Thursday, January 31, 2013

Therapist´s Manifesto: Salutogenesis and Broader Perspectives

The motivations for this post are numerous, however there is a singularity in it´s relevance. It effectively summarizes what I have come to believe is a fundamental understanding within the domain of rehabilitation.  In truth, it is a much broader understanding that extends into medicine itself...and even into our daily lives, I dare say.

Although this central philosophy has always been understood intrinsically, I was never completely sure of what to make of it or how to verbalize it. 

There is a well-established, well-entrenched dichotomy between health and illness that essentially dilutes the potential reach and effectiveness of the healthcare provider.  Moreover, this dichotomy extends into the very mind of the healthSEEKER!  Health and illness (or health and disease, to be precise) are seen as two completely distinct states and therefore exist in their own reality.  This is an intuitive understanding...however, when you examine this from a broader perspective, they are manifestations of a singular state.  It is a continuum which is characterized, at one extreme, by perfect health and at the other extreme by disease. Therefore it can even be considered, not as a ¨health-disease¨ dichotomy, rather varying states of health.  This is likely to resonate to some as simple semantics, but the general philosophy was termed Salutogenesis by sociologist Aaron Antonovsky.  The term describes an approach focusing on factors that support human health and well-being, rather than on factors that cause disease.  The most popular and intuitive Pathogenetic approach is the most familiar...the focused efforts on disease-fighting.

Although this general central philosophy is not difficult to understand, it is a rarity within the healthcare fact, it is sometimes viewed as ¨alternative¨.  But the unfortunate reality is that we have been conditioned to exist within the pathogenetic paradigm...where health needs to deteriorate to a preset level before it is ¨worthy¨ of being labelled as an illness and therefore worthy of intervention.  This is observed in respect to all of the so-called ¨health standards¨...blood pressure, weight, cholesterol levels, etc.  They are all considered ok until they reach a critical which time they morph into a specific pathology and so begins a Pathogenetic intervention.

The Salutogenetic approach does not dismiss or conflict with the Pathogenetic effectively BONDS with it and forms a much larger singularity.  Within this singularity, both exist as equally powerful and valid factors that work to contribute to systemic homeostasis.  Therefore, one does not need to ¨wait¨ for a specific pathology or condition to appear.  Whether in times of health or illness, a focus on salutory factors always contributes to the establishment and maintenance of a homeostatic state.

If I extend this general philosophy to a more specific narrative (CP, MS, Fibromyalgia, Autism, etc...), the overall understanding and framework hold up quite nicely.  With respect to the conditions listed above, the physical, environmental, chemical, and psychological stressors are amplified to various degrees compared to the healthy population.  The critical factor for consideration, when approached from the Salutogenetic perspective, is whether these stresses are received by the system as pathogenic, neutral, or salutory.  This is determined by what Antonovsky termed as Generalized Resistance Resources (GRR´s).  Therefore, the more GGR´s available to the system, the better chance the varying stressors will manifest as neutral or salutory.  In the CP, MS, FMS,, these GRR´s are characterized by respiratory mechanics, immune system function, lymphatic competence, interstitial fluid flow, and others.

Therefore we arrive to the overall message and intention of this post: The most fundamental, successful, and reliable therapeutic interventions are the Salutogenetic ones.  Even within specific, well-identified diseased states, the salutory stresses serve to develop and support progress and improvement.  Not only does it contribute to a homeostatic state, it effectively defines the ability to adapt to additional stressors by the building up of GRR´s.   The most glaring example of the salutogenetic approach is massage is essentially effective for EVERYONE and EVERYTHING.  Why?...because it is a Salutogenetic stimulus (hypothalamic tuning results in automatic muscular relaxation, improving interstitial fluid flow increases fluid drainage and lymphatic performance, improved circulation contributes to better O2 delivery and metabolic performance, etc..)

