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00:00:01

Being Human

The Neuro Power Hour

22 Plays1 month ago

In this episode, Dr. Michael Powers highlights the importance of extending our thinking beyond biological and anatomical processes. Outcomes for patients with neurological conditions are NOT dependent solely upon medical diagnosis, rather, human elements such as psychology and social connections have an outsized impact on patient recovery and quality of life. Expand your neuro toolkit by learning how to optimize your therapeutic alliance in this episode!

References

All music courtesy of Free Music Archive and used via attribution 4.0 international license.

Intro and Outro: Stylin' by JMHBM
Transitional: Our Reality by Ketsa

Contact: neuropowerhour@drmichaelpowers.com

Transcript

Introduction to NeuroPowerHour

00:00:10

Speaker

Welcome to the NeuroPowerHour. your host and neurological navigator, Dr. Michael Powers, physical therapist, board certified in neurologic physical therapy and clinical electrophysiology.

00:00:21

Speaker

Let's get started. I'm calling this episode Being Human because this episode is going to focus on things that are distinct to being human, including the biopsychosocial model, social determinants of health, quality of life, psychosocial adaptations. Human beings are complex. We've got thoughts. We've got emotions. So to obtain maximal clinical efficacy and to just be a good clinician and healthcare provider, we need to acknowledge what's going on as we're working with a human.

00:00:52

Speaker

So despite

Understanding Patients Beyond Clinical Measures

00:00:53

Speaker

our emphasis, and we really honed in on this last episode, the emphasis on data and objective measures, we absolutely need these. We need valid, objective measures. I think we need to acknowledge and understand the people we are working with are not merely patients. They're not just a set of lab values or numbers. They are people that are going through things that have a brain and that brain interprets what we are trying to do as clinicians.

00:01:20

Speaker

And really having an understanding of some of these psychosocial considerations I think is not only an ethical imperative, it's also going to help you to obtain better

Structure of Discussion: Biopsychosocial Model and Quality of Life

00:01:30

Speaker

clinical outcomes. So it's both ethically correct, but it's also correct from a clinical efficacy perspective.

00:01:37

Speaker

We're going to break down this topic into three distinct categories. First, I'll start by talking about the biopsychosocial model, social determinants of health, and there's some talk about changing that name maybe to social drivers of health. and quality of life. That's going to be the first bucket that I'll be discussing.

00:01:56

Speaker

Then I want to talk a

The Biopsychosocial Model Explained

00:01:57

Speaker

little bit about quality of life in the adult neuropopulation. This will be a little skim through of this topic because there's no way the neuropopulation, the adult neuropopulation is tremendously large. I'm not going to spend forever in talking about QOL for every specific diagnosis. But what I want to talk about here as it relates to quality of life is what are some commonalities that we see across diagnostic categories, because that'll tie into our third bucket, namely, what can physical therapists do to promote psychosocial wellness and assist patients with their psychosocial adaptations and

00:02:35

Speaker

and to help in terms of maximizing quality of life. So a little mental shift from outcome measures and data from last episode, we're broadening our view out, taking a holistic look, and let's then talk about some of these psychosocial considerations, or as I'm calling it, being human, and what that means in terms of us providing good physical therapy care for our patients who have neurologic dysfunction or neurologic conditions.

00:03:04

Speaker

Let's start out by talking about the biopsychosocial model. The biopsychosocial model was first put forward by George Engel. We're going on almost 50 years now. He proposed this back in 1977 as a response to the biomedical model.

00:03:20

Speaker

His argument was that psychological and social factors are relevant to health and disease. So he saw an over-reliance on a mechanistic biological model and recognized that didn't explain everything that you saw in medicine and health care.

00:03:36

Speaker

Really, he thought there were three main areas, hence the term biopsychosocial. On the biological front, this would encompass your physical health, genetic vulnerabilities, immune function, neurochemistry. So maybe typical medicine or typical organic biological processes.

00:03:56

Speaker

But he also built out and proposed that there's a psychological

Challenges in Clinical Application and Patient-Clinician Relationships

00:03:59

Speaker

component. As humans, we need to consider the role of cognition, mental health, emotions, and coping skills in terms of individuals' and patients' health and healthcare outcomes.

00:04:11

Speaker

Then we further expand this by considering social aspects. What is someone's socioeconomic status, cultural beliefs? What's going on in the environment? What's the family background?

00:04:23

Speaker

This, in a very quick nutshell, is the biopsychosocial model. And even though it's been 50 years, I think there's still some variability in terms of how much this is considered in clinical practice.

00:04:35

Speaker

I will say that within physical therapy education, I'm thrilled to see that students I've been working with recently seem to be very astute and are picking up on the importance of the biopsychosocial model, sometimes much more than experienced clinicians. And I'll say when I was trained way back in the day,

00:04:56

Speaker

We didn't put a lot of emphasis on the biopsychosocial model. It was much more a biologic model. We were very good technicians, not I shouldn't say technicians because we're a profession, but we were very focused on technique and really understanding the anatomy, the physiology, And we thought there is a one-to-one input-to-output

Social Determinants of Health and Healthcare Outcomes

00:05:17

Speaker

of what we're doing to tissues and probably underappreciating the social determinants of health, the psychology, the social aspects of clinical care.

00:05:27

Speaker

So George Engel had multiple reasons for drawing upon this biopsychosocial model. couple key ones I want to highlight here, really thinking about the so-called placebo effect. And really, if it's a one-to-one input to output or if every improvement in either function or healthcare status is purely from a tissue response, we should have no placebo effect.

00:05:53

Speaker

So the success of most treatments is influenced by psychosocial factors. The placebo effect, sometimes people have a distaste for that word or they don't like it.

00:06:05

Speaker

I prefer to think of it as a therapeutic alliance as it relates to physical therapy. And I think a lot about patients or individual stress responses, anxiety perhaps. And the more we can lower someone's threat level, put them, i don't want to say fully at ease because we need some stress within the treatment session,

00:06:26

Speaker

But the more we build that therapeutic alliance, the better outcomes we're going to see. So you could call it placebo effect. I'm going to call it therapeutic alliance because there's a vast mountain of evidence that when people experience unconditional positive regard, they're going to do better across multiple facets of life. And that's really what we're looking at here.

