Complement Ther Clin Pract. 2017 (Nov); 29: 27–34 ~ FULL TEXT
Donald McDowall, Elizabeth Emmanuel, Sandra Grace, Marilyn Chaseling
School of Health and Human Sciences,
Gold Coast, Southern Cross University,
Lismore, NSW, Australia
STUDY DESIGN: Concept analysis.
INTRODUCTION: This paper is a report on the analysis of the concept of tone in chiropractic.
PURPOSE: The purpose of this paper is to clarify the concept of tone as originally understood by Daniel David Palmer from 1895 to 1914 and to monitor its evolution over time.
METHODS: Data was sourced from Palmer's original work, published between 1895 and 1914. A literature search from 1980 to 2016 was also performed on the online databases CINHAL, PubMed and Scopus with key terms including 'tone', 'chiropractic', 'Palmer', 'vitalism', 'health', 'homeostasis', 'holism' and 'wellness'. Finally hand-searches were conducted through chiropractic books and professional literature from 1906 to 1980 for any references to 'tone'. Rodgers' evolutionary method of analysis was used to categorise the data in relation to the surrogates, attributes, references, antecedents and consequences of tone.
RESULTS: A total of 49 references were found: five from publications by Palmer; three from the database searches, and; the remaining 41 from professional books, trade journals and websites.
MAJOR CONCLUSIONS: There is no clear interpretation of tone in the contemporary chiropractic literature. Tone is closely aligned with functional neurology and can be understood as an interface between the metaphysical and the biomedical. Using the concept of tone as a foundation for practice could strengthen the identity of the chiropractic profession.
KEYWORDS: Tone, Chiropractic, Daniel David Palmer, Homeostasis, Wellness, Rodgers' evolutionary concept analysis
From the Full-Text Article:
Tone has been described as the passive neurological condition of
strength found in all body tissues.  For this reason, gymnasts
quest for it, body builders exhibit it and personal health requires it.
In the health discipline of chiropractic, tone is a foundational
principle for practice.  Despite this, tone, and its relevance to
contemporary practice, is not well understood. [24, 57, 60] A
comprehensive understanding of tone may help explain the schism
that has emerged in contemporary chiropractic practice between
reductionism and holism. 
Since antiquity, ‘tone’ has had multiple meanings that have led
to confusion and controversy about its meaning.  Tone evolved
from the ancient Greek root word ‘tonus’ to describe the breath of
life that inhabits the human body.  This meaning extended into
the realm of metaphysical constructs that were difficult to research
and validate with scientific methods. [13, 40] Donahue  discussed
the two disciplines of Greek healing located at Cnidus and Kos in
Asia Minor and compared them to modern chiropractic concepts.
He explained that the Cnidian concept is similar to the modern
medical theory of reductionism, or reducing the function of
humans and nature into parts.  The Koan perspective is a holistic
study of health and disease, similar to the chiropractic concept of
tone.  The Koans regarded disease as a disruption of tone or
functional unity, leaving the whole person out of balance with
nature. They believed in the body's natural ability to heal itself. This
ability has been referred to by Hippocrates as ‘vis medicatrix
naturae', a Latin term for his self-healing philosophy. 
Both perspectives of reductionism and holism have continued to
serve humanity over time. Around 200AD, Galen, the Greek
physician, during his service to the Roman empire, successfully
negotiated a middle ground of drawing from both perspectives. 
Marcellus, a Roman historian, circa 410 AD, described choices for
* Corresponding author. healthcare in Roman medicine as including both these healing
perspectives.  Galen's work continued to refine and use Greek
and Roman medicine in medieval times until the German-Swiss
physician, Paracelsus, in the 16th century, reformed medicine
from the superstitions of curses and devils to metaphysical arguments
seeking cause and cure. It was a patient-centred approach to
healthcare that supported a holistic foundation for the concept of
tone. During the 16th century the Flemish/Netherlandish anatomist
and physician, Versalius, and the French barber surgeon, Pare, used
metaphysical reasoning to expand on Paracelsus' ideas of cause and
cure, thereby further developing this holistic foundation and
beginning the transition to more innovative methods of healthcare
evidenced by their work continuing to be published in the 17th and
18th centuries.  During the 19th century, the scientific method
of investigation was consolidated.  This brought great strides in
the basic sciences of physics, chemistry, anatomy and biology, relegating
tone from the spiritual metaphysical overtones of tonus to
an expression of physiological health. 
