Primary Care, Physical Therapy, Chiropractic Medicine, and Massage Therapy: Entire Healthcare Fields Have Changed

April 13 2026

From the Author

The goal of this article is to explain the condition in primary care fields. This understanding will allow you to reach out to primary care physicians and to create an integrative medicine model. This is a beautiful and pleasant way to practice massage therapy—safe and effective.

Much of this opinion piece relates to material described in my previous articles. I will try to avoid repeating myself; at the end, at the bottom of this article, I will offer links to articles on the subject as references.

Four years ago, I started experiencing a sense of desperation—burnout-like feelings. As usual, I used to receive referrals from MDs, PTs, and DCs. I worked with a neurology group that typically referred cases of tension headaches, sleep disorders, muscular aches and pain, and weakness. Primary care physicians referred patients with various conditions such as hypertension, anxiety, and back and limb disorders.

PTs and DCs usually referred patients who needed fascia release and mobilization.

All of these cases, which I had successfully treated for 46 years, suddenly stopped responding. I did everything correctly, exactly as in previous years, but faced a mishmash of outcomes. Psychologically, this was a very difficult period of time. There would be temporary relief, and then all symptoms would return.

Usually, I ask patients to describe the main symptoms affecting their lives and explain that we cannot treat all disorders a patient is suffering from at the same time. Suddenly, it struck me that all these cases were classic chronic stress-related disorders, including neuroinflammation, autonomic dysregulation, and small blood vessel damage.

Because this condition is the result of a multisystem biological mechanism, I could not achieve sustainable results. I changed to a protocol I was familiar with—addressing dysfunctions of systems—which allowed me to start helping patients again who suffered from sciatica, headaches, muscular pain and aches, neck disorders, etc.

I am a strong believer in the integrative medicine approach. This multidisciplinary approach is safe and effective.

Throughout my career, I have practiced this approach. Primary care physicians have always been, and still are, the gatekeepers who orchestrate treatment plans and decide on needed consultations.

Over the last four years, we have been reading more and more data about burnout in the primary care physician community. I created a questionnaire and asked a few primary care physicians who trust me and know me to fill it out. Based on their answers, I wrote this opinion piece.

You are welcome to post agreements, disagreements, and your own views and opinions.

By the way, when talking to DCs and PTs—my colleagues—I hear similar complaints: “We are doing everything correctly, as usual, but cannot achieve desirable results and often witness worsening of conditions.” It is a terrible feeling of desperation, burnout, and loss.

In my articles, I wrote about this, but I am planning to specifically address why, in cases of autonomic irregularity, chiropractic adjustments, physical therapy methods, and massage therapy did not work.

Before starting the discussion on primary care burnout, I would like to stress an important point: PTs and DCs work strictly with disorders, while many massage therapists provide spa massage focused on relaxation or offer deep tissue massage. Even in these conditions, we increasingly hear about negative reactions to massage. Fewer and fewer people agree to deep, strong-pressure massage. All of this will be discussed in another article.

I must refer you to reliable statistical data.

Reliable statistics indicate:

75% to 90% of primary care visits are related to stress-associated conditions.
Approximately 20 million Americans are currently living with Long COVID.
More than 100 million Americans have been infected with COVID-19, with evidence suggesting an increased risk of cognitive impairment, including neurodegenerative conditions.

Please agree: collectively, these millions of people represent a massive phenomenon. Therefore, they are seeking help from us—primary care physicians, PTs, and DCs. This is the reality of pandemic proportions: patients moving from specialist to specialist seeking help.

Primary Care Before and After COVID-19:

From Structured Diagnosis to System Overload and Chronic Stress-Driven Clinical Complexity**

Abstract

Prior to the COVID-19 pandemic, primary care operated within a relatively stable biomedical framework centered on diagnosis, classification, and management of well-characterized diseases. The pandemic, however, introduced a substantial burden of chronic, multisystem, and poorly defined conditions—many of which are stress-mediated and lack clear diagnostic boundaries. Concurrently, primary care physicians (PCPs) experienced escalating system-level pressures, resulting in increased burnout and reduced clinical capacity. This convergence has created a dual challenge: clinicians operating under chronic stress are tasked with managing patients whose conditions are themselves driven by chronic stress-related dysregulation. This opinion piece examines the transition from a structured, disease-oriented model of care to a complex, stress-driven clinical environment for which primary care systems remain insufficiently prepared.

