Wellness and the Chiropractic Lifestyle
Matthew McCoy
Anthony J. Carrino
The concept of wellness is sometimes difficult to fully appreciate in today’s health care environment. Although the idea of having a well child is most likely every parent’s ultimate goal, the perception of what a well child actually is may differ from one parent to the next. Lifestyle, ethnicity, financial status, education, region of the globe where one is raised, and accessibility to health information, care, and resources are but just a few of the many influences on one’s definition of what it means to be well. It is also prudent to understand that western allopathic influences on the perception of wellness may be completely different from what is perceived in many older eastern cultures. As you can see, coming up with one model or definition for wellness is a difficult if not impossible task.
There are many fatal and nonfatal diseases known to man at this time that do not always exhibit outwardly expressed symptoms. This may give an individual a false sense of security that everything is okay, and this also forms the basis for public health efforts aimed at prevention and screening. On the other hand, treating every outwardly expressed symptom without a thorough understanding of its cause is not necessarily advantageous from a health or economic perspective. In fact, many of the symptoms from which people seek relief from doctors around the world may simply be the body’s way of self-regulating and adapting to stress in an effort to achieve homeostasis.
Consider the following: As the pediatric patient presents for evaluation, how does the doctor’s thinking and perspective affect the doctor’s opinion and the direction of examination? There are obvious differences in worldviews between allopathic and alternative health care practitioners when attempting to evaluate a sick child. Determining just how sick a child presenting with symptoms is and what the relationship of the presenting symptoms are with their sickness are fundamentally different than evaluating how healthy a child’s body is as it attempts to adapt to internal and external stress. In both instances, the health care provider’s goal is certainly to improve and correct the presenting problem, but often to the dismay and confusion of many concerned parents, the interventions may be, and many times are, worlds apart.
We will attempt to explain health and wellness from the perspective of the science and philosophy of chiropractic and how chiropractic attempts to engage parents in a proactive health care process. It is important to understand that proactive health care should not be forced or distorted by any one practitioner’s worldview nor should any parent feel that only one type of health care practitioner can and should provide such care (1).
It is important for parents to create a team that covers most, if not all, aspects of the health care their children will need as they mature. The ultimate goal is to rely on one’s self to foster health over a lifetime thereby achieving what most would appreciate as a state of wellness.
We will attempt to give a broad overview of wellness beginning with a review of the current shift from infectious to chronic disease being the leading cause of morbidity and mortality. Then we will move on to the history, definitions and constructs related to health and wellness. Following this will be a discussion on the determinants of health and our responsibility as health care providers to expand our advocacy beyond the individual into those aspects of environment and life course that represent the true causes of disease. The authors will review the chiropractic literature on wellnessfocused care, discuss guidelines and standards of care related to wellness based services and finally we will discuss wellness as it relates to the chemical, physical, and emotional causes of disease and the chiropractic lifestyle.
THE SHIFT FROM INFECTIOUS TO CHRONIC DISEASE
Chronic disease has been steadily replacing infectious disease as a significant cause of morbidity and mortality through the 20th century and into the 21st. At the same time, life expectancy is also on the rise and, cumulatively, these events have led to a rise in chronic degenerative conditions such as osteoarthritis, cancer, coronary heart disease, stroke, diabetes, and other related diseases. While there are genetic predispositions, environmental and social determinants that are being explored, these conditions are in large part considered lifestyle diseases and primarily attributed to behaviors related to excessive body mass, poor diet, nutrition and lack of physical activity (2).
Because the nature of these chronic diseases tends to be attributed to behaviors, a holistic approach has been advocated that involves regimens such as dietary, nutritional, physical, and psychological practices. Healthy living practices involving these regimens have been practiced for centuries and are centered on the physiological uniqueness of the individual (3). For some, in a wellness paradigm, illness—especially chronic illness—is viewed as the culmination of persistent and insidious behaviors that lead to poor health outcomes (4).
The causes of death in the United States in the year 2000 were (5):
Tobacco (435,000 deaths; 18.1% of total deaths in the United States)
Poor diet and physical inactivity (400,000 deaths; 16.6%)
Alcohol consumption (85,000 deaths; 3.5%)
Microbial agents (75,000)
Toxic agents (55,000)
Motor vehicle crashes (43,000)
Incidents involving firearms (29,000)
Sexual behaviors (20,000)
Illicit use of drugs (17,000)
Given this list and given the trend within the chiropractic profession toward the treatment and management of disease, primary and secondary prevention, and the focus of the insurance industry on reimbursement for disease treatment, it is no wonder that certain factions within the profession have sought to solidify a role in this niche. Wellness is decidedly different from prevention, health maintenance, or even health promotion.
