Dr David McGrath

Spine Physician

MB BS (Hons) FAFOM, RACP, FAFMM
Master of Pain Medicine

1. Focus on the diseased or damaged component

2. Focus on the cause of the damage, as in environmental inputs

3. Focus on the structural processing of the inputs or causes

Each of these approaches has a utility at specific times. Let's look more closely at the advantages and disadvantages.

Focus on the diseased or damaged component

This is often thought of as the medical model and might consume 99% of our efforts. Most modern imaging is focused on seeking static pathology. (CT, MRI, XR's). Once identified, interventions are directed at the identified abnormal components.

Its best application occurs when the causative input has ceased, such as an acute trauma or limited exposure to a toxic input. This also implies that no further causative input processing is necessary. However the damaged tissue will cause disruption to processing other non causative inputs. What is sought by this approach is the return to normal component properties. If this is unsuccessful, then a focus may need to return to one of the other strategies.

The method fails when there is no unique or major component fault leading to poor function. That is; the fault is multi-component.

There is also the difficulty of identifying a primary pathology among other identified pathologies which are innocent bystanders. Pathologies can also relate to historical events or natural aging, having no relevance to current dysfunction.

Having identified a unique source of disorder there remains the challenge of successful intervention.

Focus on the cause of the damage, as in environmental inputs

This is the classical causation approach. The system cannot cope with the input. Removal or modification of the input leads to a return to stability or cure. Success is dependant upon correct identification of the offending input and the ability to intervene. For example, exposure to the influenza virus may be of no value if the input cannot be contained. Internalization of the virus makes eradication difficult. We have more success with bacteria as specific poisons have been developed (antibiotics) which reduce exposure by selective destruction. Low level toxins such as carbon monoxide may not be identified or ubiquitous, making intervention a social problem. There is also the possibility of multiple inputs overwhelming usual adaptive measures. This makes the identification of offending inputs difficult; as by themselves they are insufficient to create disorder.

Focus on the structural processing of the inputs or causes

This is the least understood of the 3 approaches. Inputs are processed according to our structural history (ontogeny) which begins at conception (genetic heritage). In other words, causes have a degree of uniqueness dependant on the individual. This brings us to the concept of structural compatibility. If the input can be processed without component damage, that particular input is not a cause of ill health. If inputs are resistant to modification or are ubiquitous then a focus on processing could have major benefit. The focus changes from "what is wrong?/what is the cause?" to "what am I doing wrong?". Unfortunately this is just as difficult, in most cases, as finding a cause or identifying relevant pathology.

If we knew all of the normal processing pathways and were in a position to identify abnormal processing of common inputs we could create a diagnostic system based upon this information. Treatment would be directed at restoring normal processing pathways.

In medicine the lack of an identified cause or relevant pathology often leads to the expression "functional". This implies poor processing of inputs which normally do not leading to pathology or symptoms. It can be used in a derogatory sense, as in a personal failure.

I believe we need to look more closely at this issue without the negativity.

As with the other approaches, there are pitfalls. Incorrectly identifying a faulty pathway will lead to an ineffective intervention.

In Summary

There are 3 main ways to view a problem. We can consider that faulty components within the system are the problem. We can consider that we are subject to inputs or causes which damage components and lead to faulty function. Lastly we can consider that we lack the necessary function or organization to deal with certain inputs leading to component damage. There is circularity in this thinking which is unavoidable but occasionally forgotten. Function and component properties mutually determine each other within the wider context of environmental inputs. They are really different facets of a wider viewpoint, which can be difficult to maintain. Nonetheless failure to do so leads to disease. (dis-ease or lack of comfort)

There are times when all 3 facets of our existence need to be considered concurrently.

A simple mechanical analogy.

A motor car is overheating. The radiator or cooling mechanism is insufficient (pathology), the cause is a hot day, and the engine needs tuning (processing of fuel and air inputs). Interventions might include, attention to the radiator, avoiding hills (reduces heat production) or an engine tune up. Failure to intervene leads to engine damage and more focus on damaged components. Generally the more "upstream" the intervention with respect to the causal inputs (either in time or component processing) the greater the efficiency. A tuned engine is more effective than an efficient radiator and "prevention is better than cure"

This understanding invites a general definition of health.

A healthy system is able to process all of its usual inputs without any damage to its components. Health is thus environment dependant.

Typical Interventional Strategies

Causal

Infection Hygiene, toxic output control, noise abatement, car safety, healthy diet, avoidance of extreme sports, occupational safety measures

Component

Surgery, strength exercise, massage, electrical modalities, mobilization, manipulation, drugs

Processing

Skill training exercises, learning, perceptual training, Alexander technique, Feldenkrais.

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