Functional medicine (FM), founded on systems biology, is an approach to illness in which a practitioner strives to identify and correct the root causes of dysfunction.
In this model, categorical classification of a person’s disease is much less important than understanding the underlying mechanisms of disease that are the source of the illness and its symptoms.
At a glance
The Functional Medicine practitioner (FMP) starts by identifying, through the patient history, which systems are malfunctioning. Next, when needed, through laboratory testing, he or she defines the metabolic nature of that dysfunction.
Then based on the results obtained, the practitioner develops a targeted plan to restore the function of the particular pathways and systems underlying the illness. As a result, not only are the symptoms improved but the disease process itself is halted or reversed, and the overall function of the person is improved.
Taking an FM history
As a case example, John is a 57-year- old, high-functioning executive who presented to his chiropractor with knee pain. He was diagnosed with osteoarthritis (OA), without any recent acute injury. Exercises, an NSAID, and post-exertion icing were recommended. And while these measures were helpful, John’s problem remained chronic. It restricted his lifestyle activities to increasingly greater degrees.
John sought out another healthcare practitioner who, after taking a careful and thorough history, understood that John’s knee pain was the final manifestation of a series of processes that had developed over many years. The FMP identified the factors that had set the stage for illness (antecedents), factors that had set off the illness (triggers), and factors that were maintaining and facilitating the illness (mediators).
Before continuing with the development of this case study, it will help to familiarize yourself with the systems involved in FM. The practitioner’s approach will then be easier to grasp.
The FM Matrix
Seven functional medicine systems are labeled in the accompanying diagram, which is commonly referred to as the “Functional Medicine Matrix.” The word matrix signifies the dynamic and interconnected web within which health or illness develops over time.
Multiple systems (sometimes called “nodes”) in the matrix are involved in most illnesses, either as antecedents, triggers, or mediators. These systems are all embedded in—and interactive with—lifestyle and environmental factors.
The interactive matrix systems
Notice in the diagram that the gastrointestinal (GI) system is connected to the other systems, especially the immune system. The basis for this particular connection is that the digestive system constitutes about 70 percent of the immune system’s components.
Every meal is an antigenic assault, which most people are prepared to deal with. But a person with any one of a spectrum of common GI dysfunctions will react to food and bacterial antigens with a systemic inflammatory response that will exacerbate any underlying condition, including the inflammation of OA.
The dysfunction timeline
As one takes a careful patient history, the development and evolution of the presenting problem over time becomes clear. After eliciting the history, the FMP tells the story back to the patient, creating a strong relationship between healthcare provider and patient because the illness is now understood in the context of the patient’s life.
A domino effect
In the OA case under discussion, the stage for John’s problem was already being set before his birth. John grew up in a household where there was preexisting marital stress (and subsequent divorce).
John’s mother was a smoker and a heavy consumer of carbohydrates. As a result of his own similar high carbo- hydrate intake, John had 28 mercury fillings in one year.
Mercury is known to impair the immune system, and this along with stress, a poor diet, and cigarette smoke, all conspired to give John asthma, resulting in a recurrent use of antibiotics (four to seven times a year) between the ages of 5 and 12.
One course of antibiotics can disrupt intestinal bacterial ecology for at least two years, so while John outgrew his asthma by age 13, he had also begun to suffer from irritable bowel syndrome (IBS), lactose intolerance (the antibiotics had eliminated his lactobacillus population), moderate oral yeast overgrowth, and with the traumatic dissolution of his parents’ marriage and the destabilization of his social and academic life—depression.
John injured his right knee twice in his teens and once in his early 30s. As he relocated and opened his own business in a “hyper-allergenic area of the country,” he developed recurrent sinus infections that always required antibiotics. His irritable bowel worsened. After another injury to the same knee in his late 30s, he had a right meniscectomy. Despite his surgeon’s reassurance, he was never able to return to his favorite sport of racquetball because rotational knee motions caused pain.
