How DCs Could Lose the Back, Neck and Musculoskeletal Pain Market

If you've read my first two articles in this series [May 1 and May 15 issues], you know I'm not a big fan of the medical movement to dominate the wellness care marketplace by teaching medical students and practicing physicians how to provide services in the new medical field called "lifestyle medicine." I made a suggestion that chiropractors should either embrace offering "lifestyle wellness" in their practices or face the possibility of losing their place in the wellness marketplace. I think it could potentiality be even worse than that.

Now for my biggest concern of all: chiropractors losing their dominance in the musculoskeletal pain market. How? Simple! Recall from my first article a CME course from Harvard's Institute of Lifestyle Medicine titled, "Lifestyle Medicine – Acute Low Back Pain." According to the course description, "Physicians will receive simple tools to allow patients to recover from their acute back pain episode and to make informed decisions about their behaviors and lifestyle factors related to back pain."

The question you need to ask yourself as a chiropractor is, what is the connection between back, neck and musculoskeletal pain and a patient's lifestyle habits that would motivate Harvard to offer a lifestyle medicine course exclusively on back pain? Plenty! And the direct reason is the lifestyle modification connection with metabolic syndrome.

A Quick review of Metabolic Syndrome

Here's what the Mayo Clinic has to say on metabolic syndrome; "Metabolic syndrome is a cluster of conditions, increased blood pressure, a high blood sugar level, excess body fat around the waist and abnormal cholesterol levels, that occur together, increasing your risk of heart disease, stroke and diabetes. Having just one of these conditions doesn't mean you have metabolic syndrome. However, any of these conditions increase[s] your risk of serious disease. If more than one of these conditions occur in combination, your risk is even greater. If you have metabolic syndrome or any of the components of metabolic syndrome, aggressive lifestyle changes can delay or even prevent the development of serious health problems."

Acute Versus Chronic Systemic Inflammation

Inflammation with acute injury is a natural part of the body's defense system. However, as the tissues repair, if the immune system doesn't eventually return to normal, the patient can be transformed into a state of chronic systemic inflammation. This is what typically happens in the case of patients with a high body mass index combined with metabolic syndrome.

The immune system responds to bad lifestyle habits such as a poor diet, stress, abdominal fat and sedentary living much as it does to an acute sprain / strain injury: by releasing inflammatory cytokines. In other words, immune cells react the exact same way regardless of the cause. Chronic systemic inflammation can easily be diagnosed if you are on the lookout for the inflammatory changes that take place in the patient, and can be easily confirmed by performing a few non-invasive tests. The problem is, most chiropractors fail to notice the changes and fail to identify it. If the patient has both acute and underlying chronic inflammation and it gets overlooked, it usually doesn't get treated.

Since research clearly shows that chronic systemic inflammation can be a contributing cause of neck, back and general musculoskeletal pain syndromes, chiropractors should be on the alert for the presence of metabolic syndrome, especially when assessing patients with an elevated BMI. Even though not all patients with an elevated BMI will have chronic systemic inflammation, the presence of it should trigger further testing to confirm if the syndrome does exist.

Chronic systemic inflammation, like that associated with elevated BMI and metabolic syndrome, is a totally different type of condition than acute inflammation, which means it requires a totally different type of treatment protocol, including lifestyle modifications and different types of nutritional supplements.

Not Treating Metabolic Syndrome Could Cost Us the Back Pain Market

Since back pain is one of the most common complaints physicians see in their practices and nearly 70 percent of all patients are either overweight or obese, metabolic syndrome is a condition physicians are being taught may contribute to musculoskeletal conditions, including neck and back pain.

The conventional wisdom used to be that extra body weight on a patient's frame stressed their low back, causing pain; therefore, most physicians prescribed drugs for the pain and told the patient to lose weight. However, research has not shown obesity to be the primary cause of back pain. On the other hand, research does suggest that overweight or obesity, as demonstrated by an elevated body mass index (BMI), is clearly associated with neck, back and other musculoskeletal pain syndromes due to the presence of a chronic systemic inflammatory state.

In fact, as a patient's BMI increases, a metabolic shift occurs in their fat cells such that a systemic, chronic inflammatory state develops, resulting in a condition in which higher BMI correlates with a higher level of chronic inflammation. Plus, if a patient has an elevated BMI and also has metabolic syndrome, research now suggests the combination of the two is the best evidence to date that the two are contributing to musculoskeletal pain.

Since most physicians in the past did not have any solution for back pain except drugs, most did not even want to treat these types of cases. As a result, many of these patients ended up, one way or another, in the office of a chiropractor. But all of that is about to change as physicians incorporate lifestyle medicine full-time in their practices throughout the world.

You can be assured physicians are being brought up to speed on the connection between back pain, poor lifestyle habits and metabolic syndrome. You can also be assured they are being taught the best treatment approach for all three is to prescribe multiple anti-inflammatory lifestyle modifications including dietary changes, nutritional supplements, stress management, proper sleep and exercise ... along with pharmacologic intervention, of course.

One more assurity: MDs who get involved with lifestyle medicine will begin to make a big difference on how many of their patients eventually find their way into a chiropractic office. Their efforts could skew the numbers quite significantly against us.

What Must We Do Clinically?

Clinically, chiropractors must start to test for BMI and metabolic syndrome in their patients because the inflammatory chemistry of the metabolic syndrome can become superimposed over areas of new tissue injury, such as a recent sprain or strain; or over sites of previous injuries, causing reduced tissue healing in the new area of injury and ongoing pain. Research suggests metabolic syndrome is associated with an increased expression of many of the common musculoskeletal conditions chiropractors see on a daily basis.

Chiropractors must fully understand that metabolic syndrome can reduce healing and cause back pain, because without that understanding, some DCs might think their adjustments are not working. In addition, if chiropractors are not following these protocols and patients continue to have pain after a few adjustments, many of them might mistakenly think chiropractic care is not working and stop care.  The minimum chiropractors must do is to evaluate patients for both acute and chronic inflammation, and if both are found, inform the patient and recommend a treatment protocol for both.

Opportunities for DCs in the Field of Lifestyle Wellness

Chiropractors must take charge and "ownership" of the lifestyle wellness market and incorporate non-invasive testing into their routine workups to determine if patients have both acute and chronic inflammation. We must become our patient's lifestyle awareness educator, and possibly appoint one of our staff to become a lifestyle education assistant (LEA; a term I coined 15 years ago) to provide patients education and support with the problems they face with chronic lifestyle-induced inflammation. Chiropractors should consider going into their communities to spread the word on lifestyle wellness education by conducting lifestyle screenings and providing educational lectures.

The final installment in this four-article series [appearing in the June issue of Dynamic Chiropractic's sister publication, DC Practice Insights] explores a systems and treatment approach to help chiropractors integrate lifestyle wellness into their practices. I feel many more patients will be helped using the combination of chiropractic care and multiple anti-inflammatory lifestyle modifications. Since a growing body of evidence clearly shows that lifestyle-induced chronic inflammation is an initiator and perpetuator of back, neck and musculoskeletal pain syndromes, it is imperative that we as chiropractors become informed and use this new knowledge to help patients.