In summary, the broader perspective does not suggest a continued ¨cleaving¨and ¨compartmentalization¨ for the sake of ease.  Although from a macro level (State, Provincial, Institutional) this may serve a greater good, the micro management (care-seeker to care-giver) should always consider the systemic singularity of the person and implement the appropriate balance of salutogenetic and pathogenetic strategies. 

Sunday, January 13, 2013

Immediate versus Long-Term Response

It has been quite a long "layoff" over the holidays, which has allowed for more time to generate new thoughts and formulations...both a blessing and a curse given that time and energy are sometimes in short supply.  However, I thought I would begin the 2013 "season" with a shorter and more "global" rant that centers around perspective...which has often been explicitly explored in this blog, but has always been a consistent undercurrent throughout.  Achieving a proper perspective is a difficult task and is arguably very subjective...based on your own value system, environment, and personal "prism" you may have an approach or attitude that varies greatly from others.  However, if things are expressed conceptually, then the eventual outcome will always be the correct one for you.  Concepts (or frameworks) are effectively neutral and therefore should fit universally across most philosophies. 

A fundamental understanding that needs to be established (whether a care-PROVIDER or care-SEEKER) isthe distinction between Immediate response and Long-Term response.  This will ultimately help in being able to effectively identify what is really happening and what specific intervention is the source of the progress.  Given that most people attempt to combine or "marry" multiple interventions together (in the hopes of somehow extracting all the good from each), it is an intelligent strategy to at least have an understanding of how your system will respond to either or all of the specific interventions. 

In order to project this concept more effectively, I will use a familiar therapeutic example to illustrate the paradoxical behaviour that some interventions may exhibit.  I sue the term "paradoxical" because the general conception is that once a specific therapy is implemented, the response will be immediate and manifest in the same way throughout...but this is relatively simplistic and, more importantly, deceptive.

Trans-Fascial Viscoelastic Stimulation
The adjacent photo represents an example of Trans-Fascial Viscoelastic Stimulation (TFVES).  I have detailed the specifics of the technique in this blog before, but it is essentially a manual massage technique that generates many systemic and mechanical benefit and improvement. 

This technique can be implemented across a braod and diverse range of conditions, pathologies, and considerations. If we use the example of a healthy individual complaining of generalized upper back pain and muscular tension, there are indeed a wide range of treatment options...but the understanding of how the body will respond will ultimately guide the care-seeker towards the most realistic and convenient option.  Further, it provides the professional will much more information from which to formulate a treatment strategy.  Using TFVES (this can also be exported to most forms of manual massage), the immediate response is one of reduction in localized muscular tension and a generalizing decrease in pain.  This is a result of an autonomic response from the hypothalamus as well as a mechanical "pumping" of the interstitial fluid that increases lymphatic drainage and a recycling of metabolic waste.  Therefore, the immediate benefit is release.  This essential phenomenon will continue in the initial stages of treatment and will effectively extend throughout the first few weeks of application.  Once this stimulus has been applied consistently for a longer period of time, it will accumulate and solicit mechanical and structural changes within the connective tissue / fascial network.  Through the process of mechanotransduction, the connective tissue (architectural "scaffolding" of the body) will essentially strengthen.  In other words, the architectural / fascial "sub-failure" that resulted in the initial pain and muscualr tension will have been resolved. 

Sensory stimulation, promotion of interstitial fluid flow, and increase circulation generate the immediate response of releasing muscualr tension and alleviating some general discomfort whereas the long term response is characterized by a strengthening of the structural architecture which contributes to reduction of injury recurrence and a more stable mechanical system.

This brief rant is, of course, a general overview of a much more complex systemic mechanism...but it should provide some insight into the multiple considerations that need to be examined when seeking / formulating treatment.  Although it can be overwhelming when examined to the extreme, once the general concept has been integrated it is actually quite elegantly simple.  As I have recently read and posted in the blog Facebook page: "Simplicity is the ultimate spohistication".  A well-delivered stimulus that is properly and consistently applied will be sufficient to generate a global systemic response from the body and ultimately contribute to it's development and improvement. 

Cheers and Happy 2013! =)