Archive for the ‘my thoughts’ Category

International Fascia Research Congress, Vancouver, BC – Day 3

| March 30th, 2012 | No Comments »

Today began with a keynote speech by Carla Stecco who spoke on the nature of fascial anatomy.  One of the most amazing pieces of information I took from this was the fact that the sheaths of the limbs and trunk (aponeurosis of the deep fascia) that are traditionally classified as “disorganized” can actually be dissected into 2-3 layers of highly organized, aligned collagen fibers that are each oriented in discrete directions in each layers whose fibers are shifted 78 degrees from each other throughout the body and are capable of gliding on each other.  The other aspect, which actually came up several times over the last days is that there are penetrating collagen fibers that bind across various levels of fascia to affect sensory organs and allow force transmission across nested fascial layers.

I chose not to attend the discussion of imaging techniques and devices that followed, but from the tweets that I have seen there is a huge desire for a 4D sonograph now.  I have no idea what that is nor why it is so lusted after but I am glad that those that stayed had a good time.  I was not alone in missing some of the events of the day, I think overload was being reached by many of us and I know I enjoyed the time to be quiet with my thoughts and organize myself for the trip home.  

In the afternoon I returned to congress-land and heard some very interesting presentations, one on plantar fasciitis, one on immobilization of rats (which requires metal harnessing and ankle cuffs, those rats are apparently very much not keen on bondage), one on trigger point release using myofascial techniques and finally a study designed to demonstrate the actual force generate with different applications of Swedish massage.  This last one was an amazing demonstration of several important facts.  One, that the Fascial Research Congress model is generating clinically relevant research (the study was conceived after the presenter attended the second congress in Amsterdam.  Two, that there is a lot of very basic research to do on clinical application of manual therapy – after all, we cannot actually say with any scientific certainty the amount of force that we are generating on the tissue of our clients.  Three, that research is a rough go.  The presenter, brave soul that she was, led us through an elegantly designed trial to determine the compressive force generated by Swedish massage technique.  She covered the various challenges she faced and how she managed to overcome many of them.  She showed us some lovely, very tidy printouts of force generation waves generated by the strokes, and then she had to tell us she had no data to share.  All of her data was invalid due to faulty calibration of the testing equipment.  Oh my.  Despite this I would say she did in fact share quite a lot of data, just no outcomes.  I was relieved to hear she hasn’t given up and she may be able to salvage some of the data she had acquired through the magic of algorithms (okay, I think they are magic, some people think of what I do as magic, I think of algorithms as magic, we each have our own perspective).

After the bittersweet conclusion of the parallel panel presentations we concluded the afternoon with a panel entitled “Art & Science/ Research & Practice”.  Here was our opportunity to hear the thoughts and hopes of a few that I think reflected the hopes and dreams of many of us.  

Maureen Simmonds and Paul Standley both spoke about the importance of clearer, more standardized language and communication between clinicians and researchers to aid in the development of a greater understanding of whether what we do in the clinic is actually doing what we think and if it can create the kinds of impacts in the real world that simulated work in the lab does in petri dishes and research animals.  

Robert Schleip likened himself to Alice in Wonderland as he as a clinician who has entered the world of the scientist and continues to find both worlds “curiouser and curiouser” (I think I have applied the analogy a bit differently than he did, but I think the idea is the same).  He also pointed out the fact that he is not the only person to have shifted their position on the continum of clinician and scientist, nor is there only one direction to go on that voyage.  the rabbit hole goes both way and it is the both the people that switch burrows and those that simply reach a hand into the other hole to give or receive, or perhaps to join with a hand reaching back, that enrich and invigorate the worlds of fascial research and manual therapy.

Geoffrey Bove concluded the panel with an case study of his experience in reaching hands across the divide, and switching rabbit holes both.  Initially a clinical practitioner, he is now the researcher stretching his hand out to the clinician, in the person of Susan Chapelle, to bridge the gap and create new and fascinating (fascia-nating?!?!) discoveries regarding the outcomes of rubbing rat adhesions.  He presented with an interesting combination of practicality and emotionalism as he discussed the challenges of research and collaboration clearly demonstrating the passion that is brought to the work.

I departed prior to the final remarks to catch a ferry but I left feeling full of knowledge and enthusiasm and hopeful for the future of my profession.

