Hello, and welcome back to the fourth episode of the Focal Allied Health Practitioner Podcast. What we’re going to be doing today is we’re going to be looking at the effects of psychosocial stress on our patients. And we’re basically going to be looking mostly at neuromusculoskeletal impacts. However, we will sort of discuss other aspects as well, and you can potentially extrapolate some of these, aspects to, to other aspects of patient management and, and so forth. So, you know, stick around. Let’s have a little bit of a dive into psychosocial stress and yeah, what it’s going to do of your patients. We’re also going to have a bit of a look at musculoskeletal interventions and how they may theoretically impact a person’s ability to deal with stress and traumatic events. So that’s, that’s quite interesting as well. I think where we can, potentially be helping people with stress when we are doing musculoskeletal intervention and, so forth.
Okay. So let’s go to it. So during this episode, I’m going to be referring extensively to an article by Jos Brosschot. Now, excuse me, Jos, if I’ve just butchered your name, but basically he produced a paper which was published in 2017 in the European Journal of Psychotraumatology. And there will be a link to the paper in the show notes on our website. Now, as with Jos’s article, I will refer to psychosocial stress from here simply as stress. Now, stress is, as we probably are all pretty much familiar with stress is very much a killer. They reckon that something like 50% of sick days taken by workers are due to stress. And the risks for heart disease due to stress are at least comparable to those of smoking and obesity, which is pretty crazy. When you think about it, I’d, I’d never been aware that it was that much of a problem.
So, you know, if you can help your patients manage their stress better and deal with stress, then it’s, it’s equivalent to them stopping smoking or potentially losing weight, which is, which is pretty an amazing fact. I reckon, you know, stress is something that you really want to be able to do something about and, you know, try and manage, manage your patients stress if at all, possible to try and maximize their, their outcomes. Now, a pertinent point here, and something that I really want to emphasize is that prolonged or chronic stress is what damages health. So short term responses to stress are normal and completely harmless. Well, you know, maybe depends on if they happen repeatedly and repeatedly, but in which case, maybe that it becomes chronic stress, but certainly, you know, short term in response to a particular dangerous situation, you know, that’s completely normal.
It’s a physiological response, but what happens is that when you get these prolonged aspects of, of stress, that is what ends up damaging health. Because, you know, typically if you imagine we’re out in the jungle and you know, you’ve got the tiger, that’s, you know, running after you or whatever, obviously you, you have a very acute need for stress and you, you know, you deal with it either by running away from the tiger or fighting it and killing it, or by being eaten, you know, because if you’re eaten, you’re resolving the stress at no longer becomes a problem to you. But certainly, you know, if you run away or you, you kill the tiger or whatever, then you’ve dealt with the stressor and you know, your body can relax. But the trouble with our, our modern society and our modern life is that the stress just never goes away.
You know, if you’ve got work stress, you’re overloaded. It. It’s just, it’s not an, that just happens in the short term. It’s something that sticks around and persists. And so therefore they, or those aspects are going to be having more chronic effects upon people’s health. Now Brosschot makes the reference to his research where he found that, when angered people’s blood pressure returned to normal more quickly, if they had the option of extracting some sort of revenge on the cause of the action, sorry, the anger, which to me was actually very interesting that, you know, if you have some way of, you know, basically causing revenge or getting revenge, then actually your blood pressure, returns to normal more quickly. So it tends to reduce or stress. And the interesting thing that he found about that was that you just have to have the option.
People don’t actually have to exercise that option, but when given the option to, you know, extract some sort of revenge on the cause of the anger, that is what actually caused the reduction in blood pressure more quickly after the stressful event. So you can, you know, hopefully rely on the person’s Goodwill to not actually take revenge on the person. But, that’s, that’s, I think rather an interesting thing now further research found that, when blood pressure or sorry, that blood pressure returned to normal more quickly, if people are distracted from their anger. So this is another important point. It seems that this negative sort of rumination or this chewing over the anger event is what causes the prolonged stress response. So this and negative rumination can also elicit stress responses in the body prior to exposure to the stressor. So this is important as well.
