Whole-Person Health: An Enactive Allostatic Framework for Musculoskeletal Conditions
/Whole-Person Health: An Enactive Allostatic Framework for Musculoskeletal Conditions
The current approach to musculoskeletal conditions often focuses on isolated symptoms—a sore knee or a tight back. However, effective care must move beyond this reductive and mechanistic lens. We need to adopt a whole-person approach that targets the full spectrum of factors influencing an individual’s health and well-being, including lifestyle factors, social support, and integrated physical and psychological well-being (Mickle et al., 2023; Rabey & Moloney 2022; Rojas-Valverde et al., 2025; Tanner et al., 2025).
This is where the concept of enactive allostasis becomes a valuable lens for assessing and treating musculoskeletal conditions. Derived from the active inference framework, enactive allostasis focuses on how the body and mind actively adapt their physiological state in the face of constant change (Harrison et al., 2025).
Allostatic load from chronic stressors such as psychosocial factors, previous injury, inflammation, etc. can diminish resilience, contributing to the emergence and maintenance of musculoskeletal conditions. Essentially this approach is looking at the system as a whole, rather than each piece in isolation (in other words, the whole is greater than the sum of its parts).
Allostatic Load and Resilience
The enactive allostatic framework offers a flexible understanding of musculoskeletal conditions by emphasizing adaptability and complex systems. When an individual faces chronic stressors—such as ongoing psychosocial challenges, previous injuries, or persistent inflammation—the cumulative wear-and-tear is referred to as allostatic load. This load can diminish the body's natural resilience, contributing to the emergence and maintenance of chronic pain and musculoskeletal conditions.
In essence, this framework looks at the system as a whole, rather than each piece in isolation. It affirms that the whole is greater than the sum of its parts—a change in one area (e.g., sleep quality) affects the entire system.
Four Resilience Phenotypes
Within the enactive allostatic framework, individuals can be categorized into four distinct resilience phenotypes. These phenotypes exist along a continuum that reflects the varying outcomes of adaptive strategies in response to stressors (Harrison et al., 2025).
Four Resilience Phenotypes:
Fragile: Characterized by significant allostatic overload in response to stressors.
Durable: Associated with allostatic overload, but with a greater capacity to withstand stress before significant dysregulation, though not adapting positively.
Resilient: Demonstrates effective allostatic recovery, meaning an ability to bounce back from stress and return to a stable state.
Pro-entropic: A phenotype at the most adaptive end of the spectrum. Pro-entropic individuals not only recover from stress but also exhibit increased allostatic accommodation, or "growth," meaning they become more resilient and adaptable in the face of future challenges.
Knowledge of these four phenotypes can be directly applied to better understand musculoskeletal health across the entire lifespan. They help clinicians recognize where an individual currently sits on the spectrum of adaptability.
The 'ball and cup' analogy provides one of the clearest visuals to help understand resilience of a biological system. A complex system's stability is linked to the depth of the basin. Building resilience (the dashed line) in a system makes it less likely to be pushed past a tipping point into a dysfunctional state. In terms of musculoskeletal conditions perturbations that may push the system towards its tipping point include trauma, systemic inflammation, physical inactivity, poor sleep, and psychological factors (such as depression, stress and anxiety symptoms).
Fostering Adaptability and Resilience
Adopting this whole-person approach informs the development of context-specific, multidisciplinary strategies that aim to shift individuals toward a more resilient end of the spectrum. Successful treatment approaches are effective because they foster adaptability and resilience through a number of interconnected physiological, psychological, and social processes (Langevin et al., 2024; Nijs et al., 2024; Pitcher et al., 2023; Shepherd et al., 2025).
These multidisciplinary strategies can include:
Mind-Body Interventions: Reducing the perception of threat and improving emotional regulation.
Physical Activity, Exercise and Movement: Increasing physiological capacity and promoting active coping.
Massage and Manual Therapy: Modulating the nervous system and reducing acute allostatic load.
Multimodal Therapies: Combining approaches to address biological, psychological, and social factors simultaneously.
Glossary of Terms
Active inference - A normative framework that elucidates the neural and cognitive processes underlying sentient behavior, beginning with first principles. This framework posits that perception and action work in concert to minimize a shared functional known as variational free energy.
Allostasis - Refers to the body's capacity to maintain stability by actively adapting to both internal and external environmental changes.
Allostatic load - The ’wear and tear’ on the body associated with chronically high levels of stress and arousal.
Enactivism - A perspective that emphasizes the active role of an organism in constructing and experiencing the world through its interactions with its environment.
Exteroception - Perceptual inference based on sensory signals originating from outside the body (e.g. vision, hearing, touch, taste, smell).
Health - A state of physical, mental, and social well-being and not merely the absence of disease and infirmity.
Interoception - The overall process of how the nervous system (central and autonomic) senses, interprets, and integrates signals originating from within the body, providing a moment-by-moment mapping of the internal landscape of the body across conscious and nonconscious levels.
Perturbation - An external factor that potentially interferes with the system’s behaviour.
Resilience - Refers in general to a system's capacity to recover, grow, adapt, or resist perturbation from a challenge or stressor.
Salutogenesis - The process by which individuals move from a less healthy state to a healthier state. The concept of salutogenesis emphasizes health factors that promote and maintain good health rather than focusing solely on pathogenesis.
Whole person health - Involves examining interconnections among all organs and systems of the body, as well as the effects of multicomponent interventions across physiological, behavioral, social, and environmental domains.
References and Sources
With over 15 years of clinical experience and extensive study of massage therapy research, I'm committed to creating resources that foster the professional development of massage therapists globally. Whether you're a seasoned massage therapist or a curious newcomer, this massage therapy glossary is here to be your one-stop shop for understanding terms as it relates to massage therapy. Additionally this post highlights a substantial body of evidence supporting the use of massage therapy in alleviating pain and enhancing quality of life across a range of health issues.
This is a selection of sources I used to help formulate my ideas based on over-lapping concepts from massage therapy, physiotherapy, chiropractic, osteopathy, lifestyle medicine and traditional healing approaches.
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