The word ‘tone’ was first used by Daniel David Palmer (D D
Palmer), the founder of chiropractic, in the late 1890s to explain
health.  Palmer's work on tone continued for a period of almost
20 years. [36, 38] During this time, he observed that many personal
health issues failed to respond to the healthcare provided.  This
failure to respond, he argued, was due to a loss of tone in an organ
or body system which, when restored or recovered, would build
health and empower a person to reach their ‘destiny’. Palmer used
the analogy of musical tone to describe a cause-and-effect model of
health and disease for chiropractic, which was at odds with causeand-
effect models of other health professionals.  Since then, the
profession has evolved and basic concepts such as tone are being
questioned.  The aim of this paper is to clarify the concept of
tone as originally understood by Palmer and to monitor its evolution
Concept analysis is well established in the health sciences as a
methodology to examine concepts. Of the many methods of
concept analysis, Rodgers  method has been chosen for this
analysis as it is systematic, with clear-cut phases. Also, it allows for
the clarification, description and explanation of a concept by analysing
how it is used within the discipline and in other healthrelated
areas.  Rodgers described a ‘concept’ as a “cluster of
attributes”, and ‘analysis’ as the “breaking apart of a thing to
identify its constituent components”.  She described her
method as ‘evolutionary’ for she argued that concepts are not fixed,
rather they are continually subject to change over time.
Rodgers  method involves six primary activities, many of
which can be undertaken simultaneously during the investigation.
First a concept of interest is identified, together with any associated
expressions including ‘surrogate’ terms. Care must be taken that
any ‘surrogate’ terms are indeed terms that are used interchangeably
with the concept, and are not really a related concept. The
second activity is to select an appropriate ‘realm’ (setting and
sample)for data collection.
The third and fourth activities, the collection and analysis of the
data, involve two components. Here the researcher examines the
literature, using an inductive and discovery approach, to identify
the ‘attributes’ or ‘real’ definition, or common usage, of a concept as
opposed to its ‘nominal’ or dictionary definition. [43, 44] As well,
the contextual basis of the concept needs to be explored to “gain an
understanding of the situations in which the concept is used, the
use of the concepts in those varying situations, and its use by
people with potentially diverse perspectives”.  Here the
‘reference’ of the datadactual situation in which the concept is
useddneeds to be collected to assist with clarifying the scope and
application of the concept. Where possible, the ‘antecedent’dor
events associated with the concept in the pastdneed to be identified.
Similarly, where available, the ‘consequences’dor results of
the use of the conceptdneed to be determined.  A fifth activity
requires the researcher to, if appropriate, identify an exemplar of
the concept. The sixth and final activity involves identifying any
hypotheses, as well as implications for the future of the chosen
Three sources of data were used to collect data for this concept
analysis of tone. First, Palmer's 1896 to 1914 articles, chiropractic
books and journals were reviewed and the five most relevant
sources were selected. A 1910 document by Gregory, a student of
Palmer, was also located. Second, searches were conducted for the
period 1980 to 2016 in three main relevant databases (CINAHL,
PubMed, MANTIS) using key search terms including ‘tone’ and
combinations of the associated wordsd‘chiropractic’, ‘Palmer’,
‘vitalism’, ‘health’, ‘homeostasis’, ‘holism’ and ‘wellness’. Three
sources were discovered. Third, additional data were retrieved for
the 1980 to 2016 period, primarily from chiropractic sources,
although other health disciplines were also searched. A total of 41
sources were located from 1980 to 2016 trade journals, websites,
private collections and books.
