Chiropractic and Wellness: Are We Walking the Walk?

Much has been said about establishing chiropractic as a wellness profession - in fact, I have said quite a bit about it myself.^1-6 We were "talking the talk" of wellness even before the phrase came into vogue.^7-8 Although "wellness" is now a mainstream concept adopted by hospitals, industry and government organizations, "chiropractic" and "wellness" are still not consistently linked in the public's awareness.

Why not? Several factors contribute to this situation, but I will address only two: education and research. Do chiropractic education and research reflect our professed orientation toward wellness? The short answer is: no. The "why" and "how" will take a little longer to explain.

Chiropractic Education

Why do our colleges lack a wellness orientation? In the past, the pressing need for accreditation drove the establishment of our first educational standards, resulting in a curriculum similar to those of medical schools.⁹ Our coursework is heavy on basic science, pathology and the management of symptoms, whereas wellness is characterized primarily by the multidimensionality of health and the importance of active self-care. Chiropractic education focuses on the physical dimension only, and emphasizes passive care.

Coursework in epidemiology and the social sciences, which would lay the foundation for understanding the multidimensionality of health, is almost totally absent. Coursework in health education and clinical training in self-care counseling, (which would train chiropractors to teach their patients how to help themselves) is also lacking, leaving this important aspect of wellness to be learned on a catch-as-catch-can basis by practitioners.^5,9 Further highlighting our lack of attention to "health promotion and prevention," a term essentially synonymous with practitioner-provided wellness care in the "outside world," is the prevailing ignorance about national initiatives such as Healthy People 2010. A recent survey of chiropractic college faculty showed that 45 percent of respondents were completely unfamiliar with Healthy People 2010.¹⁰

Recently, an upsurge of faculty interest in wellness occurred. A special track on health promotion, introduced at the March 2004 Association of Chiropractic Colleges/Research Agenda Conference, was met with tremendous enthusiasm. Several chiropractic colleges are introducing formal coursework in wellness and the American Chiropractic Association (ACA) has launched a wellness campaign. The membership of the Chiropractic Health Care Section of the American Public Health Association is growing, and the section is increasingly focused on health promotion and prevention issues.

Chiropractic Research

Does chiropractic research reflect a wellness orientation? A quick scan of the list of more than 75 randomized controlled trials (RCTs) involving chiropractic care and/or spinal manipulation reveals an overwhelming predominance of pain management studies.¹¹ None focuses on health promotion and prevention.

This situation is, of course, readily explained and perhaps justified. An RCT is a study design well-suited to a reductionist approach (single cause, single effect), such as finding out if a drug or other single procedure (such as manipulation) affects a single symptom (such as pain). By its nature, wellness is "caused" by multidimensional factors. It is always more difficult to document prevention than it is to document cure.

However, what is not justified, but perhaps explainable, is our near obsession with RCTs. The explanation goes back to our history of being considered inferior to medicine, resulting in a desire to excel in the "hard sciences." Perhaps because of that, chiropractic education has failed to recognize the importance of epidemiology, the social sciences and health services research. In those disciplines, we can find scientific approaches to investigate complex interactions, such as doctor-patient communication, and multifactorial "conditions," such as wellness and quality of life.

Emblematic of the "medical wannabe" mindset is our current tendency to focus almost exclusively on attempting to gain funding from the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH), an agency with a historical focus on physiological mechanisms of disease - certainly not on prevention or wellness.

We might be better served by developing stronger connections with such funding agencies as the Centers for Disease Control and Prevention (health promotion and prevention), the Health Resources and Services Administration (health professions training; health promotion and prevention) or the Agency for Healthcare Research and Quality (health care delivery). For the past few years, several individual chiropractors and chiropractic institutions have begun to cultivate such connections.

Conclusion

Our profession appears to be taking some first steps toward "walking the walk" of wellness. It is imperative, however, that these steps go in the right direction by utilizing existing bodies of knowledge suited to the study and practice of wellness. We will then be in a position to make unique contributions to the art and science of wellness.

So, perhaps a slightly longer and more accurate answer to the question, "Do chiropractic education and research reflect our profession's professed orientation toward wellness?" is: not yet.

References

1. Hawk C. Toward a wellness model for chiropractic: the role of prevention and health promotion. Topics in Clinical Chiropractic 2001;8(4):1-7.
2. Hawk C. Should chiropractic be a "wellness" profession? Topics in Clinical Chiropractic 2000;7 (1):23-26.
3. Hawk C. The role of chiropractic in providing clinical preventive services. Topics in Clinical Chiropractic 1995;2(1).
4. Hawk C. The wellness hypothesis. In: The Chiropractic Theories. Leach R, ed. Baltimore: Williams & Wilkins, 2003:399-415.
5. Hawk C, Dusio ME. Chiropractors' attitudes toward training in prevention: results of a survey of 492 U.S. chiropractors. J Manipulative Physiolog Ther 1995;18(3):135-140.
6. Hawk C, Dusio ME. A survey of 492 US chiropractors on primary care and prevention-related issues. J Manipulative Physiolog Ther 1995;18(2):57-64.
7. Ardell DB. High Level Wellness: An Alternative to Doctors, Drugs and Disease. Berkeley, CA:Ten Speed Press, 1986.
8. Hettler B. Wellness: encouraging a lifetime pursuit of excellence. Health Values 1984;8(4):13-17.
9. Coulter ID, Adams AH, Sandefur R. Chiropractic Training. In Mootz RD and Cherkin DC, eds. Chiropractic in the United States: Training, Practice and Research. AHCPR Pub. No. 98-N002, 1997:17-27.
10. Pearson G, Hawk C, Robinson P, Killinger L. Faculty survey of attitudes toward Healthy People 2010. Presented as part of "Promoting Health Promotion in Chiropractic Education and Practice," ACC-RAC, Las Vegas, May 2004.
11. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med 2002;136:216-227.

Dr. Hawk can be reached at 2500 Walnut Hill Lane, Dallas, TX 75229, or by phone: 972-438-6932, ext. 7136; fax: 214-902-2482; or e-mail: chawk@parkercc.edu.