by Meridel I. Gatterman, MA, DC, MEd
If chiropractors have not lost the holistic worldview of health promotion and wellness, what is the basis of their claim to this paradigm? If paradigm embraces the shared commitment of the group, then promoting the health and wellness of our patients is a shared commitment.  By what right do we claim to be practitioners of this specialty? Are we bound together by common elements of our education and apprenticeship, sharing common goals? Are we training our successors through professional communication and practical procedures to be health promotion and wellness practitioners?  This article will seek to answer these important questions in what is essentially a “paradigmatic” issue.
Chiropractic Scope of Practice
As primary-contact practitioners, chiropractors share the responsibility of licensed health professionals for promoting health and preventing disease.  This is consistent with the Association of Chiropractic Colleges (ACC) paradigm that includes health promotion in its statement of the scope of chiropractic practice.  Not every patient receives health promotion and wellness counseling based on individual preferences and needs.
How Do Patients Come to Know Chiropractors as Health Promotion and Wellness Practitioners?
The majority of patients come to doctors of chiropractic for relief from musculoskeletal conditions, most commonly back and neck pain. They may not have been satisfied with conventional medical care for their condition. Some have been referred by an enthusiastic, satisfied patient who understands the health benefits of chiropractic. Word-of-mouth referral is the way most people seek chiropractic services.  Patient education is delivered through one-on-one interaction that develops trust in the patient-doctor relationship.
Many of the patients who experience improvement under the care of a chiropractor want to know what they can do to sustain their newfound wellness or sense of well-being.  This lays the groundwork for ongoing and wellness care by incorporating concepts of health promotion. Addressing individual patient needs is an ongoing process that is introduced as patients respond to treatment. Not all patients are responsive to lifestyle modification and counseling proceeds in response to patient receptiveness. Exercises are prescribed on an individualized basis. The benefits of a healthy diet are emphasized, especially in those patients whose weight and body mass are risk factors. Both physical and mental fitness are important components of health promotion and wellness. Factors contributing to enhanced performance at both work and play are commonly addressed. Strategies for promoting the patient’s active role in health and recovery are often welcomed more than a prescription for drugs. 
Chiropractic Undergraduate Courses Promote Health and Wellness
It is difficult to determine all of the classes that address health promotion and wellness in the chiropractic curriculum. Few colleges have classes with titles that specifically identify these subjects. Nonetheless, health promotion and wellness subjects are taught throughout the entire four- to five-year course of chiropractic studies (Table 1). The chiropractic curriculum provides a substantial foundation for the understanding of nutrition. Courses include the biochemistry of proteins and their role in maintaining homeostasis and immunity, 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 classes provide information from Healthy People 2010 on leading health indicators including: tobacco use, substance abuse, responsible sexual behavior, injury and violence, immunization and access to health care. Screening and risk assessment, along with counseling for lifestyle modification and injury prevention, are included. Classes that focus on the neuromusculoskeletal system provide a background in the assessment and management of posture and spinal health. Enhancement of function through physical activity and exercise is approached by considering 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, and stress management is discussed relative to individual patient needs. A patient-centered partnership for promoting health and wellness is an important part of traditional chiropractic care,  as is counseling that encourages healthful living practices and wellness procedures. 
Typical Chiropractic Courses That Include Health Promotion and Wellness
|First-year coursework typically includes the following:|
|Functional Anatomy/Biomechanics||Human Biochemistry|
|Introduction to Physical Exam Skills||Fundamentals of Nutrition|
|Second-year coursework typically includes the following:|
|Community/Public Health||Nutritional Assessment|
|Clinical Nutrition||Applied Clinical Chiropractic|
|Third-year coursework typically includes the following:|
|Chiropractic Clinical Application||Clinical Internship|
|The fourth year consists of a clinical internship.|
|Modified from: Christensen MG. Job Analysis of Chiropractic. A Project Report, Survey Analysis, and Summary of the Practice of Chiropractic Within the United States. Greeley, CO: National Board of Chiropractic Examiners, 2005.|
The Council on Chiropractic Education (CCE) standards consider that doctors of chiropractic must be able to provide wellness care. Doctors of chiropractic must be able to promote health maintenance as well as to perform common screening procedures and wellness assessments in different age groups.  These standards also 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 counseling. 
