But it sells life by promising miracles; in fact generic bupropion 150 mg, it does little more than delay death purchase generic bupropion line. Most o f the dying are in degenerating states due to the ravages of disease caused by poor health habits buy bupropion 150mg fast delivery, age, and occasionally traum a. Medicine cannot cure these conditions; but in its m arketing of life, it simultane­ ously invades the province of “natural” death. T he thing most dying people want is to be in a familiar place with loving people. But because of medicine’s control over death, the patient is wired, doped, and incarcerated in a sterile hospital room surrounded by indifference. T he recognition will dawn that medicine cannot cure death and that spon­ taneous remissions of term inal illness are the product of the patient’s will to live. First, since so much time has been spent saying what health is not, som ething should be said about what health is. And then, as a second task, building upon these concepts, a new medicine can be constructed. It was to be like a villa on the Bosphorus and on the top floor it was surrounded by loggias. Somerset Maugham, The Summing Up Thus far I have tried to dem onstrate that medicine has little to do with health. O ur preoccupation with the provision of services has precluded analysis o f the factors conducive to health. We have spent so much time defining and classifying the sick and sicknesses that we have learned very little about health and the healthy. Nevertheless, we do know a few things, and we can build upon them while we try to find out more. Perhaps the greatest debt we owe to Rene Dubos lies in his recognition that the cause o f disease is multiple. For decades (and in some backwaters today) it was assumed that disease was caused by a “single bullet,” a single cause. This is the premise of the germ theory of disease, patiently constructed by such pioneers as Pasteur, Koch, and Lister. Dubos acknowledges that there is a physiological basis to disease, but he convincingly accounts for the greater impact of environm ental and social factors. At times he comes close to attributing disease solely to extraphysiological factors, but stopping short, ultimately he provides the foundation for our em erging understanding o f disease. In simple terms, every person carries the potential for every disease at all times. But through circumstances that vary with every individual, some people get sick while others, similarly situated, do not. Rather, the physical base for disease, which probably varies with the nature o f the disease, m ust be triggered by events external to the individual. A logical extension of this theory is that some people “select” diseases (or injuries) because they find illness preferable to stress. To Parsons and others, some individuals choose or are forced to choose to play a sick role in given social settings. To Dubos they are clear: Because a hum an being is the subject of many changing and inevitable dem ands and stresses, medicine can never produce health through its focus on specific disease conditions. A disease- free world is impossible: The concept of perfect and positive health is a utopian creation of the mind. It cannot become reality because man will never be so perfectly adapted to his environment that his life will not involve struggles, failures, and sufferings. The less pleasant reality is that in an ever-changing world each period and each type of civilization will continue to have its burden of disease created by the unavoidable failures of adaptation to the new environment. Consequently, to Dubos a healthy society is one in which the natural adaptability of the species is enhanced, not one in which disease does not exist. Health is m ore than the absence o f disease—in fact, it often cohabits with disease. A person with diabetes or with a heart m urm ur is not sick but merely a different person—one with certain constraints. T he W orld Health Organization definition is gener­ ally considered to be the most comprehensive: “A state of complete physical and mental well-being and not merely the absence of disease or infirmity. Most definitions of health which seek to go beyond the absence of disease focus on functional capacity—health is said to be that state in which the indi­ vidual can function. Functional capacity is im portant and basic to health, but it too is insufficient. First, health is too frequendy m easured against some objective and extrinsic standard such as the absence o f pathology, the capacity to function in a given social role, or the freedom from disability. Second, health is erroneously conceived o f as a state or property of an organism rather than as a dynamic condition, a constantly evolving source of energy. Because of these deficiencies, current conceptualizations o f health have inculcated a deep dependence on the part of the public: a dependence on the social setting for definitions o f health synonymous with functioning