Long-term Physical Effects of Stress

So you can see that, while short-term stress can be useful and necessary, long-term, prolonged, or unrelenting stress is not a good thing. What begins as a nervous stomach or feelings of nausea during a short-term stressful situation can develop into irritable bowel syn­drome, ulcers, and other serious physical ailments in cases in which stress is constant and severe.

The American Academy of Pediatrics has already warned that more and more teens are exhibiting physical symptoms linked to stress, including headaches, chest pain, sleep disorders, and belly pain. That’s worrisome news, since those sorts of problems have the potential to become more serious and result in conditions such as digestive disorders, sleeping disorders, migraines, heart disease, and perhaps even contribute to some types of cancer. Doctors are urging their patients to be aware of the warning signs of stress-related physi­cal problems and to take measures to address them.

In this post we’ll have a look at situations that can result in long-term stress, how long-term stress can affect you physically, what physical symptoms you might experience, and how you can recognize potential problems. Long-term stress also can have significant psycho­logical effects, and you’ll learn more about those in the next post. To begin, let’s look at some common and not-so-common situations that can result in continual or frequent stress.

As you know from previous post, How Stress Affects You Emotionally, some people are more susceptible to stress than others, and some are better able to deal with it when it occurs. Some situations, however, are pretty much universally stressful, as noted on the Holmes and Rahe stress scale. Among those universal stressors are the deaths of a spouse or child, divorce or separation, serving time in jail, death of a family member, illness, marriage, preg­nancy, a child leaving home, changing schools, and having a mortgage. (It’s interesting that even occasions or events that we consider to be happy ones—such as getting married or preparing to welcome a new baby into the family—come to us with a good measure of stress).

Fortunately, most of these big stressors occur only on an occasional basis and are not ongoing. Some situations, though, are ongoing and can result in ongoing or constant stress.

Certainly, ongoing physical, sexual, or emotional abuse is reason for extreme levels of stress. So is living in a violent environment, such as a war zone or even a very dangerous urban neighborhood. These sorts of situations, even if they stop, have long-lasting results, includ­ing both physical and psychological problems.

While it’s impossible to ignore terribly traumatic experiences like physical, sexual, or emotional abuse or other forms of violence, there are other stressors that might be so constant in your life that you don’t even recognize them. It’s a worrisome fact that you can get accustomed to living with stressful situations to the point where you barely think about them—they’re just the way it is. These situations might include constant worrying about succeeding in school, getting accepted into college, finding the money to go to college or rent an apartment, getting invited to the prom this year, your girlfriend or boyfriend breaking up with you—these sorts of low-level stressors that often remain under the radar. They might not be at the forefront of your mind’s agenda, but they’re always a little below the surface, nagging at you like a mosquito bite that won’t stop itching.

If you’re exposed to ongoing or long-term stress, you might notice over time that your neck and shoulders feel cramped and tight, mak­ing it difficult some days to even turn your head without neck pain. You might notice that your stomach is frequently churning, and you wonder if it’s safe to eat or whether you should skip lunch and just have a soda. You don’t understand why you have headaches so often until your dentist says she can tell that you’ve been grinding your teeth as you sleep, a habit that often results in headaches. To top

it off, your asthma, which you thought you’d outgrown by sixth or seventh grade, has returned, making it difficult for you to play on the baseball team.

You feel like your body is falling apart and you’re only 18 years old! What will it be like when you’re 40 or 50 or 60? If you feel that you’re stressed out and already experiencing some physical prob­lems as a result, the best thing you can do is to address the situation now. If you don’t learn how to handle stressful situations now can mean that you’ll lack the skills you need to cope with them as you get older, and it’s likely that physical problems would only become more severe. Let’s take a look at some of the serious physical con­ditions that are associated with stress, and the problems they can cause.

Also known as hypertension, high blood pressure causes the heart to work harder to pump blood to the body and contributes to car­diovascular disease, stroke, eye problems, and kidney disease. While experts are still trying to determine whether long-term stress actually causes high blood pressure, evidence strongly points to a connection between the two. The School of Public Health at Johns Hopkins Uni­versity in Baltimore reported on a study which revealed that ongoing stress among teens can lead to elevated blood pressure, more than doubling the risk that those teens would experience chronic high blood pressure as adults.

Increasing numbers of teens also are experiencing elevated blood pressure levels due to factors such as obesity, inactivity, and poor eating habits. Other factors that contribute to high blood pressure include genetics and aging. High blood pressure has been called “the silent killer,” because there usually are no symptoms. This makes the condition particularly dangerous.

