A Mission Statement for the Chiropractic Profession and the World
Salutogenesis was first coined by Aaron Antonovsky in his 1979 book Health, Stress and Coping. According to Antonovsky, “life experiences help shape one’s sense of coherence (a global orientation); life is understood as more or less comprehensible, meaningful and manageable.” According to Bergman et al, “Comprehensibility means that the world is interpreted as rational, understandable, structured, ordered, consistent and predictable, a dimension referring to the cognitive controllability of one’s environment. Manageability denotes the extent to which individuals perceive that resources are at their disposal which are adequate to meet the demands. The meaningfulness represents the motivational component. It refers to the extent to which a person feels that life makes (sic) sense emotionally, that at least some of the problems and demands posed by living are worth investing energy in, are worthy of commitment and engagement, and are challenges to ‘welcome’ rather than burdens that one would much rather be without.”
Case-in-point, Antonovsky and his contemporaries argued that the more a person comprehends the world around them, assigns meaning to experiences and can manage stressful events, the better health he or she will express. Antonovsky was the first scholar to describe health as a continuum existing between the extreme of total absence of health and total health. By and large, this model helps to better illustrate how humans promote ease or health and resisting illness as opposed to treating dis-ease. According to Super et al, “Sense of coherence (SOC) reflects a coping capacity of people to deal with everyday life stressors.” As coping capacity improves, so does health. Therefore, improving SOC decreases the likelihood of poor lifestyle choices, health disease incidence, mortality risk, and improves mental health and quality of life. Because an individual’s SOC develops early in life, conceivably throughout adolescence and into early adulthood, it can have a profound effect on an individual’s life trajectory.
Within the construct of the salutogenic model exists the concept of generalized resistance resources. “The term generalized resistance resources (GRR) was coined by Antonovsky and comprises the characteristics of a person, a group or a community that facilitate the individual’s abilities to cope effectively with stressors and contribute to the development of the individual’s level of SOC2.” Specific examples of GRRs include individual resources such as attitude, self-efficacy beliefs, or knowledge or environmental resources such as social support and cultural stability. When GRRs are present, SOC improves.
Chiropractic care fits well into Antonovsky’s schema of health because it seeks to promote adaptability, rather than the treatment of disease. We find in private practice that patients attracted to chiropractic care are already well-versed in or at least curious about the concept of vitalism wherein the human body recovers from disease on its own rather than via medication or surgery. Traditional chiropractic concepts suggest that stressors exist in mechanical, toxic, and emotional forms and as the world becomes more globalized, patients’ ability to adapt to the effects of these stressors diminishes, while SOC decreases. As a result, patients make increasingly poor decisions commensurate with their health vis-à-vis posture, lifting, trauma, sleep, diet, drugs, emotional hygiene, technology, etc. Consequently, patients’ GRRs diminish forcing them to seek new and novel ways of adapting. Chiropractors serve as a vital cog in this mechanism to help educate patients on the tenets of vitalism and salutogenesis and provide them with tools to better cope, i.e., chiropractic adjustments, nutritional counseling, exercise promotion, and smoking cessation among others, particularly because other healthcare providers are not doing this.
In light of most traditional medical offices promoting mechanism and allopathy, chiropractic offices by design must promote salutogenic principles. Simply de-emphasizing medical procedures and infrastructure can reinforce the constructs of vitalism. In our office, we place the majority of our emphasis in consultation, examination, and procedure on subluxation-correction, which shapes the office dialog into one of health promotion. We consistently reinforce the virtues of prevention throughout the course of our patients’ care plans and coach them to make decisions that lessen the burden on Innate Intelligence. While we do account for symptomatology in our care planning, we place special attention on the effect of nervous system function on overall health. We discuss the concept of subluxation as intelligent adaptation and Innate Intelligence as a constructive force. We also regularly promote the body’s innate recuperative power and work with allied healthcare professionals to minimize unnecessary medication and surgery, and whenever possible, promote cost-effectiveness in care to improve accessibility. We find that when we make it easy for patients to comply with our recommendations, their SOC improves and their health follows.
There’s an existentialist tint to Antonovsky’s hypotheses, which was originally popularized by early modernist thinkers like Albert Camus, Soren Kierkegaard, Jean Paul Sartre, and Martin Heidegger. These philosophers first proposed concepts like world-view, which were shaped by a person’s experiences throughout his or her lifetime. Additionally, existentialist thinkers supported the notion that life is finite and that a person’s search for meaning in his or her lifetime is what gives life its depth. In many ways, Antonovsky’s theories about SOC resonate with these philosophers’ expository reflections because he believed that health is a reflection of a life well-lived. In this way, the degree to which a person’s SOC—and his or her health—has evolved can predict happiness and contentment. This has profound implications for our messaging as chiropractors because it frames better health as a means to enlightenment. It is therefore incumbent on us to be steadfast and relentless in our outreach to both new and existing patients, because Antonovsky would say we are literally saving lives.