in that setting, and an even m ore profound dependence on services to produce states of health. This dependency, which feeds the growth of the medical care system, also frustrates the conceptualization 182 What Then Is Health? So health then is a mix of social and environm en­ tal contexts conducive to health and individual behavior and choice consistent with those contexts. T here is abundant evidence that social and environm ental factors singly and in combination frustrate and even prevent individuals from maintaining their health. But as interactions with a degraded physical environm ent and a perverted social order multiply, disease is often the result. Trees and shrubs that flourish in other settings become ragged and thin and often die when they border a heavily traveled road. But the m aturation of an organism can be stunted and warped by a debilitating environm ent. T he cigarette smoker, the coal miner, the alcoholic, and angry and hostile businessmen all have one thing in common: They are stead­ ily broken by their environm ent. But it is not the physi­ cal environm ent alone that can be unhealthy; the social order contains pathology as well. T he child who is re­ Four Conditions of Health 183 peatedly told that genitalia are “dirty” may fulfill the paren­ tal prophecy by contracting a venereal disease. For centuries hum an beings have tried to subjugate the environm ent to their will. But, as Gregory Bateson remarks, “the creature that wins against its environm ent destroys itself. We view disease as a thing apart—not another constituent of nature but an implacable enemy. We seek to suppress disease, to crush it with drugs, to burn it with lasers, and to cut it out with surgical tools.

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If the patient’s own respiratory rate is less than the set respiratory rate generic bupropion 150 mg without prescription, the ventilator will ensure that the required breaths are given bupropion 150mg with mastercard. Let us take an example where the set rate is 14 breaths per minute discount 150mg bupropion amex, and the tidal volume is 500ml. Each time the patient attempts to take a breath, the ventilator will deliver a tidal volume of 500ml. The disadvantage is that if the patient’s respiratory rate is high, the minute ventilation can be significantly high, resulting in respiratory alkalosis. However the additional breaths will not have the same tidal volume as the set tidal volume, and will be spontaneous breaths. The tidal volume of these breaths will depend on the respiratory effort, and the amount of pressure support applied. Ventilation 110 Handbook of Critical Care Medicine For example, if the patient has a spontaneous rate of 20, and the set rate is 14 with tidal volume of 500ml, the patient will receive 14 breaths with a tidal volume of 500mL. The remaining 6 breaths will have a tidal volume depending on the patient’s respiratory effort, airway resistance, and the pressure support. The higher the pressure support, the larger the tidal volume of these breaths (because in effect these breaths are similar to pressure control ventilation). If respiratory alkalosis develops, the respiratory drive will fall, and the patient will breathe less frequently. Because there is a mandatory set rate, the required minimum minute ventilation is ensured. Spontaneous ventilation with pressure support In this form of ventilation, there is no set rate or tidal volume. The inspired tidal volume depends on the respiratory effort, airway resistance, and the pressure support. Usually however, the machine has a minimum limit, and if the patient does not breathe adequately the alarm will sound, and the machine will take over and ventilate the patient. This mode is an effective weaning mode – if the pressure support is sufficiently low, and the patient’s respiratory parameters and blood gases are adequate, he is probably ready for extubation. A pressure support of approximately 8mmHg is just sufficient to take away the dead space effect of the endotracheal tube. Choice of ventilator modes and settings These depend on the requirements of the patient. Neuromuscular blockade is usually required, although if the patient has little spontaneous respiration this could be done without. How to determine the initial settings in a patient who has just been ventilated The usual set rate will be between 10 and 14 breaths per minute. The tidal volume is usually between 6 and 12 ml/kg body weight, preferably closer to 6ml/kg. Start with a high FiO2, and then reduce it to maintain a pulse oxygen saturation of over 95%. The ratio between the inspiratory time and expiratory time must also be set; this is known as the I:E ratio and is generally between 1:2 and 1:1. Note that these values are just rough guides, and will depend on the individual patient, and underlying condition. This can be done by the following Ventilation 112 Handbook of Critical Care Medicine o Suctioning out bronchial