And we can all relate to this, obviously, you know, if you, if you’re doing a, say a big talk and you’re nervous about doing that talk, then obviously what’s going to happen is you’re going to start getting stressed about that because you’re ruminating over it. And you’re chewing on that, that thought that you’re going to be exposed to this stress beforehand. And it starts to this, that the stress response within your body. So this, this is not good. And this is part of the problem where the chronic stress comes from now. They, as in Brosschot’s team, they coined this term called perseverative cognition as basically the constant or perseverative, thinking about negative effects in, negative events in the past or in the future. Now perseveration in itself is a, a very interesting term, very interesting concept. And when you get into neuroscience, you sort of hear more about this term perseveration and the easiest way to explain it that I think is thinking about somebody with obsessive compulsive disorder, because we’re all fairly, fairly familiar with that these days.
And we know that some people with OCD are unable to leave the house, basically because they, they think that, well, they worry that they’ve forgotten to turn the stove off, or they worry that they haven’t locked the house and they have to go and check 10, 20 times to make sure that the, the house is locked or they haven’t forgotten to turn the stove off or whatever. So that inability to break a thought pattern or in this case, a thought pattern, but can be emotional pattern. It can be some sort of neurophysiological effect event within in the body. So perseveration can be a normal event, but it can become pathological where you just can’t break almost like the reverberating loop that is happening within the nervous system. and so that’s what they’ve sort of defined here is that this per perseverative cognition is where people are just constantly thinking about negative events to either have occurred to them, or that could be, potentially occurring to them in the future.
And so this negative perseveration rumination has been linked to the increased heart activity and hormone responses. So, so this stuff changes the body and you know, those of us that work with the body, this shouldn’t be any sort of range and wonderful thing that we are sort of hearing about here. you know, you’ve all been aware of people who get tight muscles and so forth and, you know, increased tenderness and tightness within muscles and, and so on as a consequence of this sort of getting stressed and worked up about things, but it is having autonomic effects. It’s also having endocrine effects within the body as well. And so therefore is potentially having, a lot of, negative effects within the body as well. Now there’s this thing called negative bias and research has found that most people actually tend to have a negative bias in their thoughts.
And this therefore means that we tend to sort of catastrophic size if just left to our own devices and this rather interestingly links in with daydreaming and they found that positive daydreaming actually didn’t make people happier. So, you know, you can sit there and think happy thoughts all day. It doesn’t actually tend to make people happier overall, but negative and especially noteworthy is that mutual daydreaming makes people happier. So basically the idea that people are sitting around without something to focus on and just kind of daydreaming is really only going to end up with a situation where people are at best in a neutral situation, but more likely that’s actually going to have a negative impact upon them. So people who say are in chronic pain and they’re unable to work and they’re unable get out and, and do something productive and distract themselves. They’re potentially sitting there and ruminating and daydreaming about this.
And so even if they’ve just got neutral daydreaming where they’re just sort of thinking about things and, you know, not being particularly negative, that is still going to bias them towards a more negative outlook on life. And even if they’re sitting there with a positive daydreaming experience overall, that isn’t actually going to make them happier, it’s just going to maintain the status quo is what this research thinks. sorry. Suggests. So, so that’s, that’s very interesting and makes us realize that, you know, we need to be very careful about our patients and what they’re thinking about and what they’re ruminating on basically during the day when we are not, not seeing them. And you need to be careful as well as a practitioner about what sort of thought patterns, what sort of integrative things are you reinforcing when they’re actually in the office with you? So the way I tend to sort of describe this is, you know, if you have some, anybody that comes into your office and they’re in chronic pain, or if they’re in stress or, or whatever, and you start talking about the thing that is causing the pain or the, or, sorry, talking about the pain or talking about the chronic stress events, et cetera, that’s happening within their life, then you are potentially actually going to reinforce that negative cognition.
