Musculoskeletal Conditions and Resilience

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Resilience is fundamentally about the ability to adapt and function effectively within a changing environment. This concept is often discussed in the sports world, where resilience can impact performance, recovery, and overall well-being (Den Hartigh et al., 2022). Importantly, these same concepts of resilience can be applied to promote musculoskeletal health across the lifecourse. Within the framework of enactive allostasis, four distinct resilience phenotypes are identified: fragile, durable, resilient, and pro-entropic (Harrison et al., 2025). These phenotypes exist along a continuum that reflects a spectrum of adaptive strategies in response to stressors. This continuum is characterized by varying outcomes, progressing from allostatic (over)load in the fragile and durable phenotypes, to allostatic recovery in the resilient phenotype. Each phenotype is shaped by a combination of biological, psychological, social and environmental factors.

Key aspects of this understanding of resilience:

  • 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 resilience phenotypes can be used to develop context-specific strategies that foster adaptability and resilience for people in dynamic environments. This could include a multidisciplinary approach focusing on lifestyle factors that enhance resilience like getting restorative sleep, stress management, and engaging in regular physical activity (Artz et al., 2024; Langevin et al., 2024; Mudd et al., 2025; Nijs et al., 2024; Pitcher et al., 2023).

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).

Glossary of Terms

Allostasis - The flexible regulation of physiology, underwriting maintenance of variables within specified ranges by pre-emptive responses based on current and predicted future physiological states, external environments and behavioural goals.

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).

Interoception - The processing of sensing and perceiving sensory signals relating to internal bodily states.

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

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