secretions which are blocking the airways and causing collapse of distal alveoli. Increasing the minute ventilation is not a useful manoeuvre to improve oxygenation. This can be done by reducing the set rate or reducing the tidal volume and the pressure support. Biphasic ventilation Biphasic ventilation is another mode of ventilation where the machine controls only pressure, which moves up and down within a lower and upper baseline. If the patient is breathing spontaneously, the spontaneous breaths are freely superimposed on the moving pressure baseline. De-escalation of ventilation, and weaning the patient off the ventilator De-escalation or reduction of ventilator support should be commenced as soon as the patient’s respiratory parameters show signs of improvement. However, in patients with severe lung disease, de-escalation should be performed very slowly and carefully. If the patient tolerates a level of reduced support, further de-escalation should be attempted. Weaning can be considered if several basic criteria are satisfied, namely: x Improvement in the patient’s primary lung disease or underlying condition. Weaning is considered if the patient is on the lowest possible ventilator support. Consider the following when attempting to wean: x The patient is breathing spontaneously and comfortably with adequate spontaneous tidal volumes and respiratory rate. Usually, this is best done in the mornings, when the full complement of staff is around. Ventilation 114 Handbook of Critical Care Medicine Some people prefer a trial of T-Piece prior to extubation. This is not essential however, if the patient is on spontaneous mode with minimal pressure support, there is no evidence that a T-Piece trial gives better weaning results. What is a T-Piece trial and what does a T-Piece do A T-Piece is a tube shaped like a T. An oxygen supply is connected to one end of the T, and this drives the expired air out. The need for this oxygen flow is to ensure that expired air is expelled, or else the dead space would be too large. After extubation Generally, a repeat arterial blood gas is done about 30 minutes after extubation. Sometimes however, the patient may be unable to breathe on his own and may require reintubation. Tracheostomy is advantageous in that it makes suctioning easier, reduces the risk of nosocomial infection, and avoids the possibility of tracheal stenosis and tracheomalacia due to prolonged intubation. Less severe and recurrent embolism can result in episodic breathlessness and cough with desaturation. A fourth heart sound and loud P2 may be present, and evidence of right heart failure may manifest. Pulmonary embolism 116 Handbook of Critical Care Medicine Diagnosis Since the signs and symptoms are non-specific, a high index of suspicion must be maintained until the condition is excluded. Pulmonary embolism 117 Handbook of Critical Care Medicine Treatment Resuscitate the patient first. A fluid challenge should be given carefully, as volume overload may result in right heart failure.

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Child stunting (linear growth failure secondary to pre- and post-natal poor nutrition and infection) in Indonesia is reduced by better parental education bupropion 150 mg visa. Such parents are more likely to practice protective measures such as giving vitamin A generic bupropion 150mg mastercard, completing childhood immunisations bupropion 150 mg amex, provide a cleaner environment, and use iodised salt. Charles Dickens noted recorded this phenomenon among patients resident for a matter of weeks during the 1850s. Obese people have increased concentrations of insulin and cortisol in their serum and decreased plasma growth hormone levels, but these are probably due to being obese since they normalise when weight is lost. Wahrenberg ea (2005) found that a waist circumference of less than 100 cm excludes insulin resistance in both sexes. Montgomery and Ekbom (2002) reported an increased risk for diabetes and obesity among the offspring of women who smoked during pregnancy. Hypothyroidism, hypogonadism, hypopituitarism, and Cushing’s syndrome are associated with obesity among other things. The characterization of an obesity gene (ob) on chromosome 6 in mice (and its human homologue) was reported in 1994. It was hypothesised that the ob gene on chromosome 7 produced an ob protein (this 1883 turned out to be leptin ) that acted on brain ob receptors leading to satiety and a reduction in food intake. In fact, in excess of one hundred genes have been implicated in the determination of body weight. These act mainly through the brainstem and hypothalamus and influence food intake and tendency to exertion. Leptin (‘ob protein’; Gk: leptos, thin) levels are chronically elevated in obese humans. Apart from the few people with inherited leptin deficiency, therapeutic leptin use failed to work. According to Watts (2007) cells produce leptin to prevent too much weight loss during lean times