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International Fascia Research Congress, Vancouver, BC – Day 2, the night

| March 29th, 2012 | No Comments »

Tonight I watched a prophet perform. Not what I expected to see at a Fascial Congress but I am not sure what other words to use. Gil Hedley was the final act in our multimedia night. After three amazing, room-stilling videos that were highly anticipated, onto the stage came a wiry, kinetically unstable bundle of poetry reading anatomist.

Perhaps I have had too much coffee, not enough sleep or entirely too much mental stimulation but Gil Hedley’s presentation on his new thinking around fascia makes me what to sign up to join whatever cult he’s leading or drink whatever kool-aid he’s pouring. He brings an inspiring combination of respect, enthusiasm, joy and intellect into the world of fascial dissection.

I am someone who loves my words and concepts and rather resent having to give up a perfectly good story for a new idea. Even though Hedley’s whole presentation was a debunking of his own, infamous “fascial fuzz” speech that has become an easy, u-tube click away, introduction to fascia for the uniformed, I loved it. I now have to discover a new story to tell myself about the development of adhesions and what I am doing in my work. Daunting. I am inspired though by the enthusiasm, dance, poetry and joy that was displayed on the stage of the grand ballroom of the Sheraton Wall Centre tonight in Vancouver, BC

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International Fascia Research Congress, Vancouver, BC, Day 2

| March 29th, 2012 | No Comments »

Today is a new day of learning and the overload is starting to set in.  Not in a bad way, but you can see the shiny eagerness beginning to fade, there is more movement during presentations and alternate seating is becoming more popular and the familiar seats begin to feel entirely too familiar to our posteriors.

A great day none the less with some wonderful clinical information and tonight a multimedia presentation of fascial videos that I, along with several others from the look of the bar and cafe here at the hotel, will be late for.  I admit that I have stepped away from a few presentations seeking some quiet retreat time to process some of the information.  After some dinner though I look forward to watching some highly visual presentations that I am betting won’t stress my lack of chemistry knowledge as several of the presentations today did.  

The flip side of the restlessness is an increase in casual interaction between attendees and lots of chatter.  As I sit and type several tables of congress attendees sit together chatting, eating and drinking.  I suspect many a new research project will be hatched over the next several days.

In terms of the learning there was a shift from the mechanical to the fluid as our keynote speakers focused on the issue of fluid dynamics in the interstitium and the wonderous fourth state of water – bound water.  The water talk, given by Gerald Pollack from the University of Seattle, was my third exposure to his theories and seems to have been a bit of a charm as several of the concepts seemed to sink right into my brain rather than flying inches or feet over my head.  Dr. Pollack’s research has focused around the behaviour of water at it’s edges, where it contacts hydrophilic (water lovings) substances and air, and there is the creation of an exclusion zone where the water enters the bound, or fourth state.  In this zone the water is denser, negatively charged, has a viscosity similar to honey and just generally is really different from what he calls bulk water.  Beyond the interesting implications for us manual therapy practitioners whose clients are all largely composed of water there are real world implications.  

 

In the real world the exclusion zone offers explanations for cloud to cloud electric activity (= lightning), why the basilisk lizard really can walk on water, why heavy objects float and offers interesting possibilities for water decontamination, perhaps even desalination, and the ability to harvest electricity from water – all using only the radiant energy of light to accomplish the task.

There is the report for today, stay tuned for the final day’s report where imaging and more anatomy and clinical discussion look to be the highlight.

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International Fascia Research Congress 3 – Vancouver, BC, Day 1

| March 28th, 2012 | No Comments »

***Beware – this post is a total fascia geekfest, if you are not prepared to deal with that, read a different post!  Also, any factual errors are my faulty memory, not faulty presentations.***

 

Today I had the absolute pleasure of beginning my time at the 3rd gathering on scientists and clinicians who have an abiding interest in fascia in all its varied and wonderous forms.  I began the day with a flight to Vancouver and a slightly late arrival – but I got before the real geek-out stuff began, so it is all good.  