Data were entered on a spreadsheet with columns headed
‘author,’ ‘year of publication’, ‘database’, ‘discipline’, ‘relevance’,
‘page number’, and ‘words and phrases used’. The reading, data
entry and analysis were undertaken by the first author. Further
analysis culminated in five main columns titled ‘surrogates’, ‘attributes’,
‘references’, ‘antecedents’ and ‘consequences’. When final
agreement was reached, interpretations were accepted. When
agreement was unattainable, interpretations were omitted.
The results for this concept analysis of tone, as related to the
chiropractic profession, are summarized and tabulated according to
Rodger's [43, 44] evolutionary analysis protocols. Table 1 provides a
summary of the data. Following the table, the results will be discussed
using Rodgers' categories of surrogates, attributes, references,
antecedents and consequences.
A ‘surrogate’ is a word or words that are interchangeably with
the concept being analysed.  This analysis revealed five surrogates.
In 1900, Palmer interchanged ‘tone’ with the term ‘inharmony’
which he described as a lack of balance or lack of
homeostasis. A decade later, Palmer  used ‘neurological tension’
which provided a clearer physiological understanding of tone. More
than eight decades later, Donahue  was aware of the dilemma of
tone being poorly understood. He proposed ‘homeostasis’ as an
interchangeable term for a new and better version of tone arguing
that homeostasis is an effect of tone, not a definition. Tutashinda  simplified the complexity of tone by describing it as ‘balance’.
Rosner  described tone as an optimum health gateway and
recommended a better understanding of the chiropractic emphasis
on tone as a function of the nervous system.
Attributes of tone and references
‘Attributes’ and ‘references’ are closely related: ‘attributes’ are
the real definition or the common usage or characteristics of the
concept, and the ‘reference’ is the actual situation in which the
concept was used.  To highlight their inter-relationship they
will be discussed together. Rodgers and Knafl  maintained that
the primary achievement of a concept analysis is the identification
of the concept's attributes (or characteristics).
A total of 29 sources described the ‘attributes’ of tone and 10
described their ‘references’. These attributes and references
showed little development since their first descriptions in Palmer's
early work. Attributes of tone were not clearly described in Palmer's
early work. [34, 36, 38] Here, he saw tone as a source of energy that
could vary and, when variations did occur, they preceded symptoms.
For Palmer, when someone had little or no energy this
indicated the absence of tone and was therefore linked to poor
health and disease.  Normal tone, a constant source of energy,
depended on nerve tension within the nerve trunk. The nerve trunk
became the optimum location to change that tension, regardless of
cause  and this became the foundation principle of chiropractic.  Causes of tension, according to Palmer, included structural
pressure, food and chemical poisons, depression and mental health
disorders, and fatigue from lifestyle choices.  Palmer expanded
his concept of tone in later writings. [36, 38] Ebrall , by examining
the period between 1895 and 1910, linked neurology and tone
across health professions and confirmed that chiropractic understanding
of neurologywas well established at that time. Collation of
Palmer's work indicated that the concept of tone was similar to the
creative expression of music or art. 
Donahue  argued that tone was in essence a driver for optimum health
and its reference was to explain quality of life. In a later
paper, Donahue  researched the loss of emphasis on tone that
had occurred in the chiropractic profession and argued that, while
tone was poorly understood, it still had value and could provide an
innovative way for researching health and disease outcomes for all
interventions. Mootz, Coulter, and Hansen  studied the growing
public use of chiropractic services and proposed an agenda to
integrate chiropractic innovations and concepts into mainstream
health care. Of the six recommendations that they made, Mootz,
Coulter, and Hansen's determination of the barriers to usage of
chiropractic came closest to exploring the impact of the loss of
emphasis on tone. These barriers included a lack of familiarity with
chiropractic concepts like tone and its value for preventative care.
Rosner  also identified a loss of emphasis of tone over time. He
proposed a need for the inclusion of tone into a modern context of
functional or therapeutic use of neurology.