A doctor or nurse can measure your blood pressure with a device called a sphygmomanometer, which consists of a stethoscope, arm cuff, dial, pump, and valve. You can also get your blood pressure taken at health fairs, at special machines in some drug or grocery stores, or with home blood pressure monitors. High blood pressure can be treated with lifestyle changes and medications, if necessary. People who are susceptible to hypertension should be careful to monitor their blood pressure so it can be kept at an acceptable level. If you’ve never had your blood pressure taken, or haven’t had it taken for a long time, it’s a good idea to do so in order to establish a base­line reading. If you have your blood pressure taken several times with similar results, you’ll be able to keep an eye on it to see if remains about the same.

Keep in mind, though, that blood pressure is susceptible to your reactions to what’s going on around you and can vary significantly within a short period of time. If you’re on your way to a health fair to have your blood pressure checked and you’re nearly run over by a bus on your way, for instance, chances are your blood pressure will be quite high when you arrive! A good thing to do would be to wait for an hour or two and have it taken again to see if it’s come down.

Blood pressure for some people tends to elevate just at the thought of having it checked, resulting in a sort of false reading. Some people with high blood pressure do well to purchase a machine they can use at home to keep track of daily readings. If there’s a history of high blood pressure in your family—that is, if your mom, dad, or any of your grandparents have or had the condition—you should get yours checked occasionally and keep track of the results.

 

As with high blood pressure, it’s not yet clear whether stress is an independent factor or a primary cause of heart disease, but evidence strongly points to a link. It’s sort of like a chain, where one link leads to another. People who are under a lot of stress for a prolonged period might end up feeling isolated or angry, traits which have been linked to increased risk of heart disease. Or, stress causes some people to react with unhealthy behaviors, such as smoking, excessive drinking, physical inactivity, or overeating, all of which also can contribute to heart disease. Experts suspect that high stress levels can further elevate blood pressure and levels of cholesterol, which is a soft, waxy substance found in your body’s bloodstream and cells. Everyone needs cholesterol, but when too much of it builds up it can block the flow of blood to the heart and result in health problems, including heart attack. Some studies suggest that stress changes the way the blood clots, and that could be a factor for heart disease. If stress actu­ally is a primary factor in heart disease, it could be due to frequent and excessive exposure to stress-related hormones such as cortisol and adrenaline.

Regardless of whether stress is a cause or a contributor to heart disease, the evidence certainly points to a link between the two.

The term heart disease actually refers to a number of condi­tions that affect the heart, including coronary heart disease and heart attack, congestive heart failure, and congenital heart disease. Together, those conditions cause more than 652,000 deaths in the United States every year, according to the Centers for Disease Control and Prevention—more than any other disease. The most common type of heart disease is coronary heart disease, which is when the arteries that allow blood to flow to and from the heart get narrowed and hardened due to buildup of plaque.

Some people don’t have any symptoms of coronary heart disease until they have a heart attack, also known as a myocardial infarction. This happens when the heart can’t get enough blood and the cells of the heart muscle don’t receive enough oxygen and begin to die. The more time that passes between the beginning of a heart attack and the start of treatment to restore blood flow, the more damage will occur to the heart muscle. If the heart sustains a great deal of dam­age, cardiac arrest could result; this is when the heartbeat stops, and it can lead to death.

Other people get a warning that coronary heart disease is present in the form of angina, which is a pain or feeling of pressure in the chest, and sometimes in the shoulders, arms, and back. This occurs when the heart muscle isn’t receiving enough oxygen.

Tests to determine whether or not a patient suffers from coronary heart disease include:

> Electrocardiogram (EKG), which measures the electrical rhythms, rate, and regularity of the heartbeat

> Echocardiogram, which provides an image of the heart

> Exercise stress test, which measures how effectively the heart pumps when it’s working harder than usual, requiring more oxygen for the heart muscle

> Chest X-ray, which provides an image of the inside of the chest, including the heart

> Cardiac catheterization, in which a thin tube is inserted into an artery in the groin or arm and threaded up to reach the coronary arteries. This allows a doctor to check the insides of coronary arteries to determine blockage and other factors affecting the arteries and your heart.

> Coronary angiography, which is when a dye is injected through the catheter used in a cardiac catheterization, allowing a doc­tor a better look at the flow of blood and whether blockages are present

Treatment for coronary heart disease usually involves making lifestyle changes, and it often includes medicines and medical treat­ments. Sometimes, but not always, surgery is required to open arter­ies and improve blood flow.

