LIFESTYLE MEDICINE APPLICATIONS FOR THE CHIROPRACTIC PROFESSION

Introduction

Since 1895, chiropractic has successfully anchored itself on a professional identity of having a different approach to health through natural methods. To avoid being jailed for practicing medicine, the original chiropractic paradigm of care differentiated the profession from medicine in the early 20th century.¹ This turned out to be a winning strategy for the profession and was successful in establishing initial cultural authority. The early ideology to explain the cause of disease, though useful in the early 20th century, fails to check the box of evidence-informed care in the 21st century. Similar to the study of history and ancient civilizations, the profession would benefit by focusing upon the richness of the professions’ past to move forward into the future. Such a focus allows the appreciation of early professional struggles to achieve cultural authority while not over-interpreting or relying on philosophical tenets from the past.²

The original paradigm of care that saved the profession in the early 1900s may now act to hinder professional growth and advancement in the 21st century as a greater percentage of practicing chiropractors utilize evidence-informed practice guidelines.³ The trends in the literature illustrate the need for change from traditional biomedical health care models towards those that are sustainable.⁴ For example, society is now expecting their health care provider to utilize technology, innovation and to integrate care with other providers.⁵ The utilization of electronic media presents opportunities for healthcare providers to communicate preventative, lifestyle medicine information to improve patient satisfaction and clinical outcomes while removing the requirement for a live visit.⁶ Such factors have become vital in delivering effective care as well as educating and empowering the patient within the health care relationship. The power-distance relationship between the practitioner and the patient diminishes as providers empower patients to play a greater role in their own health care goals.

In addition to the health and wellness needs of the individual, the public health needs of the community must also be considered. Nevertheless, a patient-centered, evidence-informed approach to address individual patient chief complaints and problems is still a requirement for all healthcare providers. To fully integrate with other health care disciplines, the profession has a role to play in addressing public health concerns regarding safety, care through the lifespan and community action.⁷ This will require chiropractic education institutions to evolve from preparing graduates to run a solo office to fully integrating into a variety of health care systems. Further research can effectively provide options as to how collective and integrative solutions for chiropractic can provide benefits throughout the population.

The health focus of the future has presented the opportunity to take on a goal of sustainability through preventive practices by providers that are supplemented by dedication to lifestyle medicine approaches.⁸ Lifestyle medicine is an approach to health emphasizing healthy diet, regular physical activity, avoidance of tobacco products, healthy sleep patterns, and managing stress.⁸ For chiropractic, this provides the chance to demonstrate the benefits of maintaining a healthy, fully functional spine and musculoskeletal (MSK) system.⁹ Indeed, the total mass of the MSK system enables metabolic health and exerts a significant influence on individual well-being.¹⁰ Sarcopenia and osteoporosis are two devastating conditions that can occur with aging as well as cancer treatments that can be combated by having a healthy MSK system.¹¹ Accordingly, it can be postulated that the fitness and functionality of the MSK system presents the opportunity to affect the health of the individual to a large degree.¹² Further, the importance of muscle mass, strength and metabolic function in the performance of activities of daily living (ADLs), athletic and recreational activities are directly connected. Performing tasks to maintain a home and property are examples of ADLs and how a healthy MSK system can affect the lives of individuals.

The concept of lifestyle medicine originated at the end of the 20th century as an evidence-based approach for treatments and preventative public health measures to counteract the rise of chronic preventable condition.¹³ A landmark publication by Rippe¹⁴ presented lifestyle medicine as an approach to lower the risk factors of disease and to assist in the care of ongoing conditions by promoting good health. Lifestyle medicine may also involve maintaining a healthy weight through regular physical activity, injury prevention, and effective treatments to reduce the likelihood of conditions becoming chronic.¹⁵ In addition, lifestyle medicine may include patient education to enhance patient empowerment enabling greater levels of self-care such as avoidance of tobacco products, moderation of alcohol consumption, and regular use of safety devices; seatbelts and bicycle helmets.¹⁶ The American College of Lifestyle Medicine provides the most up to date definition of lifestyle medicine as a the primary use of evidence-based therapeutic lifestyle interventions to treat chronic conditions through the following six pillars: 1) whole-food, plant based eating, 2) physical activity, 3) restorative sleep, 4) stress management, 5) avoidance of risky substances, 6) positive social connections.¹⁷

It is likely that a significant majority of chiropractic practices include some of the six pillars in their office intake form or as part of patient history taking and treatment plans. Moreover, if the practitioner is continuing to see patients on a regular basis, this provides the opportunity to monitor significant lifestyle medicine factors, connecting these items to the health of the spine and MSK system. The objective of this paper is to present the importance of including the spine and MSK system as part of a critical component of lifestyle medicine to enhance individual and public health outcomes.

