Diffusing Managed Care

The biomedical model of American medicine, which worked effectively for infectious diseases, needs to be evaluated for applicability for today's population needs. This model views the body like a machine that requires a mechanic to make repairs. This model is based on the following principles:

I. The mind and body are distinct organ systems that function separately. Thus, the physical body is unrelated to the mind and spirit.

II. The body is a network of functionally interdependent parts. The medical doctor focuses on one body part in treating a patient, as if one part can be repaired separately from the others.

III. The belief in physical reductionism looks for causes of disease at more and more basic levels such as genes. This approach excludes social, psychological and ecological dimensions. It focuses on the body as the center of disease control. Hence, it is expected that more vaccination programs will be mandated, even if they lack appropriateness and safety.

IV. Every disease has a single cause. Find the offending agent and chemically annihilate it. The resemblance to anti-missile warfare is striking.

The allopathic medicine paradigm, however, is cracking due to social change. While it works for acute diseases, e.g., infections, it does poorly in managing chronic diseases that have no single cause and involve psychosocial and ecological forces.

With the aging of baby boomers, the incidence of chronic disease in our society will accelerate, leading to a demand for a new treatment model, one which closely parallels the health care practices and philosophy of the modern chiropractic physician. The change from biomedicine to the integrated practice is accelerated by managed care and is forcing major changes in allopathic practice. Now is the opportunity for the chiropractic profession to offer important complementary health care services within this integrated model. Lest we forget, the internet offers patients information for their problems, which further fuels the pressure on MDs. With a broadened view of health management, a DC with a holistic practice has services that are needed for tomorrow's market.

Chronic Back Pain

While 90% of Americans will experience low back pain in their lifetime, more and more Americans suffer with chronic low back pain: a vastly different syndrome for the acute type.
In contrast to the guidelines for acute LBP, chronic LBP has had little attention from researchers. My guess is that because chronic LBP is composed of many chronic joint/muscle complaints, unrewarding to most allopathic researchers, since they can't discover or chemically invent the magic bullet. Chronic conditions are much more complex than just pain control. The focus shifts from pain to helping patients feel better and function better at work and in the activities of daily living.

A review of data on treatment effectiveness for pain lasting more than three months associated with idiopathic low back pain reveals the following:

1. bedrest - no value
2. NSAIDs - low value
3. back school - no value
4. heat/cold - low value
5. supervised exercise - low value
6. facet injection - no value
7. stretching - valuable
8. traction - low value
9. any surgery - no value

Many interventions for chronic LBP are either ineffective or show little evidence-based efficacy. Approximately 33% of patients with acute LBP will have favorable outcomes within one week. However, patients with poor outcomes at seven weeks are likely to have poor outcomes one year later.

Treatment goals for chronic LBP should focus on using evidence-based data to improve or restore range of motion activity levels, which are a key function for reintegration into the work force or society. Clearly, chronic problems necessitate pain control, but they go far beyond this single problem. Since the source of pain in low back syndrome is unknown for the majority of cases and may involve the disc, the root nerve, the facets, the paraspinal muscles and ligaments, as well as intraspinal encroachments, it is obvious that a single magical pharmaceutical would be ineffective and highly limited. Further, can patients with chronic LBP take daily steroids, NSAIDs, gold shots etc., without destroying their homeostasis?

The solution that carries great potential is broad-based chiropractic care management in an integrated setting. We can offer nonpharmaceutical care designed to restore function and reduce pain. DCs can incorporate physical activities and exercises specific to their patients' needs. Careful instruction in daily activities, as can be tolerated, has been demonstrated to be better than bed rest or exercise for improving function and quality of life. Enhancing the fitness of patients will give them a level of confidence and satisfaction, and they'll demand chiropractic services as a mainstream benefit.

LBP is not only a leading cause of work-related disability but also has important socioeconomic consequences. A new perspective for chronic LBP is needed as America ages. A huge opportunity for the chiropractic profession is being presented, provided we remain nonpharmaceutical doctors and integrate our health services with family medicine, internal medicine, rheumatology, etc. Thus, we cooperate with MDs in patient care, while remaining distinct in our holistic paradigm.

Now is the time for a quantum leap into the mainstream of America's health care system. "Failure is not an option," says a friend of mine, who is the chief operating officer of a chiropractic network. What do you think?