How the Webster Technique Advances Salutogenesis During Pregnancy and Birth
“The Webster technique is a specific chiropractic sacral analysis and diversified adjustment. The goal of the adjustment is to reduce the effects of sacral subluxation and SI joint dysfunction. In doing so, neuro-biomechanical function in the pelvis is facilitated.”
Chiropractic care is about adaptability, pure and simple. The goal of any chiropractic adjustment is to improve the patient’s ability to cope with stressful stimuli, thereby improving their health. In the context of pregnancy, Webster care, which is specialized chiropractic care for pregnant women, is designed to provide comfort and improve the likelihood of an easeful birth. We find that when pregnant women are under care early and often, the likelihood of trauma to the birthing individual and baby statistically decreases. Research has also shown that women utilizing chiropractic care during their pregnancies are statistically likely to have a 15-20% shorter labor time. The hypothesis is that when the pelvis is aligned and level, baby engages more effectively in the first phase of labor.
This happens for several reasons. Dystocia, difficult or obstructed labor, is often caused by what is called in utero constraint, which can be further caused by mechanical restrictions in the pelvic floor and uterus. There are six primary markers that chiropractors look for in addressing in utero constraint: sacroiliac alignment, sacrotuberous ligament tone, piriformis tone, pubic symphysis alignment, round ligament tone, and iliopsoas tone. Each of these biomechanical markers play a role in baby’s positioning and while chiropractors do not turn breech babies, we can facilitate optimal fetal positioning by removing interference.
The sacrum moves into nutation and counternutation with normal ambulation. We find that with certain stressors, most notably mechanical trauma, the sacrum can get locked into nutation on one side. Not only can this be uncomfortable for the pregnant person, it also decreases the amount of real estate baby has to move in utero. Typical symptoms can range anywhere from dull back pain and pelvic pain, to sciatic radiculopathy, burning pubic pain, lower thoracic and rib pain, and of course, malposition. This type of subluxation or mechanical misalignment and motion problem can often manifest early in life and exaggerate in pregnancy due to the influx of progesterone required to sustain a pregnancy. In the third trimester, this can be particularly impactful because baby can grow large enough to get stuck against the leading edge of the sacrum, coccyx, or pubic bone, especially during descent in labor. Chiropractors perform an easy test called a Webster check to identify posterior element opposite of the nutation restriction. In this check, the patient lies prone on a pregnancy pillow made of memory foam with a belly cutaway while the chiropractor bends the patients knees and looks for a difference of more than an inch in flexion. This check evaluates quadricep and iliopsoas tension, and with a pelvic rotation, the involved leg will be more restricted. The chiropractor then corrects the sacral restriction with a gentle adjustment utilizing a drop piece that uses gravity to accelerate the fixated joint into position. The piece drops out roughly 3/8ths of an inch and is perfectly safe and comfortable for the pregnant person.
Because the pelvis is a three dimensional structure, nutational restrictions also affect other pelvic structures. Typically, anterior inferior (AI) sacrum subluxations yield ipsilateral anterior superior pubic symphysis subluxations, which can lead to pubic pain, symphysis pubis dysfunction, constraint, and in severe cases, separation. As pregnancy progresses, influx of the hormone relaxin can magnify these patterns and in the presence of instability, pain and a sensation of pelvic “slipping” or “grinding” can result. Often this necessitates a modification of the technique as well as strengthening exercises and/or the use of a Serola belt, however, minus instability this is usually easily correctable using one of several techniques: a gentle vibration of the affected joint utilizing the edge of the doctor’s hand, an instrument-assisted adjustment or in other cases, a drop akin to the sacral adjustment described earlier.
We also commonly identify sacrotuberous and round ligament hypertonicities ipsilateral to the AI sacrum, bilateral piriformis hypertonicities, and iliopsoas hypertonicities contralateral to the AI sacrum. All of these tissues operate as struts to the bony pelvis and can shorten and lengthen due to the position of the associated joints. Correction typically requires sustained, gentle pressure and/or active release, which again is perfectly safe for the pregnant person. In complicated presentations as in breech, these findings may switch sides and require more frequent visits and intensive care. In our office, we often modify these approaches to include Spinning Babies protocols such as Three Sisters to aid in patient comfort and improve results.