WHAT IS HEALTH?
Humans have been concerned with health and disease probably since time began but the use of the word health to describe well-being is a more recent event. The word health is derived from the old English word hoelth which meant a state of being sound (6). Prior to Hippocrates and even continuing to this day, in some circles, health was considered a divine gift (7).
In 1948 the World Health Organization (WHO) defined health as: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (8). This definition has become a standard part of many, if not most, chiropractors’ report of findings and lay lectures despite criticism of the definition itself (9,10,11). Critics argue that the definition is “utopian, inflexible, and unrealistic, and that including the word ‘complete’ in the definition makes it highly unlikely that anyone would be healthy for a reasonable period of time.” Critics also bemoan the inherent relationship to happiness imbedded in the definition and argue that health and happiness are two distinct life experiences.
The WHO definition contrasts only minimally with definitions of health that equate the absence of symptoms to being healthy. This is exemplified in the 11th edition of Merriam-Webster’s Collegiate Dictionary which defines health as “the condition of being sound in body, mind or spirit, especially; freedom from physical disease or pain (12).” The Webster definition, although inclusive of previous thinking, can be confusing when one looks at the meaning of underlying sickness and its relationship to wellness. These concepts will be explored further in later sections of this chapter.
In 1986, the WHO released the Ottawa Charter for Health Promotion which stated that health is “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities (13).” The Ottawa Charter was launched at the first international conference for health promotion that was held in Ottawa and re-oriented health care services toward prevention of illness and promotion of health. It stated that the role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Strategies for health promotion were outlined including advocating for health resources, enabling individuals to become empowered to control the determinants of their health, and mediating the collaboration of both government and independent organizations toward health promotion.
Determinants of Health
While it is seemingly widely believed within chiropractic that individuals are completely responsible for their health—the reality is much more nuanced. In fact, much of what causes disease or leads to ill health is often beyond the individual’s capacity to alter, and the usual suspects such as diet, cholesterol level, exercise, and so on are relatively proximal causes of disease.
The factors that combine to affect the health of people and their communities are known as determinants (14) of health and they include:
The social and economic environment
The physical environment
The person’s individual characteristics and behaviors
Some go as far as stating that fundamental causes of health and disease are those related to social support and socioeconomic status (14,15). In terms of the social and economic determinants alone, studies show that wealth is strongly and causatively linked to good health with improvements in life expectancy and infant mortality considered to be the result of increased wealth and advancements in technology in more developed countries (16,17).
It is important for chiropractors to have a clear understanding of the role of determinants since society oftentimes blames the individual for his or her health problems when other factors that may be beyond his or her control have a greater influence. At this point, the consensus is that individual characteristics and behaviors make up a small portion of the determinants that go into a person expressing disease or health.
This does not mean that chiropractors do not play a major role in addressing the determinants of health. In fact it suggests that chiropractors need to take a larger role in understanding, studying, and changing those aspects of society that foster these determinants. At first this may seem daunting for the chiropractor wanting to provide wellness care since it means that they have to go beyond counseling patients on diet, nutrition, exercise, sleep, and a positive mental attitude, and take an environmental and life course approach to human health and disease. Further it means that the chiropractor must take a proactive approach in his or her communities and beyond to advocate for and against those things that are causes of disease or health. This means taking an active role in considering social relationships, living conditions, neighborhoods and communities, institutions, and social policies as they impact health and disease.
Beyond what the good chiropractic care may do for the individual, this approach helps the profession itself move beyond the “one spine at a time” approach and see the bigger picture of the health puzzle. This puts the chiropractor in an authoritative position as he or she begins to work on school boards, school wellness councils, local public health agencies, and clinics. This will lead to greater responsibility for the chiropractor to get involved in his or her community, engage in community health needs assessments, and lead real change at both a local and national level. It requires that we intervene in multiple areas where health is influenced (18).