DISCUSSION

Lifestyle Medicine and Chiropractic

A maintenance care approach that focuses on the spine and MSK system is a method used by certain practicing chiropractors to continually monitor patients and provide treatments on a regular basis. Such a treatment approach has demonstrated effectiveness in some MSK conditions. However, it has also become associated with long periods of care without measuring reliable outcomes to determine progress and end of care goals.¹⁸ The approach is similar to the dental profession, specifically, dental hygiene where patients see the provider on a regular basis without the presentation of pain or other symptoms. Evidence suggests that maintenance chiropractic care may be beneficial as secondary or tertiary prevention for individuals with previous episodes of low back pain.¹⁹ However, applying a maintenance care approach to every patient is not following the best evidence.¹⁸

Studies done involving North American and Australian chiropractors revealed that these two provider groups believe maintenance care to consist of spinal manipulation, exercises, dietary advice, patient education and vitamin supplementation.²⁰ Axén and colleagues¹⁸ provide a recent definition of maintenance care as a preventative therapeutic concept provided to patients that respond well to initial treatment and continue to do so for as long as the patient perceives benefit. Other studies advocate for the profession to accept that it is well known as specialists for care of the spine and MSK system utilizing a conservative approach.^21,22 Combining the professions’ expertise in spine and MSK systems with maintenance care fits well with integrating lifestyle medicine to compliment chiropractic care.

Similar thiough different to maintenance care, wellness has been a term more appropriate and accurate to chiropractic care in that it encompasses a greater scope of patient care.²³ Some wellness treatment plans within the profession have been linked to entrepreneurial activities to elevate the number of visits, endorsement, and marketing of products to increase the income collected from each patient.²⁴ Such an approach is used to increasingly seek higher levels of patient visits and income, regardless of diagnosis or treatment care needs. Income centered approaches are linked to the entrepreneurial aspects of health rather than evidence-based, patient-centered, clinically competent and safe delivery of health care to the public.⁷Further, this has caused some level of conflict within the profession between those believing that providing limitless ongoing care is beneficial for health and those that follow evidence-informed guidelines.

It is well documented that most patients seeking chiropractic care are doing so for musculoskeletal complaints.²⁵ A 2017 scoping review discovered that the reasons individuals sought out chiropractic care were low back pain (49.7%), neck pain (22.5%), and extremity problems (10%).²⁵ The findings also revealed that in addition to spinal manipulative therapies, chiropractors used patient education and self-care such as home exercises.²⁵ These findings are in line with practice guidelines to provide evidence-based, self-care options that include encouraging patients to remain active.²⁶ Evidence also suggests that early and active intervention into MSK conditions results in less sick leave and reduction of future chronic problems.²⁷ Since multimodal treatments are within the repertoire of chiropractors, the profession would benefit by providing patient education regarding lifestyle medicine to offer greater options for self-care and patient empowerment.

Effect of the Spine and Musculoskeletal System on Overall Health

Musculoskeletal conditions are among the largest contributors of the need for rehabilitation services among children, and account for approximately two-thirds of all prevalent cases in adults.¹² The same Lancet study identified 1.7 billion people globally having musculoskeletal conditions, with low-back pain contributing to the need for rehabilitation and the main reason for adults prematurely leaving the workforce in 134 of 204 countries examined.¹² As a major portion of the human skeleton is supported by the axial skeleton, the spine is therefore a critical component of the musculoskeletal system and overall health.²⁸ The spine provides structural support for the entire body, protection for the spinal cord as well as permitting movement and flexibility for the upper body. A professional directive to focus on public health, emphasizing the spine/MSK system and lifestyle medicine has the potential to address major health concerns that the US and the world are currently experiencing. Easy to follow educational instructions and demonstrations related to food choices, exercise and healthy sleep patterns could be provided as part of chiropractic visits.