So Mrs Jones comes in and she’s a chronic pain patient, and you say to her, hi, Mrs. Jones, how are you doing? How’s that pain doing today? You know, what things have you done during the week? Oh, did that make your pain worse, et cetera? So what we probably should be doing as a practitioner is that we should stop asking them about their pain and start asking them out the increased function within their life. And so clearly on the first visit, you need to quantify the pain. You need to sort of try and work out where they’re at and you know, what’s going on in their life and where it hurts. And you know, what are potentially the, the pain generators within the person and, you know, what, what do you need to do to actually re reduce that and how you can clear that up for the patient, et cetera.
But once they’ve got, you’ve got that initial baseline information, it would be a really good idea to not discuss pain again, in the future with that patient, at least for a good period of time, you know, do a, do a course of care and then maybe do a re-exam where you reify the pain and so forth. But at the visits in the interim, ask them to things like, you know, what extra activities were you able to do since we saw you last? What, you know, what benefits did you get? How did you get on with doing these things and, and ask them about the positive things that they’re going to have done so that you shift that negative bias away from actually reinforcing those pain messages. So just be very, very careful about that. Now, it’s also very interesting to note that exposure to negative words has been shown to increased blood pressure.
So they did this with elderly people and they exposed them to like frail and falls and unhealthy and so forth. And they found that it actually increased blood pressure, whereas positive things like active, independent, and so forth with these older adults actually tended to lower blood pressure and actually had a positive effect. So this is also are very important when you’re in practice, be very careful about using too many negative words, make sure that you’re very positive and upbeats and reinforcing the, the positive outcomes that they’re experiencing, et cetera. Okay. Now, another very interesting thing was that this, this paper was, is describing how that you actually tend to have continued autonomic changes. So things like increased heart rate, even when you are asleep. Okay. So if you have something like a stressful event, that’s coming up, so say you’ve got to do a speech the next day, and you’re not a great public speaker.
You’re not happy about it. And you go to sleep. What will happen is that your stress responses will continue to be activated even though you are asleep. Now, this is very interesting because clearly this suggests that conscious rumination cannot be the only cause of the autonomic changes here. Unconscious stress appears to be an ongoing factor within the stress responses. Now, this sort of links on further where injured and, and even dirty animals have increased corticosteroid, which is a stress hormone within the body. So somebody being stressed, it can be as a consequence of them being injured, or even just being dirty and unwashed and so forth could potentially impact upon your patients. Now, for us, maybe the dirty unwashed is less of an issue, but we are dealing with people that are injured all the time. And so you’d need to realize that just the fact that the patient is injured is going to accentuate the stress responses within that patient.
And so therefore this is going to potentially be a complicating factor with management of that patient. So this basically suggests that the default state for stress is that stress is actually earned on by default and as such, you don’t actually need a stressor within the environment. So this is amazing. Really, we’ve always tended to think that what actually happens is that people will trot along and their stress responses off. And then what happens is they encounter a dangerous situation or a, a threatening situation or whatever, and the stress response kicks in, and then they sort of maybe deal with the stress and then they go away and then the stress response goes away. And that’s not actually what appears to be the, what actually appears to be the case is that the default, the, the stress response is switched on by default. And what happens is that your prefrontal cortex actually inhibits areas within the stress, sorry, that produce stress responses such as the amygdala and so forth.
But the prefrontal cortex only does that when it perceives safety. So just think about that, that we are wired to be stressed. And the only time we actually turn that stress off is when our brain is able to inhibit that stress response. And it will only at that stress response when it feels like it’s safe now as such a person who is confident and who is at ease at the world is more likely to be inhibiting their stress responses. And in contrasts an individual who’s hypervigilant and so on, or is always expecting danger or an attack, et etc, is going to find it much more difficult to feel safe. And therefore their stress responses are more likely to, remain activated. So people who have dealt with trauma within their lives that have lent to the situation where maybe in the, as, when they were, being raised and as a child and growing up on, they may never have actually felt safe.
