Posts Tagged ‘continuing education’

Some gutsy learning

| May 26th, 2014 | No Comments »

vis·cer·al

adjective

  1. of, or relating to, the viscera
  2. relating to deep inward feelings rather than to the intellect

synonyms: instinctive, instinctual, gut, deep-down, deep-seated, deep-rooted, inward


 

 

I found this definition online and it perfectly encapsulates the nature of the course I went on this weekend. The course was called Visceral Manipulation I and both of the definition options above speak clearly to the nature of the work we did this weekend.

 

The course reviewed the anatomy and physiology of the internal organs – and reminded me that the lungs, heart and brain – with all their accessory bit are a part of that viscera. Our focus though was on the gut organs this time. The other definition is very appropriate to as the work requires that you use your knowledge of the structure of the body and then release it to simply feel the body. I knew going in that for myself the need to be patient and quiet my mind in favour of listening to my body would be my greatest challenge.

 

I am very aware, with a kind of chagrined pride, that I tend to over-think things at times. I often have said that I am more comfortable in my mind than in my body – but I have also said that my education and practice as a massage therapist has balance that to some degree. This weekend was, for me, another step toward embracing that balance. I do not think that I will ever be someone who first speaks to how they FEEL, I suspect I will always first go to the place of THINKING, but I do believe my life is richer for the fact that I strive to improve the balance between the two.

 

What is all this work for anyway? What will it help and might you be one of the people that experiences this work when next you are on my table. There are many indications for this work, some are emotional or life related (stress, depression, anxiety), many more physical – including digestive issues, disease process or history in the body – especially those where organs have been damaged or altered – right through to pain patterns in the body, especially those that are persistent and respond to, but do not resolve, with direct massage. Quite a few of you might just be finding yourself experiencing something a bit different in the near future. If you are interested in this work specifically feel free to ask more when you are in next time or to drop me an email or call.

 

For myself, I had an interesting time on the receiving end of all of this work and will be bringing some of treatments into my own self-care regime. I am interested to see the way this subtle and progressive work unfolds within me over the next weeks.

 

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August newsletter

| August 20th, 2012 | No Comments »

Modalities Massage Therapy

August Newsletter

 

Dear clients, This Thursday, August 23rd, is the deadline for aromatherapy orders.  Check out the webpage on direct orders for the short list of products and pricing.  Contact me by phone or email to place your order. As always, orders should be in within a week and I will contact you regarding pick-up. Beginning in September there will be some small changes in my work schedule.  I will be teaching infant massage at Mothering Touch again but on Wednesday mornings and I will no longer be working at Achieve Health Monday and Wednesday mornings.  In terms of hours here at Modalities there will be only small changes and a continuation of the ‘temporary’ addition of Tuesday mornings.  New hours as of September 1/2012 will be:

Monday: 10am to 6pm Tuesdays: 10am to 4:30pm; one 7 pm appointment Wednesdays: 12:30pm to 4:30pm Thursdays: 9am to 4:30pm; one 7 pm appointment Friday: 10am to 6pm

I have been doing some blogging lately and wanted to share those thoughts with you. The following links will take you to them: food and drug efficacy and DNR and final wishes.

As we move into the fall I hope that we all have the opportunity to enjoy some more warm weather and sunshine. For those of you coming under the influence of school I hope your return to classes goes smoothly.

Best wishes,

Sheila Hobbs, RMT

250-361-5246

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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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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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BC Generations – onsite visit

| October 21st, 2011 | No Comments »

The last step in the initial intake for participation in the BC Generations is to do the on site visit.  The visit was very quick, I don’t think I was even there 20 minutes.  I arrived a few minutes late (sigh) but was quickly signed in and there was the standard double checking to ensure I was who they thought I was by a young man at the front desk who had a package with my name and lots of coded stickers to put on my forms.    He gave me my blood and urine lab form and directed me to give my samples before the end of November.  He then led me to an adjacent room divided  into separate cubicles where a research nurse greeted me.

The nurse asked me a series of screening questions (pregnant – no; hand arthritis – no; pacemaker – no, etc to ensure they could do all the tests and get the right outcomes.  She then got to the tests.

First, my blood pressure and heart rate, twice, of course.  All good in the blood pressure department.  Next was a revisit of the waist and hip measures (only once) where I discovered that I had been too precise in following their waist measurement instructions – I would have like it they had used her explanation – measure at the belly button!  Then height, both standing and sitting (this will let them determine spinal shortening).  

Next – all the cool toys!  First a grip device – where I discovered that my left hand is puny and my right is super strong – enough to offset the left’s puniness in the combined total.  I guess I can now tell clients I have one strong hand when they comment on how strong my hand are!  After that, my most dreaded machine – BMI calculator.  I am not going to share the exact results of my weight, BMI and percent of fat.  I will say that I definitely have some losing to do!  And some really detailed motivational number.  I now know that my body fat is fairly evenly distributed (though my arms are the fattest – who knew!) and that my right leg and left arm are fatter and stronger than their opposites.  Finally I stuck my foot in this machine that assessed the bone density of my heel (calcaneus) bone.  Here again was some good news – very dense bones.  In part this has to do with weighing so much (the bones get denser to support your mass), and with being on my feet a fair amount for work (lots of weight-bearing). 