A recent review of maintenance care provided by chiropractors in Scandinavia indicates that patients and practitioners agree on the need; however, such visits were not much different from previous visits the patients received without emphasis on public health concerns.¹⁶ Previous studies have demonstrated that chiropractors provided maintenance care to patients over 65 including spinal manipulative therapy that included exercise, nutrition, relaxation and rehabilitation.²⁹ Another study surveyed chiropractic students, academic faculty and field practitioners revealing that a large majority favored clinical preventative services that included diet and exercise.³⁰ Also noted was a gap in education to effectively provide evidence-based, preventative health services offered by chiropractors.³⁰ This provides the basis for chiropractic educational institutions with the opportunity to integrate lifestyle medicine into their respective curricula. Educational institutions currently provide public health education on topics related to lifestyle medicine. An expansion of content within existing courses and the addition of at least one course focusing on lifestyle medicine would provide greater exposure to students to this concept. Moreover, the application of lifestyle medicine should be included and assessed within the clinical portion of a chiropractic students’ education.

Chiropractic and Public Health

It is well documented that patients seeking care from a chiropractor do so for complaints related to the MSK system and spine.^9,25 The chiropractic model of dealing with pain and discomfort of the spine, joints, and many areas of the MSK system, often times at a reduced cost to conventional care, is also well documented.²⁵ Such an approach has resulted in the profession gaining cultural authority for back and neck pain contributing to general health and well-being. The most prevalent health problems patients sought out for chiropractic care were back pain (63.0%), and neck pain (30.2%) with many also receiving care from conventional medical providers that included prescription (23.0%) and/or over-the-counter medications (35.0%).³¹ Moreover, results of this same study reported that 63.8% of patients stating chiropractic care combined with medical treatment as helpful.³¹

A maintenance care approach to improve the health and wellness of patients by increasing the number and frequency of passive care treatments is not supported by evidence.³¹ This can result in patient care practices by some practitioners to over-treat. Rather than taking this approach, one focused on public health and improving public health outcomes is the preferred method the profession should pursue.⁷ This presents the opportunity to reshape the value-added benefits of services provided by chiropractors to achieve improved public health outcomes by focusing on prevention with an emphasis on a properly functioning spine and MSK system. The good news is that chiropractors and other health care professionals have demonstrated willingness towards following evidence-informed practice guidelines to enhance public health outcomes.³

Approaches to achieve the highest levels of health outcomes can include self-care interventions that are accessible, affordable, adaptable to the community, nation and regional customs.³² Health care providers can become key supporters of self-care by ensuring patients apply such treatments effectively and safely by tailoring interventions to patient needs, monitoring of symptoms, providing coping strategies and lifestyle choices.³³ This could be done using conventional face-to-face office visits, telemedicine, telephone or videoconferencing. To improve patient self-monitoring behaviors, self-care skills and clinical outcomes, telemedicine has been effective.³⁴ An additional advantage of telehealth is the benefit of staying connected with patients without requiring an in-person office visit.

There is increasing evidence that self-care interventions are effective for reducing both communicable and non-communicable diseases.³⁵ Passive treatments are inherent to most of the care delivered by chiropractors involving manipulation of joints, mobilization of the spine, other joints and soft tissues of the MSK system that the profession is well known for. However, a greater utilization of passive care treatments for low back pain may result in adverse events causing patients to seek out pain relief pharmaceuticals and specialty visits.³⁶ Accordingly, less reliance on passive care to maintain or keep individuals on the right track to health is aligned with evidence-based approaches to patient care.

If the chiropractic profession were to embrace a lifestyle medicine approach, a benefit could include advocating for the five types of prevention cited in public health literature: primordial, primary, secondary, tertiary, and quaternary.³⁷ Primordial prevention involves addressing the root causes and social determinants of disease, while primary prevention focuses on not getting the disease or condition in the first place. Major public health conditions present in developed countries and increasing in developing countries are related to poor daily habits that would respond well to lifestyle medicine approaches. Recognizing early signs, symptoms, complaints and implementing measures to relieve or not make it worse falls under secondary prevention.