00:06:47

Speaker

Other key concepts with the biopsychosocial model is that the patient-clinician relationship influences medical outcomes. We are not separate as physical therapists. We're not separate objective observers to the treatment. We're part of this dynamic relationship. And so that relationship we have with our patients 100% is going to impact outcomes.

00:07:12

Speaker

You can think about it may impact adherence or participation with your recommendations. It's going to impact possibly their immune system, again, in terms of are they experiencing fight, flight, or freeze, or do they feel at ease around you?

00:07:27

Speaker

So biopsychosocial model is something that we can't go into treatment just thinking of a purely mechanistic model. Biopsychosocial model is real and it absolutely impacts our patient outcomes. Related to the biopsychosocial model is this concept of social determinants of health. So there's talk within the profession of moving towards the term social drivers of health. Either way, I'll stay with the term social determinants of health because that's what's on the Healthy People 2030 website.

00:07:59

Speaker

Healthy People 2030 is a government

Behavioral and Social Influences on Health

00:08:01

Speaker

initiative aimed at not only identifying the social determinants of health, but also objectively looking to improve some of these by certain metrics. Definition of social determinants of health per Healthy People 2030 is the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.

00:08:33

Speaker

Pretty expansive definition in really what we're looking at here. If you think of our ICF model, most of these social determinants of health are going to be in that participation area.

00:08:45

Speaker

So even though as physical therapists, maybe we are emphasizing in the day-to-day treatment, we're at the body function and structure or activity. Maybe we're working on improving motor control, working on improving balance, working on improving sit-to-stand transfer.

00:09:01

Speaker

Really, what we should be thinking about in the background is how is this impacting someone's participation? But also conversely, we should be thinking, how are these social determinants of health, these participation factors impacting what I'm seeing in the clinic?

00:09:20

Speaker

If we think that what we see as that patient walks in is all that's impacting their functioning, we're missing a lot of the picture because these social determinants of health may be invisible to us, but they are absolutely impacting how the patient moves through the world, including how they're moving as we interact with them in clinical practice.

00:09:44

Speaker

Briefly want to mention

Disparities in Access and Treatment Outcomes

00:09:45

Speaker

the main categories of social determinants of health as per Healthy People 2030. Highly recommend you check out Healthy People 2030 to get a further understanding not only of the categories, but some of the areas that are deemed to be goals that are officially being tracked by the government.

00:10:04

Speaker

The five major categories are healthcare care access and quality, neighborhood and built environment, social and community context, economic stability, and education access and quality.

00:10:20

Speaker

I'm not going to go into depth about each of these categories, but we'll see these pop up again a little bit later in this podcast when we talk about quality of life across some of the adult neuro conditions, and we'll see evidence linking educational status, socioeconomic status, employment status,

00:10:43

Speaker

with perceived quality of life. So this does impact what we see in terms of overall quality of life and healthcare outcomes. A JOSPT article from 2019 had a nice summary of social determinants of health, summarized multiple other evidence sources,

00:11:03

Speaker

And what I found really striking about this review is the estimated effect of variables on health and recovery. This is, ah again, a summary of evidence, and this was the author's interpretation of what really impacts patient health and recovery.

00:11:21

Speaker

The estimated effect of variables on health and recovery, 10% thought to be from environmental factors, 20% from the actual medical or healthcare that's provided, 20%. 30% is behavioral patterns, so psychological from that biopsychosocial model, 30%, so cognition, motivation, et cetera.

00:11:45

Speaker

40% social and economic circumstances. If we then accept these percentages, we've got from a biopsychosocial model, 20% deemed to be biology, 40% social.

00:11:57

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thirty percent psychological forty percent social That's huge. So again, if you're not considering the biopsychosocial model as you're interacting with patients, you're missing the boat.

00:12:08

Speaker

The

Accuracy of Treatment Outcome Data

00:12:09

Speaker

other thing I want to call attention to here, this is linking to some of these social determinants of health, is just access to physical therapy services. We know for a fact that patients in the ICU are less likely to receive rehab, either PT or OT, if they come from a lower socioeconomic status, live in rural areas, and or have limited English proficiency.

00:12:32

Speaker

This really begs the question, though, as we look at gathering data on outcomes of treatments, And I don't want us to question every single thing because we'll go crazy, but I think some some healthy skepticism is reasonable.

00:12:45

Speaker

If we look at treatments that say, well, we know that physical therapy yields these results in the ICU or physical therapy gets these results in these specific patient populations.

00:12:56

Speaker

But if not everybody is receiving therapy, do we know that those are our true physical therapy outcomes? If not everyone is getting equal access to care, we probably don't know the true impact that we can have in physical therapy.

00:13:11

Speaker

So something to think about there. But going back to the estimated effect of these different variables on health and recovery, keep in mind that it's estimated 20% of your patient's outcomes is what you're doing.

00:13:26

Speaker

30% can be explained or is impacted by behavioral patterns. So if you don't know how to talk to a patient, if you don't know how to help them with either motivation or remove barriers that they have set up, we'll talk later about cognitive behavioral therapy,

00:13:41

Speaker

then you're leaving 30% treatment efficacy on the table. And if you don't have an understanding or an appreciation of social and economic circumstances, you're missing 40% of what's impacting their outcomes.

00:13:53

Speaker

So you think you give

Impact of Social Hierarchy on Health Outcomes

00:13:54

Speaker

them a home exercise program that is tip top, pristine, it's shiny, it's the best thing ever. and they are struggling socioeconomically, they've got multiple other stressors, and then you're going to get mad at them for not carrying out on the home exercise program, you've missed the boat in that case.

