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98 m a s s a g e & b o d y w o r k n o v e m b e r / d e c e m b e r 2 0 1 8 technique THE SOMATIC EDGE Understanding Inflammation's Progression By Til Luchau Unless you've really been out of the loop, you've surely heard inflammation is to blame for almost every known malady. Or at least, that's what the diet, supplement, and self-help ads claim. But, even if the health-care marketplace has overhyped and oversold inflammation in its relentless search for the next big thing, it's no exaggeration to say inflammation plays a key role in a wide range of conditions—from depression to tendon pain, fibromyalgia to cancer, and joint problems to aging itself. 1 For massage and manual therapists, inflammation can be puzzling with its many different types, manifestations, and mechanisms; its impossibly intricate physiology (Image 1); and the numerous (and often conflicting) views on how we should (or shouldn't) work with it. For example, beginning massage therapists are usually taught that inflammatory conditions (such as acute injuries or swollen joints) are strict contraindications to direct massage. But many experienced practitioners will quietly confirm that careful, pressure-based work, sometimes directly with inflamed areas, can often be beneficial. (However, I'm not recommending you try this based solely on what you're reading here; don't risk worsening your client's pain and inflammation without specific training and supervision.) There are also bigger questions about the nature and function of inflammation that might influence the way we think and work. What roles do the brain and nervous system play? How do psychosocial factors (such as stress or depression) play in to inflammation? Could pain itself be a type of inflammatory response? Let's start by reviewing some inflammation basics. In later columns, I'll dive deeper into specific questions, including how we, as manual therapists, can work with inflammation in helpful ways. INFLAMMATION IS GOOD Inflammation is simply the immune system's tissue protection and repair response. It can be triggered by injury, infection, or irritation. Inflammation is necessary and good: though it can be uncomfortable, without inflammation, the body can't protect or heal itself. Normally, inflammatory responses are self-limiting, and wind down when their protection and repair tasks are complete. WHEN INFLAMMATION TURNS BAD Problems happen when there is either: • Hypoinflammation, such as when a compromised immune system can't fight an infection or heal an injury; or • Hyperinflammation, which can happen when either immune reactions are out of proportion to the threat (as in allergic reactions or autoimmune disorders) or when normal inflammatory reactions don't resolve and become chronic. Chronic or unresolved inflammation is implicated in an ever-lengthening list of conditions, including asthma, Alzheimer's, depression and mental illness, hypersensitivities, rheumatoid arthritis, metabolic syndrome, and certain cancers. Inflammation is not only a factor in nearly all chronic diseases, but also in nearly all musculoskeletal complaints, including chronic pain. 2 PROGRESSION OF INFLAMMATION Healthy inflammatory responses progress over time, moving through acute, repair, and adaptation phases (Image 2). Though many of these functions happen simultaneously (for example, resolution processes begin even while inflammatory processes are in their early development), each step sets the stage for the next. Acute Response Within seconds or minutes after damage, danger, or pathogen detectors trigger an acute inflammatory response, proinflammatory histamine and kinins increase vascular and cell permeability, and the affected tissues swell with plasma and immune cells (such as leukocytes). Cytokines (signaling proteins) recruit roaming immune cells; local warmth and redness (Image 3) indicate that the active inflammatory responses are at work; and pain and tenderness (from nociceptor irritation by proinflammatories, pressure from swelling, and protective reactions) help guard against further strain or mechanical distress during this initial phase. Repair Within hours or days, specialized cells (such as mononuclear cells and macrophages) begin the process of degrading and removing damaged or diseased cells. Once unleashed, these destructive processes are kept in check by innate anti-inflammatory and pro-resolution mechanisms to minimize "bystander" damage to other tissues. 3 Simultaneously, fibroblasts (which

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