I’m not sure the origin of this fellow but he looks a bit stressed. He is clearly alarmed, and ready to scurry off to somewhere less exposed. It doesn’t take a physiognomy-specialized psychologist to recognize that he is on high-alert. Candidate for a manip? Probably not. Heavy on the fear-avoidance scale.

Lets take a closer gander:

Yes, sympathetic juices are flowing. Heart rates up, pupils are dilated, arrector pili muslcles in full force, and a tactical exposure of the one defense mechanism this critters got going for him (sharp teeth) - a characteristic likely evolved from years of startling harassment via his predators.

So, how do you deal with a patient with “resting stress face”?  RSF.

First of all, by recognizing it. Facial features are a display of emotion, state of health, and subconscious or conscious current perceived threat level. Treatment is often dictated based on facial features and body language. A grimace says “don’t go there”, and no matter what you are trying to achieve, I doubt it will be successful if your treatments are full of grimace evoking “digs” for the soul purpose of thinking you “found the spot” (unless laced with a HEAVY dose of placebo.) Even if a pain-evoking maneuver somehow WAS necessary, do you think the patient body’s reaction would be conducive to maintaining that? The body’s reaction to what you are introducing is mediated by the patient’s perception of the interaction, and if that interaction has already began in a state of fear/stress/pain (ie sympathetic state), hopes of disengaging that via “fight fire with fire” appears an odd strategy.

Of course, there are the outliers who come in to their sessions with masochistic desire for a heavy-handed therapist to dig out the pain- and I believe expectations are well-linked to success rates. How a patient THINKS they will respond to treatment, has PREDICTIVE VALUE on how they actually respond. This has been validated in research looking at surgical outcomes, as attitudinal and mood factors were strongly predictive of surgical outcomes (Rosenberger et al 2006). You don’t have necessarily to ditch the IT-band fascia release to appease the guy (or gal) demanding it, but in my case I am left feeling like a bit of a con-man lest I use this opportunity to discuss WHY this high-stimulus blast of inputs may individually favor that person. And even that could backfire, and requires a hell of a lot of tact! Maybe dealing with that interaction is truly the art, in the art & science of PT.

Back to RSF…

RSF is probably a yellow flag.

There is research that links stress level to delayed healing. The science of that is basically that stress increases release of cortisol, which facilitates anti-inflammatory mechanisms, and decreases pro-inflammatory mechanisms, and has an inhibitory effect on the immune system (which is why persons on long-term steroids are prone to infection/disease/illness and need to be careful.) Ever wonder why everyone is sick during finals week? Stress much? Cortisol may be good in the short term, but actually delays healing! After all, the process of inflammation is one’s body sending immune cells to the site and eventually assisting in the repair phase of the tissue.  

Cortisone injections are pretty popular. I’m not against these, as they may certainly be a better option than going under the blade, and actually do physiological change the tissue environment and may open a window for change if conservative measures fail. However, I don’t think they should be first on the menu.

One research article notes: “3824 trials were identified and 41 met inclusion criteria, providing data for 2672 participants. We showed consistent findings between many high-quality randomised controlled trials that corticosteroid injections reduced pain in the short term compared with other interventions, but this effect was reversed at intermediate and long terms”(Coombs et al. 2010)

 Essentially a short-term blast of pain relief (mechanisms may include removal of neurally sensitizing agents inherent to inflammation, immediate placebo effect of getting “something done” to the tissue, and a rapid chemical change in the affected environment) is at the potential cost of a slower recovery.

Further research has been conducted regarding tissue healing in stressed-out rats (as if the rat-life isn’t stressful enough); the DIY research project would be conducted as follows: grab two of the closest rats, jab them with something sharp, let one roam freely in a fun-filled rat amusement park, ruffled by soft wood shavings, neutral colors and self-propelled exercise wheels, and put the other in a tight tube that makes all the limbs immobile and only allows breathing (we haven’t tried this on humans yet, probably a euro study in the mix…) and what do you find? The wound healed 27% slower in the stressed rats vs the non-stressed, and they showed 2.5x greater growth of staphylococcus (ie higher risk of infection) as well as higher cortisol levels. (Padgett et al 1998)

And here is a great link to a paper that looks at stress in not only mice but humans too:

Fun facts:
Students with wounds heel on average 40% slower during exams compared to being on holiday. Also, research found persons living stressful lives heal 24% (Marucha 1998) and persons in hostile environments/relationships heal up to 60% slower (Kielcolt-Glaser et al 2005).

So how do we assist in alleviating stress in our patients? I would argue for:

1) Thorough evaluation and sensible explanations

2) Listening to the patient’s FULL account of their experience and evaluating the patients’ view of their pain/issue and considering that in your explanation/delivery of your treatment plan (not to mention GIVING a treatment plan…preferably with an overall internal locus of control)

3) Considering the individual when applying a treatment (ie what matters is how they react to your treatment, and how their bodies physiologically react, which is often NOT biomechanically sensible!)

An example of a thorough evaluation of say a person with sciatica would be ruling out signs of nerve damage, and telling a patient “because your reflexes are intact, you have good sensation, and we don’t see any weakness in the muscles, this is a great indicator that you are not experiencing any true nerve damage. While I understand your problem is with pain, pain is not necessarily a good indicator of tissue damage, or even tissue health (and go on to give examples)”. Knowledge of this on behalf of the patient may alone promote stress relief.

Considering the individual’s view of their pain and applying that to your explanation is where some craft is involved. You don’t always want to go all Butler/Moseley on a patient and start launching explain-pain rhetoric, as what your scholarly view intends and what message actually gets across can be very different (not to devalue their research and their messages as they are a HUGE attribute, but I think we need to use good judgment on what verbal information is, on the patients’ side of the coin, mentally impregnable). Be simple. I went through a phase of WAY too technical explanations regarding my sometimes incoherent understandings of pain processes. If the patient is interested, and the interactions cater to it, I may use something like this:

“Your tissue is full of tiny nerves that pick up on stimulus, such as mechanical (poke on their leg lightly now) stimulus and chemical stimulus such as inflammation. Something increased the sensitivity of your tissues here, so now with 10% stimulus, the tissue reacts as if it is undergoing 80% stimulus. This causes lots of protective behavior in the tissues, like muscle tightness to control everything, and heightened pain perception so your tissue can analyze EVERY little thing that happens to it. That is just how our body sometimes deals with things, and it’s the body’s way of paying close attention to the area. What we need to do is desensitize the tissue, by SLOWLY allowing it to accommodate to an increase in stimulus, and we can do that in the following ways…”

“the following ways” is where a huge amount of freedom comes in, and although there are a million guru explanations for specific and technical applications of specialized skilled techniques, it think in reality were just desensitizing the tissue via a few somewhat explained and hopefully admittedly unexplained mechanisms. Loading tissue in novel ways can be a great way to do this, as can strengthening surrounding areas, as can reducing stress, as can giving a patient a plan. Lets leave the mechanisms of treatment for another day.

In summary, try to help your patient find ways to both understand how stress may negatively affect them, and to seek strategies to alleviate stress. Simple exercise may be the answer. Or meditation may be useful for your patients in sandals. Or maybe a glass of wine and a mental break from the days stressors. Try to promote a positive view of the condition by avoiding stressful terminology (avoid constantly referring their disc herniation, tear or “blocked segment”.) Be aware of your patients’ view of their problem, and attempt to be a good judge of their level of acceptance to your treatment, using verbal, visual, and tactile cues to fill in the gaps when beneficial. 

-Tal Blair, DPT

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