In the USA, amazing amounts of money are currently being spent for medical/allopathic care. In addition, a huge amount of money is simultaneously being spent on alternative/complimentary health care approaches. Frequently, there is animosity between traditional and alternative practitioners and groups. This is an unfortunate situation.
A new paradigm combination might be helpful in resolving some of this conflict.
I see the patient's presenting condition (illness) as an result of the interaction between the patient/host and the disease process.
HOST + DISEASE = ILLNESS
Traditional care (allopathic/medical/disease-orientated) requires an accurate diagnosis of the disease process and the utilization of appropriate medical or surgical management for a good clinical outcome to be realized.
Usually the illness is not approached from the host perspective. The patient or host is an amazingly complex organized being which is trying to maintain a stable "homeostatic state" for healthy function. Unfortunately, many factors can adversely impact the host potential. Physical trauma to the body's tensegrity systems, unhealthy life-styles and mental/emotional stress (allostasis/allostatic load) can all adversely impact the host's quality of life.
Many different approaches could be viewed as host-oriented in nature:
- Stress Management
- Ayurvedic Medicine
The osteopathic profession, since its inception, has believed the musculoskeletal system plays an important role in both healthy function as well as being another potential risk factor, when dysfunctional, in the development of disease processes.
Mechanical dysfunction of the musculoskeletal system is called somatic dysfunction by the osteopathic profession.
Mechanical/somatic dysfunction can have many possible adverse impacts on the arms of the cell schematic and secondarily impact normal tissue physiology and pathology.
- Thoracic and rib dysfunction may alter vasomotor tone (SNS function) which can impair circulation to the innervated tissues. This could decrease circulation and lower tissue resistance/health of the related tissues and make them more susceptible to infection, tumor development or other pathological processes. The altered vasomotor tone might also result in suppressed tissue levels of medications even though the blood levels of the medication are at therapeutic levels.
- Alter neurological function (efferent)
- Innervation role (impulse function)
- The innervation impacted by the somatic dysfunction can be either stimulated or inhibited; the outcome can not be predicted.
- Asthma could be a good illustration of the role of somatic dysfunction as a risk factor and the related innervation alteration.
- PNS (parasympathetic nervous system) stimulation of the Vagus could predispose to bronchial constriction. This could be associated with either cranial, cervical or pelvic somatic dysfunction.
- SNS (sympathetic/motor contribution) inhibition could predispose to impaired bronchial dilation and could also be associated with thoracic or rib cage somatic dysfunction.
- Neurotrophic transport role
- Trophic substances (neurotransmitter, growth factors, etc.) are produced in the nucleus of the neurons. These materials travel down the axons, at various rates of flow, cross the neuromuscular junction and end up in the tissues of the innervated end-organ. 30 mm. of Hg pressure is enough to impair the normal flow of these essential trophic substances. Increases in muscle tone secondary to somatic dysfunction could produce this detrimental pressure on a nerve. As a result, normal tissue function might be impaired and a predisposition to various disease processes might develop if this trophic flow is altered.
- Three vital physiological functions are dependant on a properly functioning rib cage.
- Ventilation: during ventilation/inspiration, a normal functioning rib cage expands and the thoraco-abdominal diaphragm glides downward toward the abdominal cavity. This decreases the intra-thoracic pressure and enables air to flow into the lungs. A dysfunctional rib cage, impaired by somatic dysfunction, may result in less than optimal ventilation; the movement of air and oxygenation.
- Venous blood is a very viscous fluid and would require a remarkable amount of force to pump upward against gravity, ie, upward from our legs (especially when the patient is in the upright position) and back to the right side of the heart. As the functional rib cage expands and the diaphragm normally descends toward the abdominal cavity, the central venous pressure in the right side of the heart is secondarily decreased and this enables the venous blood to be "sucked" back into the heart. Thus a functional rib cage plays a crucial role in normal venous circulation and might be impaired if rib cage somatic dysfunction inhibits this pumping potential.
