The Stress Response Following Serious Injury or Illness: A Biopsychosocial Approach: Difference between revisions

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Physiotherapists can have a significant role in identifying and early management of patients who present with a stress response following serious injury/illness. Physiotherapists are not typically associated with mental health interventions, but they can have a large impact on the mental well-being of patients.             
Physiotherapists can have a significant role in identifying and early management of patients who present with a stress response following serious injury/illness. Physiotherapists are not typically associated with mental health interventions, but they can have a large impact on the mental well-being of patients.             


Traumatic injury is responsible for 11% of global mortality and contributes to a significant amount of physical and psychological morbidity for all age groups<ref>Organisation, W. H. (2010). World Health Organisation (WHO)</ref>. Patients with traumatic injury report a substantial reduction in health-related quality of life compared to other patients, including long-term psychological and physical disability. There is a known associations between injury, depression, anxiety, ASD and PTSD<ref name=":0">Wiseman, T., Foster, K., & Curtis, K. (2013). Mental health following traumatic physical injury: an integrative literature review. ''Injury, 44''(11), 1383–1390</ref>.  
Traumatic injury is responsible for 11% of global mortality and contributes to a significant amount of physical and psychological morbidity for all age groups<ref>Organisation, W. H. (2010). World Health Organisation (WHO)</ref>. Patients with traumatic injury report a substantial reduction in health-related [[Quality of Life|quality of life]] compared to other patients, including long-term psychological and physical disability. There is a known associations between injury, [[depression]], anxiety, ASD and [[Post-traumatic Stress Disorder|PTSD]]<ref name=":0">Wiseman, T., Foster, K., & Curtis, K. (2013). Mental health following traumatic physical injury: an integrative literature review. ''Injury, 44''(11), 1383–1390</ref>.  


A traumatic experience triggers the stress response ie the hormonal and metabolic changes in the body following physical or emotional trauma or critical illness that cause disequilibrium and threaten homeostasis.<ref>Desborough, J. P. (2000). The stress response to trauma and surgery. ''British Journal of Anaesthesia, 85''(1), 109-117.</ref><ref name=":1">Correia, M. I. T. D., & De Almeida, C. T. (2005). ''Nutritional Support for the Critically Ill Patient: A Guide to Practice (2 ed.)'': CRC Press.</ref> See [[Stress and Health]]
A traumatic experience triggers the stress response ie the [[Hormones|hormonal]] and metabolic changes in the body following physical or emotional trauma or critical illness that cause disequilibrium and threaten homeostasis.<ref>Desborough, J. P. (2000). The stress response to trauma and surgery. ''British Journal of Anaesthesia, 85''(1), 109-117.</ref><ref name=":1">Correia, M. I. T. D., & De Almeida, C. T. (2005). ''Nutritional Support for the Critically Ill Patient: A Guide to Practice (2 ed.)'': CRC Press.</ref> See [[Stress and Health]]


=== Biopsychosocial Model ===
=== Biopsychosocial Model ===
[[File:Figure 2 The Biopsychosocial Model.png|thumb|Figure 2. The Biopsychosocial Model.]]The [[Biopsychosocial Disorders|biopsychosocial model]] underpins physiotherapy assessments and interventions. It interconnects physiology, psychology and socio-environmental factors associated to an injury or illness and has been well established within physiotherapy for the past 25 years. It ensures physiotherapists assess and treat a patient holistically and apply intervention to help manage both physical and mental concerns.             
The [[Biopsychosocial Model|biopsychosocial model]] underpins physiotherapy assessments and interventions. It interconnects physiology, psychology and socio-environmental factors associated to an injury or illness and has been well established within physiotherapy for the past 25 years. It ensures physiotherapists assess and treat a patient holistically and apply intervention to help manage both physical and mental concerns.             


== Factors Influencing Stress Response ==
== Factors Influencing Stress Response ==


=== Internal Factors ===
=== Internal Factors ===
Memories of traumatic injury or critical illness can remain prominent for patients and induce frightening recollections, nightmares and delusions.<ref>Ringdal, M., Plos, K., & Bergbom, I. (2008). Memories of being injured and patients' care trajectory after physical trauma. ''BMC nursing, 7''(8), 1-12.</ref> Altered mental status (in the forms of both delirium and coma) is common in the ICU, and often worsened by sedation.<ref name=":2">Jackson, J. C., Hart, R. P., Gordon, S. M., Hopkins, R. O., Girard, T. D., & Ely, E. (2007). Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem. ''Critical Care, 11''(1), R27.</ref> Other traumatic stressors related to the in-hospital care received include longer ICU length of stay, longer hospital stay, intubation and length of mechanical ventilation<ref name=":2" />. These factors may also be mediated by age, severity of illness and abruptness of onset<ref name=":2" />.
[[File:Nightmare.jpeg|thumb|Nightmare|alt=|337x337px]]
Memories of traumatic injury or critical illness can remain prominent for patients and induce frightening recollections, nightmares and delusions.<ref>Ringdal, M., Plos, K., & Bergbom, I. (2008). Memories of being injured and patients' care trajectory after physical trauma. ''BMC nursing, 7''(8), 1-12.</ref> Altered mental status is common in the [[The Intensive Care Unit|ICU]] (see [[ICU Delirium]])), and often worsened by sedation.<ref name=":2">Jackson, J. C., Hart, R. P., Gordon, S. M., Hopkins, R. O., Girard, T. D., & Ely, E. (2007). Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem. ''Critical Care, 11''(1), R27.</ref> Other traumatic stressors related to the in-hospital care received include longer ICU length of stay, longer hospital stay, intubation and length of mechanical [[Ventilation and Weaning|ventilation]]<ref name=":2" />.  