Tertiary prevention involves reducing the signs and symptoms of a disease or condition that is already present. Most conventional medical health care is focused on tertiary prevention/care. Reimbursement for providers, including chiropractors, is focused on taking care of conditions at the tertiary stage. This may lead to extended treatment plans, unnecessary diagnostic/lab testing, selling of products to achieve increased payment levels rather than achieving evidence-based, patient-centered and safe health care.³⁸ A lifestyle medicine focus is an approach to achieve positive patient outcomes because of providing less passive care treatments and options for patients to perform self-care activities beyond the limited time of an office visit.

Lifestyle Medicine and Prevention of Non-Communicable Disease

Approximately half of the deaths from 1990 to 2000 in the US can be attributed to preventable behaviors such as cessation of smoking, dietary improvements, and increased physical activity.³⁹ The present health of the US population and many Western countries reflects increased levels of metabolic syndrome, overweight/obesity, Type II diabetes mellitus (T2DM), and cardiovascular disease (CVD).⁴⁰ Moreover, the progression of these conditions coupled with poor diet and sedentary behaviors may lead to further secondary conditions such as premature degenerative joint disease and cognitive decline. Current investigative research presents the argument for Type III diabetes that involves a direct connection between poorly controlled blood sugar and Alzheimer’s disease.⁴¹ A greater emphasis on public and population health could serve as an approach to ensure chiropractic is aware of and devotes resources to improve community public health initiatives through a unique and cost-effective method by focusing on the spine and MSK system.

According to the Lancet, approximately 60% of non-communicable diseases can be attributed either directly or indirectly to disorders of the MSK system.⁴² The MSK system occupies a significant percentage of total body mass equaling 40% of body weight and 50% - 75% of body proteins.⁴³ Disruptions or injuries to the MSK system can have far-reaching effects on physical function, quality of life and overall health. One of the most critical ways the MSK system affects overall health is related to physical function. The architecture of the body is supported by the skeletal system, anchored to muscles, ligaments, and tendons to provide movement, balance, and coordination. Disorders to the MSK system can take on many forms affecting one’s quality of life, including joint pain, and muscle weakness resulting in major effects on function and mobility.¹² Decreased levels of function can be linked to decreased levels of mobility and sedentary lifestyles. The chiropractic profession has positioned itself as spine/MSK experts to increase the functional ability of patients to move without pain.

Inability to move, or movement that is accompanied by pain can be directly linked to less movement/mobility, especially for exercise purposes thereby leading to negative outcomes regarding cardiovascular health and circulating levels of blood sugar.⁴⁴ Moreover, modern technological advancements have resulted in further declines to physical activity leading to increases in CVD as one of the leading causes of morbidity and mortality on a global level.⁴⁵ MSK conditions limiting human movement exacerbate sedentary lifestyles further resulting in a decreased ability to control levels of blood sugar to fall within recommended ranges.

Current treatments for T2DM focus on a combination of pharmaceutical intervention with little lifestyle changes. Dependence on drug interventions without lifestyle changes may exacerbate a cycle of drug dependence without realizing the benefits of lifestyle modification to enhance quality of life.⁴⁶ Furthermore, cardiovascular health can have a direct effect on levels of systemic inflammation negatively affecting blood vessels, the heart, joints and internal organ systems.⁴⁷ By providing emphasis on the MSK system, chiropractors can focus on enabling movement, preserve muscle mass and improve control of circulating blood sugar levels enhancing cardiovascular health.

It is vital to maintain a well-functioning MSK system to perform at maximum physical capacity. The ability to perform work at any level is not just a requirement for highly laborious efforts or sports performance. ADLs require specific levels of strength to perform various activities such as lifting from the floor to waste, waste to chest, and over the head. Increased independence and reduced mortality risks has been linked to maintaining functional strength as one ages.^48,49 The majority of household and employment related activities require less maximum strength when compared to heavy labor occupations or sports performance. Nevertheless, all human activity requires recruitment of the MSK system to perform required efforts. Accordingly, the MSK and spine expertise of chiropractors is uniquely suited to ensure vital health metrics related to individual and public health outcomes are met enabling individuals to move and perform ADLs at a highly functional level throughout their lifespan.

