The American Public Health Association (APHA) is the world's oldest and largest association of its kind, founded more than 140 years ago and boasting over 25,000 members. The APHA has championed myriad public health causes including tobacco control, food quality and safety, breast-feeding and many others; and advocated for policies to impact conditions that affect millions, including diabetes, heart disease, and many other chronic and debilitating conditions. However, until 2011, the APHA did not have a policy statement about musculoskeletal pain. Now it does, which provides opportunities for chiropractors to capitalize on this increased awareness by taking a public-health perspective toward prevention and management.
Pain Leads to Policy
Musculoskeletal pain has a profound global impact. Low back pain alone is the single largest source of years lived with disability, causing 83 million disability-adjusted life years in 2010. How could an organization so dedicated to the health of populations have had such a "blind spot" with regard to such an overwhelmingly common condition and source of disability? It is possible that the "blind spot" stemmed from the APHA's birth in an era of blossoming understanding of infectious disease control. (Research presented at an early APHA conference included Walter Reed's research on control of yellow fever.)
As a personal anecdote: I am a chiropractor working on a PhD in public health / epidemiology, and when I first tried to locate a public-health-educated PhD advisor to chair my dissertation committee, I couldn't find anyone who viewed low back pain as an "epidemiology problem." Epidemiology was viewed by these individuals as pertaining to infectious disease. My fruitless search ultimately led me to find a topic related to infectious disease so I could start my dissertation.
Despite a foundation of infectious disease control for population health, APHA does have sections that represent interests of a variety of groups engaged in many spheres of public health, including groups interested in physical activity, aging, ethics, and even musculoskeletal health. In fact, there has been a Chiropractic Health Care APHA membership section since 1995.
The CHC section noted the musculoskeletal health policy gap in the APHA, and worked from within the organization to champion "Musculoskeletal Disorders as a Public Health Concern," now APHA policy 20114. This multi-year policy-making process, led by then Section Chair Paul Dougherty, DC, caused the APHA to officially widen its gaze to encompass the impact of conditions chiropractors and other manual therapy and health care providers witness every day: arthritis, low back pain, neck pain, osteoporosis, and many others. Chiropractors within the APHA helped influence official APHA policy for the benefit of the public's health.
Think Beyond Your Office
Now that the APHA officially champions "advocacy for public health legislation that supports the prevention and management of musculoskeletal disorders" (APHA policy 20114) and has been influenced to rethink musculoskeletal pain as a public health concern, how can chiropractors also learn from this? If the relationship with the APHA is a two-way street, how can the chiropractic profession improve in response to the way this large public health organization adapted to rethink musculoskeletal pain? The key is in the policy quote above, specifically: "prevention and management."
Many chiropractors might rightly think: Aren't we already deeply involved in the management of low back pain and other causes of musculoskeletal pain? What could we learn about management from the APHA? And some might think chiropractors are already involved in prevention of low back pain and other musculoskeletal pain, perhaps envisioning spinal manipulation for chronic low back pain, or assigned home care or supervised exercises for individual patients.
However, to really prevent musculoskeletal pain, and to really think like public health agencies and practitioners, the chiropractic profession needs to widen its own gaze to consider the prevention of musculoskeletal pain at the population level. That is, the chiropractic profession needs to think: How can we reduce the overall burden and severity of musculoskeletal pain? Just as dentists think, How can health systems help prevent cavities in the first place? or public health nurses think, How can the health system help prevent diabetes in adolescents?, chiropractors need to actively consider how health systems can either stop musculoskeletal pain from happening at all, help less people get it, or help minimize its severity when it appears. Asking those questions about a reduction of the burden and severity of musculoskeletal pain in populations allows the public health perspective to influence the chiropractic perspective.
Two Ways to Participate
So, how exactly can chiropractors influence the burden and severity of musculoskeletal pain in populations?
1. Produce and respond to research about modifiable risk factors for musculoskeletal pain in populations. For example, if it is discovered that educational status is a risk factor for low back pain (and it is), chiropractors might involve themselves in educational advocacy from a public health perspective to try to impact low back pain in populations. If it is discovered that adolescents who consume alcohol are more likely to have headaches (and they are), chiropractors might involve themselves in policy and advocacy to tackle adolescent substance abuse from a public health perspective – all to try to impact the burden and severity of headaches in populations. There are other examples of modifiable risk factors that also might be addressed at the population level.
2. Look beyond the individual patient. There is clearly a need for the provision of skilled patient care in this area by chiropractors and other health care providers; musculoskeletal pain afflicts so many. But by looking beyond the individual patient to the population level, chiropractors might find that they can professionally influence the burden and severity of the conditions they treat before these conditions ever afflict patients – and thereby help people be more healthy by default because the populations from which they come are flourishing.
Help Shape the Future Today
Imagine a future with less back pain, neck pain and headache – where these conditions that plague so many are no longer such common sources of disability. Just as chiropractic influenced public health by helping APHA to view musculoskeletal disorders as a worthy public health concern, public health can influence chiropractic by helping chiropractors look at the big picture: how to participate in changing the burden and severity of musculoskeletal pain in populations. We can all rethink musculoskeletal pain.
You may find it is easier and more effective to make a difference by joining organizations committed to population-level and system-level changes. In addition to participation in chiropractic professional organizations, consider membership in the APHA and other public health organizations. If you would like to join other chiropractors in the APHA, please contact Kim Khauv, DC via email at drkhauv@gmail.com or visit www.apha.org.
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