Inability to perform everyday tasks, particularly relating to washing and toileting, may lead to frustration and embarrassment. Evidence has shown that people with physical disabilities are at a higher risk of developing psychiatric and substance disorders.<ref>Turner, R. J., Lloyd, D. A., & Taylor, J. (2006). Physical disability and mental health: An epidemiology of psychiatric and substance disorders. ''Rehabilitation Psychology, 51''(3), 214-223.</ref> There is also accumulating evidence to suggest that depressive symptoms are commonly associated with increased reliance on medical services, and in turn, increase the health costs.<ref>Hunkeler, E. M., Spector, W. D., Fireman, B., Rice, D. P., & Weisner, C. (2003). Psychiatric symptoms, impaired function, and medical care costs in an HMO setting. ''General Hospital Psychiatry, 25''(3), 178-184.</ref>
Inability to perform [[Activities of Daily Living|everyday task]]<nowiki/>s, particularly relating to washing and toileting, may lead to frustration and embarrassment.


Patients of serious injury or illness often experience pain as a result of the injury or illness and its management. Numerous neuroimaging studies have shown that brain regions activated by nociceptive stimuli can also be affected by various emotional and behavioural states<ref name=":3">Hooten, W. M. (2016). Chronic pain and mental health disorders: shared neural mechanisms, epidemiology, and treatment. ''Mayo Clinic Proceedings, 91''(7), 955-970.</ref>. Chronic pain is often comorbid with psychiatric disorders, with depression having received the most attention to date<ref name=":4">Gureje, O., Von Korff, M., Kola, L., Demyttenaere, K., He, Y., Posada-Villa, J., . . . Iwata, N. (2008). The relation between multiple pains and mental disorders: results from the World Mental Health Surveys. ''Pain,'' ''135''(1-2), 82-91.</ref>. It has been observed that persons who report multiple pain conditions are more likely to experience depressive symptoms<ref name=":4" />. In addition, epidemiological and functional imaging studies suggest that a bidirectional relationship exists between chronic pain and mental health concerns, suggesting that not only does pain induce stress and problems with mental health, but poor mental status may influence pain<ref name=":3" />.
People with physical disabilities are at a higher risk of developing psychiatric and [[Substance Use Disorder|substance disorders.]]<ref>Turner, R. J., Lloyd, D. A., & Taylor, J. (2006). Physical disability and mental health: An epidemiology of psychiatric and substance disorders. ''Rehabilitation Psychology, 51''(3), 214-223.</ref>
 
Patients of serious injury or illness often experience pain as a result of the injury or illness and its management<ref name=":3">Hooten, W. M. (2016). Chronic pain and mental health disorders: shared neural mechanisms, epidemiology, and treatment. ''Mayo Clinic Proceedings, 91''(7), 955-970.</ref>. Chronic pain is often comorbid with psychiatric disorders, eg depression<ref name=":4">Gureje, O., Von Korff, M., Kola, L., Demyttenaere, K., He, Y., Posada-Villa, J., . . . Iwata, N. (2008). The relation between multiple pains and mental disorders: results from the World Mental Health Surveys. ''Pain,'' ''135''(1-2), 82-91.</ref>. Epidemiological and functional imaging studies suggest that a bidirectional relationship exists between chronic pain and mental health concerns, suggesting that not only does pain induce stress and problems with mental health, but poor mental status may influence pain<ref name=":3" />.


=== External Factors ===
=== External Factors ===
Acute bouts of stress and anxiety were identified by Kellezi et al. (2017) as common conditions affecting one’s mental health following severe illness/injury. They suggested that these conditions were commonly identified at 1 month post injury/illness, and although their prevalence decreased over time, their incidence still remains high at 12 months.<ref>Kellezi B, Coupland C, Morriss R, Beckett K, Joseph S, Barnes J, Christie N, Sleney J, Kendrick D. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology. 2017 Jul 1;52(7):855-66.</ref> The combination of several external factors such as a lack of family and social support, financial and/or insurance issues, or contextual conditions (such as deployment and subsequent return home in military personnel) can lead to anxiety and depression, and impact on physical function, pain, and often affecting one’s return to work.
[[File:Stress responses.jpeg|thumb|Stress effects]]
Acute bouts of stress and anxiety affect one’s mental health following severe illness/injury. These conditions were commonly identified at 1 month post injury/illness, and although their prevalence decreased over time, their incidence still remains high at 12 months.<ref>Kellezi B, Coupland C, Morriss R, Beckett K, Joseph S, Barnes J, Christie N, Sleney J, Kendrick D. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology. 2017 Jul 1;52(7):855-66.</ref>  


