Cheryl Hawk, DC, PhD, Michael Schneider, DC, PhD,
Marion Willard Evans Jr., DC, PhD, MCHES, Daniel Redwood, DC
Logan College of Chiropractic,
Chesterfield, MO 63017, USA.
Objective The purposes of this project were to develop consensus definitions for a set of best practices that doctors of chiropractic may use for promoting health and wellness and preventing disease and to describe the appropriate components and procedures for these practices.
Methods A multidisciplinary steering committee of 10 health care professionals developed seed statements based on their clinical experience and relevant literature. A Delphi consensus process was conducted from January to July 2011, following the RAND methodology. Consensus was reached when at least 80% of the panelists were in agreement. There were 44 Delphi panelists (36 doctors of chiropractic, 6 doctors of philosophy, 1 doctor of naturopathy, 1 registered nurse).
Results The statements developed defined the terms and practices for chiropractic care to promote health and wellness and prevent disease.
Conclusion This document describes the procedures and features of wellness care that represent 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.
From the Full-Text Article:
Chiropractic wellness care (sometimes referred to as maintenance care [MC]) is accepted by the profession as an integral part of chiropractic practice. [1-6] The theory of MC suggests that ongoing chiropractic care may have value in maintaining and promoting health, as well as preventing disease.  In the late 1990s, a survey of a small sample of US doctors of chiropractic (DCs) (n = 658) self-reported that they recommended MC to 79% of their patients but that only 34% of those patients elected to pursue this type of care.  The respondents estimated that 23% of their practice income was generated from MC (averaging 14 visits per MC patient per year).  However, according to the authors, “no definition of MC was provided with the survey”; therefore, it is not certain how the respondents were interpreting this term. The National Board of Chiropractic Examiners conducted a larger survey in 2003 (n = 2574) and included “wellness” as a category for presentation of chief concern. The Practice Analysis of Chiropractic reported that the survey respondents estimated that 8% of their patients presented for wellness care.  Because these were both indirect studies and definitions were not provided, the true prevalence with which patients request or use wellness care remains unclear.
Adding to the confusion, some in the chiropractic profession have used the term MC to mean wellness care. However, in the conventional health care arena, the term MC has a distinct meaning. Health insurers and Medicare have defined “maintenance care” as the care provided for a stable condition without any additional functional improvement of the patient’s net health outcome; MC is not considered (Editor’s Comment: by Medicare at least) to be medically necessary care.  Because of the misunderstandings between wellness care and MC, it has been recommended that DCs use the term wellness care, which is more accurate and encompasses a greater breadth of patient care. [9, 10]
For some DCs, wellness care consists solely of periodic analysis and spinal manipulation for the correction of asymptomatic spinal subluxations (areas of dysfunction). However, for other DCs, wellness care includes not only spinal manipulation but also advice and instructions on aspects of health behavior. Most DCs report that they provide instructions to patients regarding health promotion and wellness, particularly on physical fitness, diet, changing unhealthy behaviors, self-care strategies, and stress reduction. [1, 11-13] The National Board of Chiropractic Examiners survey results showed that more than 90% of DCs reported that they implemented 6 of 8 wellness strategies in daily practice; the other 2 (smoking cessation and disease prevention/screening) were still in the majority (81.5% and 77.9%). Thus, wellness care for most DCs is reported to consist of more than spine care alone.
There has been an effort to develop an accepted definition of the practice of providing chiropractic care for the purposes of health promotion, disease prevention, and wellness. The American Chiropractic Association developed a consensus-based internal document in 2001 on wellness care, which states
Since its inception, chiropractic has been based on an active care model that emphasizes wellness. Wellness requires active patient participation. It is a process of achieving the best health possible given one’s genetic makeup by pursuing an optimal level of function. The goal of wellness is to maintain the most favorable balance between internal and external environments. Wellness care incorporates active lifestyle changes consistent with the goals of Healthy People 2020, the U.S. Department of Health and Human Services’ blueprint for improving the health of Americans. As an active care model, the commitment of the DC to wellness emphasizes collaboration with patients on the development of a lifelong path for health promotion and disease prevention. Wellness is a patient-centered process.
In 2010, a multidisciplinary consensus process defined chiropractic terminology related to levels of care, which included wellness care.  This document included the following:
Wellness requires active patient participation.
Wellness is a process of achieving the best health possible, given one’s genetic makeup, by pursuing an optimal level of function.
Optimizing levels of function may include a combination of health care strategies such as chiropractic adjustments, manipulative therapy, manual therapies, exercise, diet/nutrition counseling, and lifestyle coaching. 