Social Networks and Health
The concepts related to determinants of health and disease discussed above are further reinforced by recent studies on social networks and their impact on disease and behavior. Two examples are related to obesity and smoking. In one study, researchers examined whether weight gain in one person was associated with weight gain in his or her friends, siblings, spouse, and neighbors. They found that a person’s chances of becoming obese increased by 57% if he or she had a friend who became obese, 40% if one sibling became obese, and 37% if a spouse became obese (19).
In another similar study, researchers examined the extent of the person-to-person spread of smoking behavior and the extent to which groups of widely connected people quit together. They found that smoking cessation by a spouse decreased a person’s chances of smoking by 67%, by 25% if a sibling, a friend by 36%, and a co-worker by 36%. Analysis of their data further showed that clusters of smokers quit in concert with one another (20).
Cohen (21) argues that health outcomes are associated with certain aspects of social relationships such as social support, social integration, and negative interaction. Cohen uses these aspects to suggest that we need to broaden our view of intervention in social networks to improve health.
In perhaps the most thorough review of the data and the theory on social causes of health and disease, Cockerham'(15) reviews the evidence that social factors have direct causal effects on health and disease (15). Arguing that stress, poverty, unhealthy lifestyles, and conditions at home and at work are all directly associated with illness, Cockerham signals an emerging paradigm shift beyond individual explanations for health and disease.
A BRIEF HISTORY OF WELLNESS
Now that we have some sense of the general understanding of health and its determinants, we will now take a look at how the wellness concept developed and evolved. Healthy living practices involving regimen and lifestyle change have been practiced for centuries and indeed concepts about fitness, personal responsibility, and health can be traced to the ancient Greeks and winds their way through the 19th century, the 1950s, the 1970s, and into the present day.
The first written record of the word is in a diary entry of Archibald Johnston in 1654 referring to his daughter no longer being ill: “I … blessed God … for my daughter’s wealnesse (22).”
Wellness has its origins in the concepts of lifestyle change and personal responsibility and shares much
of this history. The 19th century brought with it a movement focusing on the relationship between spirituality and health led by William James and his “mind-cure movement” more commonly known as New Thought. Phineas Quimby popularized New Thought after he became interested in alternative approaches to healing and became convinced that alterations of attitude cured the sick. As fate would have it, Quimby treated Mary Baker Eddy who founded Christian Science after Quimby’s death (23).
of this history. The 19th century brought with it a movement focusing on the relationship between spirituality and health led by William James and his “mind-cure movement” more commonly known as New Thought. Phineas Quimby popularized New Thought after he became interested in alternative approaches to healing and became convinced that alterations of attitude cured the sick. As fate would have it, Quimby treated Mary Baker Eddy who founded Christian Science after Quimby’s death (23).
The power of spirituality and the mind in health and disease were commonplace in America at this time and these concepts influenced others such as John Harvey Kellogg, a medical doctor who founded the Battle Creek Sanitarium where he combined lifestyle change with enemas, vegetarianism, fresh water, fruits, vegetables, grains, nuts, and yogurt with exercise, fresh air, and abstinence from coffee and alcohol. Kellogg also advocated a positive state of mind, and while his ideas about sex didn’t survive, his other notions about health and fitness no doubt influenced the development of wellness (23).
From intellectual and religious roots of the 19th century, wellness concepts and terminology began to gel in the 1950s. The holistic concept of wellness involving physical, mental, spiritual, and social aspects began to emerge in the 1950s and the 1960s under the leadership of Halbert Louis Dunn, a public health expert who seems to be the first to flesh out wellness as a concept and begin to define and operationalize it. He was also ahead of his time in anticipating the effects of infectious disease decline and the simultaneous increase in the burden of chronic, lifestyle-based diseases (23).
Dunn defined what he called “High Level Wellness” as:
an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable. It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning (24).
Wellness, according to Dunn, was a continuum, holistic, and personal, and had to do with potential. Selfknowledge and integration were the key to reaching a high level of wellness. Dunn was no doubt influenced by Erich Fromm, Carl Rogers, Gordon Allport, and Abraham Maslow considering his focus on potential, self-esteem and self-actualization.