1. Pre-COVID Primary Care: A Structured Diagnostic System

1.1 Core Model of Practice

Before COVID-19, primary care was grounded in a biomedical diagnostic paradigm characterized by a linear clinical logic:

symptom → differential diagnosis → diagnostic testing → diagnosis → treatment

This model relied heavily on:

standardized clinical guidelines
evidence-based protocols
disease classification systems (e.g., ICD frameworks)

Implicit within this structure were several assumptions:

diseases are identifiable and classifiable
pathology is measurable
therapeutic targets are clearly defined

1.2 Dominant Disease Categories in Primary Care

The pre-pandemic case mix largely consisted of well-defined conditions:

A. Chronic Diseases

hypertension
diabetes mellitus
cardiovascular disease
obesity

B. Acute Conditions

infectious diseases
minor injuries
episodic illnesses

C. Stable Mental Health Disorders

anxiety disorders
depressive disorders (diagnosable and guideline-driven)

These conditions were:

clinically recognizable
diagnostically bounded
supported by standardized treatment pathways

1.3 Workflow and Cognitive Structure

The typical primary care workflow followed a structured sequence:

Chief complaint
History and physical examination
Diagnostic refinement
Laboratory and/or imaging evaluation
Treatment planning

Despite recognized inefficiencies—particularly those associated with electronic health record (EHR) systems—the underlying clinical logic remained coherent and functional.

Notably, even prior to COVID-19:

physician burnout was increasing
administrative burden was expanding
EHR-related workload was rising significantly

Interpretation:
Primary care systems were already operating under strain, though still functionally intact.

2. Pre-Existing Stress in Primary Care (Pre-COVID Baseline)

Burnout had already emerged as a significant systemic issue, driven by:

documentation burden
extended working hours
workflow inefficiencies
reduced professional autonomy

Burnout is classically defined by:

emotional exhaustion
depersonalization
diminished sense of professional efficacy

Key Insight:
Primary care entered the COVID-19 pandemic with an already elevated baseline of chronic occupational stress.

3. COVID-19: Disruption of the Primary Care Model

The impact of COVID-19 extended beyond increased workload; it fundamentally altered the nature of clinical presentations and decision-making.

3.1 Erosion of Diagnostic Clarity

Post-COVID clinical presentations increasingly include:

persistent fatigue
diffuse musculoskeletal pain
cognitive dysfunction (“brain fog”)
autonomic disturbances
anxiety and depressive symptoms
non-specific, multisystem complaints

These presentations are characterized by:

absence of definitive biomarkers
poor alignment with traditional diagnostic categories
temporal inconsistency

Consequence:
A substantial increase in diagnostic ambiguity.

3.2 Emergence of Chronic Stress-Mediated Syndromes

Post-COVID conditions frequently demonstrate features consistent with regulatory dysfunction, including:

chronic stress physiology
neuroinflammatory processes
dysautonomia-like presentations
central sensitization

These patterns suggest a shift toward disorders of regulation rather than discrete structural pathology.

3.3 Escalation of Clinical Complexity

Primary care now routinely encounters:

overlapping physical and psychological symptomatology
multisystem involvement
unclear or multifactorial causality

This represents a conceptual shift:

from: “What disease is present?”
to: “Which systems are dysregulated?”

4. The Physician Perspective: System Overload and Burnout Acceleration

The pandemic significantly intensified pre-existing systemic pressures:

increased patient volume and complexity
rapid and frequent protocol changes
expansion of telemedicine
heightened emotional and psychological demands

Consequently, burnout rates increased, manifesting as:

worsening emotional distress
reduced quality of care
increased workforce attrition

Simultaneously, structural challenges—including administrative burden, staffing shortages, and productivity pressures—persisted and intensified.

