Today happens to be the day after the annual New Year's Blowout and Hangover (Two aspirins, please, and don't slam the lid!). It is also the day after an annual, 104-year-old Boston ritual.Each year, the members of the "L" Street Brownies, a social club from South Boston, migrate to the beach, strip down to basics and plunge into the waters of Boston harbor, usually in 30-degree weather. Moreover, many club members are over the age of 50! Obviously, this is a time to take serious inventory of essentials and to be thinking about survival skills.
This concept easily could be applied to chiropractic, the research agenda in alternative medicine, and medical care in general. We can begin with a revealing quote from Eric Lander of the Whitehead Institute of the MIT Center for Genome Research: "Modern medicine is like taking your car to a mechanic who has no idea of what is under the hood and is trying to fix the car based on listening to the noises it makes."1
Indeed, modern medicine truly is stalled in a quagmire. A groundbreaking and brilliant editorial by the editor-in-chief of Alternative Therapies in Health and Medicine, Mark Hyman, basically purports that the conventional wisdom in orthodox medicine has coaxed us too often to expend our energy and resources performing the pathologic examination of tissues, and ultimately arriving at what is termed the "diagnosis." But the diagnosis should be only the beginning of the proper analysis of a patient - not the end unto itself. Instead of asking, "What is the pathology?" Hyman implores us to consider: "What are the cellular processes involved?" "What genetic polymorphisms might contribute?" and "What are the biochemical and metabolic indicators or biomarkers of the abnormal function that precede or coexist with pathology?" Taking this argument a step further, Hyman cites a classic text in pathology that focuses on the basic steps - four intracellular processes - that must be considered when assessing any disorder or disease: (1) adenosine triphosphate (ATP) production; (2) maintenance of cell membrane integrity; (3) synthesis of enzymatic and structural proteins; and (4) preservation of the genetic apparatus of the cell.2
Realizing that both altered biochemistry and gene expression lead to disease expression, and that phenomenology is the consequence of physiology, we are led to a virtually ironclad conclusion: Form always follows function. Sound familiar? We are talking about the progression of deviations from the functional norm, which is precisely the argument advanced by chiropractic theory that a subluxation is intended to represent the model by which joint fixations, however subtle, should be identified, located and treated. What a windfall! Now we can argue that chiropractic had it right all along in distancing itself from the traditional disease model and seeking underlying causes through its pursuit of the subluxation.
By the same token, however, chiropractors should never become complacent, for I have taken pains to indicate that the subluxation represents the best model for identifying what is held to be joint dysfunction and subsequent aberrations of the nervous system. Like the traditional pathologies mentioned above, it is not a finished product or an end unto itself, but merely the starting point at which the true mechanisms underlying the disorder ultimately may be unearthed. This indeed is where only research can be expected to take the dominant role in moving health care in the direction of wellness and prevention - two other hallmarks with which the chiropractic and numerous branches in the field of alternative medicine have identified themselves.
By way of example, Hyman presents his own case study in which a 29-year-old woman is diagnosed with cervical dysplasia, cervical inflammation, and human papilloma virus. With her conventional laboratory markers being normal, it was only when her nutritional assessment indicated that she had genomic irregularities, which precede abnormal methylation and DNA repair, detoxification, and estrogen metabolism, that some progress seemed to be at hand. Her treatment plan was based upon these findings: to improve gene expression, optimize methylation and DNA, repair enzymes,3 enhance glutathione reserves and detoxification, reduce oxidative stress and normalize the environment of intestinal flora, and upregulate the hydroxylation of estrogens. Recommendations to the patient included eliminating alcohol consumption to reduce abnormal estrogen metabolism, increasing cruciferous vegetables in the diet to facilitate the hydroxylation of estrogen, use of supplements such as folate and vitamin B12 to improve methylation4 or n-acetylcysteine, alphalipoic acid, and selenium to activate glutathione-recycling enzymes,5 and fluconazole to reduce vaginal yeast overgrowth. This clearly represents an interdisciplinary, multipronged approach aimed at the underlying causes of cervical dysplasia, cervical inflammation, and human papilloma virus at the biochemical and cellular level, which, in just two months, returned the patient's condition to normal.1
Where else could we be looking for early markers of dysfunction or disease? There are myriad examples; I can draw one from my own recent observations on homocysteine and how this marker can be construed as a risk factor for patients likely to undergo spontaneous vertebral and carotid artery dissections.6,7 Even though homocysteine is more commonly known as a risk factor for arteriosclerosis,8 in addition to promoting arterial fragility, which could lead to dissections as I have argued elsewhere,6 it also has been implicated in a host of other problems deleterious to one's health. In particular, elevated homocysteine levels have been linked to (1) cognitive decline,9,10 (2) poor memory performance in the elderly,11 and (3) increased osteoclast activity.12
The point here is to heed such early warning signs before they display clinical symptoms and take appropriate action to reverse them. In this particular instance, taking folic acid and vitamin B12 would be the course of action to follow to avoid far graver circumstances.4,13
So, where does all this fit in with the research agenda? We need look no further than the NIH to witness the directives and priorities of federally funded research from this body:
1. For chiropractic in particular, the conference sponsored by the National Center for Complementary and Alternative Medicine on June 9-10, 2004, and a project concept overview issued from NCCAM a few months later, made it abundantly clear that underlying biomechanical, immunological, endocrinological and neurophysiological consequences of such manual therapies as spinal manipulation, mobilization or massage must be identified and understood.14 This is a vital prerequisite for making inroads into managing a broad number of conditions (primarily musculoskeletal) which, thus far, have largely eluded widespread treatment due to gaps in our knowledge and in public utilization of manual therapies.