And so therefore they never know what it’s like to actually feel safe. And so it’s going to be very hard for those people to actually turn off that stress response because their brain is so wired that nowhere is safe. And as a consequence, they are going to find it much harder to, to deal with that. And so on. So another thing is to think about, well, what actually happens within our environment these days think about social media and that fear of missing out that those sort of tools tend to ferment within us. You know, it’s, it’s been well recognized that social media is, is very good at promoting anxiety within people that fear of missing out, you know, what am my mates doing? What am I missing out? You know, teenagers are, are having all sorts of problems with anxiety and so forth. And there’s, you know, good evidence that’s suggesting that social media is at very least a contributor to that.
And so think about that from that context that people, maybe aren’t able to turn off that because they just never feel relaxed because their phone’s buzzing at them the whole time and, you know, Johnny and their other mates, or, you know, Janine and their other mates or whatever are out there having a great time and they’re missing out, et cetera. And so it’s just firing out that stress response constantly, which is not good. Now also maybe take a person who’s injured. So whether that be back pain or ankle pain, sprain or headaches or anything like that, it’s likely that that sort of patient will feel unsafe as well because their ability to deal with of the world is compromised by their injury. So somebody who’s got back pain, for example, if they had to suddenly deal with a stressful or a threatening situation with their environment, they are not going to be able to do that as well because their back is stuffed.
And so if they had to maybe quickly move because somebody was coming at them or a car suddenly turn the corner and so on. So they’re going to be in a hypervigilant state or an increased vigilant state. And therefore their, their stress responses are likely to be increased. There’s also the interesting thing that stress responses and pain are associated. So if you can reduce your patients stress level, it’s likely to reduce your patient’s pain as well. So this is, this is an interesting concept as well. So if you have somebody who is being, being stressed and they’re releasing all this cortisol into their system and they’re releasing adrenaline and everything else, that’s likely to be facilitating pain, maybe not so much the cortisol, because that tends to have an anti-inflammatory effect, but certainly the adrenaline tends to facilitate C fiber activity and so forth nociceptive fiber activity, and is going to increase problems and potentially going to potentiate neuro neurogenic type of inflammation and so on.
So there’s all these ways that, stress is potentially going to increase pain. But if you could switch that stress off, then you are potentially going to reduce the patient’s pain and reduce the likelihood of inflammation within their body and so forth. So how might you do that? So let’s, let’s talk, maybe some nitty gritty of talked a lot of theory so far, but you could potentially make the patient feel safe. So you could try and create a calm, positive healing environment. Now, this might be difficult if you are working within a busy emergency ward in a hospital or something like this, but within a private clinic, it’s very possible that you could produce this sort of healing environment. It’s really sort of no brainer staff greet your patients with a smile, make sure your receptionists are greeting the patients with a smile, reassure your patients that they’re in the right place.
Use positive encouraging words within your interaction with the patient. And you are potentially going to decrease their pain. You can decrease their stress responses. You’re going to make them feel safe. You’re going to facilitate healing within their body. So, you know, don’t dismiss this stuff as just being woo woo, garbage, blah, blah, whatever this stuff actually, you know, there’s good physiological reasons why you would want to do this with your patients to, to facilitate the healing environment. Now, another aspect of this is that by understanding your patient’s problem, you will also potentially make them feel safe. So research found that patients don’t just want pain relief. Okay. Clearly they want that they don’t, you know, most patients come to you to get some sort of pain relief, but they don’t just want that. They want to be heard. They want to know what is going on with them.
And they want to know that you are able to help them. So the, this idea of getting a diagnosis of getting a reason why this is happening is very important for a lot of people, particularly if they don’t have, any sort of medical training, et cetera, it’s very easy for us who have got, you know, that are healthcare practitioners to forget this about our patients. You know, we kind of understand that you can’t always come up with a clear cut diagnosis and that this ambiguity in healthcare and, and, you know, you have to be dealing with a certain degree of, you know, complexity and chaos and so on within the system. And, you know, I often say to my students, you know, if you wanted black and white realities, you should have done computer science. You know, don’t, don’t come into healthcare, expecting things to be clear, cut and unambiguous.
