There is no escaping it. Mental wellbeing is a huge factor that we cannot dismiss. It can be all too easy as a physiotherapist to brush it under the carpet and refer onto someone else if we are faced with clients who present with mental ill health. However, physiotherapists can generate a relationship of trust and openness with their clients and as such we may be best placed to encourage an open and honest discussion. Not just about physical and social factors, but also about the state of mind and how this could be feeding into the aches and pains that they may be feeling.
Low mood, depression, sadness, frustration, irritability and anxiety can all result from injury. We can see this very clearly in both humans and our four-legged canine friends. When did you last see a family member who is typically active sustain an injury that prevented them from participating in their hobby? Chances are that their mood changed along with how they were interacting with their day-to-day activities. And what about the last time your dog hurt themselves and meant they couldn’t charge around the park or dart into the water for a swim? If they are anything like Hercules (my crazy canine!) then they may retreat to their bed and feel a little sorry for themselves.
This is a perfectly normal response to both pain and the loss of being able to partake in activities that we truly enjoy. Getting injured can have a significant impact on our mental wellbeing. However, our mental wellbeing can also have a significant effect on musculoskeletal aches/pains and injuries.
A study by Lynn Lavallee and Frances Flint in 1996 (reference below if you are interested) identified that injury rate and severity appeared to be increased by tension/anxiety, anger/hostility and total negative mood state/depression within male football and rugby players. Kerr and Minden (1988) similarly indicated that stressful life events were significantly related to both the number and severity of injuries. More recently, a 2018 study by Haupt et al, demonstrated that recovery from musculoskeletal injury (length of stay in hospital and time within the Intensive Care Unit following orthopaedic surgery) was significantly increased in those with diagnosed depressive symptoms.
The mind-body connection is truly exceptional and really untapped by science at this point. However, evidence is certainly suggesting that mind and body influence each other. In my experience as a physiotherapist, I would make a strong case that a significant percentage of clients I see have psychosocial factors that influence their ability to perform tasks how they wish.
Allow me to provide a hypothetical example: A 22 year old male who enjoys being physically fit and is a regular gym goer begins a course of physiotherapy. He used to play football weekly at University with a group of friends he socialised with and recalls them as his family. Since graduating, his football has stopped and he has lost touch with the social group he had as everyone has gone their separate ways following University. Over the last 6 months (corresponding with his departure from Uni), he reports that he has been getting an on-off pain in his neck/shoulder area which irritates him when he is at work (primarily desk-based) or if he is particularly stressed. Whist this doesn’t stop his gym activities, it is an irritant and he is becoming increasingly frustrated by it. He has tried many things and searched a variety of solutions on the internet.
After assessing him, he demonstrates some expected tightness around his mid back and shoulders (as we might expect from someone who was desk bound during his study periods and now at work), but there is nothing glaringly obvious that stands out to be the cause of his symptoms. In fact, I can’t reproduce his symptoms in the clinic. He questions, “I bet you think I’m making this up!”
Needless to say, I did not think he was making it up, but there certainly wasn't a clear pattern here. Further questioning delved into his sleeping habits, nutrition, intricate gym planning and so on. Still there was nothing significant that led towards the pain he was experiencing. And so, I asked a very simple, very subjective question: “Are you happy?”
The answer took me by surprise, and the client began to shed a tear. He reported that he has not felt the same since leaving University and missed his friends (whom he referred to as his family). He missed playing football, and reported that his current work meant that he was unable to get to training. He reported feeling trapped and he didn’t know how to enhance his mood anymore.
After a long discussion, and providing an outlet for the client to express how he felt, we talked through some activities that could help to manage his tightness through his mid back and I set him a challenge to get his football out and perform some individual ball manipulation tricks (keepy-uppys) in his garden every night for 5-10minutes after work.
A week later and his whole demeanour had changed. He reported that whilst he felt a little silly as a 22 year old male standing in his garden kicking a ball around to himself each night, it gave him a sense of relief and allowed him to “de-stress” from his day at work. He felt that he wanted to play football again and would speak to his boss to discuss more flexible working hours.
I saw this individual for only a couple more sessions over the course of the next three months and over that period he had returned to football training and his mysterious shoulder/neck pain had completed subsided.
As you may expect, this was not a hypothetical scenario. This was a real interaction that happened when I was a junior physio and immediately opened my eyes to the impact of psychosocial factors on the experience of our physical body. This is a real example of how the mind can influence the body and vice versa. A small dose of encouragement was all it took to change this client’s perspective and free him from a pain that had been bothering him for a number of months prior.
I propose we utilise our roles as physiotherapists and our time with clients to try and empower a freedom of both movement and mind.
Feel, Think, Move
Haupt, E. et al (2018) Pre-injury depression and anxiety in patients with orthopedic trauma and their treatment Injury 49, 6, 1079-1084
Kerr, G. & Minden, H. (1988) Psychological Factors Related to the Occurrence of Athletic injuries J Sport & Exercise Psych 10, 2, 167-173
Lavallee, L. & Flint, F. (1996) The Relationship of Stress, Competitive Anxiety, Mood State, and Social Support to Athletic Injury J Athl Train. 31(4): 296–299