Process versus outcome: challenges of the chiropractic wellness paradigm.

OBJECTIVE: The purpose of this article is to discuss the term wellness in the context of the philosophy of chiropractic. DISCUSSION: PubMed and Index to Chiropractic Literature show an upward trend in use of the term wellness. Wellness may be used differently depending upon the profession and may be considered a process by some and an outcome by others.
CONCLUSION: There appears to be no consensus on the definition of wellness or how it is being used. Wellness is not exclusive to chiropractic, and wellness is not synonymous with health, although is often used that way. Wellness is a societal trend, and chiropractic as a health care profession may be a good fit for this concept.

Introduction

The term wellness is ubiquitous and is not a term that is unique to the chiropractic profession. Almost every profession including chiropractic, medicine, dentistry, optometry, physical therapy, podiatry, psychiatry, and veterinary medicine have incorporated this buzzword into its discipline. According to Pilzer, wellness in 2007 was expected to be a $500 billion industry; this is an increase of $300 billion from 2002.

The use and definition of the term wellness in a myriad of inconsistent ways can be quite problematic. Merriam-Webster's Dictionary defines wellness as “good health especially as an actively sought after goal.” In popular culture, wellness may be equated with a fad that engenders youth and motivation. For example, in The New Wellness Revolution, Pilzer states that the wellness industry is “comprised of products and services provided proactively to healthy people (those without an existing disease) to make them feel even healthier and look better, to slow down the effects of aging, and/or to prevent diseases from developing in the first place.” In this instance, wellness is used as a marketing ploy or as a motivational tool to get people to purchase cosmetic or elective products. One can observe this emerging trend by the increase of grocery stores carrying organic products, the sale of bottled water, vitamin-fortified food, elective cosmetic procedures, and other current changes in the health and fitness industries. Consumers seem to be willing to pay for these items.

But is wellness amenable to chiropractic? The purpose of this article is to discuss concepts of wellness that fit within the chiropractic paradigm.

Wellness in PubMed and Index to Chiropractic Literature

One possible way to observe the increase in use of wellness is to observe the number of times the term wellness was used as a word in a journal article title. If one performs a PubMed search of article titles, 19 titles included the term wellness in the 20-year period of medical journals between 1957 and 1977. Afterwards, there was an increase in use of the term (Table 1).

Table 1

Number of occurrences of the term wellness in PubMed by decade

1950s	1960s	1970s	1980s	1990s	2000sa
4	6	35	433	904	1220

PubMed search as of 31 December 2008.

The term wellness may have first appeared in a PubMed indexed journal in 1957 in Journal of National Medical Associations: “Points of Attack for Raising the Levels of Wellness.”

In a pattern that parallels medical literature, use of the term wellness in the chiropractic literature has seen an increase in usage in the past few decades. A search of the Index to Chiropractic Literature found 119 articles that used the word wellness (Table 2). The earliest article in Index to Chiropractic Literature that used wellness was in 1985 in an article titled “Wellness Clinic Tools.” However, there are other earlier chiropractic articles that may have included the term wellness but were not indexed in this search engine.

Table 2

Number of occurrences of the term of wellness in Index to Chiropractic Literature by decade

1980s	1990s	2000sa
9	36	74

Index to Chiropractic Literature online search as of 31 December 2008.

Mechanistic versus vitalistic views of wellness

The study of classic philosophy has seen a divergence between the views of the body as a machine, a mechanistic approach to health care, and the body as a vitalistic entity. The mechanistic point of view is the antithesis view of wellness because of its limited view of health and the body. The mechanistic view of the body had its origin when Descartes suggested that the body works like a machine, that it has the material properties of extension and motion, and that it follows the laws of physics. This implies that the body can be broken down to chemical and physical laws that are positivistic and can be repeatable in observation.

A vitalistic view differs from a mechanistic one (ie, vitalism is “a doctrine that the processes of life are not explicable by the laws of physics and chemistry alone and life is in some part self-determining”). Vitalism recognizes the important linkage between the mind and body connection that the practicing allopathic physician may overlook. This viewpoint may be held by some chiropractors who consider themselves wellness providers.

When considering wellness, we might consider 2 additional concepts: health is not the absence of symptoms, and some diseases are healed by the body itself. If one looks at health as the absence of symptoms, there are many conditions that can exist where the patient will not experience symptoms. As well, symptoms may not be the best way to judge overall health because, in some cases, it may be beneficial for the patient to feel pain as this is a protective mechanism. Pain slows the person down so they have an opportunity to heal, and it could serve as a warning sign of larger problems in the body that may not be currently perceived by the patient. The body has an effective capacity to heal when injured or when disease is present. This suggests that the body is vitalistic in nature and that if we are going to consider the wellness paradigm, a vitalistic perspective may be more amenable to the concept of wellness.

Allopathic medicine versus chiropractic concepts of wellness

In allopathic medicine, wellness may refer to the preventive medicine procedures that help achieve an early diagnosis of certain conditions. Sanford Brown, MD, in the Journal of Family Practice Management stated, “We all practice wellness medicine to the extent that we ensure that our patients receive regular Pap smears and mammograms, tetanus boosters and other immunizations, and PSA (Prostrate-Specific Antigen) and occult blood tests.”