That’s not the way it works, but the patients from patient’s perspective, they don’t understand that. And, and really, they shouldn’t have to understand that. Yes, you need to make them aware that you can’t promise anything and that, you know, you can’t guarantee them results and everything else, but it’s your job as the practitioner to find answers for them and to give them the best answer that you possibly can so that they can then come to terms with their injury or whatever. Now, I’ve actually long maintained that the purpose of a report of findings or a case discussion with a patient isn’t so much about explaining to the patient what’s go is going on though. You know, I’ve just high like that. That’s very important. It’s also about letting them know that you understand what is going on and that you are going to be able to handle it.
So they want to plan. They want a roadmap out of their situation, and they want to know that you are the person that’s going to be able to help them with it. Or if you are not the person to, to help them with them, who is, who do they need to go and see instead? And so if you feel like a patient isn’t the appropriate one for you, give them reasons why not. And give them a clear picture as to where they need to go next, who, who you going to refer them to and why this is going to be the best thing for them moving forward. And if you can give that to them, that’s going to come them down. It’s going to relax them. It’s going to help turn off those stress responses and, and facilitate healing within the body. Okay. So, so make sure you do that.
I’d like to also sort of touch on the idea of a man, the manual therapy debate. Now this has been going on within the manual therapy professions for a long time now. And a lot of people rat on manual therapy, they just think that, you know, oh, it’s just a waste of time and it facilitates dependence on, on, you know, the practitioner and it doesn’t facilitate independence, the patient and, and, you know, there’s, there’s no evidence that suggests that manual therapy has any long term value in terms of a treatment for the patient and blah, blah, blah. Now, I really think we forget the fact that patients like manual therapy and if you’ve had manual therapy, you know, particularly if you’re the type of, and that like that, I know some patients don’t particularly like it, but most patients like some sort of touch, they like some sort of, massage, or even if it’s just trigger point or even just placing your hands on the patient, it feels nice for the patient.
It helps them relax. And this whole touch aspect, a lot of people go through their lives with getting very little touch, very little human interaction in that way. And so as a practitioner, you can provide some of that and you might think, you know, oh, I’m above touching patients. And you know, I’m not being, you know, talking about unprofessional touch here. I’m talking about, you know, professional touch with the patient discount, the beneficial effects of that touch. So many people find it relaxing. It’s going to facilitate safety for the patient. It’s going to facilitate a better state of mind so that they actually feel like they are in a safe place. And therefore their prefrontal cortex is going to feel like it can start inhibiting the Amy and it’s going to relax them. And it’s going to take away all of those or not, maybe not all of it, but it’s going to reduce things like adrenaline and all those things that we know that facilitate pain and everything else.
So while yes, that you don’t want to overtreat your patients, you don’t want to make sure that they become dependent on you and, and everything else. Certainly in the short term, I see no reason why manual therapy shouldn’t be included in your patient plans. If it’s appropriate, you know, if it’s not an appropriate therapy, fine, don’t do it. But if, if there’s any doubt, do some manual therapy on people because they like it. It’s going to help put them in that, you know, safe place. And they’re going to feel better as a consequence. Now, interestingly, another thing beyond this, and, and this is kind of a bit beyond the article that we were just talking about a second ago, there’s the hippocampus within the brain. Now we know that the hippocampus area, which is on the media aspect of the temporal lobe, it’s very important for memory.
