The types and frequencies of improved nonmusculoskeletal symptoms reported after chiropractic spinal manipulative therapy
A minority of chiropractic patients report having positive nonmusculoskeletal reactions after spinal manipulative therapy but such reports cluster predominantly around specific symptoms. It would be interesting to find out if these can be verified objectively and, if so, to investigate if they are caused by the treatment or if they are signs of natural variations in human physiology.
Health Promotion and Wellness: Paradigm Lost, Gained or Maintained?
Chiropractors are well-suited by a patient-centered paradigm to be health promotion and wellness practitioners. [6] 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.
Health Promotion, Wellness and Primary Care
Two articles in the Feb. 26, 2009 issue of DC [1,2] brought to mind the ongoing paradox of chiropractors as primary care providers and spinal specialists. While the major focus of the chiropractic research agenda is the continuing promotion of the idea of chiropractors as specialists, this concept has not worked well for many in the profession and denies patients the benefits we can offer as primary care doctors. As long as we are satisfied to limit ourselves to one area of the body (the spine) and one modality (manipulation), we can readily be dismissed as therapists rather than full-fledged physicians. And by designating chiropractors as specialists with a co-pay double that of primary care practitioners, insurers can limit the amount paid out by making the coverage equal to the co-pay.
Preventive Medicine, Health Promotion and Wellness
Doctors of chiropractic can provide disease prevention, health promotion, and wellness services. As a resource to the community, they serve as conduits to other health care practitioners, services and information resources.4 As direct-access practitioners, chiropractors are ideally suited to act as health educators to serve as health and wellness advocates and to conservatively promote disease and injury prevention, in addition to specializing in spinal care. They are ideally suited to go beyond disease prevention. Working with patients to promote their health and wellness is an integral part of chiropractic practice.
Health Promotion and Wellness Initiatives
Over the past four years, a number of initiatives have been undertaken by the chiropractic community to promote the health and wellness of patients and the general public. A number of these initiatives were under the auspices of the American Chiropractic Association’s (ACA) committee on health promotion and wellness. Chaired by Ron Rupert, dean of research at Parker Chiropractic College, and assisted by Cathy Burke, ACA education director, a number of subcommittees instituted initiatives that put health promotion and wellness at the forefront of academic endeavors.
Health Promotion: Wellness For Chiropractic Practice
trauma-related hospitalizations in the United States. In a recent study, fall-related injuries accounted for 6 percent of all medical expenditures for people age 65 and older in the U.S. [1] And according to the Centers for Disease Control and Prevention (CDC), in the year 2000, falls among older adults cost the U.S. health care system more than $19 billion. With the population aging, the number of falls and the costs to treat fall-related injuries are both expected to increase.
Lasting Health Care Reform Requires a Health Care Revolution
The current polarization within health care stems largely from a clash between two different health care paradigms that go as far back as ancient Greece. The Coans, led by Hippocrates, adhered to a holistic world view in which the patient was viewed as a whole and promotion of health included diet, exercise and a balanced lifestyle. In contrast, the Cnidian School focused on diseases of parts located in organs or organ systems.2 The Coan School held that disease had a natural basis that was the result of an imbalance within the person. The Cnidian tradition saw diseases as real entities with an existence distinct from the person.2 The current biomedical model dominated by specialists is a legacy of the Cnidian School.3 Health care research and treatment practices today are directed by the prevailing reductionistic paradigm, thereby lacking focus on health promotion and wellness.
Assessment of Community Needs for Health Promotion and Wellness
Chiropractic physicians as autonomous practitioners offer first-contact care. In addition to managing acute and chronic conditions, they are well-situated to promote the health and wellness of both patients (people seeking care for health problems) and clients (apparently healthy people). [1] Individuals increasingly are seeking active participation in their own health care. To effectively fulfill the role of health promotion and wellness practitioners, chiropractors must assess the needs for health promotion and wellness in their individual communities. Factors that should be considered when assessing a community’s health-promotion and wellness needs include: access to health-promotion and wellness resources, risk exposure, income levels, cultural norms, health insurance coverage and barriers to access.
Health Promotion and Wellness: A Paradigm Lost?