In the practitioner role, some chiropractors employ a coaching relationship where they work alongside the patient toward reaching his or her optimum expression of quality of life. The approach to wellness may be that it is a lifelong process compared with episodic interventions only when the patient has a symptom present. Chiropractic philosophy would be in support of this position. Wellness is an ongoing, lifetime process with daily decisions that lead a person either toward optimal health or away from it. The net total of the positive decisions and the negative decisions dictates how fast the patient is moving on the wellness continuum.

It may be that wellness in other professions may not necessarily be congruent with the chiropractic approach to wellness. In orthodox medicine, wellness has traditionally focused on the patient as being passive in the healing process, a subject on which procedures and testing are performed. Depending upon the medical practitioner, a patient can go years between visits to an allopathic physician. In this example, the medical doctor does not take the role of a coach.

What is wellness? Is it a process or an outcome?

Definitions of wellness can be categorized into 2 groups based on their objective or desired end result. The first is wellness as a process-oriented event, or in a sense, the term is used as a “verb.” The second group is wellness as an outcome-oriented event or an end result; this grouping of wellness uses the term as a “noun.”

Wellness as a process looks at the lifestyle changes, such as diet and exercise. A person can choose to achieve his or her optimal goal of health and is an active participant in the process. Several examples of wellness as process include:

A process of optimizing nervous system function to enhance all bodily systems; an active process employing a set of values and behaviors that promotes health and enhances quality of life.

Wellness is an active, lifelong process of becoming aware of choices and making decisions toward a more balanced and fulfilling life. This process can lead to a healthier state of well-being that allows individuals and communities to thrive.

Wellness is an active process through which people become aware of, and make choices towards, a more successful existence.

These definitions express wellness as processes or lifestyle choices that a person actively uses as he or she embarks on a journey toward optimal health.

Another process-oriented definition uses the term degree, which is defined as “a step in a series” and “the extent, intensity, or scope of something especially as measured by a graded seriess.” “The degree to which an individual experiences health and vitality in any dimension of life.” This is an important distinction because it is a way to evaluate where we are in the process. Wellness as a process considers that the patient is constantly aware of the lifestyle choices he or she makes that will lead him or her toward a better life, not as a destination, but as a journey.

The second grouping of wellness focuses on using wellness as an outcome. Lerner and Hoffman and Deitch use the term state in their definitions of wellness. State is “mode or condition of being.” This state will have defined objectives that describe it as an outcome or an end result. Therefore, wellness is the state or an outcome that is obtained through steps of achieving a goal, such as proper nutrition, exercise, and positive mental outlook. A study of the state or a snapshot in a moment of time may allow outcomes to be analyzed for the effectiveness of lifestyle changes on wellness because it lends itself more easily to empirical assessment and scientific verification.

Health versus wellness

A conflict may arise when the term wellness is confused with health. Does one lead to the other or are they synonymous?

The definitions in Table 3 indicate 2 different meanings for the terms. Health refers to an end state—an objective or outcome. Wellness is connected to a process, a proactive seeking. Health is the goal of optimum function, and wellness is the lifestyle choices that one engages in to strive toward optimal health.

Table 3

Wellness versus health

Source	Wellness	Health
Merriam-Webster's Dictionary2	“good health especially as an actively sought after goal”	“sound physical or mental condition. also: overall condition of the body”
Dorland's Medical Dictionary16	None provided	“a state of optimum physical, mental and social well-being and not merely the absence of disease or infirmity”

It appears the 2 terms are used interchangeably even though both refer to unique and distinct processes very different from each other. These 2 terms can be confusing to the public, and the unresolved issue surrounding this debate is if the terms are synonymous or separate. If they are synonymous, then why should we use both of them together? However, the concept of wellness in popular culture is here to stay and is being integrated into the chiropractic profession and its associations more and more everyday without being clearly defined.

Not all usage of the term wellness may be congruent with chiropractic. The allopathic usage of wellness as preventive medicine, which includes vaccines, pap smears, and other procedures, may be outside the scope of chiropractic. But on the other hand, there are other concepts regarding wellness that fit into the chiropractic model. Both uses of the term wellness as process and as outcome are robust uses that carry the potential for effective patient education and patient-outcome–centered practice. However, consensus on this term would help to provide a focus for researchers and clarity for the public and other organizations within the field of health care.

Conclusion

There are several challenges that face usage of the term wellness. There appears to be no consensus on the definition of wellness or how it is being used. Wellness is not exclusive to chiropractic, and wellness is not synonymous with health, although is often used that way. Wellness is a societal trend, and chiropractic as a health care profession may be a good fit for this concept. Hopefully, this dialogue will encourage the chiropractic profession to further its philosophical dialogue to resolve these dilemmas.

Funding sources and potential conflicts of interest

The author reported no funding sources or conflicts of interest for this study.