Tone was also seen as a medium bridging the physical (spinal
manipulative therapy) with general health and physiological processes
that are normally outside the scope of musculoskeletal
therapeutics.  Eingorn and Muhs' research also proposed tone
as a common platform that could be understood by all health
professionals. Coulter  proposed that this broader perspective of
tone would allowmetaphysical models of research such as heuristic
and phenomenological studies to be added to the knowledge base
Griner  prioritised the neurological changes in tone from
structural to systemic to improved general health. Keating 
described tone as neurally-mediated health of all cells and tissues
of the body. These perspectives were expanded further by others in
the discipline. For instance, Carey, Clum, and Dixon  described
tone as a component of the personality of the profession, whilst
Senzon  considered tone as a moral ethic of improving public
health for the profession and a lens to understanding bio-theology.
Thus, tone became a cause-and-effect model for chiropractors. By
modifying tone, the argument was that pain, metabolic and organ
function could alter. Tonewas seen as a means of preventing disease
and promoting health. In their research, Masi and Hannon 
confirmed tone as a baseline for structural function. They constructed
a bio-tensegrity systemas a basis for passive human resting
muscle tone using the muscle's intrinsic molecular tension. Loomis  argued that a better understanding of tone by chiropractors
could be gained from clinical research. Research investigating poor
muscle-organ function during ill health was a beginning to
strengthen the groundwork for the benefits of tone. Kent 
considered tensegrity as an example of how the chiropractic
concept of tone worked with the nervous system. Hohenschurz-
Schmidt, Esteves, and Thomson  extended the tensegrity system
of mechanical structural tension into the concept of biotensegrity
from the structural tension observed in human cells.
Others like Kobesova and Kolar  and Jang, Park, Park, Kim,
and Sohn  described tone as a driver for creativity, emotions
and learning. Others [8, 20] considered tone to be a metaphysical
element of health. Hill, Ellison, Taylor, et al.  provided an
example of the research needed for metaphysical interventions like
tone. They measured the telomere length in human cells as an effect
with spiritual beliefs as an intervention. Findings from this
study concluded that the intervention had increased telomere
length thus, reducing cell ageing. However, they noted that they did
not understand the pathway of the effect. Doufesh et al.  saw the
application of tone as a bridge between prayer and physical health.
‘Antecedents’ are conditions occurring prior to and leading to the
formation of a concept.  In the 19th century, tone in human
physiology was well understood as the passive normal tension of
human tissue. [9, 29] The chiropractic concept of tonewas developed
for the purpose of helping people with unresolved health problems. [35, 36] Palmer theorised unresolved health problems as resulting
from misunderstanding the causation of disease.  Palmer's observations
led him to question the infectious causes of disease. He
questioned why, when two people have similar lifestyles and circumstances,
one gets ill and the other stays healthy. He developed
the concept of tone to explain this observation. Senzon  asserted
that tone was founded on metaphysical beliefs based on a premodern
philosophy and departing from the previous Cartesian
worldview. Others  have agreed with this interpretation, namely
that Palmer used underlying spiritual beliefs and intuitive learning to
develop the concept of tone, which is a mixture of what is understood
today as human health, sociology, and neurology. [9, 30, 42]
According to Palmer, focusing on tone could address poor health,
pain and disease that was not responding to available health treatments
or that resulted in adverse effects like addiction to or
poisoning frommedication and complications fromsurgery. Tone, as
a concept therefore, provided an explanation for Palmer's understanding
of the cause of disease. 
‘Consequences’ are the events, situations or phenomena that
follow the use of a concept. [43, 44] Palmer  formed his concepts
into a system of health care with the concept of tone as its
foundation principle. He then, in 1897, formed a school in
Davenport, Iowa, USA, with tone as a themed curriculum. 
Further expansion of tone into a religious framework was
considered for legal protection  but not implemented. 