Following completion of a book for patients titled Chiropractic, Health Promotion, and Wellness, [1] I received a short description of the book from the publisher that stated, “Chiropractors have traditionally offered manipulation for neuromuscular skeletal problems. Today, many chiropractors are repositioning themselves as wellness providers.” I promptly replied that chiropractors have traditionally counseled patients on health promotion and wellness. In mentioning this incident to a well-known research director, a non-chiropractor who has been involved with chiropractic for 14 years, he responded, with equal surprise, that practicing health promotion and wellness is not a new direction for chiropractors.
Health Promotion: Whose Job Is It?
Health promotion often is associated with disease prevention and considered a public health problem. [1] With the significant reduction in the prevalence of infectious diseases as a result of improved nutrition, sanitation and better living conditions in industrialized nations, chronic diseases related to self-imposed lifestyles have become increasingly important. These “lifestyle diseases,” including obesity, hypertension and chronic pain from arthritis, are as compromising to quality of life as are the more life-threatening conditions such as heart disease, stroke and cancer. So whose job is it to address “lifestyle diseases”?
Public Health, Wellness, Prevention, and Health Promotion: Considering the Role of Chiropractic and Determinants of Health
As health care providers, we must understand how the determinants of health interact with each other so that we may best serve the needs of our patients and communities. Many determinants of health overlap or have a direct influence on one another. Poverty can directly relate to working conditions, physical environment, education, and maternal health. Healthy choices and lifestyles may be influenced by education, physical environment, and social/family networks. We cannot address one health determinant without considering the interaction of the other determinants of health. Various new methods for evaluating how chiropractic and musculoskeletal care can be better investigated, such as through qualitative and population health methods, may assist with obtaining a more clear view of chiropractic’s impact on population health.63, 64 An integrated and holistic approach may assist us to help our communities achieve better health. If we are to make an impact on the health of the population, we must take the time to address the unique characteristics of our patients and the communities that we are serving.
Advising on Prevention in Chiropractic: A Look at Public Health Promotion and Health Behavior Theory Use in Clinical Education Settings
Included in the health care responsibilities of primary contact practitioners is the requirement that they serve as a relevant information source for their patients when it comes to reducing health risks. Chiropractors may effectively achieve disease intervention and prevention by participating in the health education of their patients. Clinicians should teach and model this educating and advising role. In line with chiropractic philosophy, their perspective should be holistic. In order to minimize intrusion upon the practice of their clinical expertise, health education tools are recommended for use by these practitioners with an HP conscience. Chiropractic has traditionally regarded itself a wellness profession. As prevention and a wellness model of care can be postulated to predict the future growth of this profession, the development of a wellness ethos acceptable within conventional health care is desirable. Thus, there is urgent need to prepare future DCs (current interns) for the role of advising prevention. Emphasis should be placed on providing interns with HP techniques, skills, self-efficacy, and motivation in an effort to prepare them for the challenge of interfacing with an increasingly evidence-based health care system.
Chiropractic researchers or program planners may derive benefits from the application of health behavior theories in designing interventions targeting healthy behavior. In applying theories or adopting models that have been successful in other settings the concept of targeting a population based on shared characteristics or risks and tailoring change messages for improved health outcomes should be seriously considered.
A Framework For Chiropractic Training In Clinical Preventive Services
Combining the framework of the USPSTF recommendations with the publicly available USPSTF resources should be relatively easily adapted to different chiropractic colleges’ needs and preferences. It would ensure that graduates are prepared to contribute substantively to the national effort toward disease prevention and promoting the health of all Americans.
Stress: The Chiropractic Patients Self-perceptions
Patient perceptions are known to be important in health care. A number of chiropractic patients perceive they are moderately or severely stressed. Interventions that reduce stress, or even the patient’s perception of being stressed, may be construed as valid, non-specific clinical interventions. It may be timely for chiropractors to actively contemplate including stress management routinely in their clinical care protocols.
Maintenance Care: Health Promotion Services Administered to US Chiropractic Patients Aged 65 and Older, Part II
On the basis of the response of participating chiropractors, this study describes the therapeutic components of MC for the elderly patient. For these patients, MC does not simply consist solely of periodic visits for joint manipulation, but it involves an eclectic host of interventions (e.g., exercise, nutrition, relaxation, physical therapy, and manipulation) that are directed at both musculoskeletal and visceral conditions.