Until his mid-40s, John was not aware of chronic pain, in all likelihood because his youthful immune system was able to counter-regulate the inflammatory drivers in his gut. However, by his mid-40s, he developed borderline chronic-fatigue syndrome and fibromyalgia that resolved with lifestyle changes.
His recurrent antibiotic usage continued, as did his IBS. Intense mountain biking induced chronic knee pain and stiffness, so he gradually limited his exercise to long road riding. His lower right leg gradually became bowed.
In his late 40s, he underwent significant, decade-long financial stress that eventually caused him to close his business and become an employee. At the onset of that stress, he was diagnosed with virally induced hypothyroidism (de Quervain’s Thyroiditis) and secondary adrenal insufficiency.
In the ensuing decade of financial stress, John became intolerant to multiple foods (bread, gluten, sugar, dairy), each one eliciting a different inflammatory response (muscle aches, joint aches, brain fog, sinus congestion). Interestingly, his lactose intolerance cleared up with his first dose of lactobacillus.
He also noted that whenever he was able to eliminate problematic foods from his diet, his IBS cleared along with a reduction in his muscle, joint, and sinus issues. Despite this benefit of food elimination, it concerned him that his diet needed to be more and more restricted to keep his OA, IBS, body pain, and growing fatigue under control.
John appeared at the chiropractor’s office intermittently when his financial stress began, but when he developed sciatica and was no longer able to exercise, (in his mid-50s) his visits became regular. He found the treatment helpful but not curative, and he was therefore considered to be a partial responder to chiropractic treatment.
In his late 50s John consulted an FMP who quarterbacked his healthcare. He underwent an extended course of antibiotics to eliminate his chronic sinus infection, and with nasal hygiene and a nasal steroid he has been able to remain off antibiotics.
With the use of a broad array of probiotics and herbals chosen to normalize inflammatory pathways and support his adrenal glands, his energy and mood improved. He avoided wheat, yeast, and sweets, and was able to eat a wide variety of fruits and vegetables previously not tolerated.
He determinedly resolved hisfinancial situation, and within four months his physical signs of malab- sorption (onychorrhexis) and allergies resolved. With less psychosocial and inflammatory stress, more nutrients, better sleep, and consequently better resilience, his body pain was reduced, and exercises were used to strengthen his knee, hips, and back, allowing him to return to biking and long walks.
Taking John’s history revealed a domino effect of multiple antecedents (childhood stress, asthma, sinusitis, antibiotics, mercury, IBS, knee injuries), mediators (low hormonal output, inflammatory cytokines, financial stress, nutrient deficiencies), and triggers (virus, financial loss, inappropriate exercise). Clearly, multiple matrix systems were involved: structural/mechanical, immune, hormonal, detoxification (mercury), psychosocial (financial, family), digestive/nutritional, and oxidative stress (not discussed in this study).
Did John suffer from seven different diseases (OA, IBS, depression, candidiasis, recurrent sinusitis, hypothy-roidism, adrenal insufficiency) requiring “one pill for every ill,” or were these diseases all manifestations of one inflammatory process taking place at varying locations?
Are the underlying antecedents (smoking, diet, virus, mercury, trauma) triggers (psychosocial stressors, injury, financial stress) and mediators (inflammatory molecules) a useful part of the case formulation? The FMP feels they are essential, the sine qua non of treatment. The lens you use to view illness determines the recommendations you make.
When problems become chronic and defy resolution, you can best serve the patient by taking a good look under the hood, seeing the full picture and, based on facts and data, prescribe a comprehensive, step-wise treatment plan.
Functional Medicine provides chiropractors with a roadmap for such an approach to the recovery of health.
Robert Hedaya, MD, DLFAPA, has been practicing medicine since 1979 and is a pioneer in the Functional Medicine field. He is the founder of the National Center for Whole Psychiatry in Chevy Chase, Maryland, as well as the founder of Functional Herbals LLC. He can be contacted through drhedaya.com or drhrejoint.com.