
much more to do.
The breakthrough that may have the
greatest potential to be a truly transformative
“game changer” in developing
models for collaboration and integration
is the inclusion of chiropractors on the
medical teams serving active-duty members
of the US military as well as military
veterans. Shortly after the turn of the
21st century, the US Congress passed
2 landmark laws bringing chiropractic
into the mainstream of military and
veteran health care. In 2000, President
Clinton signed the National Defense
Authorization Act, which required that
chiropractic care be made available to
active-duty military personnel. Then,
in 2002, President Bush signed the
Department of Veterans Affairs Health
Care Programs Enhancement Act, which
included a mandate to establish a permanent
chiropractic benefit within the
Department of Veterans Affairs health
care system. Each of these laws built
upon successful pilot projects in the
1990s that demonstrated the value of chiropractic
services while developing ways
to integrate chiropractors into the health
care teams at military bases and Veterans
Administration hospitals. Full access to
chiropractic services in both systems is
currently in a multiyear phase-in period.
When chiropractors work alongside other
health care personnel for the benefit of
their common patients, camaraderie often
develops that has the potential to heal
longstanding divisions, prejudices, and
misconceptions on all sides. 
Interdisciplinary cooperation is further
fostered by the presence of chiropractors
on the staffs of more than 200 US hospitals
and the sports medicine staffs for the
Olympic Games and numerous teams in
the National Football League, National
Basketball Association, and Major League
Baseball, as well as collegiate, scholastic,
and youth club sports.
These collaborative ventures encourage
the strengthening of mutual respect
between chiropractors and members of
other health professions through the
natural give-and-take of daily doctor-todoctor
interaction. No profession can be
all things to all people, and learning how
the skills of others can complement one’s
own should, ideally, elicit feelings not
of competition but relief and gratitude.
From such unexpected insight ideas for
cooperation, collaboration and the creation
of a higher synthesis can emerge.
The history of medical-chiropractic
cooperation and joint ventures is as yet
neither broad nor deep, but great possibilities
may lie in this mostly untapped
ore. Planners and policy makers can
(and should) envision and seek to implement
models for such cooperation, but
it is in the actual joy and friction of
working together as colleagues that the
most practical and sustainable models
are likely to arise. This is what makes
the Department of Defense, Veterans
Administration, and sport-related programs
so crucial to the development of
chiropractic’s full potential as an integral
part of the overall health care system.
Research is another key area where
chiropractic-medical collaboration has
grown and deepened in recent years.
Interdisciplinary research came to the
fore earliest in Canada and Europe and is
now well established in the United States
as well. The first paper in a medical journal
to be coauthored by a chiropractor
and a medical physician appeared in
Canadian Family Physician in 1985, 
the result of a collaborative effort by
Kirkaldy-Willis, a world-renowned
orthopedist, and Cassidy, a chiropractor
who later became the first member
of his profession to serve as research
director of an orthopedics department
at a university hospital (University of
The approximately 300 subjects in this
study were “totally disabled” by low back
pain, with pain present for an average of
7 years. All had gone through extensive,
unsuccessful medical treatment prior to
participating as research subjects. After
2 to 3 weeks of daily chiropractic adjustments,
more than 80% of the patients
without spinal stenosis had good to
excellent results, reporting substantially
decreased pain and increased mobility.
After chiropractic treatment, more than
70% were improved to the point of having
no work restrictions. Follow-up a
year later demonstrated that the changes
were long-lasting. Even those with spinal
stenosis, a particularly challenging subset,
showed a notable response. More than
half improved, and about 1 in 5 were
pain free and on the job 7 months after
In a recent example of medicalchiropractic
a Chicago chiropractor, and Bakris, a
medical hypertension specialist at the
University of Chicago and director of the
Rush University Hypertension Center,
published a study  in which upper
cervical chiropractic adjustments led to
sustained improvement in chronic hypertension
patients, “similar to that seen by
giving two different anti-hypertensive
agents simultaneously,” with 88% of subjects
in the treatment group experiencing
greater than an 8–mm Hg drop in diastolic
For more 2 decades, the US federal government
has supported various chiropractic
research projects. This has included
funding of clinical trials, infrastructure
development, a series of research agenda
conferences, and R25 grants to several
chiropractic colleges to enhance the teaching
and understanding of evidence-based
health care among chiropractic college
faculty and students.
Criteria for Referral to a Chiropractor
Regarding criteria that medical physicians
may wish to consider in deciding
when they should refer patients to
a chiropractor (and to which individual
chiropractor), it may be most helpful
to address the most challenging question
first. This is the issue of duration of
care and the potential for overtreatment.
Although a fully adequate discussion and
explanation of this issue would require
another article, we propose the following
starting points for informed consideration
of the matter:
Duration of care for similar conditions
varies very widely among chiropractors.
As noted by former chiropractic
college president and national association
executive, J. F. McAndrews, 
“Depending on which chiropractor
a patient sees, the recommended
course of care for the same condition
may vary drastically, from several visits
with one doctor to several dozen —
sometimes hundreds — with another.”
That such disparities exist and such
excesses are apparently legal may
indicate a flaw in the health care market
and regulatory systems as currently
constituted. Managed care, despite its
many problems and limitations (wellknown
to chiropractors and medical
doctors alike), has placed some limits
on such extreme practice variation.
The problem, however, is as yet unresolved.
No doctor can know the course of a
patient’s recovery in advance. Routine
treatment plans for extended courses
of care (ie, dozens of visits) should
be considered red flags, particularly if
patients are encouraged or required
to sign advance commitments for
such programs or required to pay in full upfront.
Ethical, efficacious treatment plans
should be individualized. There is no
evidence-based rationale for recommending
precisely (or approximately)
the same course of care for all patients.
Chiropractors who do so are not practicing
in a professional manner.
Retraining neuromusculoskeletal patterns
and rebalancing musculoskeletal
structures sometimes does require
an extended course of care. This is
widely recognized by chiropractors,
osteopaths, physical therapists, and
physiatrists. It is particularly true in
cases of higher complexity resulting
from trauma or significant structural
distortion or with patients whose general
health is poor. In a small number
of cases, this might require several
dozen or more visits over a period of
months or even years. Both authors
of this review have had patients who
legitimately fit this pattern.
A treatment plan appropriate for a
modest number of carefully selected
patients should not be applied in a
broad-brush fashion to all or most of
a chiropractor’s cases. Medical physicians
may legitimately consider such
a pattern to be very strong evidence
against referring patients to a particular
chiropractor. Fortunately, there are
many ethical chiropractors to whom
referral can be made with confidence.
To be judged legitimate, extended
courses of chiropractic care must
gradually increase emphasis on
active care (exercise) and gradually
decrease passive care (manipulation and related therapies).
Additional questions for medical doctors
to consider when seeking the right
chiropractor for referrals include the
Have you heard positive reports from
patients or others in the community
regarding the care given by this
Will the chiropractor allow you to
visit his or her office and observe at
least a few patients being treated?
Will he or she send you initial reports
and timely updates on patients you
Does he or she routinely X-ray all patients (current guidelines advise against this) or fail to use X-ray and other imaging procedures when clinically indicated?
Chiropractic is currently in transition,
steadily moving toward a more mainstream
status. Chiropractors can play a meaningful
role in both treatment and prevention,
complementing the efforts of other
healing arts. Recent changes in the public
health curricula of chiropractic colleges,
with strong support from the Council on
Chiropractic Education, demonstrate a
dramatic upgrading of evidence-based
prevention approaches in chiropractic educational
settings. As students with greatly
enhanced prevention training graduate
and begin their careers, this should ripple
across the mainstream of chiropractic
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