Dunn suggested that very soon various levels of wellness would be able to be ascertained and measured objectively, and he compared this with the ability to diagnose disease. In a similar way, wellness would one day be “diagnosed” and that knowing the level of wellness enjoyed by individuals, families, or communities would become an important public health measure. Dunn argued for the development of wellness indexes that could be used to track individual and population wellness (25). He referred to them as objective yardsticks of wellness that would include biochemical, physiological, and psychological aspects. Dunn included spirituality, altruism, creative expression, and love as essential components of wellness. Dunn went on to write a number of scholarly articles on wellness (26,27,28,29,30,31,32,33,34).
As the 1970s began, a full-fledged wellness movement centered on active health promotion through lifestyle change had begun (23). Travis developed a wellness inventory based on Dunn’s work to assess states of wellness in 12 dimensions and he focused much more on personal responsibility (35).
In 1974 the Canadian government released a groundbreaking document known as The Lalonde Report and titled A new perspective on the health of Canadians (36). According to Hancock: “The Lalonde Report was the first modern government document in the western world to acknowledge that our emphasis upon a biomedical health care system is wrong, and that we need to look beyond the traditional health care (sick care) system if we wish to improve the health of the public (37).” The Lalonde Report suggested that there are four general determinants of health including:
Human biology
Environment
Lifestyle
Health care services
According to The Lalonde Report, health is maintained and improved not only through the advancement and application of health science but also through the efforts and intelligent lifestyle choices of the individual and society. The Lalonde Report was widely read around the world and especially in the United States and this gave further fuel and legitimization to the wellness movement.
Ardell emerged in the late 1970s as a bona fide wellness guru, according to Williams, and was fundamental in presenting Dunn’s ideas to the public at large (23). Though Ardell, not unlike some chiropractors, rejects any spiritual aspect of wellness and argued the field would be better off without it (38).
The 1970s also brought with it the emergence of the first campus wellness programs, workplace wellness programs, wellness curricula in schools, state wellness programs, and wellness councils (23). The 1979 Surgeon General’s Report, Healthy People both established national health objectives and served as the basis for the development of state and community plans (39).
In 1982, Naisbitt published his book Megatrends (40) in which he identified wellness as the new health paradigm, and while $1.5 trillion of the US economy is currently devoted to the business of treating disease, it is suggested that in the 2000s the purchase of products and services related to the lifestyle or wellness
approaches would add an additional $1 trillion to the economy (41).
approaches would add an additional $1 trillion to the economy (41).
From the days of ancient Greeks, through the 19th and 20th centuries, through the present day, wellness, it seems, has finally arrived.
Wellness Concepts and Definitions
As the concepts of prevention, maintenance, health promotion, and wellness have entered the mainstream, their definitions have become blurred. Everyone seems to have their own definitions of these terms and nowhere is this more apparent than with wellness and its related terminology. Database searches on wellness reveal a whole host of disciplines, topics, and assorted resources related to the term. According to Mackey, wellness is a research topic in the fields of medicine, public health, occupational health, social work, mental health, health management and economics, women’s health, and nursing (42).
A search of the Index to Chiropractic Literature using the term wellness in all fields and limited to the peer-reviewed literature yields a total of 84 items. Most of these are commentaries, with some surveys, conference presentations, and a few more rigorous studies. From a marketing perspective, the attention paid to wellness has increased within the chiropractic community in concert with the increased attention being paid to it within the health care industry itself and within what can now legitimately be called the “wellness industry.” Despite all this attention, the concept of wellness remains poorly understood (42,43).
In discussing holism from the perspective of American allopathy, Rosenberg, like others, points out the elusive nature of the concept while suggesting its significant historical nature (3). Mackey also points out the term’s elusive meaning, stating that definitions vary and lack of consensus exists regarding definitions. This, according to him, leads to the fragmentation of research and limits the application and understanding of wellness (42). Reviewing the literature on wellness, Mackey notes the differentiation between the terms health as a state of stable physiological function and a measurable clinical state, and wellness as the subjective experience of health, a felt state, or a state of well-being. She further notes that the terms health promotion, wellness promotion, and quality of life are frequently used interchangeably with wellness and well-being adding to the confusion (42).
Mackey argues that wellness as a state of being has not been described and investigated independently of disease or illness and that this has contributed to a lack of understanding of the actual state of being well. Mackey further differentiates wellness apart from some future state using the term lived wellness (42).
As we saw previously, Dunn defined wellness as “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable (24).” Wellness in this context always seems to be in the future.