Family and social support play a key role in the recovery of mental health following severe injury. Family support In particular is of great importance since they provide a large portion of the care: they may offer transportation, finances, leisure, and emotional support.<ref>Kellezi B, Coupland C, Morriss R, Beckett K, Joseph S, Barnes J, Christie N, Sleney J, Kendrick D. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology. 2017 Jul 1;52(7):855-66.</ref> Moreover, they are often involved in the rehabilitation goal planning, which may be adapted based on the resources available at their own home. Previous family-intervention studies reported benefits such as improvements in psychological distress, level of functioning, and employability in individuals with traumatic brain injury. Conversely, family stress and unhealthy family communication were found to impair the rehabilitation process.<ref name=":5">Shoulson I, Wilhelm EE, Koehler R, editors. Cognitive rehabilitation therapy for traumatic brain injury: evaluating the evidence. National Academies Press; 2012 Jan 28.</ref>  
Following severe illness/trauma the combination of several external factors such as a lack of family and social support, financial and/or insurance issues, or contextual conditions (such as deployment and subsequent return home in military personnel) can lead to anxiety and depression, and impact on physical function, pain, and often affecting one’s return to work.
 
Family and social support play a key role in the recovery of mental health following severe injury. Family support In particular is of great importance since they provide a large portion of the care: they may offer transportation, finances, leisure, and emotional support.<ref>Kellezi B, Coupland C, Morriss R, Beckett K, Joseph S, Barnes J, Christie N, Sleney J, Kendrick D. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology. 2017 Jul 1;52(7):855-66.</ref> Moreover, they are often involved in the rehabilitation goal planning, which may be adapted based on the resources available at their own home. Family stress and unhealthy family communication were found to impair the rehabilitation process.<ref name=":5">Shoulson I, Wilhelm EE, Koehler R, editors. Cognitive rehabilitation therapy for traumatic brain injury: evaluating the evidence. National Academies Press; 2012 Jan 28.</ref>  


Insurance and compensation-seeking behaviour have also been shown to impact on psychological well-being. Previous studies showed longer lasting symptoms for compensation seekers or litigants, and can cause delayed work return as well as increased levels of psychological stress secondary to the unresolved financial issues, the injury, or a combination of both factors.<ref name=":5" />  
Insurance and compensation-seeking behaviour have also been shown to impact on psychological well-being. Previous studies showed longer lasting symptoms for compensation seekers or litigants, and can cause delayed work return as well as increased levels of psychological stress secondary to the unresolved financial issues, the injury, or a combination of both factors.<ref name=":5" />  


Contextual factors can affect one’s psychological well-being following an road traffic accidents, for example. Being involved in an RTA can be both stressful and psychologically traumatic, and it has been reported that many individuals involved in RTA’s do not have their psychological reactions attended. This has been suggested to trigger a psychological stress response when these individuals are exposure to environments associated with the traumatic memory.<ref>Smith B, Mackenzie-Ross S, Scragg P. Prevalence of poor psychological morbidity following a minor road traffic accident (RTA): The clinical implications of a prospective longitudinal study. Counselling Psychology Quarterly. 2007 Jun 1;20(2):149-55.</ref>
Contextual factors can affect one’s psychological well-being following a road traffic accidents (RTA). Being involved in an RTA can be both stressful and psychologically traumatic, and it has been reported that many individuals involved in RTA’s do not have their psychological reactions attended. This has been suggested to trigger a psychological stress response when these individuals are exposure to environments associated with the traumatic memory.<ref>Smith B, Mackenzie-Ross S, Scragg P. Prevalence of poor psychological morbidity following a minor road traffic accident (RTA): The clinical implications of a prospective longitudinal study. Counselling Psychology Quarterly. 2007 Jun 1;20(2):149-55.</ref>


== '''Flags During Assessment''' ==
== '''Flags During Assessment''' ==
During a physiotherapy assessment, [[The Flag System|the flag system]] can be useful to identify any signs or symptoms that may require further attention and investigation. psycho-social flags allow physiotherapists to assess a patient holistically using a bio-psycho-social model, and direct treatment towards the needs of the patient. Orange and yellow flags can help a clinician identify signs of psycho-social struggle that may increase the risk of long-term disability, developing mental health concerns or potential misuse of medications.   
[[File:YellowFlag1.jpg|thumb|Yellow Flag]]
During a physiotherapy assessment, [[The Flag System|the flag system]] can be useful to identify any signs or symptoms that may require further attention and investigation. psycho-social flags allow physiotherapists to assess a patient holistically using a bio-psycho-social model, and direct treatment towards the needs of the patient.   