rather than to prevent obesity! Leptin 1881 Lambert Adolphe Jacques Quételet (1796-1874), Belgian astronomer, mathematician, statistician, and sociologist. When injected into the peritoneum it causes a reduction in feeding and an increase in energy output. It inhibits 1887 neuropeptide Y (a powerful appetite stimulant) in the arcuate nucleus of the hypothalamus. Galanin is an orexigenic peptide that probably acts at the level of the paraventricular nucleus. It was indicated as an adjunct to diet and exercise for obesity or overweight adult (> 18 years) patients with associated risk factors, e. It should be avoided in uncontrolled serious psychiatric disorder and it was not recommended for people on antidepressants. It was not recommended during pregnancy and is contraindicated during breastfeeding. Social or cultural factors may moderate or mediate the association between obesity and mood disorder. Unresolved dynamic-neurotic factors and learning theory are generally considered to be operative. Suggested psychiatric criteria for obesity (Volkow & O’Brien, 2007) Need to eat more to be satisfied (tolerance) Dieting-associated distress/dysphoria Eats more than intended Always wants food and can’t curtail amount consumed Avoid activities because of fear of rejection due to obesity Overeats despite knowing of ill effects and psychological sequelae Clouston, in 1881, wrote that fattening a patient would improve the mental state. Direct intra-hypothalamic injection of chlorpromazine in animals leads to an increase in food intake. Morbid obesity provides an increased reservoir for psychotropic drugs with persistence of the effects of such drugs. Animals that have their food intake restricted have less cancer than do animals allowed to eat as much as they wish. Adami and Tichopoulos (2003) felt that the risk of cancer from obesity is small relative to the 1899 effects of smoking, a view not shared by Haslam and James. Anti-obesity drugs do not cause particularly significant weight loss and have their own adverse event profile. The chief approach is a normal reducing diet: eat plenty of fibre and 1905 exercise regularly. As long as the calorie content of the diet is reduced it doesn’t seem to matter whether the emphasis is on protein, carbohydrate or fat when composing such a diet. Obese people tend to eat more than they report during a diet and to overestimate physical activity. Self- monitoring, response prevention strategies to counter identified behavioural and cognitive cues, reinforcement, family or marital work, and psychotherapy are all useful in individual cases. Liposuction (fat removal by suction) may reduce weight (often temporarily), girth, and leptin levels in plasma, but it may not improve metabolic problems associated with obesity and therefore may not reduce the risk for coronary disease. There is a small mortality risk in the short term and abdominoplasty may be required by many patients. Central stimulants (phentolamine, diethylpropion, and amphetamine) act on adrenergic receptors causing central stimulation and may precipitate psychiatric problems. In acute treatment, fluoxetine and fluvoxamine may cause weight loss (at least in the short term), whereas citalopram, sertraline and paroxetine seem to be weight 1907 neutral. Phentermine (Ionamin), an amphetamine derivative1909, should not be given for longer than 6 months and is usually given for 4-6 weeks. Phentermine therapy should be adequately supervised and is not a first-line therapy. Side effects include headache, anxiety, insomnia, hypertension, bradycardia, and palpitations. It should be avoided in the presence of current or past psychiatric disorder (including anorexia nervosa and depression). According to Eckel (2008) efficacy and safety data for phentermine are limited and there is a potential but low possibility of abuse. Orlistat (Xenical), 120 mgs (capsules) tds with meals, used in conjunction with a low calorie diet1910, promotes weight loss by selectively inhibiting gastrointestinal and pancreatic lipase activity, so reducing dietary fat absorption by 30%. According to Anonymous (2007) orlistat (tetrahydrolipstatin) is the obesity drug with most evidence for efficacy and safety1911. Some concern has been expressed over an association between orlistat and hypertension. The commonest adverse effect is nausea, others including headache, dizziness, constipation, vomiting, and dry mouth being less common. Most obese patients do not need medical help to lose weight and most will drop out from treatment. Yanovski and Yanovski (2002) remind us that the main approaches to the treatment of obesity are behavioural (improved diet and increased physical activity) with weight-loss medications reserved for patients at substantial risk because of their obesity and where non-drug treatments have failed. In motivated patients, the aim is to achieve gradual and modest weight loss by caloric restriction, physical activity, and behavioural treatments.