Tone as a concept provided a platform for research that could
provide an evidence-base for chiropractic. Health problems could
be perceived in a broader health context, one that included the
metaphysical [2, 55], rather than the narrow illness focus model as
seen in medicine. [5, 19, 24, 55] This perspective could be seen as a
strength of chiropractic.  Recognizing strengths and weaknesses
of the concept of tone  could: enhance the identity of
the chiropractic profession [6, 7, 47]; build personality for the
chiropractic profession [15, 61]; be a bridge for interprofessional
healthcare development [10, 39, 45]; recognize tone as a unique
source for creating new knowledge [11, 47], and; overcome internal
professional discipline barriers.  Epstein et al.  posited
that tone could improve general health, immunity and nonmusculoskeletal
A greater emphasis of tone is possible with the  classification
of the semantics of chiropractic's concepts as traditional, with
medical services positioned as complementary, rather than vice
versa, to give tone improved context for the profession. Researching
the effects of tone on the telomere length may provide evidence
that could inform the understanding of tone. 
Concept analysis of tone: summary
The five components of this concept analysis discussed above
are illustrated in Figure 1. Together they show how tonewas perceived
by Palmer, developed as a foundation concept for health and disease,
and discussed by others both within and outside the
The purpose of this researchwas to clarify the concept of tone as
originally understood by Palmer and to monitor its evolution over
Our analysis found:
five surrogates had been used to describe tone: ‘inharmony’,
‘balance’,’nervous tension’, ‘homeostasis’ and ‘optimum health
gateway’. Such surrogates are likely to have caused confusion
29 attributes or characteristics of tone and 10 references to the
actual situation in which the concept was used. There had been
little development of the concept of tone although its emphasis
in the chiopractic profession had diminished over time. Attributes
included sub-clinical symptoms, neural tension, foundation
principle of chiropractic, and the personality of the
profession. Tone was also considered a moral ethic for
improving public health and, for some authors, tone became a
cause-and-effect model for chiropractic.
11 antecedents were identified as leading to the formation of the
concept of tone. These included metaphysical beliefs and an
understanding of the passive normal tension of human tissue.
The concept was in keeping with the understanding of
neurology at the time.
25 consequences, the most important of which are the chiropractic
system of health care with the concept of tone as its
foundation principle; the establishment of chiropractic education
institutions; the potential for enhancing the identity of
chiropractic, and recognizing tone as a unique source for
creating new knowledge.
Concept of tone in chiropractic defined
The concept of tone in chiropractic defines the human nervous
system as a pathway for sources of intelligence to interface with
human function improving health, thought and knowledge. 
Tone can be understood using the analogy of the human body as a
musical instrument to illustrate this mechanism of expression. The
expression of tone through an instrument's vibration, when used
over time and with varying intensity, may need mechanical
adjusting to maintain its optimum tone. The skill and inspiration of
the artist is compared to the intelligence and music created as the
expression of knowledge. Tone affects quality of life, resonating
through the human body and nourishing it with health.  Thus,
the concept of tone leans to the historic concept of tonus, recognised
as a value of health over time, understood by Palmer as a
pathway for knowledge that can be measured and analysed using
human physiological changes, developed as a foundation principle
into a system of healthcare and taught as a theme in a unique education
system that created graduates for a new health profession.
Tone defines functional neurology and is an interface to better
understand the relationship of metaphysical and mechanical
research.  This metaphysical concept of tone has the potential
for strengthening the identity of the chiropractic profession.
Rodgers  recommended the inclusion of an exemplar as a
clear illustration of the characteristics of the concept in a relevant
context. A model case of tone may be viewed within the framework
of a chiropractic clinic. This clinic provides a service where a
chiropractor is available for individual advice, a health evaluation
for the presenting complaint, observation of any consequential loss
of tone, as well as education for the patient on the concept of tone
and its effects and treatment to restore tone.