# Orange Flags: indicators of serious mental health problems and represent the equivalent to red flags of mental health. They can help indicate psychopathology such as schizophrenia, clinical depression, post-traumatic stress disorders or personality disorders. Identifying these will require the patient to be referred for a specialist psychiatric assessment. This can be screened using a patient health questionnaire-2 (PHQ-2)<ref>Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. ''Med Care, 41''(11), 1284-1292.</ref>
# Orange Flags: represent the equivalent of red flags for mental health and psychological problems<ref>Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. ''Med Care, 41''(11), 1284-1292.</ref>
# Yellow Flags: identify concerning thoughts, feelings and behaviours linked to the stress of their recovery, change in lifestyle, and social context which may influence a patient’s state of mental health. These include any unusual emotional responses such as increased worry, fear and anxiety, or unusual pain behaviours such as poor coping strategies, avoidance behaviours and over-reliance of passive treatments such as medications. These will be particularly important to monitor if a patient has had an injury/illness that is life changing.
# Yellow Flags: identify concerning thoughts, feelings and behaviours linked to the stress of their recovery, change in lifestyle, and social context which may influence a patient’s state of mental health. These include any unusual emotional responses such as increased worry, fear and anxiety, or unusual pain behaviours such as poor coping strategies, avoidance behaviours and over-reliance of passive treatments such as medications. These will be particularly important to monitor if a patient has had an injury/illness that is life changing.


== '''The Role of the Physiotherapist''' ==
== '''The Role of the Physiotherapist''' ==
The link between physical health and mental health is widely accepted, yet many health professionals have reported being under-prepared to manage both the physical and the mental health needs of patients. Physiotherapy is considered to be integral to the treatment of the physical aspects of musculoskeletal, cardio-respiratory, and neurological conditions, and it plays a significant role in managing chronic pain and preventable diseases.<ref>Connaughton, J., & Gibson, W. (2016). Do Physiotherapists Have the Skill to Engage in the "Psychological" in the Bio-Psychosocial Approach? ''Physiotherapy Canada, 68''(4), 377–382</ref> Even when patients have no co-morbid mental health issues, health professionals working in a variety of care settings, including physiotherapists, provide reassurance, psychological support, and education to reduce distress and promote behavioural change.<ref>MacNeela, P., Scott, P. A., Treacy, M., Hyde, A., & O'Mahony, R. (2012). A risk to himself: Attitudes toward psychiatric patients and choice of psychosocial strategies among nurses in medical–surgical units. ''Research in nursing & health, 35''(2), 200-213.</ref> Any treatment regime needs to take a holistic approach to both the physical injury itself and the adversity induced by it. Recovery from injury, illness, surgery or any life stress requires two key factors:
[[File:Figure 2 The Biopsychosocial Model.png|thumb|Figure 2. The Biopsychosocial Model.|alt=|493x493px]]The link between physical health and mental health is widely accepted. Physiotherapy is considered to be integral to the treatment of the physical aspects of musculoskeletal, cardio-respiratory, and neurological conditions, and it plays a significant role in managing chronic pain and preventable diseases.<ref>Connaughton, J., & Gibson, W. (2016). Do Physiotherapists Have the Skill to Engage in the "Psychological" in the Bio-Psychosocial Approach? ''Physiotherapy Canada, 68''(4), 377–382</ref> When patients have no co-morbid mental health issues physiotherapists should provide reassurance, psychological support, and education to reduce distress and promote behavioural change.<ref>MacNeela, P., Scott, P. A., Treacy, M., Hyde, A., & O'Mahony, R. (2012). A risk to himself: Attitudes toward psychiatric patients and choice of psychosocial strategies among nurses in medical–surgical units. ''Research in nursing & health, 35''(2), 200-213.</ref>  
# Diagnosis and targeted effective treatment for the cause of the problem.
 
# Identify and minimise barriers to treatment and addressing psycho-social factors and what to do with them.
Any treatment regime needs to take a holistic approach to both the physical injury itself and the adversity induced by it. Recovery from injury, illness, surgery or any life stress requires two key factors:
 
'''1.Diagnosis and Targeted Effective Treatment for the Cause of the Problem:''' Targeted treatment comprises of either a specific exercise program for functional purpose or surgery followed by rehabilitation. Simple, classical medical intervention is based on reductionism (knowing which structure is faulty and fixing it). This is a proven method and is ideal, however, there is often no clear diagnosis, or treatment is not as effective as intended. These and other factors can create barriers to recovery.


=== Diagnosis and Targeted Effective Treatment for the Cause of the Problem ===
'''2. Identify and Minimise Barriers to Treatment and Addressing Psycho-Social Factors and What to Do with Them:''' Physiotherapists should look at the whole person, their circumstances and how they react to the stimulus or threat associated with their injury. These factors have the biggest influence on recovery from injury but are almost completely neglected in modern medicine. All good clinicians are aware of how these barriers can negatively affect recovery outcomes, and how much of a challenge it can be to change them. Managing your internal and external environment requires a lot more time and effort because some barriers to recovery are related to long held beliefs and behaviours that are engrained into our daily lives. Changing these can require a big effort for some patients, but can result in positive and long-term change.
Targeted treatment comprises of either a specific exercise program for functional purpose or surgery followed by rehabilitation. Simple, classical medical intervention is based on reductionism (knowing which structure is faulty and fixing it). This is a proven method and is ideal, however, there is often no clear diagnosis, or treatment is not as effective as intended. These and other factors can create barriers to recovery.  