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Definition Whole-body physical medicine could be defined as Understanding the condition order bupropion 150mg with amex, its causes and its likely diagnosing and treating disorders of the somatic remedies buy generic bupropion 150 mg on line, as well as having appropriate educational tissues within a conceptual basis of the interdepend- tools purchase bupropion 150 mg without prescription, is a pivotal role for the practitioner of naturo- ency and continuity of all the tissues of the body, pathic medicine including their reciprocal influence on (and by) the In naturopathic physical medicine, this becomes state of mind and emotions (Ferrell-Torry & Glick central to healing, as lifestyle modification, manage- 1993, Shulman & Jones 1996). Prevention of further injury and monly employed in the treatment of patients (and physical dysfunction results from skillful and coher- their symptoms) with conditions of a pathological ent educational processes in the clinical setting. Salivon & Polina (2005) carried out a comparative Sheldon (1940), whose classification is the clearest and analysis of anthropometric indices, matching these to most applicable to assessing patients for physical cardiovascular vegetative regulation. The researchers interventions, stated that the constitution ‘refers to those observed typological specificity of organism reactivity to aspects of the individual which are relatively more fixed unfavorable geochemical situations in young males and and unchanging – morphology, endocrine function, etc. His system was developed deficiencies in the soil (‘vital macro- and micro-elements from a study of over 4000 students whom he in soils and drinkable water’). Individuals of The endomorphic constitution has a predominance of robust physique (high endomorphic and mesomorphic soft roundness in which the digestive organs dominate components) showed higher mean values of systolic and the body economy. The researchers note that their predominance of muscles, bone and connective tissue. The Figures in the lower quintile, or below the range, contrasts of hydrotherapy applications can be greater, suggest degrees of hypotonia and weakness (Priest soft tissue procedures may need to be stronger and 1959). The ectomorphic types, or those of tending towards sympathicotonia, as suggested by slim build, on the other hand, require lighter, shorter iridological findings. Mesomorphs are more sturdy and athletic Iris diagnosis in build and can usually tolerate reasonably strong A further guide to the vital reserve of the patient is stimuli. The Somatotype has also been shown to have correlations overall color and texture of the irids is considered to be with aerobic trainability, adaptability and blood pressure. Observation may be made with a hand lens tests and measures of ventilatory capacity on subjects and penlight although, for more detailed analysis, a divided into four somatotype groups – endo- desktop ophthalmoscope or camera designed for close mesomorphs, mesomorphs, meso-ectomorphs and imaging of the iris is preferable. Turner 2000) has described as ‘symbolic topography’ Continued 90 Naturopathic Physical Medicine Box 4. Nevertheless, empirical tightness of the autonomic wreath, a radial zone lying evidence suggests that the tightness or otherwise of the outside the pupil, as well as the dilation of the pupil structure of the iris can give a good indication of the itself (Kriege 1969). This There exist several approaches to constitutional method identified chemical elements that predominated diagnosis in naturopathic medicine. Based on characteristic physical, was initially advocated by Kuhne (1902) in his widely mental and emotional patterns, individuals could be influential work. Havard further elaborated on the cranial categorized and therapeutic interventions designed. While Kuhne’s diagnosis Verbon (1948), Shanklin (1950) and Jensen (1983) focused upon identification of the pattern of advocated and expanded upon Rocine’s approach. Rank categorization incorporated some facial and fingernail diagnosis as based upon the relative size of the occipital, parietal or well. The later taxonomy of Deck (1965) has certain temporal lobes, as evidenced visually in the similarities; however, the focus is upon the iris. This corresponding cranial structures, allowed a ranking of approach is gaining greater international acceptance the digestive, genitourinary or cardiopulmonary systems, and is advocated