A Survey of Practice Patterns and the Health Promotion and Prevention Attitudes of US Chiropractors Maintenance Care: Part I
Despite educational, philosophic, and political differences, US chiropractors come to a consensus about the purpose and composition of MC. Not withstanding the absence of scientific support, they believe that it is of value to all age groups and a variety of conditions from stress to musculoskeletal and visceral conditions. This strong belief in the preventive and health promotion value of MC motivates them to recommend this care to most patients. This, in turn, results in a high level of preventive services and income averaging an estimated $50,000 per chiropractic practice in 1994. The data suggest that the amount of services and income generated by preventive and health-promoting services may be second only to those from the treatment of low-back pain. The response from this survey also suggests that the level of primary care, health promotion and prevention activities of chiropractors surpasses that of other physicians.
Chronic Pediatric Asthma and Chiropractic Spinal Manipulation: A Prospective Clinical Series and Randomized Clinical Pilot Study
After 3 months of combining chiropractic SMT with optimal medical management for pediatric asthma, the children rated their quality of life substantially higher and their asthma severity substantially lower. These improvements were maintained at the 1-year follow-up assessment. There were no important changes in lung function or hyperresponsiveness at any time. The observed improvements are unlikely as a result of the specific effects of chiropractic SMT alone, but other aspects of the clinical encounter that should not be dismissed readily. Further research is needed to assess which components of the chiropractic encounter are responsible for important improvements in patient-oriented outcomes so that they may be incorporated into the care of all patients with asthma.
Chiropractic Maintenance Care and Quality of Life of a Patient Presenting with Chronic Low Back Pain
The patient appeared to experience improvement in quality of life while showing signs suggestive of improved spinal function. The relationship between indicators of vertebral subluxation and quality of life deserves further investigation using a research design that allows for exploration of possible causal relationships.
Fostering Critical Thinking Skills: A Strategy for Enhancing Evidence Based Wellness Care
Students have demonstrated themselves capable of applying critical thinking in construction of evidence based wellness programs. With respect to unit design, selective use of learning opportunities highlighted the desirability of using obligatory learning opportunities to ensure exposure to core constructs while student feedback was found to provide useful information for enriching unit review. It is hoped inclusion of critical thinking learning opportunities in the undergraduate chiropractic curriculum will contribute to the development of an evidence based ethos in chiropractic care.
Chiropractic Care of Musculoskeletal Disorders in a Unique Population Within Canadian Community Health Centers
In Ontario, chiropractic lies outside of the publicly funded health care system and is primarily accessed by patients with private health insurance coverage or higher household incomes. Including chiropractors in publicly funded primary health care CHC teams helps reduce the burden of chronic MSK pain and disability in those patients of low socioeconomic status who would normally face barriers to accessing chiropractic care. These positive findings should stimulate further, more robust, research into integrating chiropractic care into health centers that serve clients with barriers to health care access.
Psychological Response in Spinal Manipulation: A Systematic Review of Psychological Outcomes in Randomised Controlled Trials
There was some evidence that spinal manipulation improved psychological outcomes compared with verbal interventions.
Public Health, Wellness, Prevention, and Health Promotion: Considering the Role of Chiropractic and Determinants of Health
As health care providers, we must understand how the determinants of health interact with each other so that we may best serve the needs of our patients and communities. Many determinants of health overlap or have a direct influence on one another. Poverty can directly relate to working conditions, physical environment, education, and maternal health. Healthy choices and lifestyles may be influenced by education, physical environment, and social/family networks. We cannot address one health determinant without considering the interaction of the other determinants of health. Various new methods for evaluating how chiropractic and musculoskeletal care can be better investigated, such as through qualitative and population health methods, may assist with obtaining a more clear view of chiropractic’s impact on population health.63, 64 An integrated and holistic approach may assist us to help our communities achieve better health. If we are to make an impact on the health of the population, we must take the time to address the unique characteristics of our patients and the communities that we are serving.
Process Versus Outcome: Challenges of the Chiropractic Wellness Paradigm
There appears to be no consensus on the definition of wellness or how it is being used. Wellness is not exclusive to chiropractic, and wellness is not synonymous with health, although is often used that way. Wellness is a societal trend, and chiropractic as a health care profession may be a good fit for this concept.
Consensus Terminology for Stages of Care: Acute, Chronic, Recurrent, and Wellness
Achieving consensus on this terminology related to the spectrum of patient presentations is expected to facilitate their use within the profession of chiropractic, which, in time, may facilitate better integration of chiropractic care within the health care mainstream.
