Chiropractic+



The Impact and Effects of Stress on the BodyIntroductionDuring Chiropractic clinic-observations this year I observed a vast number of patients who self-reported ‘suffering’ from “stress”. This was a ‘stand-out’ thematic presentation. Patients attributed migraines, insomnia and various ‘aches and pains’ to the presence of stress in their lives. My thoughts in listening to patients speak about stress with their Chiropractors immediately gravitated to Engel’s (1977) biopsychosocial model of disease. Appendix 1. Patients themselves were making links between biological, psychological and sociological influences in their lives. I was fascinated how Chiropractors, who many patients would consider as working in a mechanistic way, treating skeletal, predominately joint, dysfunction, might actually address a patient’s ‘other’ needs simply through the process of the therapeutic / clinical encounter. Could the Chiropractic profession in the UK adapt its primarily ‘mechanistic’ paradigm to truly incorporate the biopsychosocial model of disease first proposed by Engel in the 1970's, which is in harmony with the vitalistic philosophy of ‘original’ Chiropractic?A memorable clinical encounter was ‘Patient A’. 30 year old male, former British Marine and Commando with 14 years of military service which included 1 tour of Iraq and 3 tours of Afghanistan. His body was covered in scars from the physical trauma / wounds inflicted in combat. Significantly I recalled his account of an incident where his patrol-squadron was blown up by a roadside IED which killed 7 in his unit. Despite being severely injured and under enemy fire he saved 4 of his platoon. He, along with those he rescued, were airlifted from Afghanistan to Germany for emergency surgery. After a lengthy recovery he was awarded the Military Cross. He presented with acute lumbar discomfort and generalised lower back pain, limited range of motion, limited flexion and extension, and being “in pain all the time”. He aptly described his body as being as “hard as solid concrete”. This patient, however, did not specifically cite stress as a concern during his consultation but it occurred to me that stress was perhaps a factor that could have heightened his sensitivity to pain. He physically presented with injuries which were undoubtedly stress provoking and although I could only imagine the traumatic effects of seeing comrades killed in combat and being, personally, seriously injured – just considering his account I was aware of the vicarious traumatic effect on myself; I became physically rigid listening to his accounts. I considered that I only had a layman’s knowledge of stress, particularly of the mechanisms in which it affects the whole body in both physical and psychological ways. I also considered what role I would play, in the future, as a Chiropractor in educating and potentially alleviating symptoms of stress in my patients and these thoughts helped me identify an important gap in my knowledge base.What is stress?Stress is a natural physical and mental reaction to both good and bad experiences that can be beneficial to your health and safety. Our bodies respond to stress by releasing hormones and increasing our heart and breathing rates. Our brain receives more oxygen, giving you an edge in responding to a problem. In the short term, stress helps you cope with tough situations. Appendix 2. However if not regulated, humans run the risk of entering a cycle where stress creates stress which creates further stress and so on and so forth. In such a scenario there are potentially serious psychological and physical consequences which necessitates that chronic stress is recognised and mediated through intervention from health professionals (Sapolsky, 2010).Claude Bernard (1961) noted that the maintenance of life is critically dependent on keeping our internal milieu constant in the face of a changing environment. Cannon (1929) first called this “homeostasis.” Selye (1956) used the term “stress” to represent the effects of anything that seriously threatens homeostasis. The actual or perceived threat to an organism is referred to as the “stressor” and the response to the stressor is called the “stress response.” Although stress responses evolved as adaptive processes, Selye (1956) observed that severe, prolonged stress responses might lead to tissue damage and disease.Stress can be triggered by the pressures of everyday responsibilities, at work and at home. As you might expect, negative life events like divorce or the death of a loved one cause heightened stress. So too can physical illness. Traumatic stress brought on by war, disaster, or a violent attack, can keep your body’s stress levels elevated far longer than is necessary for survival.How does stress affect health?Stressors have a major influence upon mood, our sense of well-being, behaviour, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual’s biological vulnerability (Schneiderman, 2005).Your central nervous system (CNS) is in charge of your “fight or flight” response. The CNS instantly sends signals through the body, marshalling all resources to engage ‘survival mode’. In the brain, the hypothalamus signals the adrenal glands to release adrenaline and cortisol. Appendix 3.When the perceived fear is gone, the CNS should signal systems to return to normal. If the CNS fails to return homeostasis, or if the stressor doesn’t diminish, then the body will continue to release stress hormones (Sapolsky, 1992).Some common symptoms of chronic stress include irritability, anxiety, heightened sensitivity to pain, anhedonia and insomnia. Chronic stress is a factor in some behaviours like overeating or not eating enough, alcohol or drug abuse, or social withdrawal (Moss & Dyer, 2010).Unregulated or unmitigated stress can cause a negative stress reaction referred to simply as ‘distress’. Distress can cause the physical manifestations of symptoms such as headaches, upset stomach, elevated blood pressure, chest pain, and problems with sleeping. Research suggests that stress can also bring on or worsen certain symptoms or diseases, including the subjective level of discomfort experienced (Sapolsky, 1992).Stress may also contribute to the development of maladaptive coping strategies, causing people to turn to alcohol, tobacco, or other drugs to try to relieve their stress, or the pain caused by it (Moss & Dyer, 2010). Chronic stress may lead to physiological systems within the brain and body fluctuating to meet internal or external demands, causing deterioration, and leading to maladaption (Stratakis,1995). Physiological systems such as the central nervous system, reproductive system, cardiovascular system, metabolic system and immune system are all involved in survival and adaptation. Appendix 4. When stress cannot be normalised (enabled, disabled or decreased), it may become detrimental to health (Meyer, 2001). The detrimental effects of stress may manifest in several systems wide disorders such as: behaviour/mood disorders of substance abuse and depression (Spencer, 1999), cardiovascular disorders such as hypertension, atherosclerosis and cardiovascular disease (Hemmingway, 1999); metabolic diseases such as insulin resistance/metabolic X syndrome and obesity (Sapolsky, 2000); immune disorders that include chronic inflammatory processes, autoimmune diseases (McEwen, 1999); or vulnerability to these or other diseases (McEwan, 1999). It is widely accepted that stress can affect multiple systems within the body (Glaser, 2005), including the neuromusculoskeletal system ("type M" disorders) (Pollard, 2004) and the non-neuromusculoskletal systems ("type O" disorders) (Pollard, 2005). As with overall homeostatic function, individual functions often have an optimum range of function outside of which function is decreased or becomes pathological. Thus, it is plausible that too little or too much of a particular function may be detrimental to the optimal function of the organism. Chronic stress is associated with abnormal organ function and the presence of disease (Richards et al, 2003) while the removal of stress has been shown to rehabilitate stress induced disease (Speckens, 1995). Rehabilitation from stress is not purely a health imperative, there are enormous economic consequences which result from the effects of stress. The UK Health and Safety Executive reports that roughly 10.4 million working days are lost each year to stress, depression or anxiety. Appendix 5.Patient Stress and the Potential Mitigating Role of ChiropracticChiropractors treat conditions of a neuromusculoskeletal and non-neuromusculoskeletal nature (Hawk, 2001). The majority of conditions treated by Chiropractors are neuromusculoskeletal (Hartvigsen, 2003). Although controversy exists, from some detractors, about the role of Chiropractic in the management of the non-neuromusculoskeletal conditions, there would none the less appear to be cumulative evidence supporting the need for further research by the profession into Chiropractic’s effects through the lens of disciplines such as psychoneuroimmunology (Hardy & Pollard, 2006).Hardy & Pollard (2006) also suggest that another area of important research to be conducted would be to examine the effect of Chiropractic management on subjective variables of pain as well as objective measures of stress and provide insight into the mechanism of action.ConclusionAs a result of an overwhelming number of patients that reported ‘feeling stressed’ or disclosing self-reported correlations between perceived stressors and physical ailments during my clinical observations of Chiropractors, I examined my own, very limited, understanding of stress, particularly how stress may impact upon the patients I would see in a Chiropractic clinical context. I therefore resolved that it was important to obtain insight into the mechanisms underpinning the activation and normalisation of the effects of stress and to develop an awareness of the types of physical presentations that typically manifest when heightened or chronic stress is a serious factor impacting on a patient’s health. My investigation of the clinical significance of stress formed the basis of my self-study of academic material and reflection upon my own methods of managing stress. During my investigations I was very interested by the development of more recent Chiropractic techniques, such as Neuro-Emotional Technique (Walker, 1996) which incorporate elements of cognitive and Behavioural modification principles, Pavlovian (Classical) Conditioning, and repetition compulsion together with Spinal Manipulative Therapy. Unfortunately I was unable to read as widely as I would have liked to discover what evidence, if any, exists beyond the anecdotal to support the technique’s efficacy in treating stress related illnesses exhibiting obvious physical symptoms / presentations and doing so remains an on-going priority.I am now more alert to the health effects of stress as a consequence of noticing how prolifically they were reported by patients and then undertaking self-study during this academic year. I see the next steps for me are to research the impact of the entire therapeutic encounter – language, non-verbal cues, clinic décor and various factors – and how a positive patients experience will enhance stress reduction and potentially lead to unanticipated benefits for the patient.ReferencesBernard C. An Introduction to the Study of Experimental Medicine. Transl. HC Greene. New York: Collier; 1961 (1865).Beyond Good Health Clinics. 