We were taught the concept of the therapeutic order of care as first year naturopathic medical students and this approach makes so much sense to me. It basically provides a framework and hierarchy of care for patients. The levels are depicted as a pyramid with Level 1 as the base and Level 7 as the apex.
Level 1: Establish the Foundation for Optimal Health: involves optimizing diet, physical activity and sleep, avoiding exposure to environmental toxins, and managing stress with effective coping mechanisms
Level 2: Support Natural Self-Healing Mechanisms: includes the use of modalities like homeopathy, acupuncture, and meditation
Level 3: Restore Weakened or Damaged Organ Systems: includes the use of nourishing adaptogenic herbs, acupuncture and dietary interventions
Level 4: Correct Structural Alignment: includes spinal manipulation, therapeutic massage, physical therapy
Level 5: Address Pathology Using Natural Substances: anti-viral or anti-microbial herbs, nutraceuticals
Level 6: Address Pathology Using Pharmaceuticals: antibiotics, thyroid replacement therapy
Level 7: Address Pathology Using Surgery: orthopedic surgery, surgical removal of a tumor, etc.
Clinical Example #1: Blood Sugar Dysregulation
Level 1: Address diet, lack of physical activity, stress management
Level 2: Use of acupuncture and/or meditation to better manage stress to better manage cortisol
Level 3: Use of herbs like Ashwaghanda, and acupuncture to tonify organs of digestion
Level 5: Use of herbs and nutraceuticals to balance blood sugar
Level 6: Use of oral hypoglycemics
Clinical Example #2: Knee Pain
Level 1: Use of an anti-inflammatory diet
Level 2: Use acupuncture to reduce inflammation
Level 3: Use of acupuncture to tonify weakened organ systems in a Chinese medicine paradigm
Level 4: Referrals for chiropractic and/or physical therapy
Level 5: Use of anti-inflammatory herbs like curcumin Level 7: Knee surgery
Clinical Example #3: Hypothyroidism
Level 1: Does patient’s diet including the necessary building blocks for T4 production?, Is patient’s level of physical activity healthy (not overdoing nor underdoing)?, How is quality of sleep?, Has there been a history of exposure to environmental toxins?, How is patient doing with stress management?
Level 2: Use of acupuncture to support the parasympathetic nervous system system, use of meditation, journaling, etc. for stress management
Level 3: Use of acupuncture to tonify weakened organ systems in a Chinese medicine paradigm, use of adaptogenic herbs like Ashwaghanda and Rhodiola to support the thyroid (and adrenals) Level 4: Yoga to support parasympathetic nervous system
Level 5: Use of nutraceuticals and glandulars to support thyroid function
Level 6: Use of pharmaceutical thyroid replacement therapy
These levels aren’t necessarily sequential, and it isn’t unusual for a patient to be able to drop to a lower level of support after achieving balance with a higher level of support. An example might be being able to decrease the dose of thyroid replacement therapy (or eventually being able to discontinue this) after addressing the Level 1 issues.