mechanism behind the increased rate of type 2 diabetes in older adults is not currently known, but it is theorized that increased inflammation combined with changes in body fat distribution, as well as decreased physical activity, may result in increased insulin resistance and ultimately increased rates of type 2 diabetes. As body fat in ectopic storage locations increases, so does insulin resistance (Goodpaster et al., 2000). In fact, increased levels of both visceral adipose tissue in the abdomen and intramuscular fat are independently associated with increased levels of insulin resistance (Goodpaster et al., 2000). In a seminal study, Goodpaster et al. (2000) demonstrated that intramuscular fat is similar to visceral fat in its risk for insulin resistance. An increase in insulin resistance is important not only for the increased risk of developing diabetes but also for the increased risk of muscle and mobility dysfunction associated with insulin resistance. Far from being an isolated blood sugar problem, insulin resistance has been associated with a decline in muscle mass, decreased muscle strength, and accelerated aging (Barzilai et al., 2012). Further compounding the problem of age-related insulin resistance, aging also leads to impaired beta cell function and production of insulin in the pancreas. The beta cells are the producers of insulin, and impaired function only compounds the systemic problems associated with insulin resistance (Apostolopoulou et al., 2012). Many of the changes in the endocrine system, which sends chemical messengers throughout the body, have direct implications for changes in the interstitial system. improve their range of motion (ROM), and to increase energy and activity tolerance by improving their interstitial system response (R. Jordan, personal communication, March 10, 2020). The predicament related to focusing on the interstitial system is that it is not well understood beyond the cadaver, and an understanding of the sclerotic changes associated with GVHD is limited to our knowledge of the living interstitial/myofascial system; only partial models of this body system have developed with live tissue (Myers, 2016; Tkaczyk et al., 2019. According to Bordoni and Marelli (2017), “There are numerous articles in the literature dealing with the myofascial system . . . yet, we still do not have a thorough knowledge of its functions, just as there is no shared vision on how to classify it” (p. 110). Not one year after this problem was defined, Benias et al. (2018) answered the demand for a unified vision by proposing that the myofascial system, the interstitial space between dermal layers, and the lymphatic space need to be classified as an organ, the interstitium. There is a connection between the myofascial system and the brain, the body and emotion (Bordoni & Marelli, 2017). Physical therapy practitioners have very recently explored mind–body connections and manual therapies related to the interstitium, and both occupational therapy and physical therapy have proven the benefits of meditation related to pain performance and improved mind–body connections (Davis, 2017; White et al., 2020). Many developing manual therapies can help with the myofascial system, as can new parameters for measuring ROM improvements in GVHD (Bordoni & Marelli, 2017; Davis, 2017; Inamoto et al., 2014). Holistic practitioners with skill sets in CHAIH, such as manual therapies and psychosocial interventions, should work together to address both the physical and emotional aspects of function to optimize treatment (Bordoni & Marelli, 2017). Physical therapists are beginning to make connections between the mind and the body, and how emotions relate to the interstitial system, body pains, autoimmune responses, and ROM limitations with sclerodermic conditions (Ballantyne et al., 2019; Bordoni & Marelli, 2017; Myers, 2016). Occupational therapy practitioners are exploring mindfulness therapies for their many benefits, and evidence is emerging to show how physical and emotional pain relate to one another,
tissue , or within the muscle, which is also known as intramuscular adipose tissue (Addison et al., 2014). Increased adipose storage in ectopic locations may be one reason for the increased systemic inflammation seen with aging (Apostolopoulou et al., 2012). Inflammation may contribute to the development of a host of age-related systemic diseases such as diabetes, cardiovascular disease, and dementia (Davan- Wetton et al., 2021). Aging is associated with an increase in numerous proinflammatory cytokines, or chemical messengers, that circulate, acting as hormones throughout the body. Chronic increases in proinflammatory cytokine levels in the blood are among the most important physiologic correlates of metabolic syndrome, and increased rates of inflammation are related to both aging and inactivity in older adults (Addison et al., 2011). It is currently unknown if the increase in inflammation seen with aging is a direct result of the aging process or if it is caused by increased levels of inactivity and comorbid conditions often seen with aging (Addison et al., 2011). What is known is that older adults who have higher rates of chronic inflammation compared to their peers experience a larger loss of lean tissue and muscle strength and are more likely to experience mobility limitations and disability than those who have lower rates of chronic inflammation (Addison et al., 2011). Increased levels of inflammation are also associated with increased insulin resistance in older adults. The incidence of type 2 diabetes mellitus rises with age and may affect up to 30% of older adults (Gunasekaran & Gannon, 2011). The underlying Interstitial system changes The interstitial system comprises the fascial system, the lymphatic system, and adipose tissue. Therefore, for the purposes of this course, the interstitial system can be considered to be an extension of the endocrine system. The fascial system/ interstitium is difficult to study because it is anatomically different in live tissue compared to what occupational and physical therapy practitioners learned in cadaver anatomy during their training. Until now, understanding the interstitium was like examining a jellyfish out of the water, as fascia was only examined postmortem, where it acts completely different than in a living person (Myers, 2016). In a cadaver, fascia looks like webbing or papery-like material; in living tissue it is stretchy and surrounded by interstitial fluid. One common misconception about fascia throughout the literature is that fascia surrounds all tissue like plastic wrap; rather, fascia and cells are embedded in one another and create the interstitial spaces (Davis, 2017). Our understanding of the interstitial system and fascia is still in its infancy, as therapy practitioners who are ready to measure the effectiveness of interventions are still waiting on crowdsourcing to get more data on what an actual map of a normal human fascia would look like in living tissue (Myers, 2016; Tkaczyk et al., 2019). For now, physical and occupational therapy practitioners must rely on their vision and sense of touch, observing only the superficial dermal layer’s response to tissue mobilization, along with patient reports of “better,” “worse,” or “no change” after an intervention. Or they can use a handheld ultrasound system to assess deeper dermal layers, but this is expensive and time consuming (Tkaczyk et al., 2019). In the clinical world, there are content providers who are well known for their specialized training in manual and hands-on complementary health approaches and integrative health (CHAIH) treatment techniques, publications, and trainings in the treatment of fascia as well as the myofascial and interstitial systems. But most of the data they use are anecdotal, experiential, and/or from books by respected authorities (Davis, 2017; Myers, 2016; Tkacyk et al., 2019). Patients with graft versus host disease (GVHD), a condition that includes induration of fibrotic lesions throughout the interstitial system, seek out practitioners with such certifications to help address painful symptoms associated with tissue induration, to
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