00:14:13

Speaker

A quote that I really like to think about in terms of social determinants of health, and here this quote, I'm not making excuses for people, but really broadening out and thinking about How do social determinants of health potentially affect outcomes? Do they affect how we as individuals approach our patients? Do they affect how systematically patients are being approached?

00:14:37

Speaker

There's a quote by Marmot, and i'll link the study in the show notes, and the quote i'm pulling forward here is, The lower individuals are in the social hierarchy, the less likely it is that their fundamental needs for autonomy and to be integrated into society will be met.

00:14:55

Speaker

Marmot was talking about the social hierarchy, didn't pull any specifics into there necessarily, just saying there's a hierarchy, we all know it, and there's different aspects of where you can fall maybe lower on that hierarchy.

00:15:08

Speaker

couple personal observations I want to make here. One was as a student in an inpatient rehab facility, I would witness or be part of wheelchair seating assessment. So if someone had maybe a neurologic condition,

00:15:23

Speaker

maybe had high mobility needs, it was pretty typical to bring in a seating specialist to work with the physical therapist to determine what wheelchair components, what seating system would best meet the patient's need. Pretty standard course of action. One time we had a patient who was deemed to be a VIP. i As a student, I didn't know exactly who this person was. They either had a lot of social capital and or they had a lot of money.

00:15:51

Speaker

But I remember watching as multiple wheelchair vendors came in and it was almost like this patient was getting five or six seating evaluations. And as someone who's from Generation X, I have a little bit of a, well, I have a lot of a distaste for what I perceive to be hypocrisy, or when I see things that don't look quite right. And as I didn't say anything. I was a student, but I remember thinking, how is this reasonable to do? Not only is this one person getting...

00:16:19

Speaker

more resources, but also maybe this patient's not getting the best treatment because we're not even following our own policy and procedure. So that really struck me. And I think that drives home that resources aren't always allocated what we might consider fairly to a large extent because of these social determinants of health. The other thing I think about or I reflect upon is my time spent in clinical practice on the Navajo reservation out in the southwest part of the country.

00:16:46

Speaker

There I would work with ah vendors and sometimes I'd have case managers. If someone was on a Medicaid form of payment, they'd have a case manager who would kind of control which vendors would be used in terms of supplying wheelchairs. And what really struck me there is the tension between trying to obtain what the vendor I was working with and myself thought would be the best chair and many of these bids going to other vendors who could provide a cheaper product, but ones that were completely inappropriate for the patient. So those social

Incorporating Social and Psychological Factors in Care

00:17:21

Speaker

determinants of health in terms of access to care, neighborhood and built environment, multiple factors, cultural considerations really led to some substandard provision of wheelchairs. And that was another observation that I think ties into these social determinants of health.

00:17:40

Speaker

So to summarize this section, I'd like us all to consider the biopsychosocial model, recognizing that, yes, we want to be technically sound in terms of our hands-on examination, in terms of our use of outcome measures, in terms of interpreting data. We want to have that on lockdown. That should be a given. That's the bare minimum. But to take that next step and to really optimize your patient outcomes, really want to start thinking about, okay, what are these social determinants of health that may and be impacting my patient?

00:18:14

Speaker

Think back that psychological factors may be influencing up to 30% of the outcome and that the social aspects may be influencing up to 40% of the outcome.

Quality of Life in Neurological Disorders

00:18:27

Speaker

It's not saying that we need to understand every patient. that we need to be the same as every patient, but recognizing that we're adapting our approach to that individual patient and that we're really emphasizing building an optimal therapeutic alliance, that's going to help us in terms of getting those health outcomes that we want for our patients.

00:18:55

Speaker

Let's move then to a discussion of quality of life. At the end of the day, i would argue that that's what we're really working on as we interact with patients, their loved ones, their caregivers, their families, is improving quality of life Quality of life is a multidimensional subjective evaluation of an individual's well-being.

00:19:17

Speaker

There's some disagreement in the literature of exactly how to define it. For our purposes today, we'll say that it includes physical health, mental state, social relationships, and environmental factors. Quality

Central Fatigue and Chronic Pain

00:19:30

Speaker

of life is really important to have front and center because it's crucial to remember that our healthcare team is treating a person, not just a set of lab values or pathology, and therefore our treatment goals really do need to keep the patient's quality of life in mind.

00:19:48

Speaker

Before I dive into talking about a couple common neurological conditions and what the evidence says about quality of life, I want to start with the construct or the concept of central fatigue, because this is something that's common across multiple neurologic diagnoses, and it can absolutely impact quality of life. So we're going to start by talking a little bit about central fatigue. Then we'll talk about how various neurologic diagnoses perceive quality of life.

00:20:19

Speaker

Central fatigue is characterized by an increased perception of effort and limited endurance of sustained physical and mental activities, and there's absolutely an elevated prevalence of fatigue in neurologic conditions beyond what would be expected on basis of age or disability.

00:20:37

Speaker

Multiple sclerosis is probably the condition most associated with fatigue, but if you look at the literature across Parkinson's disease, stroke, ALS, traumatic brain injury, high percentages of individuals report and or experience central fatigue.

00:20:57

Speaker

Pathophysiology of central fatigue, currently not super well understood, but possible contributing central factors have been identified, including inflammation, axonal conduction velocity, imbalance of neurotransmitter levels, and or cortical thickness.

00:21:15

Speaker

So not always well understood, but there are central factors that are believed to be possibly contributing. Central fatigue is context specific.

00:21:26

Speaker

Think back to our biopsychosocial model. If all we thought about was the biology of central fatigue, then we would say, well, we have to find a specific marker. We need to find something that tells me, yes, I believe this person is fatigued.

00:21:42

Speaker

But because we know from the biopsychosocial model there's psychological components, social components, this central fatigue can be affected by multiple factors, including what task or skill the person is working on, the environment, think about individuals with multiple sclerosis and heat intolerance.

00:22:03

Speaker

Fatigue can be affected by poor sleep hygiene, medical conditions, depression, anxiety, and or medication side effects. I really think there's probably a lot of similarity with central fatigue and chronic pain and or concepts similar to pain neuroscience.