Denise, a fit 38-year-old information technology executive living
in southern Queensland learned about chiropractic over lunch
through a surfing colleague. After receiving conservative care for
neck pain caused by being dumped in the surf three years earlier,
Denise decided to seek an opinion from her friend's chiropractor to
explore why she had lost her confidence in surfing and did not feel
well after the injury. Characteristics of her health status now
included restricted general movement, mental dullness, loss of executive
ability, digestive sluggishness and a loss of wellbeing. Denise
was having difficulty adapting to both her personal lifestyle and
work even though a biopsychosocial health evaluation had classified
her as fit and normal for her age. Over the next year, Denise decided
to follow a treatment programto restore the loss of tone observed by
the chiropractor. As the treatment programprogressed Denise could
move better without pain in both lifestyle and work activities. She
began to surf again. Positive changes of mental clarity and more
decisive thinking at work aswell as improved general wellness were
also noticed. Restoring her tone with chiropractic care motivated
Denise to maintain this state of health with a schedule of chiropractic
‘tune ups’ as part of her wellness goal.
Implications for the future of the concept
The concept of tone has expanded from using fingertip palpation
for measuring the tone of muscle and detection of abnormal
heat from the skin in the foundation days of chiropractic to instruments
that measure tissue resistance, heat, nerve function,
organ function, metabolic change and pain. New technologies
creates opportunities for measuring the cause-and-effect model of
tone. Tone could be understood as a passive normal for the human
body and thereby enable assessment of the nervous system's
expansion and contraction.
Tone may hold value in the context of functional neurology as a
medium for the health effects of nutrition, environmental and
metaphysical interventions such as religiosity, prayer and meditation.
Extending this understanding of restoring and enhancing tone
with chiropractic adjustments to multiple healthcare interventions
promotes a unique personality/identity of the chiropractic
From the concept of tone defined in this paper the following
Tone is a medium for restoring and improving health
Tone is often understood in casual comments such as: “you
don't look so good today” when referring to skin tone, or “what
happened to you” when referring to slumped posture, or “you look
tired” when referring to loss of nerve tone. According to Palmer,
using a vertebra as an intervention tool to adjust the nerve roots
could restore that nerve tone or improve dysfunction and thereby
promote a rapid health recovery from multiple causes ranging from
injuries, poisoning and stress. While the main reason for patients to
seek chiropractic care was health recovery from illness, patients
also seek prevention of disease. This challenged the profession to
explain how specific health problems were responding to general
changes in tone with effect pathways difficult to define. The
concept of tone was understood by Palmer and others in terms of
symptom prevention, wellbeing expansion and spiritual
Tone is a pathway for molecular vibration
Tone as a pathway for molecular vibration was poorly understood
by early chiropractors. New research confirms that molecular
vibration can be expressed through nerves as sound.  The
quality of tone described as vital energy is understood today as an
innate intelligence with research concluding it is necessary for the
human systems to communicate.  According to Palmer ;
thought, human intelligence and consciousness are expressed
through tone driving creative expression, emotions and learning.
The proposal that tone neurally mediates the health of all cells and
tissues of the body may still hold value for the teaching of tone.
Tone is an interface for the metaphysical
Tone may be understood as an interface where the quality of
intelligence can be expressed. Just as a musical instrument may be
tuned (‘toned’) and yet still played poorly, so to can a ‘toned’ body
not realise its full potential if a person makes poor lifestyle choices
thus creating limitations to the free flow of intuitive knowledge.
The tone of the nervous system influences the extent to which that
knowledge is integrated into the physical structure. (see Fig. 2).
Implications for the future of the profession
Tone may hold value in the context of functional neurology as a
medium for the health effects of nutrition, environmental and
metaphysical interventions such as religiosity, prayer and meditation.
Extending this understanding of restoring and enhancing tone
with chiropractic adjustments to multiple healthcare interventions
promotes a unique personality/identity of the chiropractic profession.
This metaphysical concept of tone has generated various
contributions to modern healthcare. First, it underpinned a system
of healthcare known as chiropractic. Second, it generated schools
with a themed curriculum adding to modern medical knowledge.
Third, a new profession formed with a documented growth in the
medical sciences using 'tone’ as a foundation principle of health.
Fourth, the concept of tone generated a new platform for a hybrid
healthcare model with a research framework seeking to classify
tonal health problems. Fifth, tone could be the true personality, not
well understood, that underpins the identity of the chiropractic
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