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Pain Underfoot: Metatarsalgia
Foot pain can interfere significantly with normal activities and severely limit participation in sports. Metatarsalgia is foot pain involving the metatarsal bones in the forefoot – the complaint of pain on the bottom of the ball of the foot.
Waking Up the Gluteus Maximus
In previous articles in this series, we expounded on the importance of the gluteus maximus (GM) in athletic performance and protecting the knee from injury. We also know there is a link between iliotibial band syndrome and GM weakness.
A Chinese Medicine Story: An Interview with Mazin Al-Khafaji
Mazin Al-Khafaji's work has interested me for years. In February 2014, we invited him for the second time to speak at the Southwest Symposium in Austin, Texas.
MPA Media Wins 7 Publishing Awards
MPA Media, publisher of Dynamic Chiropractic and DC Practice Insights, among other titles, has been recognized for editorial and design excellence with an unprecedented seven publishing awards by the American Society of Business Publication Editors (ASBPE), the nation's largest organization for business-to-business publications.
Medical Qigong for the Heart: Part III
Part 1 and Part II of this series focused on the physical aspect of the Heart and mental emotional aspects of the Heart respectively. Now, I would like to focus on the spiritual aspect of the Heart.
9 Common Causes of Thyroid Imbalance and How You Can Help
How you sleep, how easily you wake up, and how much energy and stamina you have during the day are directly related to levels of the thyroid hormones.
A Guide for Talking to Doctors about Acupuncture and Brain Chemistry
Before I begin any discussion of how to talk about the effects of acupuncture on brain chemistry, nervous and endocrine function, it is essential to understand just what physicians most need help with.
News in Brief
National Chiropractic Health Month: Be Proactive; Collegiate Roundup: Academic Appointments at Parker, Logan.
Why Young People Need Chiropractic Now More Than Ever
According to a recent study published in BMC Musculoskeletal Disorders, "It is now widely acknowledged that neck pain (NP), mid back pain (MBP), and low back pain (LBP) (spinal pain) start early in life and that the lifetime prevalence increases rapidly during adolescence to reach adult levels at the age of 18."
Finders Keepers: The Secret to Relationship-Based Marketing
Becoming a successful practitioner has less to do with what you learned in school, and more to do with your ability to find new patients and keep them!
Chiropractic Research in Review
Chiropractic Treatment of Lateral Epicondylitis; Cost / Benefit Analysis: Different Doses of SMT for Low Back Pain; Imaging for Occult Rib and Costal Cartilage Fractures; Treating Neck Pain: Thoracic Thrust Manipulation vs. Non-Thrust Mobilization.
Don't Turn a 2 Into a 10
The Wong-Baker FACES Pain Rating Scale1 is so useful because it can be used by almost anyone. Patients can use the numbers associated with the faces depicted on the scale or select the face that demonstrates their current level of pain from 0-10.
A History Worth Telling
The popularity and the use of acupuncture for the treatment of animals in the United States is at its peak.
CCE Finally Takes a "Baby Step" Toward Reform
During a 16-month period from October 2010 to February 2012, I devoted four separate columns to the heavy-handed attempt by the Council on Chiropractic Education to radically change the chiropractic profession through the accreditation process.
New Medical Technologies You Need to Know
We're all familiar with how fast computers become obsolete, as well as the rapid pace of development in the field of cell phone technology. The latest smart phones are far more powerful than desktop computers were only a few years ago.
Building From the Bottom Up
I caught up with my dear friend Honora Wolfe, in her Colorado painting studio where, if she is not praying in Bhutan or doing charitable work in a Nepali free clinic, she spends most of her time now.
A Vibrating Capsule for Constipation? Relevance to Your Chiropractic Practice
The relationship between gastrointestinal (GI) complaints and back pain is not typically written about or discussed.
Peer Points: Always Seeking To Grow
Ellen "Kiki" Geary has spent the last decade honing her craft. As a specialist in integrative holistic care, she went straight from completing her master's degree in acupuncture and chinese herbal medicine from Bastyr University to building a successful and thriving practice in the small community of Anacortes, Washington.
July, 2013, Vol. 13, Issue 07
Allostasis: A New View of Stress and How it Affects the Body
By Nicole Nelson
Stress is often blamed for all biological mayhem. This is really an unfair characterization, as stress can elicit many positive health outcomes. Along these same lines, massage therapy is often touted as a great reliever of stress.In most cases, this is true. There are times, however, where massage produces some undesirable results and can aptly be named a stressor in and of itself. This article will discuss the concepts of stress and adaptation and will explore allostasis as a model of stress regulation.