Critical Insight:
Clinical demands increased in complexity while systemic support mechanisms weakened.

5. The Training Gap: Structural Mismatch in Clinical Preparation

Traditional primary care training emphasizes:

disease identification
pharmacological intervention
structural diagnosis

However, post-COVID clinical reality increasingly requires:

understanding of chronic stress physiology
interpretation of non-structural dysfunction
management of system-level dysregulation

Resulting Mismatch:

Training paradigm → disease-based
Clinical reality → regulation-based

6. The Dual Stress System: Physician–Patient Interaction

A bidirectional stress dynamic has emerged:

A. Physicians

chronically stressed
cognitively overloaded
emotionally fatigued

B. Patients

presenting with stress-mediated conditions
exhibiting nervous system dysregulation
experiencing persistent, unexplained symptoms

Implication:
The clinical encounter itself becomes a stress-amplifying system.

7. Clinical Consequences: Breakdown of the Traditional Model

Applying a structurally oriented diagnostic model to regulatory disorders frequently results in:

normal diagnostic findings
limited treatment efficacy
increased patient dissatisfaction
escalating physician frustration

This dynamic contributes to:

repeated clinical encounters
diagnostic cycling
increased healthcare utilization

8. Integrating the Stress–Tissue–Pain Model

Post-COVID conditions may be conceptualized through a multi-level framework:

Chronic Stress Activation

autonomic imbalance
hypothalamic–pituitary–adrenal (HPA) axis dysregulation

Peripheral Tissue Alterations

increased mechanosensitivity
heightened tissue reactivity
reduced adaptive capacity

Sensory Amplification

increased nociceptive signaling

Pain Perception

central processing and interpretation of altered sensory input

Outcome:
Pain and dysfunction occurring in the absence of identifiable structural pathology.

9. Conclusion

Primary care has undergone a fundamental transformation—from a system designed to diagnose and manage discrete diseases to one increasingly required to address complex, stress-mediated dysregulation.

This transition has occurred in the context of:

persistently elevated physician stress
increasing prevalence of stress-related patient conditions

The result is a reinforcing cycle:

system strain → physician stress → patient dysregulation → reduced clinical effectiveness

Addressing this shift will require not only systemic reform but also a reorientation of clinical frameworks toward regulation-based models of care.

Dear colleagues,

Hopefully, I have clearly introduced the greatest opportunity to create an integrative medicine model by reaching out to primary care physicians and explaining the important role we can play in the treatment of multisystem dysfunctions.

It is extremely important for primary care physicians and for us—but most importantly, it is not about us. It is about millions of patients who are walking from specialist to specialist seeking help, and sometimes experiencing post-treatment worsening of their conditions.

Thank you for reading.

Best wishes,
Boris Prilutsky

P.S.

In the article below, I offer a brief overview of the pathophysiological developments of chronic stress-related disorders, as well as Long COVID:
https://www.medicalmassage-edu.com/blog/medical-massage-protocol-targeting-cervical-diaphragmatic.htm

In the article below, I explain how I connected the dots and concluded that we are dealing with chronic stress-related disorders, as well as the difference between acute and chronic stress:
https://www.medicalmassage-edu.com/blog/long-covid-chronic-stress-one-source-one-massage-protocol.htm

In the article below, I clearly explain why medication is not working in cases of chronic stress and Long COVID:
https://www.medicalmassage-edu.com/blog/multisystem-biological-mechanisms-in-long-covid-and-chronic-stressrelated-disorders.htm

10. Key References

Kruse CS et al. Physician Burnout and the Electronic Health Record (2022), JMIR
Baptista S et al. Burnout in Primary Care during COVID-19 (2021), PMC
Stephenson J. Physician Workload and Burnout (2022), JAMA Network
Seda-Gombau G et al. Burnout in Primary Care (2021), MDPI
National Academy of Medicine / AMA reports on systemic burnout drivers
Kelly EL et al. Burnout in Primary Care Teams (2022), PMC