=== Identify and Minimise Barriers to Treatment and Addressing Psycho-Social Factors and What to Do with Them ===
To gain the best possible outcome from any adversity or stress, both systems need to be engaged. Rehabilitation is not a procedure or medication, it is a process with many layers and stages, and there are a number of things that can positively or negatively influence a patient’s outcome.<ref>Physiosouth. (2019). ''Successful Rehabilitation: A Patients Guide.''   Retrieved from https://www.physiosouth.co.nz/articles-and-education/successful-rehabilitation/ [Accessed 14 November 2019]</ref> During an assessment it is possible for the physiotherapist to identify any yellow or orange flags that may suggest that the patient has any psycho-social or mental health concerns caused by their illness or injury. If not properly addressed during treatment, these stressors and concerns can develop into a more serious mental health condition for the patient. Physiotherapists regularly come into contact with people with common stressors regardless of the setting and it is likely that this will influence engagement and response to treatment. These patients access mainstream physiotherapy and some may need reasonable adjustments. In almost all cases these stressors will not affect the ability to treat in a department.<ref name=":6">So your next patient has a mental health condition - a guide for physiotherapists not specialising in mental health.   Chartered Society of Physiotherapy,(2018) Retrieved from https://www.csp.org.uk/publications/so-your-next-patient-has-mental-health-condition-guide-physiotherapists-not [Accessed 14 November 2019]</ref> 
Physiotherapists should look at the whole person, their circumstances and how they react to the stimulus or threat associated with their injury. These factors have the biggest influence on recovery from injury but are almost completely neglected in modern medicine. All good clinicians are aware of how these barriers can negatively affect recovery outcomes, and how much of a challenge it can be to change them. Managing your internal and external environment requires a lot more time and effort because some barriers to recovery are related to long held beliefs and behaviours that are engrained into our daily lives. Changing these can require a big effort for some patients, but can result in positive and long-term change.


To gain the best possible outcome from any adversity or stress, both systems need to be engaged. Rehabilitation is not a procedure or medication, it is a process with many layers and stages, and there are a number of things that can positively or negatively influence a patient’s outcome.<ref>Physiosouth. (2019). ''Successful Rehabilitation: A Patients Guide.''   Retrieved from https://www.physiosouth.co.nz/articles-and-education/successful-rehabilitation/ [Accessed 14 November 2019]</ref> During an assessment it is possible for the physiotherapist to identify any yellow or orange flags that may suggest that the patient has any psycho-social or mental health concerns caused by their illness or injury. If not properly addressed during treatment, these stressors and concerns can develop into a more serious mental health condition for the patient. Physiotherapists regularly come into contact with people with common stressors regardless of the setting and it is likely that this will influence engagement and response to treatment. These patients access mainstream physiotherapy and some may need reasonable adjustments. In almost all cases these stressors will not affect the ability to treat in a department.<ref name=":6">So your next patient has a mental health condition - a guide for physiotherapists not specialising in mental health.   Chartered Society of Physiotherapy,(2018) Retrieved from https://www.csp.org.uk/publications/so-your-next-patient-has-mental-health-condition-guide-physiotherapists-not [Accessed 14 November 2019]</ref>  As well as the health benefits of regular exercise, it is also beneficial for psychological status. Exercise reduces anxiety, depression and negative mood by improving self-esteem and cognitive functioning, and is also associated with an improved quality of life<ref>Callaghan, P. (2004). Exercise: a neglected intervention in mental health care? ''Journal of psychiatric and mental health nursing''.  Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2850.2004.00751 [Accessed 14 November 2019]</ref>. The role of the physiotherapist and the treatment provided will depend on the injury/illness that is present. Treatment should be individualised to the patient using the expert knowledge from the physiotherapist regarding the type of injury/illness.
See [[Effects of Exercise on Stress Management|Effects of Exercise on Stress management]]


Psychological goals of physiotherapy include:
'''Psychological goals of physiotherapy''' 
* Raising self-esteem and confidence
* Raising self-esteem and confidence
* Improving mood and promoting well-being through a structured exercise program
* Improving mood and promoting well-being through a structured exercise program
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* Reducing social isolation
* Reducing social isolation
* Improving quality of life
* Improving quality of life
Physical goals remain similar to those in every treatment:  
'''Physical goals''' 
 