The sum up is that I am as fat as I thought, but I am not doing too bad in terms of strength, blood pressure and bone density.  Basically I am healthy enough that I can  lose the weight to fix the other measures with relative ease.  That is my own personal project though – not the BC Generation’s responsibility.

There you are, that is the total of my experience to date.  In future they may phone to ask me to participate in specific studies (which I can decline if I choose) or to come back in for a repeat of the on site visit I had (or perhaps some similar type of visit).  They now have my permission to check in on any testing results I get within the medical system.  Not to big an impact on my life given how much could come of it – an hour or so of my time now to provide information for studies over the next 25 years.  

 

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BC Generations – the forms

| October 20th, 2011 | No Comments »

My first step as a participant of the BC Generations project is the intake form.  This is a fairly thick bundle of papers you receive in the mail a few days after signing up.  Along with the intake you receive information about the project, its purpose, and a release for you to sign saying you understand and agree to participate. 

Going through the form probably took 20 minutes.  Most of the questions are quite easy to answer, though I found it interesting they always give you the option to say “I don’t know”.  First you give your vital statistics (name, age, gender, etc.) you answer questions about you lifestyle (servings of fruit and vegetables in a day, amounts of exercise within a week and its intensity) and other health habits like amount and type of drinking and smoking.  These are easy, you just have to think about your habits a bit – which I found a bit revealing.  For instance, I discovered that I do not eat as many fruits and vegetables as I thought.  My activity level, which I knew was low, registered even lower as so many of the things I do involve shorter spans of activity than they were looking for.

The next section if the intake is family history and make up, along with the medical stuff.  You are asked to identify you ethnic background and where your parents and grandparent were born.  A bit more thought there, but still pretty easy.  They also ask about the make up of your family of origin (who you grew up with) and your current family and relationship status (married or not, kids or not, etc).  This section finishes with the questions I expected sooner – your history of illness (or not) and that of you parents and biological siblings.  Here things get a bit more specific and you need to think a bit – for me my sister was the trickiest as I have never had been a caregiver for her.  Depending on how close you are to your siblings (who they lump together in one set of questions) you may have to ask them – or choose the “I don’t know” box.

The final section of the questionnaire is the one I have been dreading.  Having put on weight lately I was dreading taking measurements and writing down my weight numbers.  This part is a bit of a bother as they want you to do two measurements of both and I found the waist location description not great.  I made it  through this though I disliked the numbers as much as I expected.  

Overall, pretty easy.  I only had to go looking for one piece of information (the DIN of my prescription – and I am guessing most everyone would have to go reference that one) and the need to find a tape measure – and my dread – meant that the questions got answered a few days before the measurements got taken.  

 

 

Next – the on site intake….

 

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BC Generations Project

| October 7th, 2011 | No Comments »

I have signed up to be a human lab rat. The BC Generations Project is a 25 year study hoping to follow 40,000 BC residents between the ages (at the start) of 35-69. The BC Generations Project is part of a greater, Canada-wide project called the Canadian Partnership for Tomorrow that is hoping to reach a total of 300,000 participants in total. I will be chronicalling my progress through this project over the time – I don’t guarantee the whole 25 years, but at least the first few.

The BC Generations project will use the data and biospecimens collected in aa number of studies over the next decades that are all attempting to understand how to prevent cancer and other chronic disease. I love this project. I also feel bad for it. The researchers are looking to capture some of the most elusive data out there. Trying to connect which specific part of your life increases your risk would be difficult. Trying to find out how the different aspects of you life act together to increase or decrease your risk of disease over someone else is even more difficult. They will have to try to tease apart genetic, environmental and behavioural factors and decide which are the lynch pins. With the real possibility that there are no lynch pins – but rather an calculus level equation of factors that add, subtract, multiply and divide to land you with a negativeor a positive.

This is the reality of medicine as we are coming to understand it. No one thing is the answer, all things are the answer – and your answer is different than anyone else’s.

Initially, BC Generations will be collecting asking lifestyle questions, collecting physical data (height, weight and waist/hip ratio) and physical samples (blood, urine, and saliva). This data and the physical samples will be stored together for future use. By entering the BC Generations Project participants also allow researchers access to their health records and they may be contacted in the future for follow-up.

 

By collecting together such a large pool of samples spanning ages, genders, locations and lifestyles the BC Generations Project and the Canadian Partnership for Tomorrow is creating a resource of incalcuable value to both present and future medical researchers. Data can be extracted for fair-haired, healthy eating women across Canada, or 48-year olds with a history of maternal diabetes that live in urban settings, or 69 year-old males with heart disease in their fathers. The options are myriad and when you add in the ability to track progress over time you have a tool for the future that will offer the future a gift of knowledge about how time, behaviour and family history come together.

My first step will be to fill out the intake form (book) prior to my physical assessment. Next I have an appointment to have samples taken. From there? Who knows, but it should be a heck of a ride. I get the opportunity for a free health assessment and a chance to contribute to the evolution of preventative medicine in my province and my country.

If you want to volunteer, or just learn more about the project, go to their website.  Give some thought to what a wonderful legacy this could be.  As an orphan whose parents both died middle-aged of cancer, I consider my participation to be a gift to my son and his future children (should he have any), a gift I may never have another opportunity to give.

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