2. For health research in general, much more emphasis needs to be placed upon moving basic research information into the clinical realm. In so doing, Elias Zerhouni, the director of the NIH, has put forth the concept of translational research to both stimulate the development of novel approaches and lower the cultural and administrative barriers that might impede this type of activity.15
3. Dr. Zerhouni has gone even further to predict the future course of medicine by stating that:
"I think we are going to start to focus more on early intervention in the 21st century as compared with the 20th century. The paradigm of medicine is changing. In the past, we just didn't know about biological systems enough to intervene before a disease struck someone. You are going to see an increase, and we are seeing that now, in the approaches that are not just medication, but lifestyle changes. I think that you are going to see a lot of behavioral and social science impact on how we organize society to decrease disease burden. If we practice medicine the way we do today in 25 years, we will have lost the game."16
And finally, how does this entire communiqué tie in with the New Year and the "L" Street Brownies? We must realize that one is never too old to embrace rather than fear the future and take the plunge into inhospitable waters. The same holds true in the health care community, which needs to recognize the full values of both basic mechanisms in research and prevention in health care delivery. The chiropractic profession, and FCER in particular, are especially well-poised to take full advantage of this major opportunity.
- Hyman M. The real alternative medicine: reconsidering conventional medicine. Alternative Therapies in Health and Medicine 2005;11(5):10-12.
- Kumar V, Abbas A, Fausto N. Robbins and Contran Pathologic Basis of Disease, 7th edition. Philadelphia, PA: Elsevier Saunders, 2005.
- Kim YI, Giuliano A, Hatch KD, et al. Global DNA hypomethylation increases progressively in cervical dysplasia and carcinoma. Cancer 1994;74(3):893-899.
- Goodman MT, McDuffie K, Hernandez B, et al. Association of methyltetrahydrofolate reductase polymorphism C677T and dietary folate with the risk of cervical dysplasia. Cancer and Epidemiology Biomarkers and Prevention 10(12):1275-1280.
- Marshall K. Cervical dysplasia: early intervention. Alternative Medicine Review 2003;8:156-170.
- Rosner A. Spontaneous cervical artery dissections: another perspective. Journal of Manipulative and Physiological Therapeutics 2004;27(2):124-132.
- Rosner A. CVA risks in perspective. Manuelle Medizin 2003;3:1-9.
- Kullo IJ, Ballantyne CM. Conditional risk factors for arteriosclerosis. Mayo Clinic Proceedings 2005;80(2):219-230.
- Tucker KL, Qiao N, Scott T, Rosenberg I, Spiro A III. High homocysteine and low B vitamins predict cognitive decline in aging men: the Veterans Affairs Normative Aging Study. American Journal of Clinical Nutrition 2005;82:627-635.
- Elias MF, Sullivan LM, D'Agostino RB, et al. Homocysteine and cognitive performance in the Framingham Offspring Study: age is important. American Journal of Epidemiology 2005;162(7):644-653.
- Nurk E, Refsum H, Tell GS, et al. Plasma total homocysteine and memory in the elderly: the Hordaland Homocysteine Study. Annals of Neurology 2005;58(6):847-857.
- Herrmann M, Widmann T, Colaianni G, et al. Increased osteoclast activity in the presence of increased homocysteine concentrations. Clinical Chemistry 2005;51(12):2348-2353.
- Homocysteine Lowering Trialists' Collaboration. Dose-dependent effects of folic acid on blood concentrations of homocysteine: a meta-analysis of the randomized trials. Journal of Clinical Nutrition 2005;82(4):806-812.
- http://nccam.nih.gov/research/concepts/consider/manualtherapy.htm. Accessed 09/21/05.
- Zerhouni EA. Translational and clinical science: time for new vision. New England Journal of Medicine 2005;353(15):1621-1623.
- Zerhouni EA. April 14, 2005, quoted in the Boston Globe, April 19, 2005, pp. D1, D4.
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