After some general introductory speeches we dove right into the first keynote speaker.  A anatomist from Temple University, Mary Barbe spoke to us about her research in duplicating repetitive stress injuries (RSI’s) in rats and the tissue changes that occurred in response to various types (high, low and negligable intensities) of work.  How could this possibly relate to massage therapy you ask? Well the road hasn’t fully been built, but knowing that rest doesn’t always fix the problem and that inflammatory processes have likely come and gone prior to anyone presenting at my office (they peak between week 4 and 8 of performing the task) after months or years of a repetitive task, provides me with insight into what interventions and homecare might best benefit my clients.  simply knowing that there are significant connective tissue changes that occur within weeks of undertaking an repetitive task shouts loud and clear about the importance of the fascial work that I am a huge advocate for.

After a quick break we moved our second speaker, Michael Kjaer, whose topic was the impact of exercise on tendon tissues.  We discovered that exercise (and not a lot, 1x creates 72 hours of increased collagen production which is what builds your tendons) increases the density of tendons.  Interestingly, there seems to be little issue with maladaptive changes in the tissue to repetitive exercise as there is to repetitive work activity (there’s a thinker).  More surprisingly, it turns out men exhibit greater tendon density increase than women, and that within the female population women taking oral contraceptive exhibit even lower levels of tendon response than the general population.  Further interest in gender issues came when it was revealed that in post-menopausal women being on hormone replacement heightened tendon response.  Hmmm, that estrogen, funny stuff.  

 

After a break for lunch we broke into three groups for presentations on specific areas of fascial research.  I chose the “biomechanics” room and got to learn about different means of trying to empirically measure different types of mechanical interventions.  From pressure sensitive pads on fingers to rather medieval looking table devices this part of the afternoon was an interesting insight into the various ways we can try to research the interventions we apply with our hands and their outcomes.  I also gained an interesting insight into the world of research.  Failure, or rather, not proving your hypothesis fully or at all.  Even in those cases it was interesting to see how that research could be used to launch into better studies.

Our next keynote speaker, Albert Banes, was a doozy.  I am pretty sure I learned so interesting things, but they went by so fast I think I might be lucky to catch up with them sometime next week – after reading the paper a few times!  He seemed to be summarizing quite an extensive array of studies in the field of fascia research and had some very interesting things to say – and showed us pictures of some lab grow tendons, but it was a lot in just a little time

The final event of the afternoon, academically, was a panel of  four clinicians presenting of “scars and adhesions”.  One of the exciting bits of us BC RMT’s was having one of our own on the panel – Susan Chapelle of Squamish, BC who talked about the benefits of integretive treatment and the need for increased research that included a manual therapy aspect.  She was preceeded by a surgeon, Dr. Michael Diamond, who discussed post-surgical adhesions (things sticking together that shouldn’t after surgery) which I was surprised to find has a 65-100% incidence rate in abdominal surgeries (though they are not limited to those surgeries).  We were then treated to a new movie by Jean Claude Guimberteau, a French physician, who has now produced several in vivo movies of fascia using endoscopic techniques (his first being “Strolling Under the Skin”, presented at the first fascial congress).  We also had a naturopathic doctor, Hal Brown, present some of his case studies of the impact of the injection of aenasthetic under the skin into scars to improve function in both near and far tissues. 

The day finished with a welcome reception that was very well attended that allowed us all to review and discuss our reactions and thoughts regarding the days flood of knowledge.  I can hardly wait for day two….

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m-Medicine – the future of your doctor’s smartphone?

| January 23rd, 2012 | No Comments »

This weekend I was reading an article in the Globe and Mail regarding the impact of technology on health care, specifically mobile technology.  The article referenced several areas in which mobile technologies can improve health care with remote monitoring, to i-tunes credit for diabetic teens who comply with their insulin regimes.  The focus, and one of the most exciting parts, for me was an improvement in post-surgical care monitoring.  

Dr. Semple, the surgeon-in-chief of Women’s College Hospital in Toronto, is running a pilot project to monitor the ambulatory surgery (in hospital less than 23 hours) patients under his care.  Dr. Semple and his research team have developed an app that allows patients with a smart phone or tablet to be in regular touch with him post-operatively.  This app allows patients to photograph their surgical incisions and send them to Dr. Semple along with text regarding how they are feeling.  From this information Dr. Semple can very accurately assess the progress of their recovery and make decisions regarding any need they may have to return to the hospital for follow-up care prior to their scheduled appointment.  