Despite previous attempts to define wellness care in chiropractic practice, there is currently no standard protocol for how it is practiced and disagreement as to its benefits or whether it is appropriate.  At the heart of the disagreement is the belief by some that periodic visits by asymptomatic patients for periodic spinal manipulation will improve overall health, prevent disease, and/or decrease recurrence of spine pain. However, there is no firm evidence that supports this theory. Others question this belief and do not recommend spinal manipulation for patients who are asymptomatic. Regardless, there is currently no evidence to support either side of this disagreement.
There is general agreement and evidence that support common domain wellness procedures that are advocated as having clear health benefits such as advice on tobacco cessation, counseling patients to lose weight and increase their level of exercise. Strong evidence supports the use of these common domain clinical preventive services. 
Some clinical studies and case reports have attempted to describe possible benefits of chiropractic wellness care [6, 16-44] A few have shown some preliminary findings suggesting that there may be a possible positive effect on reducing pain and function from chiropractic spinal manipulation as a prevention strategy. However, this body of evidence is still emerging.
Although some DCs providing care to asymptomatic patients restrict their intervention to spinal manipulation, other DCs include additional (nonmanipulative) interventions during the course of their wellness visits to include screening and counseling about high-risk health behaviors. Also, there is some evidence for the effectiveness of common screening and counseling methods on health behavior related to a number of risk factors. [15, 45, 46] Although such counseling is within the scope of chiropractic practice, the evidence of its effectiveness within the chiropractic setting has not been evaluated. Doctors of chiropractic provide health promotion counseling, most commonly for physical activity and nutrition, but tobacco cessation is less frequently addressed. [47-56] Training in disease screening and prevention and health promotion counseling is provided in chiropractic college curricula, and competencies have been established by the Council on Chiropractic Education, although detailed standards have not yet been described. [57, 58] Best-practice guidelines for chiropractic care for both children and older adults recommend that DCs provide all patients with disease prevention and health promotion counseling as recommended by the US Preventive Services Task Force (USPSTF). [59, 60] However, it is not clear how many are implementing this recommendation in daily practice. To evaluate and implement wellness practice, a commonly agreed-upon set of terms and procedures are needed.
Currently, there is no standard, universally accepted definition for the provision of chiropractic care for health promotion, disease prevention, and wellness. The purposes of this project were to develop consensus definitions for the set of best practices that DCs may use for purposes of promoting health, wellness, and preventing disease and to describe the most appropriate components and procedures of these practices.
This project is important to both chiropractic and public health because it represents the first attempt at developing a comprehensive set of best-practice statements that address the issues of providing wellness care within the context of chiropractic practice. It is a synthesis of the best current evidence and collective expert opinion about a reasonable clinical approach to health promotion within chiropractic practice. It provides selected evidence-informed parameters to the role that DCs can play in providing health education, promotion, and wellness services to their patients.
Most of the common causes of premature morbidity and mortality in the United States are chronic conditions such as heart disease, hypertension, hyperlipidemia, obesity, and diabetes, which are related to lifestyle, diet, and smoking. The US Federal government has recognized the importance of wellness care in reducing the incidence of these chronic health problems, which serves as the foundation for the Healthy People 2020 initiative. The chiropractic profession could serve an important public health role because of its historic incorporation of these holistic concepts of wellness in clinical practice. [72, 73]
Our panel recognized that there were only a small number of high-quality clinical studies on the topic of spinal manipulation of asymptomatic patients for prevention of future musculoskeletal disorders, as well as for general health and wellness. We suggest that this may be an important area for future research. Although currently, there are not many studies focusing on chiropractic, there is extensive evidence for common domain health promotion and education tools.  Doctors of chiropractic who practice advising and health promotion can incorporate many of these common domain interventions such as dietary advice, therapeutic exercise and posture correction, smoking cessation, weight loss, and other health promotion/education interventions.
The information in this document may help to inform stakeholders about a reasonable and rational approach to chiropractic care for wellness. Doctors of chiropractic may use this document as a guide to the current best practices, whereas patients may use this information to learn about what to expect from a chiropractic practice that provides wellness services. Third-party payers and regulatory agencies may find this information useful for guiding policy decisions about chiropractic and wellness care.
Applying Research to Practice
The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services and develops recommendation statements for primary care clinicians and health systems.  These recommendations are based on a public health perspective and clear evidence that the benefits of any service should outweigh harm. Any screening test that is recommended for routine use with millions of Americans must take into consideration the consequences of false-negative and false-positive results. When a test has a high false-positive rate, it may lead to unnecessary additional diagnostic testing, physician visits, medical costs, and anxiety by the patient. When a test has a high false-negative rate, it may lead the patient to become complacent about new symptoms, think nothing is seriously wrong, and therefore not seek appropriate and necessary care.