00:22:21

Speaker

Speaking of pain

Validating Patients' Experiences and Management Strategies

00:22:22

Speaker

neuroscience, I'm debating presenting an episode or doing an episode on chronic pain, pain neuroscience, and It's adjacent to overall neuro, not quite there, but pretty close. So I appreciate your feedback. If chronic pain, pain neuroscience is something you'd like to hear more about in a future episode, please email me at neuropowerhour at drmichaelpowers.com, and we'll put something up for chronic pain. So as a little bit of an aside,

00:22:50

Speaker

Getting back to those central fatigue, there's a lot of it that's going to be similar to these pain neuroscience considerations in terms of sleep hygiene, good nutrition, the importance of exercise.

00:23:04

Speaker

Paradoxically, even though the person is complaining of fatigue, there's great evidence that exercise actually helps. central fatigue. There are, with central fatigue, a good number of biopsychosocial experiences or how we may see our patients present with central fatigue. So from a physical perspective, we'll see lack of energy, difficulty moving. And this could be very closely related also to depression, Whether this is central fatigue and or depression, same, different, similar. Difficulty moving, lack of energy.

00:23:39

Speaker

Cognitive, difficulty thinking and concentrating. Emotional, I previously mentioned depression, but you may see understandably so depression, anxiety, worry and isolation.

00:23:54

Speaker

And this isolation can also tie into social anxiety. aspects that we'll see, which includes a loss of autonomy and not being understood by others. And this not being understood by others, again, very similar to chronic pain and pain neuroscience.

00:24:12

Speaker

Oftentimes, this not being understood by others, feeling you have to justify something that appears invisible to healthcare providers, it just adds a tremendous emotional and cognitive toll And I bring this up because if you are working with someone who has central fatigue, you don't really want to, in my opinion, proceed as though you're asking the patient to justify it or explain it to you.

00:24:37

Speaker

I think anytime you can express an understanding that you do understand this is real, And then also present options, how in therapy we can help with judicious use of exercise, what the evidence says in terms of long-term effects of exercise, journaling, keeping a record, et cetera, et cetera. That's going to go a long way. But this not being

Discussion on Quality of Life in Neurological Conditions

00:25:00

Speaker

understood by others, again, the title of this episode is Being Human.

00:25:03

Speaker

I think not being understood by others is a challenge for most humans across many areas that we go through in daily life. Let's not add that to our patients. So someone with central fatigue, work to understand that. Don't make them have to explain it to you and then provide opportunities for learning about the central fatigue and provide education on how physical therapy works. can help with central fatigue.

00:25:29

Speaker

Let's move on then to talking about a couple conditions or neurologic diagnoses and what evidence says about quality of life specific to these diagnoses so we can then consolidate a general overall idea of what the evidence says about quality of life and neurologic conditions so that we can think about how we can assist our patients.

00:25:51

Speaker

I'm going to talk about four conditions, two that are more acute and then you're done, and two that are considered more chronic and progressive. So the two that I'd consider more acute, so it's an acute event, and then there's a recovery process are going to be stroke and spinal cord injury.

00:26:09

Speaker

Stroke quality of life, what we find in the literature is that those patients and individuals who are employed after stroke have the highest quality of life, and quality of life is also positively correlated with higher education.

00:26:26

Speaker

Hopefully some bells are going off in your head because what we're saying here is that quality life is correlated with some of these biopsychosocial factors, these social determinants of health, right? Now, we do find that there is improvement in quality of life with improved function, self-care, and activity, and that these improve with physical rehabilitation But we also find that pain, patients report a pain, is less so improved with physical rehab and no real correlation to anxiety and depression with physical rehab. That's an important consideration. So we are, as physical therapists, we're absolutely going to see improvements in function, self-care, and activity as we provide our interventions.

00:27:14

Speaker

But we may not see... associated improvements in anxiety and depression. And if we zoom out and take the big view, social determinants of health, quality of life, that anxiety and depression is going to have a negative impact on quality of life. Looking at types of stroke, so stroke severity, quality of life absolutely did correlate with stroke severity. So a less severe stroke, higher quality of life, more severe stroke would report lower quality life. That makes intuitive sense.

00:27:46

Speaker

Across all the different stroke types, researchers found that quality of life tended to stabilize about three months post-stroke. And interestingly enough, in this study, and I'll link all the references I'm citing in the show notes, in this study, there was a higher quality of life for those individuals with higher monthly incomes.

00:28:06

Speaker

So look at that. That's, to me, very interesting. We've got a couple findings in stroke that higher quality of life if you're employed, higher education, and higher monthly income. So we see a distinct link here to social determinants of health and quality of life.

00:28:23

Speaker

The other neurologic condition I want to focus on here that's kind of an acute event, then there's a lengthy recovery process or adaptation process is going to be spinal cord injury.

00:28:34

Speaker

So you get this, usually it's traumatic, doesn't always have to be this traumatic event, sustain a spinal cord injury. What does the evidence say about quality of life for individuals after spinal cord injury?

00:28:45

Speaker

Initially, there's higher rates of depression and anxiety than the general population. And as with multiple people with disabilities, there's going to be lower rates of employment than the general population.

00:28:57

Speaker

Interestingly enough, though, over time, many individuals with spinal cord injury are going to report the same life satisfaction as the general population. And this quality of life seems to improve with time from injury, which tells us there is an adaptation process that takes time.

00:29:13

Speaker

There's also the consideration perhaps of what's known as hedonic adaptation. This is psychological concept that in general, people have almost like a thermometer, a set point of happiness, and we may deviate up and down depending on external events. But over the long term, we tend to go back to a somewhat around a baseline level, which is an interesting concept, good amount of evidence to support that.

00:29:37

Speaker

couple other key considerations with spinal cord injury and quality of life. Quality of life in spinal cord injury does not appear strongly influenced by physical variables, age, or gender.

00:29:48

Speaker

Believe it or not, quality of life is not necessarily correlated with level of injury. It's strongly influenced by optimism, self-efficacy, and positive emotions.