This seems simple, wouldn’t a phone call do the same?  I see this new evolution addressing several weaknesses in the call-in follow-up.  One, for time pressed surgeons – and patients – there is no need to mesh schedules.  Patients send in their information when they can and the doctor can pick up the information whenever he chooses.  Yes, this sounds a bit like answering machine tag, but there are other factors.  When the doctor picks up that message he is not just listening to a voice trying to squeeze their information into a brief window before the beep – he is reading a summary that the patient has been able to compile at their leisure.  He is also able to pick up that piece of information anywhere.  The other highly valuable piece of information he is getting is the visual.  They say a picture is worth a thousand words, and with this technology it may very well be so,  it may even be worth a life.  The article talks about a scenario where Dr. Semple is able to save himself, his patient and the system, time and money by preventing an unneeded hospital visit from the other side of the globe, but lets look at the other possibility.  What if his patient’s bruising wasn’t benign?

Using the app the doctor could have gotten that patient into the hospital as soon as he saw cause for concern.  Post-surgical care costs can escalate through to means – unneeded return, and delay of needed return.  The later being more costly in the end for all concerned as it would be associated with re-hospitalization, care for the complication that would be more extensive than a promptly dealt with one, and, perhaps, long term health issues or death if an infection was not dealt with for a prolonged period.  Close monitoring has always had benefits in terms of preventing complication but earlier discharge offers huge savings, higher numbers of patients processed and, frankly, more comfort for the patient.  Anyone who has spent time in hospital knows it is not very restful or healing.  The food is awful, it is noisy and people are disturbing you at all hours to check your temperature.  Who wouldn’t prefer the privacy of their own room, in their own home with undisturbed nights?  When those things can be accompanied by closer monitoring we have a winning solution both for the patient, for their health and for the system.

This week there is a conference in Toronto that offers doctor’s the opportunity to explore the options of mobile health technologies and hear from leaders in the field.  I hope my doctor is on her way there! 

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Misssing the obvious…

| January 19th, 2012 | No Comments »

As a health and wellness professional I think of myself as well informed and a good clinician.  I encourage people to be thoughtful with their wellness and think about all aspects of a situation when making decisions.  I even offer my services as a wellness consultant to help other with this process.  This morning I had a moment when I was reminded that no one does it right all the time – especially when dealing with family.

One of my stepsons has eczema.  Until this fall he had been symptom-free for about two years.  Then he had a flare up  Since that time we have been struggling to bring the symptoms back under control.  They have abated at times and are in a moderate level of irritation right now.  We have tired some corticosteroid cream with not great results – for either the itching or the state of the eczema itself.  He is oatmeal bathing frequently which offers temporary relief.  We have got him off of dairy – mostly – as that helped in the past.  I modified some of my bare bottom bum cream with different essential oils, which has helped as much as anything.  I got him to add an Omega 3/6 supplement as that helped with some itching I had during pregnancy.  Overall, some symptom management has been our best outcome.

How does that moment I described fit into all of this?  I was putting cream on my own legs and thinking how dry they are with the colder weather, which led to thoughts of other skin drying activities, which led to thoughts of my stepson being in and out of hot baths multiple times a week.  Suddenly I wanted to kick myself.  In all the other suggestions we have tried, in all the recommendations, I couldn’t remember ever saying “moisturize after your bath”.

Such a simple concept, one anyone with dry skin will tell you is a necessity, and it never crossed our minds.  We shall see now whether it is the missing piece.  Will some intensive moisturizing help?  Post bath and – if I can convince him – overnight will be the next phase of treatment.  

Now eczema isn’t deadly, no permanent harm is likely to come of this, but as my stepson would attest, it is a pain, very distracting and not helpful to life as a whole, but why make this a blog?  I keen on reminding anyone I am imperfect, but I did want a reminder of what happens when I don’t slow down and think things through.   The other reasons are: to help others remember that lesson too, and to remind them too that when dealing with family, it is easy to forget some of the most basic things.  Dealing with family we can often be both more concerned and less careful than normal.  Not careless for their well being, but sometimes, in the rush of daily life, if you never sit down and give proper, systemic thought you can miss the obvious.  Next time you or one of your family members comes up against a wellness issue, give it the thoughtfulness it deserves.  And if the issue is a larger one be sure to give it its due and if you need too, get some support.