- Lymphatic fluids also play an important role in normal physiology. Lymph is made up of fluid, protein and electrolytes that have normally migrated out of the vascular tree. If these substances are not reabsorbed or properly circulated, it can have an adverse impact on the related tissues, ie, edema. The "pump" for lymphatic circulation is, again, a functioning rib cage and the altering intra-thoracic pressure which, again, "sucks" the lymph through the lymphatic channels and the lymph re-enters the venous system at the venous/lymphatic junction in the upper thoracic regions.
- Thus a functioning rib cage is crucial for these three normal and essential circulating functions in a healthy person; ventilation, venous and lymphatic circulation. If these normal rib cage "pumping actions" are impaired, could this lower the normal tissue resistance and health of the poorly oxygenated and congested tissues?
- Somatic dysfunction could, in addition, impair the afferent neurological function of both the impulse and trophic roles.
- Additionally, somatic dysfunction, especially involving the lower extremities, can markedly increase the "energy demands" on every system of the body due to an altered and labored gait. If the patient also has heart or lung disease, the increased energy demands on the impaired heart or lungs could result in the patient going into cardiac or pulmonary failure by over-working that "weak link" in the total body system.
Somatic dysfunction can impact any one of the arms of the cell schematic, all the arms or in any other possible combination, thus impairing the functions discussed above. This explains why several patients, all diagnosed with the same clinical condition, will each have a distinctive and unique clinical expression (illness). Stated in another way by one of my mentors, "We must remember that 100 patients might all have the same clinical diagnosis but they all got to that end point by a different route." (I. M. Korr, PhD.). Therefore, for the health-care provider to attain excellent clinical outcomes, each patient must be evaluated and treated uniquely.
There are three possible clinical scenarios or expressions of the Host + Disease = Illness paradigm.
HOST += ILLNESS
In this scenario, the disease process is the key component and responds very well to traditional allopathic/medical strategies. Unfortunately, the practitioner may incorrectly conclude that host-orientated approaches are unnecessary for all patients with that diagnosis.
+ DISEASE = ILLNESS
In this scenario, the host component is the key component but the patient has the same "illness expression." These patients frequently respond poorly to traditional allopathic/medical strategies, and may therefore require large doses of medications and prolonged courses of medical care in order to attain a beneficial clinical outcome. When manipulative care is added to the medical/disease orientated care, in order to remove the hindering role of somatic dysfunction on the clinical schematic, the patient’s condition frequently starts to improve and is easier to manage medically. This clinical outcome will be realized only if the somatic dysfunction is playing a significant patho-physiological role and is properly and effectively treated with OMT (osteopathic manipulative therapy). Unfortunately, the clinical outcome may be misunderstood and the clinican conclude that all patient’s with that medical diagnosis never require medical care but only OMT or other host-orientated care.
HOST + DISEASE = ILLNESS
In this scenario, the host and disease components are about equal. In these cases, either traditional allopathic/medical care or OMT will realize only about a 50-60% beneficial response. Both groups may be perplexed with the poor clinical outcome of their management strategy. The full clinical potential is not realized unless quality host orientated care or traditional/allopathic approaches are simultaneously utilized.
- All three of these scenarios have the same clinical expression as the illness. A superficial evaluation may not realize and appreciate the uniqueness of each clinical case.
- These scenarios also illustrate and suggest how important it is consider both the disease paradigm and the host paradigms when considering a patient's clinical illness, both from the diagnosis and management perspectives. Quality care requires, I believe, that we must consider the patient's illness from both the host and disease perspectives of the illness paradigm; then the patient has the greatest chance of realizing their health potential.
- This illness paradigm reality challenges Kuhn’s belief that a new paradigm will always replace an older paradigm. This clinical paradigm suggests two paradigms, host and disease models, can be combined and be synergistic in the clinical environment.
Somatic/mechanical dysfunction can additionally and adversely impact another aspect of the body's physiology; the tensegrity phenomena or its clinical expression. This can be either a beneficial or detrimental influence.
Tensegrity is an engineering term developed by Richard Buckminster Fuller. The clinical application guru of tensegrity is Donald Ingber, PhD., MD. at Harvard Medical School. Ingber believes that tensegrity is the architectural design utilized by nature and at all levels of nature and the human body.