Behaviors and Lifestyle Medicine

Human behaviors have dramatically changed from prehistoric times when humans utilized hunting, fishing, gathering, foraging for wild vegetation and anything edible. Anthropological evidence indicates the ancestors of modern humans were using the hunter-gatherer lifestyle as early as 2 million years ago.⁵⁰ Primitive peoples were required to be continually active to secure sufficient food sources to survive.⁵¹ This lifestyle required a strategy of high mobility to access large land mass areas to secure sources of food. The quest for reliable sources of food forced humans to continuously be on the move until the Neolithic Revolution beginning 10,000 years ago with the establishment of long-term permanent settlements as the result of adapting agricultural practices.⁵² Today, the only known remaining society that utilizes this lifestyle are the Hadza people of Tanzania.⁵³

Human levels of activity have exponentially changed since we no longer use hunting and gathering as a method of survival. However, our anatomy and physiology are still inherently designed for such activities. The past century has resulted in the most changes regarding the ways humans obtain food, perform daily activities and spend leisure time.⁵⁴ Humans have evolved their physical activity levels from primitive times that required them to be highly active to secure sufficient food, to labor intensive agricultural and industrial occupations. The latter half of the 20th century and into the 21st century have reversed this trend where there is an abundance of food, mainly non-labor intensive occupations, increased leisure time, survival into the 8th and 9th decades and sedentary behaviors.⁵¹ It may be postulated that the increased availability of food, and sedentary behaviors has caused an increase in non-communicable diseases and conditions that for the most part, can be avoided. The profession should appreciate the history of human movement and the factors that have and continue to affect movement and the subsequent decline in human health.

Chiropractic and Lifestyle Medicine

The evidence to embrace lifestyle medicine and to provide patients with the education and tools to enable such changes are abundantly clear. The profession established its initial cultural competency on serving the public via a method of care that was different from the medical model. The profession has progressed to the WFC supporting the involvement of chiropractors in public health initiatives related to MSK and spinal health.⁵⁵ Emphasis on providing passive treatments is not the approach the profession should keep advocating for. Following the COVID pandemic, evidence has grown supporting self-care to improve health, well-being and health care coverage.⁵⁶ Empowering patients with the knowledge and confidence to take care of health concerns provides health care providers the opportunity to ensure evidence-informed guidelines are followed. Programs that emphasize self-management education, rather than information-only education, enable patient self-efficacy and mastery of self-identified problems to improve clinical outcomes.⁵⁷ Moreover, such an approach has demonstrated to be effective for the self-management of long-term chronic conditions.^58,59 In addition, it is within the scope of chiropractors to address MSK/spine conditions using patient self-management techniques requiring little to no equipment and minimal cost.

Providing self-management education to patients rather than information education may be difficult to achieve for most chiropractors as this may not be specifically taught to them during their chiropractic education. Patient factors that could influence the success of self-management outcomes include self-efficacy, depression, pain catastrophizing and physical activity levels.⁶⁰ Noted shortcomings for providing self-care strategies include lack of training for the provider on how to customize self-management for each patient that includes simple items such as providing the correct spelling/pronunciation of their condition and prioritization of the recommendations expected of the individual.⁶¹ Despite conflicting evidence on patient self-managing for some specific conditions, there is increasing confirmation that adopting multiple lifestyle behaviors can increase a healthy lifespan.⁶² Such an approach fits well with the chiropractic profession and falls within the scope of caring for the MSK system and spine.

Increasingly, there appears to be connections between the general health of the individual and the MSK.⁶³ Cardiovascular conditions are common amongst the population with a subsequent link to MSK conditions. As the risk for CVD rises, the chance of MSK conditions increase substantially, with a 17-fold increase of risk with those having four MSK disorders and a 10-year Framingham risk of 12%.⁶⁴ Maintaining a lifetime of aerobic fitness has demonstrated benefits to muscle capillarization, enzymic activity and reduced frailty for individuals into their ninth decade.⁶⁵ Muscle strength/resistance training in combination with aerobic exercise also benefits the cardiovascular system in addition to maintaining muscle mass, strength and balance.⁶⁶

Another significant factor affecting the health of the global population by 2050 is that 1 in 6 people in the world will be over 65, a 120% increase from 2019.⁶⁷ As the population of all countries age, it is vital to ensure that health care systems have mechanisms in place to ensure an extended health-span of citizens rather than just lifespan. The United Nations Department of Economic and Social Affairs identified the top 10 risk factors facing the 50-74 age group that have not changed since 1990: high systolic blood pressure, smoking, high fasting plasma glucose, high BMI, ambient particulate matter, high LDL cholesterol, alcohol use, kidney disfunction, household air pollution and high blood sodium.⁶⁷ Low and middle income countries may have higher levels of exposure to ambient particulate matter and indoor air pollution from cooking and heating using open flame sources. The remaining factors are prevalent across low, middle, and high-income countries that can be improved with lifestyle medicine. Chiropractic and lifestyle medicine could directly improve conditions related to aging by providing patients with MSK/spine care and educating patients on how health of the spine/MSK can benefit other systems and health outcomes.

