Prognosis Fright

The implications of negative patient perspective in the recovery process

October is packed with awareness campaigns including being Mental Health month and Health & Safety month, with World Mental Health Day also featuring. In addition, there’s also Halloween at the end of the month. So, there really could not be a better time to address a particular issue that incorporates all of these – fear! Fear is an emotion I encounter regularly in consultations and I know many other osteopaths do too. Largely this is the patient’s fear of the unknown. 

• WHAT is causing the pain?

• HOW is it causing the pain? HOW will the recovery process work?

• WHERE is the musculoskeletal issue originating from?

• WHY is it causing pain among other signs and symptoms?

• WHEN will the pain subside? WILL the pain subside?

All human emotions are valid and important, including fear. It is an understandable emotion that arises in patients. Your treating practitioner will want to understand how you are feeling and wants you to know that you are being listened to. If you are comfortable doing so, feel free to express your emotions to your practitioner to allow for full rapport. It is important in the overall treatment process. Consulting with your osteopath is a safe and private place to express your fears and concerns. When fear around the diagnosis and management of a patient’s musculoskeletal condition is not discussed and addressed, anxiety can build. This induces particular responses within the body. As these responses occur, they may impact upon the patient’s prognosis. Prognosis is defined as the likely course of a medical condition (from “text-book” information or an opinion of an individual with medical experience). (Lexico, 2020). But what are these responses? Implications of prognosis-related anxiety Anxiety Anxiety has three dimensions to it. It is a psychological, physiological and behavioural state induced in both animals and humans. It comes to life by a threat to wellbeing or survival, either actual or potential. It is characterised by increased arousal, expectancy, autonomic and neuroendocrine activation and specific behaviour patterns. The body undergoes these internal changes to be able to withstand adverse or unexpected situations (Steimer, 2002). As many of you may already know, these changes can become pathological when they inhibit the ability to cope with daily life changes – especially an unexpected musculoskeletal injury. In some instances, patients may have developed and been diagnosed with anxiety prior to presenting to an osteopath with an issue, perhaps as a result of early or recent traumatic life experiences. For these patients, there may be an increased likelihood of developing mild to moderate anxiety surrounding diagnosis of their musculoskeletal pain. Research in this area is lacking at present. For me, every patient presentation is unique; the likelihood of anxiety in patients can be very difficult to predetermine.Sympathetic dominance in anxiety and

Implications Anxiety signs and symptoms arise as a result of nervous system function – response to stress. The nervous system has different divisions:

• The central division: the brain and spinal cord

• The peripheral division (autonomic and somatic nervous systems).

The central nervous system is particularly important in triggering stress responses as it regulates the autonomic nervous system and plays a key role in interpreting contexts as potentially threatening. The autonomic nervous system (ANS) has a direct role in physical response to stress and is divided into:

• The sympathetic nervous system (SNS)

• The parasympathetic nervous system (PNS).

When the body is stressed (e.g. when an unforeseen diagnosis or injury arises), the SNS can instigate the ‘fight or flight’ response. This can happen very quickly to prepare the body for immediate response to the perceived threat in an instance of acute, short-term stressors. The body shifts its energy resources toward fighting off the perceived life threat or to be used to flee from the perceived enemy. The SNS signals the adrenal glands (these sit atop your kidneys) to release hormones called adrenalin (epinephrine) and cortisol. These hormones, together with direct actions of autonomic nerves, cause:

• heart and respiratory rate to increase (to increase necessary blood supply for action)

• blood vessels in the arms and legs to dilate (to supply the muscles with blood for sudden action)

• digestive processes to quieten (to conserve as much energy as possible)  

• glucose levels in the blood to rise (as an energy source).