Health Maintenance Care in Work-Related Low Back Pain and Its Association With Disability Recurrence
In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.
Does Maintained Spinal Manipulation Therapy for Chronic Non-specific Low Back Pain Result in Better Long Term Outcome?
SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.
Zen and the Art of Chiropractic Maintenance: An Inquiry Into Health Care Values
To sum up, there is every reason to believe that significant reductions of morbidity, as well as the attainment of major cost savings, could be realized with further emphasis upon chiropractic maintenance therapy as a treatment option. By an odd twist of coincidence, Robert Pirsig’s book was turned down by no less than 121 publishers before emerging into the literary world. According to Guinness World Records, that number hasn’t been equaled by any best-selling book in history.
Chiropractors likewise having faced multiple refusals should take heart from all this information and advocate the promising evidence that lies before them, realizing that more of the same should be unfolding in the near future with the current emphasis upon evidence-based medicine. [13]
A Randomised Controlled Trial of Preventive Spinal Manipulation With and Without a Home Exercise Program For Patients With Chronic Neck Pain
This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.
Consensus Process to Develop a Best-Practice Document on the Role of Chiropractic Care in Health Promotion, Disease Prevention, and Wellness
This document describes the procedures and features of wellness care that, based on this panel’s clinical experience and evidence, represents a reasonable approach to wellness care and disease prevention in chiropractic clinical practice. This living document provides a general framework for an evidence-based approach to chiropractic wellness care. This document is a work in progress that should be refined as new evidence emerges.
The Nordic Maintenance Care Program: What Is Maintenance Care? Interview Based Survey of Danish Chiropractors
MC is a common phenomenon in Danish chiropractic practice, considered as both a secondary and tertiary preventative measure and its practice appears grounded in the tenet of patient-oriented care. A positive personal relationship between chiropractor and patient facilitates the initiation of MC. However, successful transition to MC appears to be dependent on a correct matching of complaint and management strategy. Interestingly, chiropractors in this study were more likely to offer MC to patients whose complaints include a significant muscular component.
It remains to be investigated whether MC is actually effective, both for the individual patient and in a societal/economic perspective. This is necessary in order to establish the appropriate role of MC in modern healthcare. The results from this and previous studies should be considered in the design of such studies.
Evidence-based Classification Of Low Back Pain In The General Population: One-year Data Collected With SMS Track
It is now possible and indeed necessary to follow the 45 year old advice by LM Rowe to study LBP as a continuum [1]. In our study, frequent data collection over one year made it possible to identify three substantial subgroups in the general population; those without LBP, those with episodic LBP, and those with persistent LBP. Further subsets were identified.
The Comparative Effect of Episodes of Chiropractic and Medical Treatment on the Health of Older Adults
This study provides evidence of the comparative effectiveness of chiropractic care relative to medical-only services on the functional health of older adults during acute episodes of back care. Our results are the first to show the importance of examining chiropractic use within an episode of care in traditional practice settings, rather than focusing on visit frequency alone. Moreover, we evaluated the effects of the treatments received during the episodes on ADLs, IADLs, and LBFs, which are critically important measures that inform patients, clinicians, and payers about the benefits and harms of certain treatments relative to others. Given the literature supporting a minimally effective chiropractic treatment level for back problems, this research provides additional support that such therapeutic levels are indeed beneficial in terms of protecting older persons from functional declines and self-rated health over as much as 2 years.
Prevention of Low Back Pain: Effect, Cost-effectiveness, and Cost-utility of Maintenance Care – Study Protocol for a Randomized Clinical Trial
Although LBP is and has been a challenge for society for many years, little is known about the preventive strategies available. Within the chiropractic profession there is a management culture with a preventive intent towards recurrent and persistent LBP. For the individual patient, the possibility of preventing episodes may be very beneficial and help keep the individual active. Furthermore, the ability to control symptoms and their effects on everyday life may be paramount. However, a preventive treatment with potential side effects and related costs can only be justified if it is demonstrated to have clinically worthwhile effects.
To date, there has been no large scale randomized clinical trial comparing chiropractic MC for LBP with symptom-guided treatment. This study will utilize available evidence in the field for the selection of study subjects, frequency of treatment, and treatment content. Furthermore, the study mimics the usual clinical procedures of chiropractic care, which will aid the transferability of the study results.