Maintenance and wellness care have been poorly defined amongst chiropractors with disagreements and lack of evidence as to whether periodic spinal manipulative care can improve health and prevent or decrease the occurrence of disease.⁶⁸ This lack of evidence may be combated by current, well documented lifestyle medicine research that supports providing patients with advice such as tobacco cessation, healthy diet, exercise, alcohol consumption and other beneficial behavioral changes. The United States Preventative Services Task Force (USPSTF) provides the most robust evidence guidelines that should be followed by health care providers regardless of discipline.⁶⁹

It has been recommended that chiropractic adapt the term wellness rather than maintenance care by providing patients health promotion for conditions such as cancer, diabetes, hypertension, spinal/joint pain and other chronic conditions.⁷⁰ Perhaps it would be advantageous to use neither maintenance or wellness care and adapt the term “lifestyle medicine” to ensure the profession is committed to providing patients with care and advice that is evidence-informed, congruent with the clinician’s expertise and adheres to the preferences of the patient.

The necessity for increased population and community health presents an opportunity for the profession to reposition itself as MSK/spine experts with a focus on lifestyle medicine to address the major public health concerns that span nations on a global level. Moreover, such an approach is firmly rooted in evidence that all health care providers, policy makers and the public accept. To enable the successful pursuit of this community-based approach to population health, the profession must commit to becoming a part of the health care team. The evidence is clear that chronic disease conditions are increasing and that the medical model, although effective at managing acute illness, is ineffective for upstream community based public health concerns.⁷¹ For the profession to pursue this path, chiropractic educational institutions that already teach some level of patient education, self-management and maintenance care would require changes to their curricula. Including lifestyle medicine within existing public health courses and adding one course specifically focused on lifestyle medicine is a simple first step.

In 2018, a “white paper” describing the public health agenda of the WFC was published.⁵⁵ The paper advocates for the involvement of chiropractic in public initiatives focusing on three areas: healthy aging; opioid misuse; women’s, children’s, and adolescent health. This current paper focuses on a broader perspective by adapting a lifestyle medicine approach to support the stated white paper objectives of the WFC. In alignment with the WFC objectives are the prevention of illness, promoting health and improving patient care following evidence-based guidelines. Further, it is recognized that to have an influence on public health initiatives, chiropractic should include increased levels of community engagement and contribute to sustainable health care systems in collaboration with other health care professionals.⁷²

Conclusion

This commentary provides a strategy for the chiropractic profession to adapt a lifestyle medicine approach to individual patient care that includes community and public health outcomes. Chiropractors currently have the expertise to provide patients with advice on healthy diet, recommended levels of physical activity, proper sleep, tobacco cessation, alcohol consumption, injury prevention and spinal biomechanics to ensure the health of the spine and MSK system. Secondary benefits from such advice can include reduced levels of metabolic syndrome, hypertension, T2DM, overweight/obesity, CVD, pain and dementia. Some of the above topics are covered within the programs of chiropractic curricula. The program depth of content should be examined and include the assessment of competencies for lifestyle medicine within the clinical training phase to ensure minimal proficiencies. To ensure chiropractors can function effectively within a health care team, social determinants of health is a topic that should also be included.

Human movement, health, functionality of the MSK system and spine were essential for people to survive in prehistoric times and support themselves over numerous industrial revolutions. Modern humans no longer require this level of MSK/spine health and functionality for survival except for heavy labor occupations and high-level athletics. Nevertheless, an argument can be made that the health and functionality of the MSK system and spine is required to combat the lack of requirement to move, to decrease the devastating impact of preventable diseases facing the globe. Furthermore, such an approach provides opportunities for chiropractic to fully integrate into mainstream healthcare systems by supporting a lifestyle medicine paradigm.