However, any such recommendations are suggestions for practice based on expert consensus and constitute only one component of health care. There are 3 basic tenets of evidence-based health care practice:
(1) reliance on the best available evidence,
(2) clinician experience, and
(3) patient preferences and values. 
One may view the USPSTF recommendations as the best available evidence from a public health perspective. These recommendations suggest services provided to the average person within a population of more than 300 million Americans. The individual patient in an individual practitioner’s office is no longer the average patient within the public health sector. The DC who is seeing a patient in a private practice needs to be aware of the best evidence available, but also needs to combine this information with his/her own clinical experience and the individual patient’s preferences.
Expert consensus is a form of evidence that must be relied on when higher levels of evidence are lacking. [75, 76] An approach used by consensus panels is to develop best-practice recommendations. [59, 60, 77] Best practices have been described as
“…not a specific practice per se but rather a level of agreement about research-based knowledge and an integrative process of embedding this knowledge into the organization and delivery of health care.” 
This document was produced with the input from a variety of panel members. There was participation from chiropractic clinicians with experience treating children, chiropractic educators and researchers, and members of both the American Chiropractic Association and International Chiropractors Association. More than 80% agreement was achieved by the panel members on 49 seed statements; this is an impressive level of consensus. We feel that our panel of experts was representative of the spectrum of the chiropractic profession, and therefore, we are confident that these results can be considered generalizable to everyday chiropractic practice.
The panel members recognized variations in how wellness care could be practiced within the chiropractic profession. During the consensus process, 2 models of chiropractic wellness care were discussed. The first model focuses on the management of musculoskeletal disorders and promotes education and self-care strategies to help patients prevent future recurrence of back, neck, and musculoskeletal pain. This model is based on the theory that periodic chiropractic checkups screen for asymptomatic joint dysfunction and periodic manipulation can theoretically prevent future musculoskeletal problems. The panel recommended that this model should include health promotion and education interventions to empower patients toward active self-care and wellness behaviors that optimize physical function and normal activities.
The second model of chiropractic wellness care focuses on general health and optimizing function, not only on treatment of conditions, with the theory that periodic visits to a DC may help patients prevent a variety of chronic diseases, improve immune function, and enhance a state of general well-being. This model proposes to screen patients for a spectrum of general health care problems that are chronic and preventable through health behavior change. Thus, the panel recommended that DCs using this model should follow general public health guidelines, such as those recommended by the USPSTF.
The panel noted that in both models, chiropractic wellness care is not synonymous with solely providing periodic screenings for asymptomatic joint dysfunction and spinal manipulation. Instead, the emphasis of wellness practice must include health promotion, education, and active strategies to foster positive changes in health behaviors.
Limitations and Future Studies
Neither a quantitative nor qualitative systematic review of the literature was performed. The literature search terms were limited and may have missed additional relevant or more recently published articles in the area of health promotion, disease prevention, and wellness. [78-97] There was meager evidence in the literature to inform the panel about whether periodic screenings and manipulation of asymptomatic joint and muscle dysfunction can reduce the recurrence of future episodes of musculoskeletal pain or slow down the degenerative process. Chiropractic care for prevention of injury is a theory that should be investigated in future longitudinal observational research and cost-effectiveness studies to determine the preventive benefits of such care.
The statements in this document were weighted in favor of USPSTF-endorsed screening procedures, health promotion and education, and common domain public health interventions. These interventions and screening procedures are considered common domain because they are not unique to any one health care profession. As noted previously, those in chiropractic practices who do not purport to provide wellness services or that focus chiefly on musculoskeletal concerns may object to some statements in this document that are focused on screenings and behavioral interventions for nonmusculoskeletal conditions. Also, the process for developing this document did not follow typical guideline development, such as described by the Institute of Medicine,  which should be considered in the future. Although we feel there was a representative sample from the chiropractic profession, other stakeholders were not included and should be considered for future studies.
Another limitation is that owing to the use of lower level of evidence available compared with that provided by large-scale experimental studies, a considerable amount of content for this document was generated from expert opinion. However, in the absence of a substantial body of literature and evidence, clinical practice must continue. Providing a reasonable approach to clinical practice, developed through a formal consensus of expert opinion based on best available evidence, is an important part of filling the knowledge gap. It is essential that rigorous observational and experimental studies be implemented to provide a more substantial body of evidence to inform future clinical guidelines that focus on 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.