00:30:01

Speaker

Some ways that we can tap into the optimism, self-efficacy, and positive emotions are physical activity, physically active. Individuals with spinal cord injury had a statistically higher quality of life than those that described themselves as physically inactive, especially in the areas of energy and self-confidence.

00:30:20

Speaker

Those who identified as athletes scored higher on community reintegration than non-athletes. And big considerations, same as after stroke, employment is a big one.

00:30:31

Speaker

Employment's associated with higher quality of life, improvements in financial status, self-esteem, and social integration. Let's move on to couple conditions that are deemed more significant. chronic and or progressive, so we'll talk about multiple sclerosis, and Parkinson's disease.

00:30:50

Speaker

With multiple sclerosis, quality of life is correlated across multiple variables. It's correlated with the number of complaints or impairments that the ability to perform instrumental activities of daily living, IADLs, the extent of overall disability.

00:31:10

Speaker

So those make sense. Those are our biological considerations. And now I'm going to talk about some correlations with psychosocial variables. Quality life with people with MS is correlated with depression status, education level, and income.

00:31:27

Speaker

So we've got biological variables that impact quality of life, and we've got psychosocial variables. Again, keep this in mind because you could be doing the best or what you consider to be the best treatment. I'm sure it is the best treatment for someone with MS.

00:31:42

Speaker

And depending on some of these psychosocial variables, these could have a buffering effect or these could actually impede some of the outcomes that you're seeing. With Parkinson's disease, the study i'm going to cite, there is a systematic review that looked at quality of life for individuals with Parkinson's disease.

00:32:01

Speaker

And the authors in this review split quality of life into objective and subjective aspects. So they split out the biological from some of these more psychosocial.

00:32:12

Speaker

thought that was a pretty interesting way to approach it. And what was interesting here is the authors identified some what they called subjective themes. And these subjective themes were illness experience, healthcare, everyday life, social life, identity, spirituality, religion, and environment.

00:32:35

Speaker

This, again, is based off a systematic review, and I'm just calling attention here to how nicely those subjective themes tie into social determinants of health and some of these biopsychosocial considerations that we've been talking about throughout the Some people may or may not be familiar. There's been more of a push, I think, in the Parkinson's population of Parkinson's group exercise classes, maybe boxing, really getting a lot of activity. And we know that that's helpful not only from getting the big movements, and we know the tremendous benefit of exercise in the Parkinson's population. We've got in the Neuroacademy, the clinical practice guidelines on Parkinson's disease.

00:33:18

Speaker

We'll have a whole separate episode about Parkinson's, and I'll link that in there, we're also recognizing the importance of social connections and community reintegration. So we're seeing that these classes for individuals with Parkinson's, exercise groups, boxing, et cetera, we see the importance of getting out and getting into the community in terms of overall outcomes.

00:33:42

Speaker

That was a quick look at quality of life across multiple neurologic conditions, both acute ones and chronic progressive conditions.

00:33:52

Speaker

Obviously, every person is an individual, and you're goingnna tailor your approach to individuals. But a couple commonalities I think we can carry forward. Number one, think about central fatigue.

00:34:05

Speaker

We tend to think about that as most prevalent in multiple sclerosis, which it is. But I'd encourage you to think about central fatigue maybe as a ah shadow that's possibly lurking around.

00:34:16

Speaker

Even if your patient isn't directly talking about it, it may be something that should be on your radar and that could be impacting your not only their performance in the clinic, but also their overall outcomes and their participation in quality of life.

00:34:31

Speaker

The main variables from a biopsychosocial approach that seem to share commonality in terms of quality of life across neurologic conditions are going to be education, income, employment status, having relationships and social connections.

00:34:50

Speaker

With really that employment status, the more i keep looking in the literature, the more that seems to be a lever that we can really hone in on because that employment status is going to affect income. It may indirectly affect education, maybe professional development, and it's absolutely going to impact relationships, social connection, and autonomy and self-efficacy.

00:35:22

Speaker

Finally, let's

Psychosocial Adaptation to Disability and Illness

00:35:23

Speaker

talk about psychosocial adaptation and ways that physical therapists can help our patients moving through adaptations to neurologic injury and or disease and really thinking big picture about helping to optimize and maximize quality of life. There's a concept known as the phase model of adaptation, which posits that there's a progression through stages in response to disability and illness.

00:35:50

Speaker

The phase model is pretty well accepted in literature. There may be some debate about semantics or some specifics of how this actually carries out, but we're going to proceed here talking about the phase model and accepting that, yeah, this seems reasonable, but maybe not everyone goes through all the phases. Maybe moving through phases is not sequential. Everyone's little bit different, but I would like to talk about some of the phases you may encounter in terms of adaptation to disease or injury.

00:36:19

Speaker

Grief, mourning, and sorrow are probably some of the most common initial reactions. These may last days, months, years.

00:36:30

Speaker

Grieving, mourning, sorrow, these are necessary processes to adapt to loss and to develop a new identity and a new self-concept. Early in my career, my first job was in patient rehab, working primarily with individuals with spinal cord injury. And I remember two things, actually, that really stuck with me early on, that one was ah something a patient told me, and one was something that the leader of a spinal cord support group told me.

00:36:55

Speaker

First off, a patient told me that it probably takes five to 10 years to adapt to a spinal cord injury. We talked earlier about quality of life with spinal cord injury and noted that overall, general QOL stabilizes and gets close to the general population.

00:37:12

Speaker

But here, from what my patient was telling me and from talking to other clients and patients and individuals, that seems pretty reasonable that there's a five or 10-year adjustment process to fully integrate all the changes. The other thing that was told to me that really sticks and has really informed my approach to clinical practice is when I was attending a spinal cord support group, the leader of the support group turned to me and said, oh, we call all of you able-bodied people TABs. I said, oh, okay, what does that mean? He said, temporarily able-bodied. And that really stuck with me because as we think about our patients with neurologic conditions, if we're currently fully able-bodied as PTs, it's not an us not and a them. It's probably more of a spectrum or a continuum that we all have different ability levels. We're all going on things at different points in time. And it is very likely that many of us that are fully able-bodied may experience some form of disability in the future. So that concept is interesting to me because also if we think about, okay, I'm currently temporarily able-bodied, does that possibly help down the road through the grieving process if I recognize that my current identity is not static, but it's constantly changing, that may actually help me to be more flexible or adaptable.