Interestingly, Mackey seems to embrace basic chiropractic theory while tackling what she refers to as the elusive state of wellness. She contends that the elusive nature is based on there being no identifiable problem, nothing to measure, observe, or disrupt as there is in disease or illness. These notions are the subject matter of what was once so-called straight chiropractic theory: a nontherapeutic, metatherapeutic, non-disease treatment approach to care (44). Daniel David Palmer perhaps best captured the essence of this in his discussions of tone (45). While some in the chiropractic profession appear to be moving away from such constructs (46) it seems clear that they are being embraced by other health care providers and professions (42).
In discussing wellness as it relates to women, Robynn Zender had this to say about wellness:
For the purposes of this article, wellness is defined as an individual’s subjective experience of overall life satisfaction in relation to physical, mental, emotional, spiritual, social, economic, occupational, and environmental dimensions. Women’s wellness focuses on those aspects of well-being that pertain disproportionately, or solely, to women. Wellness includes but is not limited to physical, emotional and social aspects and disruptions that alter a woman’s quality of life, such as reproductive and hormonal issues, bone health, gastrointestinal stress, and urinary incontinence. This article discusses women’s wellness through the life span, from preconception through death, and considers the implications of these issues for the nursing profession (47).
While this definition of wellness is more holistic than the older biomedical concepts of health and disease, it nevertheless retains elements of a focus on disease. It is this focus on disease and the combative methods used to manage it from which a true wellness paradigm seeks to break free (4).
Other concepts of wellness have notions of control as part of their central features. Currie reports on the results of interviews with mothers regarding perceived wellness and discusses the need for strategies for meeting a mother’s own needs and those of others. This is advocated in order for the mother to achieve a “true sense of control” over her health (48). Again we see this notion of needing strategies and tactics in order to control some aspect of our lives—in this case Currie argues that such an approach gives the mother a feeling of calmness and the confidence that comes with a greater sense of control over her life. Further reinforcing the idea of control is the contention that predictability and expectation are key elements to well-being (49).
The concept of wellness not including the complete amelioration of symptoms of disease or disease itself
seems to be making inroads into the general practice of allopathy though there is clearly some distance to go. Rappaport discusses this in relation to depression and how the goal of therapy has shifted from a total elimination of symptoms to the “achieving of wellness” which is defined as full restoration of premorbid levels of functioning and quality of life (50). Such an approach implies that people could still experience pathology while at the same time experience a sense of wellness.
seems to be making inroads into the general practice of allopathy though there is clearly some distance to go. Rappaport discusses this in relation to depression and how the goal of therapy has shifted from a total elimination of symptoms to the “achieving of wellness” which is defined as full restoration of premorbid levels of functioning and quality of life (50). Such an approach implies that people could still experience pathology while at the same time experience a sense of wellness.
Historically the wellness movement outside of allopathy has suggested that wellness be obtained without the use of pharmaceuticals, surgery, or other invasive or aggressive interventions. The colloquialism “Chiropractic first, medicine second, surgery last” illustrates just such a notion. On the other hand, allopathy seems to have embraced wellness concepts while maintaining its traditional “outside in” approach to disease. Erika Gebel argues just such an approach for diabetics and taking control of their health and wellness through the use of medications (51). We also see the notion of control once again as part of this construct in Gebel’s wellness prescription.
The idea of experiencing wellness while at the same time experiencing the signs and symptoms of disease is captured in the “health-within-illness” concept elaborated by Susan Diemert Moch through her work with women diagnosed with breast cancer. In this view, illness is an opportunity to experience meaningfulness by connecting or relating to the environment and becoming more self-aware (52). Mackey captures this concept by stating:
Being well persists over time and through change, as a unity, or continuity, of experience. That is, a pattern of good health persists over time and contributes to an overall sense of being well such that the experience of change, in the form of symptoms or illness may not actually interrupt the ongoing continuity of wellness (42).
Mackey suggests that changes in health status need not be disruptive or problematic if they are integrated into a larger pattern of ongoing behavior and continuity.
In the largest observational study of people undergoing network chiropractic care and its effects on wellness, Tonya L. Schuster conceptualized wellness in this way:
We conceptualize wellness as the generalized self-perception of health. From this perspective, wellness is distinct from health-illness; an individual can deem themselves to be in an acceptable state of wellness whether they experience suboptimal “health” in any given domain or area of functioning (53).