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WorksafeBC

| January 4th, 2012 | No Comments »

Many massage therapists in BC will not work with WorkSafeBC injured workers.  I was one of the abstainers.  The length of appointments, the payments and the reporting and billing processes were all been very limiting and difficult to sort through.  In 2011 the Massage Therapists Association of British Columbia signed a new contract with WorkSafeBC which improved the rate of pay and simplify the whole process.  Given the huge improvements, I decided to begin treating WorkSafeBC clients.  What has changed, and how is the process still unique and challenging?  That’s what this blog is all about.

First, the changes and why I like them.  The money factor, for better or worse I do this job to support myself and my family and I need to make a certain amount of money to do that, the previous contract just didn’t make fiscal sense for me.  The new contract significantly raised the rates and I am now able to offer reasonable appointment lengths balancing treatment effectiveness with fiscal feasibility.  The paperwork and hassle factor also decreased.  Credit goes to both negotiating parties for many of these improvements, but technology also plays a huge role.  The policy change that most helps the quick, effective treatment of WorkSafeBC claimants is the removal of the need for an active claim number.  As long as a claimant has a referral from their MD for the treatment and is within 8 weeks of their injury, I can treat them and have a reasonable expectation of payment – even if the claim is later denied.  This eliminates a lot of delay and the need to try to get money out of the injured worker later.  Policy now allows me up to three treatments a week for 5 weeks with the submission of only one quick form.  The technology part of the improvement begins with the form which you can submit by fax – no mailing.  Then there is billing submission.  Paper billing and the time lags of snail mail made reimbursement ridiculously slow previously and small errors could move the ridiculous into the impossible range.  Waiting 30 to 45 days is long enough, but I had heard of 3-6 month waits.  The introduction of online billing made the process much simpler.  Submission is fast and easy, billing errors are less frequent and caught sooner.  All of these factors make being “a part of WorkSafeBC’s Massage Therapy network” a much more appealing.

What are the restrictions that still make the process difficult?  Treatment limitations are the big issue for me.  The time factor is part of that, though I must say it has been far less bothersome than I had anticipated.  The big issue is the, well, let’s call it the geographical restriction.  As a Massage Therapist our training emphasizes the idea of the body being a whole.  This is not the way WorkSafeBC sees the body.  They see the injured part and the non-injured part.  When working within the agreement therapists may only deal with the injured area.  On the surface this seems reasonable.  WorkSafeBC is trying to avoid having undo advantage being taken and limiting their responsibility to the workplace injury.  The difficulty, as a therapist, is ignoring the complications of the initial injury that are causing pain and dysfunction for the worker.  I need to change my focus from improving the overall well-being of my patient, to restoring function in one part.  It seems a subtle difference but it is a difficult shift to make.  Reinforcing this shift is another of WorkSafeBC’s policies – get the worker back to work.  Again, a reasonable goal for a corporation but sometimes more difficult for a health practitioner.  

For all the limitations the thing I like is the challenge.  The above mental gymnastics and regional restricts are the less joyful part of the challenge; the injury assessment and restoration of function being the more joyful.  WorkSafeBC clients the issues are generally acute, so I get  to use types of assessment and treatment rarely called for in my other work.  The focused treatment and the newness of the injuries is a more intense and dynamic process, which adds variety to my practice.

 

 

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Integration, hooray!

| November 23rd, 2011 | No Comments »

Yesterday I got an email from one of my clients asking if  “I would be open to communicating” with her chiropractor.  I almost swooned with joy – okay, not really, I’m not much for swooning, but I was really excited.  This type of request doesn’t come very often but I am always happy to receive them.  

Most often we allied health professionals work in a bit of a vacuum.  We have only our clients recollections to inform us of what other treatments they are receiving.  Client feedback is helpful for understanding their feelings regarding progress and how their bodies experience and respond, but not so helpful in determining what another practitioner actually did, nor what they intended by doing it.

By habit. I always ask about other practitioners my client’s are seeing.  When they are receiving concurrent treatment I will often ask when they last saw that practitioner and what they work they did.  I have often determined my approach based on this feedback.  If I know their chiropractor has gotten a good re-alignment I won’t focus on my own tools for structural alignment, I will focus on soft tissue support.  If their physiotherapist has been working on nerve mobilization in the neck and shoulder I may choose supportive back work and joint mobilization to complement.  The problem is that some clients recollections don’t provide me with those insights – or I fail to inquire – and a chance to improve the quality of care I give my clients is lost.  Even worse, we practitioners may overwork an area by compounding treatments, which is as detrimental as not working the area at all.