00:38:29

Speaker

in the future. I'm known for going off on some tangents and going off in the weeds, so let me pull myself back to get back to talking about some of the phases from the phase model of adaptation that you may see your patients going through.

00:38:41

Speaker

Shock is that initial reaction. Can't believe or that something's happening. And here in shock, we may not even see emotional reactions until the event is over. Everything is shutting down. That's shock. Anxiety and denial are phases that you'll see next.

00:38:57

Speaker

Anxiety is associated with that cognitive flooding, difficulty breathing, sympathetic nervous system. Someone's not in their right mind when this is happening. Their frontal lobe's gone offline. Their nervous system is overloaded. The next few stages appear after anxiety's kind of been moved through because now the frontal lobe's coming back online. The person is trying to make sense of it. So you're going to see possibly denial and or depression.

00:39:24

Speaker

Denial, can't believe this happened. It's a defense to really move through the anxiety and the pain. People in denial, you'll see them as aloof. They're not wanting to hear what you're talking about. They're going to reject the education you're trying to provide. So don't take it personally. That's someone who's in denial.

00:39:40

Speaker

Depression, you're going to see this kick in as the denial lessens and the awareness of the loss increases. Think back to when we talked about depression as it relates to central fatigue. So here you

Managing Patient Emotions During Adaptation

00:39:53

Speaker

might see people that don't want to move as much, not going to have as much motivation perhaps as depression potentially kicks in.

00:40:01

Speaker

Then we may see some anger. This could be internalized anger. And that's a response to loss, that the person blames themselves, they're mad at themselves, maybe they don't feel a good sense of self-worth. Or you could see externalized hostility, that the anger over changes in ability status and or function is pushed outwards towards caregivers, healthcare providers, could be passive aggressiveness, demanding behaviors, attempts to really regain some autonomy and control.

00:40:35

Speaker

So again, if you're not aware of this as maybe a student or a novice clinician, you might take this personally, but more experienced clinicians recognize, okay, this is someone that is adapting and adjusting.

00:40:49

Speaker

Doesn't mean that we as clinicians need to be meek and accept inappropriate behaviors directed at us, but we can have a little more empathy and understand This is someone going through an adjustment. They're trying to get some measure of control, and they're demonstrating externalized hostility.

00:41:06

Speaker

As people move through these stages, and again, there's debate as to whether these stages are a stepwise process, we may get to acknowledgement where the patient integrates activity limitations into their self-concept or identity.

00:41:20

Speaker

Think back, maybe many of us have gone through something, maybe traumatic, but something where our self-identity has changed and we've had to struggle with, do we accept this new reality? Do we push back against it? And I think this is a challenge because an acknowledgement of a new status is typically seen or framed as maybe giving up. Or in our culture, it's very common to say, hey, you need to fight, you need to push. And there's some amount of letting go that comes with both acknowledgement and final adjustment. So recognizing an integration that is psychologically positive while still possibly striving for optimized function and quality of life.

00:42:04

Speaker

There are some differences in how these adjustments may be seen depending on the condition. So generally speaking, again, every person is an individual, but generally speaking, if there is a traumatic and or acute event, previously I talked about stroke and spinal cord injury, there's probably going to be a more stepwise linear process. You're going to get initial shock that delays emotional processing,

00:42:31

Speaker

a post-traumatic period that unfortunately often coincides with active rehab. So if you're in acute care inpatient rehab, the person is emotionally and cognitively processing what's happened while you're telling them, hey, you need to do three hours of therapy a day or you're getting kicked out to the curb. pretty tough. And that's just the reality that we're living in. But keep that in mind. If you're in inpatient rehab, someone's still trying to reconcile, oh my gosh, I've just had a spinal cord injury. I don't know how much recovery I'm getting.

00:43:03

Speaker

Do I need to do home modifications? Am I going to be able to work? And you're asking them to work on transfers. I mean, they have to work on transfers. That's just a given. But keep in mind that there's probably a lot of post-traumatic processing that's happening here.

00:43:18

Speaker

And then finally, with this traumatic or acute event, the acknowledgement and adjustment going to be correlated with a new body image. So there's some acceptance. Time frame for this is going to be variable, but probably a pretty linear process.

00:43:30

Speaker

Contrast that to chronic progressive deteriorating conditions. Previously, I talked about multiple sclerosis and Parkinson's disease. Generally speaking, those are progressive deteriorating.

00:43:41

Speaker

Time frame is variable. And with medical advancements, we keep pushing that time frame back, which is excellent. However, the adjustment here is going to be a little bit different. There may not be an experience of shock because the person is understanding that this has been going on for some time is going to continue to happen. However, each new phase, so a decline or a deterioration in function and or neurologic status may be experienced as a new illness. And because of this, maybe we don't for some patients reach that phase of acknowledgement and adjustment that

00:44:17

Speaker

Because each time we're adjusting, the proverbial rug gets pulled out from underneath us and we have to adjust to a new reality. Keep those two in mind as a PT working with individuals and patients with neurologic conditions that that adjustment may be a little bit different. Traumatic and acute may get to that acknowledgement and adjustment a little bit quicker or may get there at all.

00:44:39

Speaker

Chronic deteriorating may have a harder time getting to that adjustment and may not get there at all. One other comment I want to make here is we're with our patients. I think part of our job is to be with our patients as the experience and go through these adjustments. I don't think we need to rush them through it.