Chiropractic care is based on the tenets of salutogenesis or the promotion of health versus the eradication of disease. As is the case with obstetric care, the earlier a pregnant woman presents to a Webster-trained chiropractor, the better. The goal is to promote sufficiency early on so that the pregnant person can “cruise” into third trimester and delivery. It is in the OB’s interest to send patients early to prevent issues from magnifying and obfuscating the labor process. In our office, we ask our patients to inform us as soon as they know they are pregnant so we can immediately modify our approach and goals. Obviously, if a pregnant person presents to the OB’s office with breech or transverse baby in third trimester a chiropractor can help, especially with cooperation from allied birth workers like doulas, massage therapists, and acupuncturists.
Care plan length and frequency in our office varies depending on several factors. A patient’s history is paramount. If there is a confirmed history of trauma or a chiropractic emergency such as a malposition after 36 weeks, care will likely be frequent and involved to help the patient avoid a Caesarean section if that is their goal. For pregnant patients who are earlier in their pregnancies, care can often be spread out over longer periods of time, less frequently dependent on their physical exam findings, health goals, and birth plan.
How chiropractic offers a salutogenic basis for early parenting and the family wellness lifestyle
Chiropractic care is vitalistic in nature, meaning it focuses on the innate recuperative power of the body, allowing healing from the top down, inside out. Chiropractors do not treat conditions, nor do we base our care plans solely on symptomatology. The benefits of chiropractic care for help with ear infections has been well-documented, so it comes as no surprise that children improve with care. By establishing a strong foundation from the onset, parents are well prepared to transition to wellness care immediately upon “graduation.”
In our office, the stage is set during the first phone call. When a parent contacts our office, regardless of their child’s symptoms, we tell them that we are a neurologically-focused, corrective office that is concerned with addressing underlying causes as opposed to chasing symptoms. Immediately, this shifts the dialogue away from allopathic “treatment.” If the child or parent has seen other chiropractors before, this also clarifies the difference between their past experiences and what they can expect in our office.
On the patient’s first day after giving them a tour of the space (which is meant to differentiate the space from typical pediatricians’ offices) and going through a detailed history, we place important emphasis on subluxation: what it is, why it’s a problem, how it might be causing their child’s symptoms, how we detect it, and most important what we do to fix it. This is the single most important step in a patient’s relationship with the office. We use a “six-figure diagram” to document the steps in the timeline of dysfunction, dis-ease and ill health.
Our table talk depends on a patient’s understanding of the basic tenets of stress, Innate Intelligence, subluxation, the adjustment, and health. We come back to these concepts frequently, and by framing questions about function and health socratically, we allow new patients to come to their own conclusions about the nature of wellness. With this seed planted, we can then enter the conversation at the report of findings about typical care trajectories from correction through wellness so that there’s absolutely no confusion about the importance of wellness care.
As it pertains to the child in question, there are several key considerations to account for. When a child is in pain —potentially on a trajectory for surgery—the parents are understandably dismayed and stressed. The number one priority is to get the child out of pain and prevent invasive intervention as quickly as possible. By coming to a chiropractor, the parents are acknowledging that traditional allopathic care has failed or is failing their child, but they may not understand exactly what is involved in achieving the results they’re looking for. In these cases, I typically alert parents that care in our office, and for that matter health, is rarely linear, meaning they may not see instantaneous and incremental improvements at first. If salutogenesis is about improved adaptability to the effects of stress, the goals must be long-term sufficiency, which isn’t always top of mind when a child is in pain, but is nonetheless an essential stepping stone to achieving results. In some cases, further, short-term medical intervention may be unavoidable, as in the case of ear infections if they have already received multiple doses of antibiotics or have already had one or multiple tympanostomies; however, when performed correctly, chiropractic care can and should minimize or completely prevent future occurrences in the long term. Care performed in this manner can and should also prevent further forms of maladaptation and dis-ease in adolescence and adulthood, namely kyphosis, scoliosis, back and neck pain, headaches, vertigo, and even in some cases, learning difficulties such as ADHD and dyslexia. In this way, explaining chiropractic care as a long game strategy will help parents understand the importance of sticking with it.