Continuity and behavior are elements of what Epstein et al. term Reorganizational Healing (54), encouraging the individual to take an active role in his or her lives in an effort to increase well-being on an ongoing basis. Epstein outlines the need for individuals to be self-aware and engaged in present-time consciousness. Such awareness allows them to know when they devolve to a lower level of functioning and can then engage in activities that raise their level of functioning—all “in spite of life’s challenges.”
The chiropractic profession has long advocated for lifestyle-based approaches to health and disease, and contemporary chiropractic has asserted that there is a chiropractic lifestyle (55) and, depending on the source, this lifestyle includes such elements as proper rest, exercise, nutritional considerations, and positive mental attitude. Integration of the physical, biochemical, and psychological dimensions of health also forms the basis for such constructs (56,57).
These wellness constructs have been studied in patients (58) and in chiropractors with one survey demonstrating chiropractors’ adherence to teaching the chiropractic lifestyle to their patients (59). The study showed that of those chiropractors surveyed, 97.8% recommended exercise, 93.6% maintenance or wellness care, 93.2% offered ergonomic recommendations, 87.7% provided general nutritional advice, and 86.4% recommended stress reduction activities. These educational activities are considered primary and secondary prevention efforts, and though she did not use the term chiropractic lifestyle, Hawk (60) studied the extent that chiropractors engaged in these activities. In addition to specific care of the spine, chiropractors usually suggest therapeutic exercises, offer general fitness recommendations, and advise on nutrition, vitamins, weight loss, smoking cessation, and relaxation techniques. While none of these are the sole domain of the chiropractic profession, these constructs typically include a final element centered on a properly functioning nervous system. It is this element alone that marks chiropractic’s unique contribution to health and wellness.
The lifestyle approaches that chiropractors and others have historically advocated for have now become mainstream. As noted earlier, the purchase of products and services related to wellness approaches has become a $1 trillion industry (41).
The beginning entrenchment of wellness concepts as part of social norms is readily apparent in related legislation on both the state and federal levels. Public school systems throughout the United States that participate in the Federal Lunch program must have wellness councils and wellness policies. These policies must include nutritional and physical activity-related components and must utilize some method of objective outcome assessment and evaluation demonstrating their effectiveness (61).
In a review of the state legislation to improve employee wellness during 2001 to 2006, Lankford et al. found four categories of state legislation that appeared to be most common (62). These were tax credits, wellness policies
and programs, alternative transportation, and health insurance. During 2001 to 2006, 7 of 27 states enacted worksite wellness bills with 19% to 22% being enacted. The authors concluded that worksite health promotion legislation passed as favorably as other health promotion topics.
and programs, alternative transportation, and health insurance. During 2001 to 2006, 7 of 27 states enacted worksite wellness bills with 19% to 22% being enacted. The authors concluded that worksite health promotion legislation passed as favorably as other health promotion topics.
Wellness Constructs
Wellness constructs attempt to express its complex nature by breaking it down into component parts with such efforts being consistently applied since Dunn first started writing about it. Blanks et al. linked wellness, lifestyle, and chiropractic in their study of 2,818 people undergoing chiropractic care from 156 clinics in four countries (58). Utilizing a wellness construct consisting of four domains that included: physical, mental, spiritual, and stress that were combined into a wellness scale, results indicated that patients reported significant positive perceived change in all four domains of health and overall quality of life. These benefits were evident from as early as 1 to 3 months and showed continuing clinical improvements in the duration of care in the intervals studied, with no indication of a maximum clinical benefit.
Not only did Blanks et al. find that those undergoing network chiropractic care report a positive perceived change in four domains of health (physical, mental, spiritual, stress) but also in a related study Schuster found that chiropractic care had the added effect of lifestyle change (63). In other words, the cohort of subjects undergoing chiropractic care tended to change their lifestyle behaviors in ways that further added to improved wellness scores. The subjects reported smoking cessation, nutritional changes, and taking up such regimes as exercise, yoga, and meditation. These studies provide evidence that health and wellness survey instruments are particularly appropriate for investigating wellnessoriented disciplines.
Coulter et al. found that persons receiving chiropractic care reported better overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and were more active than the non-chiropractic patients (64).