Homeostasis and Allostasis
There are several models to describe the ways in which we adapt to our environment. Homeostasis probably comes to mind for most of you; however, there are some limitations to homeostatic theory. Homeostasis implies adaptation in order to maintain a set point. It suggests an ideal set of conditions for maintenance of the internal environment. As we now know, there are many occasions where systems are forced to deviate from set points in order to maintain health. The stressors of enduring cold or extreme heat, gestation and lactation, seasonal variations of sunlight exposure, traveling through different time zones all require the body's systems to adapt beyond set points described by homeostasis (Power 2004).
Along these same lines, homeostasis doesn't account for the wide-ranging stress responses among people. For instance, why are certain individuals more susceptible to addiction and anxiety disorders? Why do some respond positively to intensive physical training, while others seem to breakdown? And most notably for us, why do some clients feel flu-like after a massage, while others hop of the table, feeling terrific? In the early 1980s, Bruce McEwen and others set out to broaden the scope of homeostasis; the expanded theory was coined allostasis.
Allostasis has been defined as the ability to achieve stability through change. Allostasis takes a holistic view of stress adaptation as it considers the unique history and make-up of each individual. This suggests our stress responses are an expression of many things including genetics, socio-economic status, inter-personal relationships, nutrition, childhood abuse/neglect and current health status. Likewise, these same variables dictate how resilient we are when encountering stress. It stands to reason that an individual that has suffered a type of childhood trauma (i.e. abuse or neglect) might have a very different stress response than a person that had no such experience. Likewise, an individual that grew up in poverty will have a unique stress response to someone that grew up in an affluent family. It is important to recognize that our experiences and genetics cannot be separated, as each influence each other while regulating stress system development. (Gillespie et al 2009)
The Central Organ Of Stress Regulation
Allostasis suggests the body will adapt in ways that are most suitable and cost efficient for the given moment (Goldsteinn & McEwen 2001). In a healthy body, the brain orchestrates the activities of the autonomic nervous system, the hypothalamic-pituitary-adrenocortical (HPA) axis, the cardiovascular system, immune system and metabolism in order to effectively respond to internal and external stress. In large part, the coordination of these systems depends upon the nature of the stress, the length of time we are under stress and how well we cope with it. Allostatic load describes the wear-and-tear on the body and brain that results from chronic dyregulation of the mediators of allostasis.
McEwen presents four potential scenarios for allostatic loading:
According to McEwen, the brain can be "the target as well as the initiator of the stress response" (McEwen 2002). In other words, the very regions of the brain that manage our stress responses are vulnerable to physiological changes if too much stress is imposed (allostatic loading). If these changes occur, we become more sensitive and/or less resilient to stress. (Ganzel et al 2010)
Is Stress Bad?
Hans Selye, also known as the father of stress research, developed the theory that chronic stress causes an increase in the activity of the HPA axis and results in long-term chemical changes. We can probably all agree that "stress" is a pretty vague term and is often used with a negative connotation. This is indicated by an often-sited quote by Selye: "Every stress leaves an indelible scar and the organism pays for its survival after a stressful situation by becoming a little older."
Selye's mis-step may have been in the notion that we have a finite capacity to cope with stress. In the right dose and circumstance, however, stress can be extremely beneficial and can make you more resilient to future exposures. Regular physical exercise is a prime example. Is exercise a stressor? Absolutely, but when it is dosed appropriately (not too much, but enough trigger adaptive strength/endurance improvements) we get stronger, faster and most notably it can reverse stress-induced changes to the brain etc. (Marques et al 2010, Stranahan & Mattson 2012)
This is adaptation at its best: we endure a stressor, we take time to recover (provided we are healthy enough) and we end up on the other side, better than we were before. As "stress" is such an abstract and subjective concept, the allostatic model proposes a continuum to describe responses to environmental and psychosocial situations. The model suggests that individuals under stress/load position themselves along a spectrum of allostatic regulation; somewhere between allostasis (i.e. regaining physiological balance) and allostatic overload (i.e. toward physiological collapse and illness/pain). (Iribarren 2005, McEwen 1998)
In sum, our coping skills, feelings of isolation, healthy behaviors (i.e. smoking, exercise), genetics, previous trauma or abuse; coupled with the length of time we are under stress and type of stress, will determine if we adapt and get stronger or if we slide toward allostatic overload. So, is stress bad? This question may not be relevant. Perhaps points to ponder are: Where do we (or our clients) sit on the allostatic spectrum when we encounter stress (resilience) and is the brain interpreting the stress as a major threat?
Implications for Massage Therapists
Now, how do we apply what we know of allostasis to our clients? When delivered appropriately, massage has the potential to pull clients back from allostatic overload and can permit the client's own self-reparative mechanisms to resume efficient function. We know from a physical standpoint, appropriate soft tissue work can address soft tissue problems and improve neural and mechanical function. These factors can decrease the drive on the allostatic mechanisms. This means we are in a great position to induce positive changes on the general state of wellness of our clients. That being said, we must be ready to evaluate the current health, mindset and readiness of our clients before administering bodywork. We must also expect that our clients may respond to our treatments differently at different times.