Once the crisis is over, the body usually returns to homeostasis (previous unstressed, regulatory state). This recovery is facilitated by the PNS which opposes the effects of the SNS. Chronic stress (for instance, experiencing angst relating to outcome of an injury) can lengthen patient prognosis. As the autonomic nervous system continues to trigger physical reactions (referred to as sympathetic dominance), it causes wear and tear on the body. Continuous activation of the nervous system can create issues within other bodily systems integral to recovery (APA, 2020). To assist in the healing process of a musculoskeletal injury (removal of cellular debris and products from immune cell processes, tissue regeneration), the body requires adequate immune system response. This can be affected by repetitive cortisol release from ongoing anxiety related sympathetic responses. Sympathetic dominance can also cause other issues that can interact negatively with prognosis:

• insomnia - rest is necessary to promote optimum immune function as regeneration of cells and tissue occurs while we are sleeping

• muscular tension - this is not ideal when a patient is already experiencing discomfort from an injury and their osteopath is aiming to reduce potential tension around an injury site

• low energy - this can amplify reduced motivation and a negative outlook for present in a fearful patient

• digestive changes - constipation, diarrhoea and nausea (as a result of slowed digestive processes from continual sympathetic activation) can impede adequate nutrient intake. A well balanced, nutritious diet has been linked to timely recoveries (APA, 2020).

Many psychosocial factors can create anxiety, influencing a patient’s perception of their pain and prognosis. Psychosocial factors are those that involve interrelation between thought, behaviour and social elements. For example, anxiety created in a patient who is in pain, unable to work and fears losing income. Many individuals have experienced this level of stress. This stressful life situation can profoundly impact upon a patient’s perspective on their ability to recover (McGrath, 1994). Pain is unique to the individual Pain is a complex, multidimensional perception varying in quality, strength, duration, location and level of discomfort. The strength and discomfort level of pain cannot be simply, or directly, related to the nature and degree of tissue damage. For instance, a baby may experience different pains depending on the situations in which it is stimulated. Pain experiences can exist along an infinite spectrum. It can range from inability to perceive pain to a horrendous intensity. Some individuals even experience phantom limb pain – perceived pain from a limb that has otherwise been removed (McGrath, 1994). Acute vs chronic pain Acute pain is a type of pain that typically lasts less than three months or that is directly related to soft tissue damage such as a sprained ankle or a paper cut. With appropriate intervention (and early osteopathic management where appropriate), this presentation can be supported through to full recovery with a balanced approach.

Chronic musculoskeletal conditions can develop for a variety of reasons. By no means can an acute presentation of pain reside for more than three months and become chronic purely by way of prognosis anxiety. Lifestyle factors (for example, alcoholism, cigarette smoking, sedentary behaviours, poor nutrition) can contribute toward a longer recovery time for a given musculoskeletal injury/complaint, where it may be then classed as chronic pain. Research within the realm of chronic pain is mounting; it is becoming increasingly conceived as involving altered central nervous system processing. Much of the research indicates that there is evidence of central hyperexcitability in people with chronic musculoskeletal pain. To experience pain in a region of the body persistently requires nerve supply. Much of the research reveals that the region of the spinal cord responsible for this nerve supply to the chronic pain area is ‘overexcited’ and behaving differently to the typical norm. This is central hyperexcitability or what is well known now as central sensitisation. This is believed to arise as a result of repetitive nociception (pain signalling) at the given level, basically creating an adaptation at the level to behave in this way as a baseline, without a tissue damaging stimulus occurring (Choon et al., 2011). Remaining prisoner within a perspective of this nature can be detrimental. Thankfully, with help from your osteopath, gaining an understanding of pain and its purpose can direct patients away from this path. Take care of yourselves, Lenore Dyson REFERENCES Choon Wyn Lim, E., Sterling, M., Stone, A., Vicenzino B. Central hyperexcitability as measured with nociceptive flexor reflex threshold in chronic musculoskeletal pain: a systematic review. Pain. 2011 Aug;152(8):1811-20. Lexico: Oxford, English and Spanish Dictionary. (https://www.lexico.com/definition/prognosis) (2020) McGrath, P. A. Psychological aspects of pain perception. Arch Oral Biol. (1994)  Steimer, T. The biology of fear – and anxiety – related behaviors. Dialogues Clinical Neuroscience. 2002 Sep; 4(3): 231–249. American Psychological Association. Stress effects on the body. https://www.apa.org/helpcenter/stress/effects-nervous# (APA, 2020) HEALTH AND SAFETY MONTH 2020 RESOURCES https://www.worksafe.vic.gov.au/events?gclid=CjwKCAjwrKr8BRB_EiwA7eFapkjM4wWCQdrkD8JpQQHWiO7nI3dus8JtasoEgXOChWR-hHQx58GVYRoCWEUQAvD_BwE