A tensegrity structure consists of multiple non-touching rods (compression struts) and a continuous connecting system (tension system) embedding or islanding the compression struts. Ingber suggests the bones of the body are the compression struts while the continuous tension system represents the ligamentous and myofascial tissues of the body. These systems are complexly dynamic, omni-directional in movement, a system that is totally integrated, exhibits balanced tension and a total system adaptative potential when a force is introduced into the tensegrity structure. Tensegrity systems are also gravity defying structures, are multi-level hierarchical systems in which an introduced force can influence any part of the total system; from the macro to the micro hierarchical levels of this structure and this force can be distributed throughout the system in a non-linear manner.
Ingber's research demonstrates that cell shape is also important in determining the physiological activity of cells. Normal shaped cells tend to differentiate and specialize. Stretched cells have the potential to undergo uncontrolled cell growth while rounded cells tend to undergo cell death (apoptosis). The change of shape of a tensegrity system may secondarily alter cell/tissue shape. Ingber's research has also demonstrated that change of cell shape can, in addition, result in a change of biochemical and/or genetic expression of the shape-altered cells.
Tensegrity also enables the health care provider an expanded potential for understanding chronic pain. When trauma is sustained by a tensegrity system, the whole system adapts and re-balances. The area where the most adaptation is required is frequently where the pain is experienced; not where the trauma occurred or entered the system. Just treating, with OMT, the painful musculoskeletal area may be ineffective in relieving the pain since it is secondary to other areas of dysfunction and compensation. The whole system must be evaluated. See the later section describing AGR and sequencing OMT.
The clinical implications could be profound concerning the adverse role somatic dysfunction could have on the human tensegrity structure, the related tissue shape changes, the associated biochemical and genetic expression changes as well as cell differentiation and specialization potential. In addition, one must consider the potential beneficial impact of quality and appropriate manual therapy, by identifying and appropriately removing the somatic dysfunction hindrances, and thus enabling the patient to realize their optimal health potential by restoring their tensegrity potential. Remember, removing the somatic dysfunction hindrances might also have a beneficial impact on the arms of the clinical/cell schematic.
An additional concept is important for applying osteopathic principles. McEwen at the Rockefeller Institute has been trying to explain, physiologically, the shift from homeostatis to the disease state. Whenever patients experience stress, either emotional, traumatic or environmental, the patient shifts into the state of allostasis during which the body releases epinephrine, which can elevate blood pressure, and cortisol, which in the short term acts as an anti-inflammatory agent. This is designed to be a short term "flight-fight" and protective phenomena. If the patient frequently goes into the allostasis phases, never completely comes out of that state or just remains in a full blown allostatic state, it is called allostatic load. Now the elevated epinephrine levels continue to elevate the blood pressure but also predispose the patient to cardiovascular disease. Prolonged elevated cortisol levels can suppress the immune system and predispose to developing depression. Therefore, one should not be surprised to realize that a high allostatic loads therefore predispose the patient to developing a major health care problem within 3 years.
Once the allostatic load has developed, the patient can become "up-tight" which can further increase the potential for developing secondary somatic dysfunction. This "allostatic load" can also become 'organized' or "somaticized" and the patient's body will frequently "act out" the stressful problem. For example, if the patient is carrying a heavy load mentally or emotionally, they may present chronic low back pain. Patients with shoulder problems are often "shouldering (an emotional or mental) burden." Patients experiencing neck pain frequently are in a situation or relationship they perceive as a "pain in the neck". Many other examples could be given. I have called this approach "Body Language Significance (BLS)." It has often been very useful in identifying and addressing the "root causes" of the patient's allostatic load, and secondarily, many chronic musculoskeletal problems associated with chronic pain and disability.
Somatic dysfunction may be present in any of these B.L.S. examples but the patient responds poorly to quality OMT or the somatic dysfunction keeps returning. Often the original allostatic stressor occurred during the patient's youth. In my experience, the stressful expression often surfaces years later, as an adult, either on an anniversary date or when one of their children reaches the age at which the patient experienced the allostatic/emotional trauma.