00:44:58

Speaker

I really would like you to reflect on in our Western culture how uncomfortable we are with being uncomfortable. Most of us, I would argue, don't feel comfortable being with a patient who's actively crying, who's saying upsetting things, who expresses some frustration or negativity, we want to, as PTs, generally speaking, make it better. So many times I think we make the mistake of rushing in to give false platitudes, to offer up some toxic positivity, instead of really respecting that this adaptation

00:45:36

Speaker

does take time. And sometimes the best we can do is to actually be there with the patient, respect that these emotions or these expressions that maybe we're uncomfortable with need to come out and then guide and redirect back to the treatment while being with the patient and not saying everything's going to be okay, everything happens for a reason, or you'll be fine in the end.

00:46:01

Speaker

I think I've touched on a lot of things that are important to me personally from this biopsychosocial model, but I think the take-home point for me would be really think about the degree to which you as an individual provider are comfortable being uncomfortable being there for your patient.

00:46:19

Speaker

Let's

Promoting Agency and Positive Health Outcomes

00:46:20

Speaker

talk a little bit about coping styles. And how people deal with stress is really going to be influenced by what their pre-morbid coping style was. So it's not as though someone has a spinal cord injury and all of a sudden they're a completely different person by a psychosocial model. They're bringing in their prior lived experiences, their culture, their psychology into them.

00:46:42

Speaker

These coping styles are really going to impact how you approach your physical therapy treatment, but it's also going to influence what you see coming back to you. And really what we're wanting to encourage is kind of a curious mindset on the part of our patients, a mindset that is willing to explore, to take risks, and to go back out into the community instead of withdrawing.

00:47:08

Speaker

So think about these three key considerations. To what extent does your patient seek out control and information versus avoiding control and information?

00:47:20

Speaker

The more we can get our patients to seek out wanting to take ownership, wanting more information, we're going to get better outcomes. To what extent is your patient expressing, verbalizing, talking about emotional reactions versus repressing them?

00:47:37

Speaker

I get very concerned if someone had a catastrophic life-changing event and they either have a flat affect or they're saying everything's fine because that dam is going to break sometime and it's not going to be pretty.

00:47:49

Speaker

We're not psychological therapists. We're not counselors, but I think we have a good understanding that it's normal for some of these emotions to come out. So think about to what extent is your patient expressing versus repressing emotional reactions. And then finally, to what extent is your patient seeking social interactions and networks versus withdrawing? And it makes sense to want to withdraw, especially early on, you don't want to be around people. But we know from a biopsychosocial approach, the importance of human connections.

00:48:21

Speaker

So really encouraging social interactions is going to be key to helping with coping style. Consistent with coping style, we as physical therapists really want to foster what's known as an internal locus of control.

00:48:36

Speaker

A locus of control is the belief about an individual's ability to control life conditions and events. And it doesn't mean that you need to take the belief that you control every single thing, but it's the idea that you have agency, some measure of autonomy, self-efficacy, that your actions and beliefs can have a positive impact on what happens to you and around you.

00:49:02

Speaker

An internal locus of control, believing that you have an impact on your life conditions ah and events, leads to better goal-directed activity, better active learning, better health outcomes, actually across multiple domains.

00:49:18

Speaker

Contrast that to an external locus of control, where you think that life conditions and events are controlled by other people or outside events. And the key here is I would argue that whichever one you believe, whichever one you lean towards internal or external locus of control, you'll make it true by the thoughts you have, by the behaviors you manifest. And this is not some woo-woo, no evidence behind this. It's actually true because really there's going to be no ultimate way To prove this, it's not as though we can take a lab value or a lab test and say, okay, internal or external locus of control, you're right or wrong.

00:49:54

Speaker

It's really the outlook and mindset that's going to drive a lot of your behaviors and actions. Those behaviors and actions stack on each other, compound over time, and get you your outcomes.

00:50:06

Speaker

We can't force patients to have an internal locus of control, but we can actually assist them. We're not going to apply cognitive behavioral therapy per se. However, we can engage in motivational interviewing and we can apply concepts from cognitive behavioral therapy, such as pointing out errors in thinking, or areas of cognitive dissonance that can help our patients.

Supporting Psychosocial Wellness in Therapy

00:50:30

Speaker

Let's talk about some common defense reactions, and these mechanisms and reactions are automatic attempts to minimize stressors. If you pick these up in patients that you're working with,

00:50:41

Speaker

We're not going to change these and defense mechanisms. I want you to understand you're going to see them. So identify them and understand the underlying processes and work with your patient to help move towards more healthy responses.

00:50:56

Speaker

And again, going back towards engaging in the overall treatment plan by while being there with your patient. Some common reactions you may see, this is not all inclusive, would be acting out, daydreaming, denial, dissociation, humor, intellectualization, and rationalization.

00:51:15

Speaker

This is going to take some time if you're a novice clinician or a student to really get a good handle on when you see it and being able to recognize it coming out in your patient. One thing that i learned early on in my career was to be a little bit wary of patients that joke around too much. And too much is is very subjective, I know. And I like to use humor.

00:51:38

Speaker

I like good jokes. I like memes, all of that. What I'm mentioning here, though, is anytime the conversation gets a little bit real or it gets to a stressful area, if your patient is constantly joking, they're trying to deflect. And what I found my own bias is, since I like to joke around, a patient that's joking around with me kind of throws me off my game. They may throw me off track and I've missed what I should be doing clinically. So for me, excessive humor is a yellow flag that I'm not going to get thrown off. I'm going to keep circling around, maybe ask my question in a different way, but I'm going to get what needs to be gotten at because again, the ultimate goal is best outcome for my patient. So for me personally, humor is an area that I definitely look out for if I see a lot of that with patients.

00:52:27

Speaker

A lot of talk there about psychosocial adaptation, defense mechanisms, working on locus of control. Let's close by specifically talking about, okay, what can PTs for sure do to assist in quality of life in assisting our patients from a biopsychosocial model?