Rupert et al. surveyed 311 chiropractic patients, aged 65 years and older, who had received “maintenance care” for 5 years or longer and found chiropractic patients undergoing maintenance care, when compared with US citizens of the same age, spent only 31% of the national average for health care services, had a 50% reduction in medical provider visits, and had health habits that were better overall than the general population, including decreased use of cigarettes and decreased use of nonprescription drugs. Furthermore, 95.8% believed the care to be either considerably or extremely valuable (65).
In another study, Rupert reports that 79% of chiropractic patients have maintenance care recommended to them, and nearly half of those comply (66). In an online survey with 3,018 respondents by Miller, 62% responded affirmatively when asked, “Although you feel healthy, would you follow your family member’s lead and visit a doctor who focuses on wellness and prevention just so you can stay feeling that way (67)?”
In a review of the research literature, Hannon describes over 40 studies where people with no symptoms of disease experienced objective health benefits under chiropractic care (68). Hannon’s conclusion is a positive statement on the effects of chiropractic on human potential and healing: “Improved function can be objectively measured in asymptomatic individuals following chiropractic care in a number of body systems often by relatively non-invasive means. It is plausible that chiropractic care may be of benefit to every function of the body and have the potential for long-term, overall health benefit to those receiving chiropractic care.”
Wellness Biomarkers
Research incorporating health-related quality-of-life assessments and self-reported health assessments has found them to be an independent predictor of health outcome and even mortality (69). Self-reported health has been shown to be independently associated with an increase in mortality among both those with and without chronic health issues. This is true relative to various socioeconomic and age groups as well as in men, women, and over time (70,71,72,73,74,75).
Immune signaling has now been shown to affect the brain and produce changes in behavior, cognition, and emotion secondary to pro-inflammatory cytokines and is even termed sickness behavior. In such a state, people experience symptoms of weakness, listlessness, altered sleep patterns, increased pain sensitivity, and a loss of motivation and appetite (76,77). Such changes in health states can then be measured via self-rated health constructs with poorer subjective health being associated with increased levels of cytokines. This being the case, self-reported health is an independent predictor of cytokine levels (78).
Recent studies have shown that chiropractic intervention is associated with reduction in circulating cytokines and studies involving the role of beta endorphins and other peptides that mediate these effects have also been conducted (79,80,81).
In a case-controlled retrospective analysis, Kent et al. assessed the short- and long-term effects of chiropractic care on serum thiol levels in asymptomatic subjects (82). Serum thiol is a surrogate marker for DNA repair enzyme activity and is related to cellular
functioning, repair, and epigenetic activities. Serum thiol levels in this study were examined in patients with active disease and compared with levels in asymptomatic subjects. Subjects were treated from 8 to 52 weeks of care. Mean serum thiol levels were lowest in patients with active disease and neuromuscular complaints and highest in asymptomatic individuals. The researchers concluded that asymptomatic or primary wellness subjects under chiropractic care demonstrated higher mean serum thiol levels than patients with active disease and produced some values that were higher than normal wellness values (82).
functioning, repair, and epigenetic activities. Serum thiol levels in this study were examined in patients with active disease and compared with levels in asymptomatic subjects. Subjects were treated from 8 to 52 weeks of care. Mean serum thiol levels were lowest in patients with active disease and neuromuscular complaints and highest in asymptomatic individuals. The researchers concluded that asymptomatic or primary wellness subjects under chiropractic care demonstrated higher mean serum thiol levels than patients with active disease and produced some values that were higher than normal wellness values (82).
If chiropractic care has an effect on wellness, it most likely exerts this effect through the supersystems of the human body—the nervous, immune, and endocrine systems (83,84,85). There is clear evidence that chiropractic has a beneficial effect on all three of these systems. Theories from fields such as mechanobiology, for example, focus on homeostasis and the balance of mechanical factors that promote health (86). This coupled with the studies linking a connection between manipulation and adjustment of the spine and its effects on immune and endocrine function tie together nicely. These studies have shown that manipulative treatment may influence T and B lymphocyte numbers, NK cell numbers, antibody levels, phagocytic activity, and plasma betaendorphin levels. From the effects of spinal manipulation on flu victims to pulmonary function, CD4 counts, cortisol, and substance P, the literature on manipulation of the spine and manual therapy both in chiropractic and other professions provides evidence for positive effects (87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111
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