Remain similar to those in every treatment:  
* To provide non-pharmacological treatment for pain
* To provide non-pharmacological treatment for pain
* To improve muscle strength and flexibility
* To improve muscle strength and flexibility
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* Prevention of falls and other mobility issues
* Prevention of falls and other mobility issues
* Advice on weight management. <ref>Kaur, J., Masaun, M., & Bhatia, M. S. (2013). Role of Physiotherapy in Mental Health Disorders. ''Dehli Psychiatry Journal, 16''(2), 404-408.</ref>
* Advice on weight management. <ref>Kaur, J., Masaun, M., & Bhatia, M. S. (2013). Role of Physiotherapy in Mental Health Disorders. ''Dehli Psychiatry Journal, 16''(2), 404-408.</ref>
Some main findings in evidence are that: physical activity is associated with decreased risk of developing clinical depression, aerobic and resistance exercises are effective for treating depression, the effect is of the same magnitude as psycho-therapeutic interventions. Similarly, exercise has a moderate effect on reducing anxiety and can improve physical self-perceptions and self-esteem. Aerobic and resistance exercises have been best evidenced to reduce stress through an exercise-induced increase in blood circulation to the brain and release of endorphins. This increased blood flow has an influence on the hypothalamic-pituitary-adrenal (HPA) axis and subsequently reduces stress.<ref>Harber, V. J., & Sutton, J. R. (1984). Endorphins and exercise. ''Sports Medicine, 1''(2), 154-171</ref> With regard to the brain and underlying neuro-biological mechanisms and pathways, endogenous reward and motivation circuitries that are imbedded in the limbic regions of the brain are responsible for the auto regulatory and endogenous reduction of stress. Exercise techniques clearly have an impact upon these systems. This is one of the reasons why physical activity not only improves overall physical health and strength, or physiologically reduces stress, but also increases mood and decreases psychological distress, i.e., depression or affective instability, by pleasure induction.<ref>Esch, T., & Stefano, G. B. (2010). Endogenous reward mechanisms and their importance in stress reduction, exercise and the brain. ''Archives of medical science, 6''(3), 447–455.</ref>  Physiotherapy provides multiple interventions for stress management; from physical activity to managing thoughts and emotions. The relaxation response is almost universally successful in obtaining better than normal recovery outcomes. Relaxation training has been proven to reduce stress levels and improve health outcomes in every condition tested. Simple relaxation, breathing and/or meditation work very well and offer a high benefit for minimal effort. Some exercises included for patients with mental health disorders that could prove beneficial for patients presenting with these stressors are: relaxed deep breathing, muscle flexibility, relaxation, endurance, biofeedback, multi-sensorial stimulation and balance training. Recently, there has been an increased amount of research on the role of mind-body types of exercise such as yoga or Tai Chi which has shown to reduce stress. Concerns whilst designing a program include structured versus lifestyle activities, individually tailored, self-monitoring, group versus individual and self-efficacy.
Things to consider during appointments with patients who present with psycho-social concerns as a result of serious injury/illness:  
Things to consider during appointments with patients who present with psycho-social concerns as a result of serious injury/illness:  
* If the person has any specific likes or dislikes which may affect the appointment, in particular fears
* If the person has any specific likes or dislikes which may affect the appointment, in particular fears

Latest revision as of 19:04, 17 January 2023

Original Editor - Pete Woolhead as part of the Northumbria University Innovation and Contemporary Physiotherapy Project
Top Contributors - Pete Woollhead, Lucinda hampton, Kim Jackson and Aminat Abolade

Introduction[edit | edit source]

Fight or Flight Response

Acute stress can occur in up to 45% of injury survivors following a traumatic injury or illness. It involves an anxiety response that includes re-experience of the traumatic event, intrusive memories, dreams, and strong emotional distress on exposure to triggering events.[1]

Physiotherapists can have a significant role in identifying and early management of patients who present with a stress response following serious injury/illness. Physiotherapists are not typically associated with mental health interventions, but they can have a large impact on the mental well-being of patients.

Traumatic injury is responsible for 11% of global mortality and contributes to a significant amount of physical and psychological morbidity for all age groups[2]. Patients with traumatic injury report a substantial reduction in health-related quality of life compared to other patients, including long-term psychological and physical disability. There is a known associations between injury, depression, anxiety, ASD and PTSD[3].  

A traumatic experience triggers the stress response ie the hormonal and metabolic changes in the body following physical or emotional trauma or critical illness that cause disequilibrium and threaten homeostasis.[4][5] See Stress and Health

Biopsychosocial Model[edit | edit source]

The biopsychosocial model underpins physiotherapy assessments and interventions. It interconnects physiology, psychology and socio-environmental factors associated to an injury or illness and has been well established within physiotherapy for the past 25 years. It ensures physiotherapists assess and treat a patient holistically and apply intervention to help manage both physical and mental concerns.

Factors Influencing Stress Response[edit | edit source]

Internal Factors[edit | edit source]

Nightmare

Memories of traumatic injury or critical illness can remain prominent for patients and induce frightening recollections, nightmares and delusions.[6] Altered mental status is common in the ICU (see ICU Delirium)), and often worsened by sedation.[7] Other traumatic stressors related to the in-hospital care received include longer ICU length of stay, longer hospital stay, intubation and length of mechanical ventilation[7].

Inability to perform everyday tasks, particularly relating to washing and toileting, may lead to frustration and embarrassment.

People with physical disabilities are at a higher risk of developing psychiatric and substance disorders.[8]

Patients of serious injury or illness often experience pain as a result of the injury or illness and its management[9]. Chronic pain is often comorbid with psychiatric disorders, eg depression[10]. Epidemiological and functional imaging studies suggest that a bidirectional relationship exists between chronic pain and mental health concerns, suggesting that not only does pain induce stress and problems with mental health, but poor mental status may influence pain[9].