as a basic identification model by the respectively. The genetically allow prediction of healing crises, in the secondary determined iris color is thought to identify the primary strength during adulthood, and in the weakest organ constitution, the overarching structural pattern of the system at childhood. Pathological derangement of the fibers the secondary disposition, and finally tertiary strongest organ system was considered a poor categorization is determined by accumulation patterns. This method was referred to as ‘basic Upon this basic constitutional classification further iris diagnosis’ and Lindlahr advocated a combination of this diagnosis is then elaborated. Similarly, the neurogenic understanding of the model of the iridological disposition, characterized by a relatively tight and taut constitutions. For example, the connective tissue iris fiber pattern, has increased expression of genotype weakness disposition, characterized by a general laxity associated with hypertension (Um et al 2005). Fascia is one component tissue, which has major implications for manual/ of connective tissue in the body, which includes fascia, physical therapies. These tissues have particular charting method for location of the connective tissue (fascial) planes, acupuncture points and acupuncture characteristics that influence their function – they meridians of the arm, they note that ‘overall, more than have parallel collagen fibers, various degrees of undu- 80% of acupuncture points and 50% of meridian lations and are low in elastin. This category of tissue intersections of the arm appeared to coincide with has many functions (Manheim 2001): intermuscular or intramuscular connective tissue • Supports matrix planes’. The tension placed on the • Sites for muscle attachment connective tissue as a result of further movements of the needle delivers a mechanical stimulus at • Stores fat – conserves heat the cellular level. They note that changes in the • Fibroblastic activity – scar formation extracellular matrix ‘. In 2005, Langevin et al observed that: ‘The dynamic, cytoskeleton-dependent responses of fibroblasts to The principles that guide attention to fascia in physi- changes in tissue length have important implications cal medicine are based on the knowledge that fascia for our understanding of normal movement and covers, separates, attaches to and gives cohesion to all posture, as well as therapies using mechanical organs, muscles and other bodily tissues, so that there stimulation of connective tissue, including physical is true structural interdependence between all regions therapy, massage and acupuncture. As noted below – see influences of fascia extend beyond the obvious biome- notes on the work of Langevin (Box 4. He showed that also recruit neuromuscular adaptive activity, and as cells deform when gravity is removed or reduced, naturopathic practitioners – as well as other holistic the behavior of cells changes to the extent that, professions – consider that a detailed analysis of the irrespective of how good the overall nutritional state, or neuromuscular system is vital in making a coherent how much exercise (static cycling in space) is taking and complete diagnosis (Kuchera 1997). Some ele- place, when they are distorted, individual cells cannot process nutrients normally, and problems such as ments of such assessment are to be found in Chapter decalcification emerge. This research is a confirmation, were any needed, that structure is the governing feature of function, a Most commonly this aspect of understanding the validation in naturopathic medicine of the essential role interdependency in human function is faced with the of manual and other physical modalities that have the patient in pain, especially when caused by trauma potential to beneficially modify structural components and/or postural imbalance. As romuscular adaptation has occurred, in which tissues, noted in Chapter 2, the corollary to this relationship is, and a strategy of assisting in the optimal outcome of of course, that functional factors such as overuse and balanced movement, stability and muscle function, is misuse imposed on tissues will modify their structure one focus of naturopathic physical medicine. Additional discussion is to be found in Chapter 2, where adaptation pro- cesses are dealt with in depth. Body–mind Physiological The link between the body and the mind has been well established in the literature over the past three Neuromuscular system decades, and