2015. Ravaged By Stress? Tips on How to Reduce Cortisol. [ONLINE] Available at: . [Accessed 11 October 15].Cannon WB (1929). Bodily Changes in Pain, Hunger, Fear and Rage. 2nd ed. New York: Appleton. Engel GL: The need for a new medical model: a challenge for biomedicine.Science 1977, 196:129-136.Glaser R: Stress-associated immune dysregulation and its importance for human health: a personal history of psychoneuroimmunology.Brain Behav Immun 2005, 19(1):3-11.Hardy, K, Pollard H. (2006). The organisation of the stress response, and its relevance to Chiropractors: a commentary. Chiropractic & Manual Therapies, 1, 12-23. Hartvigsen J, Bolding-Jensen O, Hviid H, Grunnet-Nilsson N: Danish chiropractic patients then and now: a comparison between 1962 and 1999.J Manipulative Physiol Ther 2003, 26:65-69.Hawk C, Long CR, Boulanger KT: Prevalence of nonmusculoskeletal complaints in chiropractic practice: report from a practice-based researchprogram. J Manipulative Physiol Ther 2001, 24:157-169. Healthline Networks Inc. 2015. The Effects of Stress on the Body. [ONLINE] Available at: . [Accessed 10 October 15].Hemingway H, Marmot M: Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohortstudies. BMJ 1999, 318:1460-1467.McEwen BS: Stress, adaptation, and disease. Allostasis and allostatic load.Ann N Y Acad Sci 1998, 840:33-44. McEwen BS: The neurobiology of stress: From serendipidity to clinical relevance. Brain Res 2000, 886:172-189.McEwen BS, Weiss JM, Schwartz LS: Selective retention of corticosterone by limbic structures in rat brain. Nature 1968, 220:911-912. Melzack R: Pain and stress: A new perspective. In Psychosocial factors in pain: Critical perspectives. Edited by Gatchel RJ, Turk DC. New York: Guilford Press;1999:89-106.Meyer SE, Chrousos GP, Gold PW: Major depression and the stress system: A life span perspective.Dev Psyopathol 2001, 13:564-580.Moss, AC. Dyer, KR. (2010).?Psychology of Addictive Behaviour. London: Palgrave Macmillan. p5 Pollard H (2004). The somatovisceral reflex: How important for the "type O" condition? Chiropractic Journal of Australia, 34:93-102.Richards A, Barkham M, Cahill J, Richards D, Williams C, Heywood P: PHASE: a randomised, controlled trial of supervised self-help cognitive behavioural therapy in primary care. Br J Gen Pract 2003, 53(495):764-70. Sapolsky R., M. (1992). Stress, The Ageing Brain. And the Mechanisms of Neuron Death. Cambridge, MA: MIT Press. Schneiderman N, Ironson G, and Siegal SD: 2005. Stress and Health: Psychological, Behavioral, and Biological Determinants. Annualk Review Clinic Psychology, 1, 607-628.Selye H. The Stress of Life. New York: McGraw-Hill; 1956.Speckens AE, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooijmans HG: Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. BMJ 1995, 311(7016):1328-32. Spencer RI, Hutchinson KE: Alcohol, aging, and the stress response.Alcohol Res Health 1999, 23:272-283. Stratakis CA, Chrousos GP: Neuroendocrinology and pathophysiology of the stress system. Ann N Y Acad Sci 1995, 771:1-18.Stress and Your Body, 2010. [DVD] Professor Robert Sapolsky, USA: The Teaching Company.The Patient Patient. 2013. The biopsychosocial model of disease. [ONLINE] Available at: . [Accessed 16 October 15].Walker S: Neuro Emotional Technique: N.E.T basic manual. Encinitas (CA): N.E.T Inc; 1996.WebMD UK. 2015. Stress Symptoms: The effects of stress on the body. [ONLINE] Available at: . [Accessed 10 October 15].Appendix 1. The Biopsychosocial Model of DiseaseThe Patient Patient. 2013. The biopsychosocial model of disease. [ONLINE] Available at: . [Accessed 16 October 15].Appendix 2. The Effects of Stress on the Body Healthline Networks Inc. 2015. The Effects of Stress on the Body. [ONLINE] Available at: . [Accessed 10 October 15].Appendix 3. Function of Cortisol in StressBeyond Good Health Clinics. 2015. Ravaged By Stress? Tips on How to Reduce Cortisol. [ONLINE] Available at: . [Accessed 11 October 15].Appendix 4. Physiology of Stress Response The American Institute of Stress. 2015. Stress and Daily Life. [ONLINE] Available at: . [Accessed 11 October 15].Appendix 5. Working Days Lost Due to Stress in the United KingdomWorking days lost Work-related stress caused workers in Great Britain to lose 11.3 million working days in 2013/14 based on the LFS data. Male workers accounted for an estimated 5.4 million days off work whilst female workers accounted for an estimated 5.9 million. This represents a decrease in annual working days lost since 2001/02, when it was 12.9 million days in total. On average, each person suffering from this condition took 23 days off work. This is one of the highest average days lost per case figure amongst the recognised health complaints covered in the LFS (see: .uk/statistics/lfs/swit1.xls). Both medium and large sized workplaces were estimated to have statistically significantly higher days lost per worker than small workplaces in 2013/14. Only medium businesses had a statistically significantly higher rate in 2013/14 compared to 2011/12. The estimated average number of days sickness absence per case due to mental ill health under THOR-GP between 2011 and 2013 was 39 days per case. This represented 59% of the total days certified sickness absence. There is a disparity in the number of working days lost between the LFS and THOR-GP data. GP’s reporting to the THOR-GP scheme may not see cases of work-related stress that are not severe enough to seek medical consultation and lead to a relatively shorter duration of sickness absence. Figure 4 - Number of working days lost per case Source: Labour Force Survey (LFS) Note: No ill health data was collected in 2002/03 or 2012/13. ................
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