Employment and Quality of Life for Patients with Disabilities

00:52:47

Speaker

Let's talk then about psychosocial wellness. One thing we can absolutely do as PTs is enhance psychosocial wellness by assisting our patients to experience success in rehab activities and long-term relationships and goals. Yes, we did say we want patients to have success in rehab activities, but we also want long-term success in relationships and goals. I don't know that anyone really internalizes behavior change or changes what they're doing when they're lectured at versus when they really experience something.

00:53:23

Speaker

So this experience of success in the rehabilitation process, this experience of working with the physical therapist that treats them with unconditional positive regard, that really is invested in achieving goals. The patient seeing that they're achieving goals, all of that taps into neuroplasticity and all of that helps positively impacting psychosocial wellness.

00:53:46

Speaker

Some tangible ways we can do this as PTs is really being good with our goal setting, this collaborative goal setting. It's not just us setting goals, working with the patient, setting goals. Here's where we're going to tap into those outcome measures and that objective data. Get good with your numbers, set tangible objective goals. So when you come back to the patient, you can say, look, you improved your Tug score by seven seconds, or look, You improved your 10-meter walk, your gait speed by 0.4 meters per second.

00:54:15

Speaker

You're not giving the patient false bravado, toxic positivity. You're giving them a number that they can feel proud of. Absolutely, we can assist by referring to mental health providers, as indicated. If you're not comfortable broaching the topic of a mental health referral, you need to work on that. You can't have an inherent bias yourself. against mental health providers or talking about that, someone just had maybe a new neurologic diagnosis.

00:54:40

Speaker

Of course, it's reasonable to ask, would you like to talk to a mental health provider? Now, how you go about broaching that topic is going to be individualized to you, but you need to be comfortable with that. And I would argue or make the plea that you look into cognitive behavioral therapy. Again, we're not counselors, but a lot of the concepts of cognitive behavioral therapy where you challenge the validity of negative perceptions, not by telling someone they're wrong, but by pointing out, oh, that's interesting. So you say these things always happen to you. Have there been times when something bad hasn't happened to you?

00:55:14

Speaker

That might be an example of a cognitive behavioral approach. So really the questioning of the validity of some of these perceptions, but in a way where the patient realizing that some of these beliefs are no longer helpful, not in line with reality, and can be changed.

00:55:31

Speaker

And then finally, i think a major way that we can really assist patients, depending on where they're at in the lifespan and working career, is really thinking about helping them get back to work.

00:55:43

Speaker

A lot of people, yes, we like to complain about our jobs, our jobs are stressful, but it was pretty apparent in the discussion about quality of life, just how protective employment is in terms of self-efficacy, in terms of income, in terms of quality of life. Now, in terms of employment rates, we see a stark difference between those individuals with no disability and those who have a disability. And it's a pretty clear about a 50% gap between the two populations where the most current data I'm looking at a chart now has, and I believe this is for those 25 to 55 years old, thereabouts, in the general population population. Employment is about 82, 83%.

00:56:27

Speaker

Now, interestingly enough, pre-COVID, there is about a 50% gap. Post-COVID, we're actually seeing an improvement in rates for those individuals with disability. It's now getting in between the mid-40s. So it's gone from a 50% gap to maybe 40% gap. Still not what we love to see, but it's improving.

00:56:47

Speaker

But I do think that that's a big way that as physical therapists, we can really help as if our patients are in that working age range, helping to get them back to work via improved function, obviously, if we have access to referrals for vocational rehab, but really being open to that concept that our patients should be getting back to work if they're capable of.

00:57:09

Speaker

At the individual

Integrating Biopsychosocial Aspects into Healthcare

00:57:10

Speaker

level, unemployment is associated with depression, anxiety, and lower self-esteem. So we want to counteract that because we know when you're employed, you have a higher quality of life, you get social contact, well-being, and financial stability.

00:57:24

Speaker

I want to close with kind of a financial argument for hiring persons with disability. My vantage point as a physical therapist, I think it's ethically a good thing that people with disabilities should obtain employment. We've got the Americans with Disabilities Act. We've got legal protections. But still, people with disabilities, including those with neurologic conditions, aren't afforded the same opportunities of employment.

00:57:48

Speaker

And I don't think in many instances saying something is morally or ethically correct wins everyone over because not everyone shares the same outlook or mindset. So a couple possible arguments that you could put in your toolkit when you're talking to individuals, maybe organizations, corporations about benefits of hiring individuals with disabilities. And this is borne out in the data and i'll I'll put the reference in the show notes. You're going to have lower turnover.

00:58:15

Speaker

much, much higher retention rates. There's a tremendous amount of loyalty for people with disabilities when they're afforded the opportunity to work, demonstrate historically much less turnover, so much higher retention rate for the employer. And we know employers lose a ton of money when their staff turn over.

00:58:33

Speaker

They have also demonstrated for individuals with disabilities, friendlier dealings with customers, score higher in job satisfaction, perform more consistently, superior problem-solving skills, lower absenteeism rate. I find this one fascinating because I'm a big fan of cognitive diversity, better ability to identify creative solutions. You really probably don't want everyone that looks and thinks the same. It's well-documented in the literature you Having a team that can think creatively or think differently is going to give you better results. So I would argue there's a lot of reasons for organizations, companies to consider hiring individuals with disabilities.

00:59:15

Speaker

Put out a lot of topics today, and a lot of these discussions are very near and dear to my heart. And I want to close out here saying with what we've discussed today, I'm not saying you don't need the numbers. You don't need to be technically sound. I am a numbers person. We're going to do our outcome measures. We're going to grab that data.

00:59:34

Speaker

But if you're not open to the biopsychosocial model, if you can't wrap your head around the fact that up to 30% of your health outcomes may be coming from psychological factors, up to 40% from social factors, you're missing a lot with your patient.

00:59:50

Speaker

And at the end of the day, i think most of us got into this profession because we not only want to make the lives of our patients better, we want to be enriched by that. And ultimately, we're working to make society better as well.

01:00:04

Speaker

Thanks so much for listening to the NeuroPower Hour. I look forward to seeing you in the next episode so we can continue learning. you