Think of the last time you were under a lot of stress, whether it be work/school related, financially driven, relationship troubles, or some other component of your life not going exactly as you intended. How did it make you feel? Were you having trouble eating, sleeping, or concentrating? It’s amazing how this emotional response can have such an impact on us physically.
Now think of the last time you had a patient say that they WERE NOT under a lot of stress (I know personally these individuals are few and far between). In addition to the previously mentioned stressors, our patients may have a few more on their mind (duration of symptoms, unable to return to work, previously failed treatments, increased pain, etc). In addition to all of these things, they now need to find the time in their already stressful day to do their home exercises, which may make them feel like they’re about to explode.
But why should we, as physical therapists, care about our patients’ stress levels? Well, it may play a huge reason behind why your patient is not getting better as fast as you thought they would. Now if your next thought is that “it’s all in their head,” first of all you should be ashamed of yourself, and secondly, please check out my recent post about how to talk to patients regarding their pain. So if it’s not “all in their head,” how do you talk to your patients about the role of stress in their recovery?
That’s where research comes into play. Back in 1998, Marucha et al examined the effects of stress on wound healing. Who were the lucky subjects? Dental students of course, because learning how to put your hands in other people’s mouths without getting your finger bitten off wasn’t stressful enough. The researchers created punch biopsy wounds on the hard palate of the students during two different scenarios; one during summer vacation (couldn’t think of any better way to spend your summer), and the other three days before their first huge exam. Now if I remember back to the first exams of the semester during PT school, I’d say that tensions were high and my classmates were just a little bit more stressed out than usual, so I can imagine how happy these dental students must have been. The researchers then tracked to see how long it took each of the wounds to heal, and compared them between the two scenarios.
What did they find? The wounds that were made days before the big exam took nearly 40% longer to heal. Once again in case you missed it, it took FORTY PERCENT LONGER TO HEAL. Same type of wound, same person, all that changed were the situational stressors. Now why is that important? Remember all of those potential stressful events going on in our patients’ lives; how do you think they will help their tissue healing rates? As I have said before, pain does not always equal tissue damage. There are a variety of reasons which can exacerbate someone’s symptoms, and stress can be one of those many factors. Helping the patient make the realization that their stress can impact their tissue healing may actually be a huge breakthrough in your ability to treat the patient.
But think back to the specific scenario in the study; the wound was made BEFORE the actual stressful event occurred. Now granted the students were most likely starting to get test anxiety several days in advance of the actual exam, but this concept can be a game changer in regards to your subjective history taking. When a patient comes in for an evaluation reporting some insidious flare up or onset of symptoms, I often ask them what else was going on around that time in their life. Now this can be a touchy subject, so do not pry if they do not want to share, but often I’ve had patients tell me about a loved one passing away, a recent change in their job situation, or that they were moving into a new home around the same time that their symptoms increased. For them, this may be their “first big exam,” and this stressful situation could play a role in their persistent symptoms.
So what’s the take home message? Well, there are several. First of all, realize that your patient’s pain does not always have to be due to some type of pathological tissue issue. There are a variety of factors that can exacerbate an individual’s symptoms, and stress is one of them. By helping your patient identify these potential stressors, it may allow for them to take the appropriate steps to start managing their stress. Secondly, patient education is crucial. Tell them about the study with the dental students, and let them know that research shows changes in your immune system functioning during stressful periods of times which can impact your tissue healing rates. While you’re at it, maybe tell them about the Red Light/Blue Light study, and use that as an avenue to talk about pain sciences. Finally, and most importantly, remember to stay within your skill set. Like I said earlier, some of these topics can be very difficult to discuss with a patient, and you need to be comfortable enough with your pain science education techniques to not make the patient think you are telling them “it’s all in their head.” Remember, pain is in your brain, not in your head. You also need to recognize when a situation may be outside our scope of practice, and be willing to refer a patient to the appropriate professional if need be. So long story short, by identifying the potential stressors in your patients’ lives they may heal as fast as if they were hurt during summer vacation. Trust me, that’s a good thing.