In one child’s case, early resolution of his ear infections was the best case scenario, but isn’t necessarily illustrative of the types of results we always get in our office. In many ways, patients whose symptoms disappear immediately after beginning care are the hardest to move into wellness care lifestyle, because their parents automatically equate chiropractic care with “treatment” of the condition and leave the practice once the condition is “cured.” This is why it is so vital to set the stage in the first days and weeks of care to prepare for future care and stay the course with regard to vitalistic table talk throughout the course of care. Discussing the cause of the child’s ear infections as a consequence of maladaptation to different forms of stress, most notably pre- and perinatal trauma, chemical toxicity and emotional stress, while placing an emphasis on improved long-term adaptability not only demonstrates the utility of long-term care but also elucidates the need for the parents to be under care as well. Once the child’s symptoms disappear, care becomes about prevention, nervous system function, and health development.
Advancing Salutogenesis For More Families
Our practice has and always will be a wellness practice. We promote the principles of health instead of treating disease. We feel it is better to grow healthy kids than to fix broken adults, and while we do care for adults in our practice, we prefer to promote sustainability in health rather than patch damage. Salutogenesis by definition is about changing people’s world views to identify stressors in their lives and either remove them or adapt better to them to improve their health. In this way, chiropractic stands at the front of the health promotion movement.
I remember hearing Bruce Lipton speak at Lyceum in New Zealand in 2008 about the oscillation between animism and dualism and was struck particularly by his hypothesis that, as a culture, we had swung the pendulum so far in favor of allopathy that we must necessarily and shortly thereafter accept vitalism as we tire of medicine’s empty promises. Here we are almost 14 years later confronted with the philosophic conundrum of the century with COVID, and we still haven’t quite made that leap, although the fatigue is palpable. Patients are more open to the prospects of vitalism than ever simply because they’ve been failed by medicine.
The fact is, our patients need us now more than ever because we are the only providers who promote health. As the most utilized “alternative” healthcare providers in North America, it is incumbent on us to help our patients realize their potential and stop treating conditions. For this reason, I will never support expanded scope or prescriptive rights for chiropractors and will fight chiropractors who promote these incongruencies. I believe fervently that the omnipresent battle between DCs must be won in the hearts and minds of the patients we care for purely in the results that we achieve. If chiropractic works, let’s demonstrate it by quantitatively improving our patients’ quality of life.
These incongruencies are not just limited to allopathic chiropractors. Too often vitalistic chiropractors get hung up on the minutiae of caring for patients. We see this in online Facebook groups and Instagram feeds when chiropractors “try” chiropractic but don’t get the results they are expecting. Take for example a hypothetical constipation case. The chiropractor in question receives the patient into the clinic, performs an exam, and determines to see them weekly for a few weeks, but the patient’s constipation does not resolve. All too frequently, the subsequent question to the chiropractic community is, “What else can I do to help this child?” The answer in my mind is simple: do chiropractic right first.
Subluxation is insidious, unrelenting, and has tangible consequences to our patients’ well-being. It has a demonstrable effect on the afferent feedback to the cerebellum, the central integrative state of the brain and motor sequalae. Children are under more stress than they have ever been in modern history. Birth is becoming more difficult. Their ability to adapt is compromised as is demonstrated by the litany of poor heart rate variability assessments and thermography scans we’ve collected in the clinic in recent years. Neurodevelopmental disorders such as autism, ADHD, sensory processing disorder, cerebral palsy, and seizure disorders are on the rise. More and more children are presenting to our clinic with complaints of anxiety and panic. This represents the ultimate failure in stress adaptability. We cannot expect to care for them the way our forebears did a generation ago and expect to get the same results. Care plans need to be longer and more intense than ever before, and patients need to be prepped early and often for lifetime care after their corrective care plan ends. Our adjusting styles need to adapt to central integrative states of our patients’ nervous systems, and we must modify our care on the fly if we observe that care to be too involved or not involved enough to encourage the plasticity we’re looking for.
This is my singular mission. If our goal as vitalistic chiropractors is to improve adaptability while the “4Ts” (trauma, toxicity, thoughts, and technology) continue to wreak havoc in our lives, we must promote lifetime care in our offices, even for asymptomatic patients and to other chiropractors, for that matter. This is a conversation that we have with every patient on day one in our clinic, in our table talk, on our website, in our direct offer advertisements, and in our text and email correspondence. To not do so, in my opinion, is a crime of omission. We must hold our patients accountable for their actions. We must have technology in our offices that demonstrates in crystal clarity how they are adapting to the stressors in their lives. And most importantly, we must get results. This is how we promote salutogenesis in our practice, our community, and the world: by example. The more our patients demonstrate health from the inside out, eschew allopathic care and the need for unnecessary medication and surgery, and express vitality, the more of an impact we will make and the farther our reach will be.
—Daniel Bronstein, DC
Appearing in Pathways to Family Wellness Magazine Issue 81