Let's go back to the question posed earlier, why do some clients feel flu-like after a massage, while others feel great? Massage, even though delivered with the best of intentions, is a stressor, particularly when clients present with poor health resulting from stress and exhaustion. According to allostatic theory, this is not due to the often claimed "flushing of toxins," rather their systems do not have the capacity to process the effects of the bodywork. In other words, the resources needed to receive bodywork have already been allocated to coping with existing stress. As stated by Leon Chaitow in his book, Fibromyalgia Syndrome-A Practitioner's Guide to Treatment, "When people are very ill, as in FMS/CFS, where adaptive functions have been stretched to their limits, any treatment (however gentle) represents an additional demand for adaptation." The brain will protect the body and inflict some negative consequences when it perceives a threat is looming. So the headaches, muscle soreness, flu-like sensations that sometimes result from massage may be the brain saying, "Sorry to do this, but I will trigger responses that will make you feel a little icky in order to protect my systems and prevent you from imposing demands that I can't handle."
The Right Tool and The Right Dose
Clients that have an existing illness or that are under a good deal of allostatic load are at risk for being overwhelmed by certain kinds of bodywork. In addition to your traditional assessments/intake, I recommend asking the following three questions when developing your massage plans:
Your own assessment and the answers to these questions will certainly point you in the right direction in determining massage dosage and which tools (i.e. aromatherapy, energy work, gentle rocking, myofascial release, trigger point therapy etc.) to use. If a client is on the allostatic overload end, more massage and/or aggressive treatments will not necessarily yield positive results. Let's take two different cases, with similar physical manifestations, but two different treatment approaches.
Case 1: Joe is 25-years-old, has a great job and is training for the MS 150 bike ride. He has received weekly bodywork from you for several months. He is also working with a nutritionist to ensure he is eating the right foods and getting the right amount of fuel. He comes to you in great spirits but complains of neck stiffness and is unable to turn his head without pain. He has increased his training volume on the bike, which means increased time spent in suspect thoracic and cervical postures.
Case 2: Mary is 40-years-old and has chronic hypertension. She has never received a massage, but one of her co-workers recommends you. She comes to your office and complains of upper back and neck pain. Her face is flushed and she is gripping her smart phone as if she is waiting for the call that tells her the world is going to end. After chatting, you discover that Mary is going through a divorce and is taking care of her sick mother. Mary can't turn her head without provoking the pain.
From a mechanistic standpoint, both Joe and Mary probably need some work on their respective pecs, levators, scalenes, SCMs and upper traps. It would also be helpful to spend some time addressing the importance of optimal posture. Now, let's consider these two painful scenarios within the context of the allostasis model: Joe = Allostasis and Mary = Allostatic overload.
In Mary's case, the seizing of these muscles is probably not a physical/mechanical problem, but a manifestation of severe, unrelenting emotional stress. The fact that she is not in control of this stress makes it even worse. This is her first session; the novelty of bodywork will heighten the stress response. Mary is sitting on the dysfunctional end of the allostatic continuum; therefore, we should question if her body has the capacity to accept any more outside loading. Her bodywork session should be paired accordingly; perhaps including energy work and spending time on improving her breathing patterns.
Although Joe is enduring some physical stress, it is buffered by good nutrition, recovery and adequate sleep. The stress is intermittent and dosed so he can reap the rewards of physical adaptation to exercise. He also feels as though he is in total control of his stress. Bodywork is not new for him, so Joe is probably healthy enough to receive and benefit from a mechanistic and deeper approach to bodywork. Mary, on the other hand, lacks any significant escape from stress. Until Mary's environment changes, the ultimate therapy is the one that calms her.
Keep in mind, resilience and good health indicates successful allostasis. Generally speaking, when clients come to us stressed and exhausted, our primary responsibility is to induce as much relaxation as possible and allow a reset of allostatic mechanisms.
A better understanding of the stress response and allostatic theory will improve your clinical reasoning skills and undoubtedly make you a better therapist. Stress is not the devil- especially when encountered in the right dose and if the brain perceives it as non-threatening. It may be more accurate to say that stress does not cause disease/pain outright, but it sure can exacerbate bad situations. The clients that are bombarded by stress and feel they have no control over it, are at risk for being overwhelmed by certain types of bodywork. This places a significant responsibility on you, as a therapist, to tailor your massage to the specific needs of your clients. To finish up, I'd just like to offer you some suggested readings on this intriguing topic: The End of Stress as We Know It, by Bruce McEwen and Allostasis, Homeostasis, and the Costs of Physiological Adaptation, by Jay Schulkin.
Nicole Nelson a licensed massage therapist in Jacksonville, Fla. She has a masters degree in Health Science from the University of North Florida and is a certified Advanced Health and Fitness Specialist through ACE.
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