We know that at it’s very close to the entorhinal cortex, which is important for smell and so forth. And we know that the hippocampus is something that tends to suffer as we age, it’s particularly affected in many of the dementias in particular Alzheimer’s dementia, and tends to you get a lot of beater amyloid being laid down in it and tower proteins and so forth, which causes cell death stops the hippocampus working properly, which is why people tend to have memory issues fairly early, developing within Alzheimer’s. But the hippocampus is also important for what is known as fear extinct, which is learning to reduce your stress responses in response to certain stimuli. It does this in concert with the ventromedial prefrontal cortex, which is basically what we call the medial wall of the frontal lobe. So, you know, how there’s, there’s two hemispheres of the brain and on the inside of the bit that faces the bit of the, that basically faces the other part of the brain.
<laugh> I’m dunno if I’m making a particularly good explanation of that, but basically on the, the medial aspect of the frontal lobes, these areas are associated with reducing fear responses over time. Now, very interestingly, chronic pain and stress, or associated it with a decrease in volume in these brain areas. And so therefore deficiencies are going to reduce the ability to change the response to fear. So harking back to those people that I was talking about earlier, who, maybe have had traumatic events within their life, and they find it very difficult to turn the stress response off, they are going to find it harder to turn stress responses off and, and to recalibrate. So say, say they went through an abusive marriage or something like that. And they’re now out of that marriage, but they’re going to find it harder to turn the stress responses off that were maybe triggered during that marriage be you, if they have some sort of decreased volume within the hippocampus and maybe in those, prefrontal cortex areas now, and that is, is going to be more even so with, or true also with chronic pain.
So chronic pain patients, tend to have decreased brain volume in those areas as well. And so for therefore, those deficient are going to reduce the ability to change responses with fear now, fantastically and I, this is amazing exercise increases, hippocampus volume and neurogenesis. So therefore we can change hippocampus volume. And so you are therefore potentially going to be able to change patient’s ability to deal with stress within their environment through exercise. And I would also put forward that there’s a good argument, that much of the benefit that comes from this activation is due to activation of large diameter afferent fibers, such as those from muscle spindle, Golgi tendon organs, joint, mechanoreceptors, and so forth. So it’s even possible that things like manual therapies may also increase hippocampal neuronal function, and therefore potentially increase the ability to, produce fear, extinction, get rid of those fear responses, cetera.
So it seeing other physiological therapeutics such as, vibration may also do it and have calming effects on people as well. So therefore, you know, we shouldn’t just be encouraging exercise because it has physical benefits. So, you know, clearly it does. And that just in of itself is enough reason to get your patients to, to exercise, but it’s likely to actually improve the central processing of pain and improve your patient’s ability to reduce their stress responses. Okay. So we’ve, we’ve covered a lot here. I’m going to wind it up at this point, but basically we’ve looked at the fact that stress responses can be triggered by a variety of C that actually the default response for stress is for it to actually be switched on. And for it to be switched off, we actually have to have active functioning of our brain to turn those areas off, turn those stress responses off and that turning off will not occur until the patient feels like they’re in a safe environ environment to allow that to occur.
And we’ve actually covered the fact that using positive words and positive healing environments and so forth may actually help the patient turn that stress response off. And also things like physical therapies and exercise and so forth are, are potentially going to allow your patient to turn that off consciously, but also maybe longer term to remodel those stress responses within the brain. So is to actually reduce the, the overall excitability of the stress areas within the nervous system. So I hope you found that interesting. I find this topic fascinating. I hope I’ve conveyed some of that within this episode. We’ll hopefully be back with another episode in the new year while we will be back within another episode with another episode in the new year, if you’ve got any particular topics that you’d like me to discuss, et cetera, be sure to, to post a comment on the blog or something like that. But I’d love to hear from you either way and get your feedback about the podcast, how it’s going, et cetera. So thanks again for listening and hopefully I’ll speak to you soon. Okay.
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Brosschot JF. Ever at the ready for events that never happen. Eur J Psychotraumatol. 2017;8(1):1309934. Published 2017 Apr 10. doi:10.1080/20008198.2017.1309934
Abdallah CG, Geha P. Chronic Pain and Chronic Stress: Two Sides of the Same Coin?. Chronic Stress (Thousand Oaks). 2017;1:2470547017704763. doi:10.1177/2470547017704763