I believe strongly in the need for increased communication between practitioners to improve the impact of all of our work and ensure that patients receive the most efficient and effective care.  Thanks to that client and I look forward to the collaboration.  I will use this reminder to increase my initiative in communication, so that I am walking my walk, not just talking my talk.

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Christmas Aromatherapy

| November 9th, 2011 | No Comments »

This is my shortest post ever – just a heads up really –

I am offering some specially priced packages of my aromatherapy products for Christmas – come see what’s on offer….

I will also be doing an order with my supplier for those of you wanting your own essential oils or related products on November 18th so contact me with your wishes…

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What is Epigenetics?

| November 7th, 2011 | No Comments »

I love CBC radio.  On the weekend I was listening to “Quirks and Quarks” and a discussion of epigenetics caught my ear.  Naturally, I had to find out what this things was and how it works.

For many years the research into autoimmune diseases and chronic conditions like cancer has focused on lifestyle and environmental impacts.  These diseases have a heritable component but they are not absolutely genetic, leading researchers to try to identify why and this has led into the field of epigenetics.  Epigenetics looks at the small markers that attach themselves to our DNA, especially in utero and in early life.  These markers do nothing to change the DNA you are going to pass on to your child, they simple alter how that DNA expresses itself.  Think of them as the controllers – they can turn things on and off or make things louder or quieter.

In this new field evidence is beginning to show how things like childhood poverty, child abuse and mental illness may have physiologically identifiable marks without changing the DNA.  Further, exposure to certain substances can also create epigenetic changes even late in life.  Many of the substances considered carcinogenic act this way.  They do not alter your genes, they turn on, or turn up, genes you already have (‘genetic predisposition) increasing the growth and success of cancer cells.  This brings in the fact that they can not affect genes you do not have and if you have the gene and nothing turns it on, you won’t experience the effects.

I believe that I have seen this in action in my family.  My maternal grandfather and both of his daughters (my Mom and my aunt) have died of very similar, very aggressive lung cancers – but not my uncle.  In the cases of my grandfather and my mother they also died at about the same age (51 and 52), but my aunt survived until she was in her middle 60’s.   Strong genetic evidence – early onset, aggressive, similar patterns of meta – why did my aunt live the extra decade?  I believe the simple answer is – she didn’t smoke.  My grandparents and parent were smokers meaning life long exposure to the carcinogens in cigarettes.  My aunt, though she grew up in a smoking household didn’t smoke herself.  Epigenetically speaking, she didn’t turn up the gene.  With my uncle, he has passed his early fifties, and is a non-smoker, so the question is, did he get the gene at all?  Time shall tell.  To contrast this heritage, my maternal grandmother smoked her entire life, and lived until 80, never getting lung cancer.  No gene?  Seem so.

This is excellent reason for me and my sister – we can’t change our genetic inheritance (and there is not current test for a lung cancer gene, though they do know there is one) but we can choose our lifestyle.  Neither of us has ever smoked, neither of us drink as heavily as our parent or grandparent, we eat healthy diets with lots of fruits and veggies, and my sister (not so much me) has kept her weight low.  We our doing our part to ensure the volume stays down on our genes, only time will tell if we succeed.

On the human level the field of epigenetics brings weight to our life choices adding to the pressure many feel to “live well”.  The weight of a healthy lifestyle becomes a punishing burden as every choice seems to have dire effects not just for themselves but their children.  Women especially receive barrages of information and direction on what to eat, drink, and expose themselves to during pregnancy and breastfeeding.  I have felt that pressure, but ultimately I try to remind myself that I can only do my best and the stress of trying to manage everything carries as many negatives as a lot of the things we try to manage.   I also try to remember that this gives me power, I can impact how my body acts, I am not at the mercy of my genes, how I live, and how I teach my children to live will change what happens to us. 

From the perspective of the medical field epigenetics creates a field of unique, crafted interventions that has never existed.  We can begin to more clearly understand the most profoundly impacting life events and behaviours to allow both early intervention or to create uniquely personal watch lists given our histories.  How intriguing.

 

LINKS: 

 

epigenetics and poverty

nurturing rats and epigenetics

epigenetics of bipolar and schizophrenia

epigenetics of child abuse

 

 

 

 

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