Many believe old emotional/allostatic memories are processed and stored in the limbic system. The limbic system has been compared to a “switchboard” between the emotions and the musculoskeletal system. This would suggest there are two possible therapeutic avenues into the limbic system; either through the emotional or the musculoskeletal side. This could also explain why patients, who have experienced severe emotional trauma years earlier, will once again re-experience those emotions as the layers of musculoskeletal trauma are peeled off and sequentially exposed with OMT. Thus we have uncovered and identified the “root cause” of the allostatic load and it now can be “composted.” Someone has been quoted as saying, “we all can be vicitimized in life but we decide to either become better or bitter.” I have been amazed at how profoundly some patients lives can be changed and improved once they “compost” their “allostatic garbage.”
McEwen has discovered three factors which can play a beneficial role in the successful management of the patient.
- Develop and enjoying strong inter-personal relationships
- Regularly attendance to religious services or develop a “positive world-view”
- Living a healthy life-style
Could the first two these factors in this list also represent a tensegrity correlation and explain why inter-personal, emotional and spiritual tensegrity support systems are beneficial?
I believe the combination of quality manual therapy, to address any mechanical dysfunction in the body’s musculoskeletal/tensegrity system and secondarily the related tissues of the body, combined with the allostatic tools, can impact beneficially, from the macro to the micro levels, the complicated patient. This could represent an important combination of three approaches, osteopathy, tensegrity and allostasis-allostatic load, to offer a holistic approach of health care from the host perspective.
Interestingly, the definition of allostasis is “stability through change” but that definition and description also applies to tensegrity. This may explain why managing both the tensegrity and allostatic load components is so important for synergistic enhancing of the benefits of osteopathic manipulative care, in a holistic/host orientated management approach.
I believe the host can best be described as:
- Interactive at all levels; macro to micro
- An omni-directional structure
- A constantly adapting and re-balancing system
- A complexity of complexity
- A tensegrity of "tensegrity's"
In this context, the disease process could be viewed as localized chaos embedded or enmeshed within the dynamic and complex host. The allopathic/disease-orientated approach is to address the disease process while host-orientated care can simultaneously attempt to enable the host to realize its potential and “throw off” the disease process. As I mentioned earlier, frequently both approaches must be utilized for the patient to realize their health potential.
Because of this body complexity, this dynamic and adaptive system must be therapeutically approached with respect. When providing OMT, it is important to locate, and treat initially, the most dysfunctional area, area of greatest restriction [AGR] or key area. The appropriate OMT technique chosen must be the one which most effectively addresses the nature of the restrictive barrier (AGR). Then the next AGR is appropriately identified and treated. You keep treating the sequential AGRs as long as the dysfunctions quickly and effectively respond to appropriate OMT.
Treating the first AGR will correct that dysfunction plus 25-30% of the body’s adaptative somatic dysfunctions to that first AGR. Treating the second AGR may change another 20-30% of the body’s remaining adaptive somatic dysfunction. You keep sequencing the patient until the tissues resist further change. The body is demonstrating the patient has changed and adapted to its limit for that day.
The bottom line for OMT is that it can not be “cookbooked.” Each patient must be treated uniquely according to their individual sequence and identified restrictive barriers. “Cookbooked” or protocol driven OMT frequently is ineffective or offers only temporary relief.
I personally have trouble believing we can effectively enable patients to realize their health potential with traditional/allopathic care by treating only the disease component. This is especially true if:
- somatic dysfunction, impacting the cell/clinical schematic arms, is producing somato-visceral and visceral-somatic reflexes, or is impairing their tensegrity potential. This somatic dysfunction can be playing a crucial clinical role and may have predisposed the patient to their current condition (illness)
- allostatic load issues are not effectively addressed and are complicating the patients clinical condition
Simultaneously treating both of the somatic dysfunction and allostatic load components, in addition to providing quality traditional/allopathic/disease care, should help the patient realize their health potential and lead long productive lives.