Specific competencies for health promotion and wellness are scheduled for adoption in January of 2007. These competencies are designed to facilitate:
- patient understanding of factors that promote wellness;
- a proactive approach that encourages patients to take responsibility for their health;
- skills for counseling patients on healthy habits and lifestyle; and
- strategies for working with patients in a partnership for shared decision-making.
The National Board of Chiropractic Examiners (NBCE), like the chiropractic colleges, tests for health promotion and wellness competencies in a number of areas.  Part I of the NBCE exam tests for various aspects of health promotion and wellness in the public health exam. The associated clinical science subjects examined in part II, including geriatrics, pediatrics, toxicology, and sexually transmitted diseases, all have components of health promotion and wellness. Part III emphasizes case management that includes nutrition, exercise, protective body mechanics (ergonomics), and patient education and home care. Part IV consists of a hands-on practical examination that tests skill in practical case management. If a weakness exists in assessing the chiropractic student’s skill in promoting health and wellness, it is at this level. Perhaps this is a reflection of the absence of the practical application of these skills in the chiropractor’s clinical training.
Medicine has achieved a diminished role in the uncertainty associated with disease pathology by using a reductionist model. The science of clinical medicine is based on precise observations and theories of causation, decision-making and evidence.  Basing clinical care upon a disease model has enabled the observation of a group of signs and symptoms into identifiable syndromes with somewhat predictable outcomes. This model is ideal for disease care, but has little relevance to health care. The clinical application of this model fails to encompass health promotion and wellness. 
The Committee on Quality of Health Care in America, under the auspices of the Institute of Medicine, has concluded that the American health care delivery system is in need of fundamental change.  This implies a fundamental reform of the health care system. The prevailing model of modern medicine is strictly curative, technical, impersonal, mechanistic and expensive.  At best, the model promotes disease prevention. Health and wellness are not dependent on finding the right drug deficiency. Defining the patient’s problem as finding the right drug as a solution to their problem is different for promoting lifestyle change, habits and patterns of behavior. According to Coulter, it is not simply the case that aspects of the medical paradigm require revision.  Following Kuhn,  it is the core assumptions – the “paradigm shift”– that must be addressed. Coulter concludes that the holistic paradigm is contradictory to the biomedical paradigm and cannot be harmonized by simple tinkering. 
The primary framework of chiropractic wellness care encompasses a holistic model that considers lifestyle and promotes health. Health is not merely the absence of disease. Health encompasses an active lifestyle that leads to wellness and optimal vitality. This approach to health care is based upon interventions that include counseling and health education as their management strategies. Successful implementation of wellness care is based on a partnership between patient and doctor.  This partnership is egalitarian in nature with a respect for patient’s values, beliefs and level of understanding. The practitioner who promotes health and wellness serves as a health educator and not just a manager of disease and dysfunction. The patient in such a partnership is encouraged to take responsibility for promoting his or her health, with the doctor of chiropractic guiding and encouraging healthy lifestyle changes. This is the consumer imperative based on active coping rather than passive compliance.  Patients seeking health promotion and wellness seek out health information from various sources. With the advent of computer literacy, this is now a more viable strategy, but guidance from a trained health professional is still necessary to interpret conflicting and often self-serving information. Health care practitioners have an ethical obligation to provide accurate information to enable patients to make choices among alternative options. Patients must become knowledgeable, to access information, digest it, and translate it into forms of action.
Chiropractors are well-suited by a patient-centered paradigm to be health promotion and wellness practitioners.  Patient-centered practice emphasizes self-healing, a holistic approach to the patient, and a humanistic attitude with regard to the patient/doctor partnership. Doctors of chiropractic who emphasize wellness in their practices work with patients as partners, preferring minimally invasive procedures and therapies.
Promotion of health and wellness through recommended modification of lifestyle changes follows a paradigm that has been maintained by some chiropractors. To others, where the paradigm has been lost the paradigm can be gained and maintained.
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