Prevention and Health Promotion by DCs
Written by Editor   
Friday, August 18, 2017 08:06 AM

Chiropractic care includes a variety of minimally invasive approaches, with both treatment and prevention as essential elements of clinical practice. Although chiropractic adjustment 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.

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 a healing philosophy based on minimally invasive (nonpharmaceutical, nonsurgical) methods that included a strong emphasis on preventive approaches. 

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).

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. 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.  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.

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.

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 their realization.

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 resources.

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. 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 chiropractors.

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. 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.

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 even in the absence of problematic symptoms. There is supporting evidence for this, but it falls short of being clearly persuasive. If joint restriction is noted even in the absence of symptoms, this may serve as a rationale for the application of an adjustment.

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, 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. 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 well documented scientific evidence.

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 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. 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-to-doctor 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.

Regarding criteria that medical physicians may wish to consider in deciding when they should refer patients to a 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. Consider the following:

  • Duration of care for similar conditions varies very widely among chiropractors.  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 many with another.

  • No doctor can know the course of a patient’s recovery in advance. Routine treatment plans for extended courses of care (i.e., 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.

  • 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.

  • 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 following:

  • Have you heard positive reports from patients or others in the community regarding the care given by this chiropractor?

  • 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 refer?

  • 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, as is much of health care, is currently in transition. 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.