confirms the traditional naturopathic Neuromuscular activity in human physiology is a and holistic view that these two realms of the indi- major adaptive system that facilitates and controls vidual cannot be separated in their functions. Movement can be disturbed by icine, as early nature cure physicians such as Alfred unexpected events, as well as by the normal activities Brauchle instituted what he called ‘naturopathic psy- of life, and the level of stability in the system can be chotherapy’ as early as 1934, and included a chapter defined as the ability of a system to return to its origi- titled ‘Psychological Nature Cure’ in his 1937 book nal state after any adaptive challenge, evident in the History of Nature Cure in Biographies (Kirchfeld & Boyle process of homeostasis. The technique was based mostly on suggestion the ability to return to a desired movement pattern and hypnosis, although he also believed in the clinical after such a demand or disturbance. Sensory systems in the body, such as the propriocep- European naturopaths have also demonstrated a tive, visual and equilibrium systems, monitor struc- wide interest in this area of health care, most notably tural, postural and other changes, demands and the British naturopathic practitioner Milton Powell disturbances, and send informational feedback signals who for many years contributed a series of articles on to the central control cortex, which in turn adapts its naturopathic psychotherapy to the British Naturopathic output to the musculoskeletal system to compensate, Journal & Osteopathic Review. This type of feedback discussing the topic of phobia, his naturopathic per- control – which is clearly dependent on accurate infor- spective involved, among other aspects of care, Chapter 4 • Naturopathic Physical Medicine 93 Box 4. There is evidence that deeper muscles (also described as ‘inner unit’, or ‘stabilizer’ or ‘local’ As adaptive changes take place in the musculoskeletal muscles) contain proportionately greater numbers of system, and as decompensation progresses toward slow twitch (postural) fibers, whereas superficial more compromised degrees of dysfunction, structural muscles (also described as ‘outer unit’, or ‘mobilizer’ or modifications appear and whole-body, regional and local ‘global’ muscles; Norris 1998) are dominated by faster postural changes emerge. These changes in response to postural and overuse A simplistic summary of the effects of poor posture (and disuse) influences have been categorized in would be that a combination of this, together with aging, different ways. Amongst the simplest and most useful overuse, misuse, abuse (trauma) and disuse, lead ways of envisioning adaptational changes affecting the inevitably to adaptation exhaustion, decompensation and muscles of the body is to use the descriptions and ultimately symptoms (see Chapters 2 and 9 for more on descriptors given by Janda (1978) and Lewit (1999). They have both noted that particular muscles and Tissues gradually change from a state of normotonicity groups of muscles function primarily as guardians of to a palpably dysfunctional state, at times involving stability (‘postural’ muscles), whereas others have a hypertonicity, and at others hypotonicity, the presence of more active role (‘phasic’ muscles). These forces appear to have their greatest impact More recent clinical evidence has emerged for the value on the articular facets in the transitional areas of the of this attempt at reading the levels of adaptation vertebral column. The German osteopath Torsten Liem (2004) has It is clearly important for the naturopathic practitioner to suggested that if the rotational preferences alternate have an awareness, as best this can be ascertained, as (L-R-L-R) when supine, and display a greater tendency to the patient’s current level of vitality and vulnerability – to not alternate (i. The principle this reflects, in naturopathic standing, a dysfunctional adaptation pattern that is terms, would be the desire to avoid interfering with self- ‘ascending’ is more likely, i. Zink & Lawson (1979) described methods for testing If the rotational pattern remains the same when supine tissue preference in these transitional areas where and standing this suggests that the adaptation pattern is fascial and other tensions and restrictions can most primarily ‘descending’, i. These sites are accompanying imbalances are to be found in Chapter 6 tested for rotation and side-flexion preference.

H. Surus. Utah State University.