External Factors[edit | edit source]

Stress effects

Acute bouts of stress and anxiety affect one’s mental health following severe illness/injury. These conditions were commonly identified at 1 month post injury/illness, and although their prevalence decreased over time, their incidence still remains high at 12 months.[11]

Following severe illness/trauma the combination of several external factors such as a lack of family and social support, financial and/or insurance issues, or contextual conditions (such as deployment and subsequent return home in military personnel) can lead to anxiety and depression, and impact on physical function, pain, and often affecting one’s return to work.

Family and social support play a key role in the recovery of mental health following severe injury. Family support In particular is of great importance since they provide a large portion of the care: they may offer transportation, finances, leisure, and emotional support.[12] Moreover, they are often involved in the rehabilitation goal planning, which may be adapted based on the resources available at their own home. Family stress and unhealthy family communication were found to impair the rehabilitation process.[13]

Insurance and compensation-seeking behaviour have also been shown to impact on psychological well-being. Previous studies showed longer lasting symptoms for compensation seekers or litigants, and can cause delayed work return as well as increased levels of psychological stress secondary to the unresolved financial issues, the injury, or a combination of both factors.[13]

Contextual factors can affect one’s psychological well-being following a road traffic accidents (RTA). Being involved in an RTA can be both stressful and psychologically traumatic, and it has been reported that many individuals involved in RTA’s do not have their psychological reactions attended. This has been suggested to trigger a psychological stress response when these individuals are exposure to environments associated with the traumatic memory.[14]

Flags During Assessment[edit | edit source]

Yellow Flag

During a physiotherapy assessment, the flag system can be useful to identify any signs or symptoms that may require further attention and investigation. psycho-social flags allow physiotherapists to assess a patient holistically using a bio-psycho-social model, and direct treatment towards the needs of the patient.

  1. Orange Flags: represent the equivalent of red flags for mental health and psychological problems[15]
  2. Yellow Flags: identify concerning thoughts, feelings and behaviours linked to the stress of their recovery, change in lifestyle, and social context which may influence a patient’s state of mental health. These include any unusual emotional responses such as increased worry, fear and anxiety, or unusual pain behaviours such as poor coping strategies, avoidance behaviours and over-reliance of passive treatments such as medications. These will be particularly important to monitor if a patient has had an injury/illness that is life changing.

The Role of the Physiotherapist[edit | edit source]

Figure 2. The Biopsychosocial Model.

The link between physical health and mental health is widely accepted. Physiotherapy is considered to be integral to the treatment of the physical aspects of musculoskeletal, cardio-respiratory, and neurological conditions, and it plays a significant role in managing chronic pain and preventable diseases.[16] When patients have no co-morbid mental health issues physiotherapists should provide reassurance, psychological support, and education to reduce distress and promote behavioural change.[17]

Any treatment regime needs to take a holistic approach to both the physical injury itself and the adversity induced by it. Recovery from injury, illness, surgery or any life stress requires two key factors:

1.Diagnosis and Targeted Effective Treatment for the Cause of the Problem: Targeted treatment comprises of either a specific exercise program for functional purpose or surgery followed by rehabilitation. Simple, classical medical intervention is based on reductionism (knowing which structure is faulty and fixing it). This is a proven method and is ideal, however, there is often no clear diagnosis, or treatment is not as effective as intended. These and other factors can create barriers to recovery.

2. Identify and Minimise Barriers to Treatment and Addressing Psycho-Social Factors and What to Do with Them: Physiotherapists should look at the whole person, their circumstances and how they react to the stimulus or threat associated with their injury. These factors have the biggest influence on recovery from injury but are almost completely neglected in modern medicine. All good clinicians are aware of how these barriers can negatively affect recovery outcomes, and how much of a challenge it can be to change them. Managing your internal and external environment requires a lot more time and effort because some barriers to recovery are related to long held beliefs and behaviours that are engrained into our daily lives. Changing these can require a big effort for some patients, but can result in positive and long-term change.

To gain the best possible outcome from any adversity or stress, both systems need to be engaged. Rehabilitation is not a procedure or medication, it is a process with many layers and stages, and there are a number of things that can positively or negatively influence a patient’s outcome.[18] During an assessment it is possible for the physiotherapist to identify any yellow or orange flags that may suggest that the patient has any psycho-social or mental health concerns caused by their illness or injury. If not properly addressed during treatment, these stressors and concerns can develop into a more serious mental health condition for the patient. Physiotherapists regularly come into contact with people with common stressors regardless of the setting and it is likely that this will influence engagement and response to treatment. These patients access mainstream physiotherapy and some may need reasonable adjustments. In almost all cases these stressors will not affect the ability to treat in a department.[19]

See Effects of Exercise on Stress management

Psychological goals of physiotherapy

  • Raising self-esteem and confidence
  • Improving mood and promoting well-being through a structured exercise program
  • Motivation for self-management
  • Promotion of a more positive body image
  • Reducing social isolation
  • Improving quality of life

Physical goals

Remain similar to those in every treatment:

  • To provide non-pharmacological treatment for pain
  • To improve muscle strength and flexibility
  • To improve cardiovascular endurance
  • Prevention of falls and other mobility issues
  • Advice on weight management. [20]

Things to consider during appointments with patients who present with psycho-social concerns as a result of serious injury/illness:

  • If the person has any specific likes or dislikes which may affect the appointment, in particular fears
  • The impact of their mental health on day to day life and function
  • How you will communicate, use words they may be familiar with be respectful, do not stigmatise and remember people with a diagnosis of mental illness are people just like everyone else, communication is key
  • Try and understand the wider implication of the injury and use a holistic approach
  • You may need to develop your therapeutic relationship before proceeding with a manual assessment or intervention[19]

References[edit | edit source]

  1. ↑ Bryant, B., & Knights, K. (2011). Pharmacology for Health Professionals. (Vol. 3): Elsevier.
  2. ↑ Organisation, W. H. (2010). World Health Organisation (WHO)
  3. ↑ Wiseman, T., Foster, K., & Curtis, K. (2013). Mental health following traumatic physical injury: an integrative literature review. Injury, 44(11), 1383–1390
  4. ↑ Desborough, J. P. (2000). The stress response to trauma and surgery. British Journal of Anaesthesia, 85(1), 109-117.
  5. ↑ Correia, M. I. T. D., & De Almeida, C. T. (2005). Nutritional Support for the Critically Ill Patient: A Guide to Practice (2 ed.): CRC Press.
  6. ↑ Ringdal, M., Plos, K., & Bergbom, I. (2008). Memories of being injured and patients' care trajectory after physical trauma. BMC nursing, 7(8), 1-12.
  7. ↑ 7.0 7.1 Jackson, J. C., Hart, R. P., Gordon, S. M., Hopkins, R. O., Girard, T. D., & Ely, E. (2007). Post-traumatic stress disorder and post-traumatic stress symptoms following critical illness in medical intensive care unit patients: assessing the magnitude of the problem. Critical Care, 11(1), R27.
  8. ↑ Turner, R. J., Lloyd, D. A., & Taylor, J. (2006). Physical disability and mental health: An epidemiology of psychiatric and substance disorders. Rehabilitation Psychology, 51(3), 214-223.
  9. ↑ 9.0 9.1 Hooten, W. M. (2016). Chronic pain and mental health disorders: shared neural mechanisms, epidemiology, and treatment. Mayo Clinic Proceedings, 91(7), 955-970.
  10. ↑ Gureje, O., Von Korff, M., Kola, L., Demyttenaere, K., He, Y., Posada-Villa, J., . . . Iwata, N. (2008). The relation between multiple pains and mental disorders: results from the World Mental Health Surveys. Pain, 135(1-2), 82-91.
  11. ↑ Kellezi B, Coupland C, Morriss R, Beckett K, Joseph S, Barnes J, Christie N, Sleney J, Kendrick D. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology. 2017 Jul 1;52(7):855-66.
  12. ↑ Kellezi B, Coupland C, Morriss R, Beckett K, Joseph S, Barnes J, Christie N, Sleney J, Kendrick D. The impact of psychological factors on recovery from injury: a multicentre cohort study. Social psychiatry and psychiatric epidemiology. 2017 Jul 1;52(7):855-66.
  13. ↑ 13.0 13.1 Shoulson I, Wilhelm EE, Koehler R, editors. Cognitive rehabilitation therapy for traumatic brain injury: evaluating the evidence. National Academies Press; 2012 Jan 28.
  14. ↑ Smith B, Mackenzie-Ross S, Scragg P. Prevalence of poor psychological morbidity following a minor road traffic accident (RTA): The clinical implications of a prospective longitudinal study. Counselling Psychology Quarterly. 2007 Jun 1;20(2):149-55.
  15. ↑ Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care, 41(11), 1284-1292.
  16. ↑ Connaughton, J., & Gibson, W. (2016). Do Physiotherapists Have the Skill to Engage in the "Psychological" in the Bio-Psychosocial Approach? Physiotherapy Canada, 68(4), 377–382
  17. ↑ MacNeela, P., Scott, P. A., Treacy, M., Hyde, A., & O'Mahony, R. (2012). A risk to himself: Attitudes toward psychiatric patients and choice of psychosocial strategies among nurses in medical–surgical units. Research in nursing & health, 35(2), 200-213.
  18. ↑ Physiosouth. (2019). Successful Rehabilitation: A Patients Guide.   Retrieved from https://www.physiosouth.co.nz/articles-and-education/successful-rehabilitation/ [Accessed 14 November 2019]
  19. ↑ 19.0 19.1 So your next patient has a mental health condition - a guide for physiotherapists not specialising in mental health.   Chartered Society of Physiotherapy,(2018) Retrieved from https://www.csp.org.uk/publications/so-your-next-patient-has-mental-health-condition-guide-physiotherapists-not [Accessed 14 November 2019]
  20. ↑ Kaur, J., Masaun, M., & Bhatia, M. S. (2013). Role of Physiotherapy in Mental Health Disorders. Dehli Psychiatry Journal, 16(2), 404-408.
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