Congestive heart failure, sometimes called chronic heart failure, occurs when the heart can’t pump enough blood and oxygen to keep other body organs healthy and functioning properly. This can result in a number of serious problems, including kidney failure and other conditions. There is no cure for congestive heart failure, but in many cases it can be managed through lifestyle and with medicines and other treatments.

Congenital heart disease is the most common type of major birth defect; it can be caused by genetic factors, or, sometimes, because a developing fetus is exposed to something that damages the heart. Congenital heart defects include abnormal valves and holes in the walls that divide the chambers of the heart.

Simply being exposed to high levels of stress does not cause any of these conditions. In people who have other risk factors or exist­ing problems, however, stress is suspected as a contributing factor to heart disease.

Strokes are sometimes called “brain attacks” because, as during a heart attack, blood flow is restricted. With a stroke, however, the blood flow to the brain is cut off, meaning that the brain doesn’t get the oxygen and glucose that it needs to survive, and brain cells begin to die. If a stroke is not treated early, it can cause permanent brain damage.

There are two kinds of stroke: ischemic and hemorrhagic. Ischemic stroke, which accounts for about 80 percent of all strokes, occurs because either a blood clot or too much plaque clogs blood vessels and blocks the flow of blood to the brain. A hemorrhagic stroke occurs when a blood vessel in the brain breaks or ruptures and blood seeps into brain tissue, damaging brain cells.

Although stress does not directly cause strokes to occur, people with high blood pressure are four to six times as likely to have a stroke as those who don’t have high blood pressure, and stress also has been connected to other risk factors for stroke, including irregular heart rhythm, smoking, excessive use of alcohol, being overweight, and coronary artery disease.

The immune system is an amazing collection of cells, proteins, tis­sues, and organs that continually work together to fight off substances that threaten to harm the human body. The immune system employs a series of steps, known collectively as the immune response, to seek out and destroy organisms and substances that, if left alone, could cause disease or infection. When the immune system is functioning properly, it is incredibly effective in protecting you. It can kill bacte­ria, viruses, and infected cells; assure immunity from diseases; and generally help keep you healthy.

When the immune system is compromised, or not working prop­erly, however, it is not always able to protect the body as it should. Basically, there are four things that go wrong with the immune sys­tem: immunodeficiency disorder, autoimmune disorder, allergic disor­der, and cancers of the immune system.

Immunodeficiency disorder occurs when parts of the immune system are not working the way they should—or don’t even exist. Some people are born with deficient immune systems, while the immune systems of others are damaged by infections or drugs. There are different levels of immunodeficiency disorder, ranging from mild to severe. People with mild immunodeficiency disorders might suffer from allergies and tend to get more colds and other respiratory infec­tions than others, while someone with very severe immunodeficiency disorder may be almost completely helpless in fighting infection. You may have heard of “the bubble boy disease,” a condition called severe combined immunodeficiency. Its more informal name comes from the case of a boy from Texas who lived in a plastic bubble that had to be kept entirely free of germs because his damaged immune system did not allow him to fight off any sort of infection. That, of course, is an extreme form of immunodeficiency disorder.

Sometimes immunodeficiency disorder occurs when the immune sys­tem is damaged by a disease or certain types of drugs. AIDS (acquired immunodeficiency syndrome) is a disease that, over time, destroys the immune system by making it unable to fight off what would normally be harmless organisms. Some medicines, including chemotherapy and immunosuppressant medicines given to people who have had organ transplants, also can cause immunodeficiency disorder.

Autoimmune disorders occur when something in the immune sys­tem goes haywire, causing it to attack a part of the body as if it were an invader looking to cause harm. Autoimmune disorders include lupus, which causes pain in the joints and muscles and can involve the kidneys and other organs; juvenile rheumatoid arthritis, in which the immune system attacks joints of the hands, feet, or knees; and scleroderma, which leads to inflammation of the skin, internal organs and joints. These disorders can be life altering and debilitating.

Sometimes the immune system overreacts to certain substances within the body, causing an allergic disorder. This can cause symptoms ranging from sneezing and watery eyes to a dangerous condition called anaphylaxis. Examples of allergic disorders include asthma; eczema; drug allergies; seasonal allergies; food allergies; animal allergies; aller­gies to toxins, such as bee stings; and environmental allergies, such as allergies to dust mites or mold.

Cancers can occur in the immune system, as in other parts of the body, when cells grow in an uncontrolled manner. This damages the immune system and makes it unable to do its work. The two most common types of cancers affecting kids and teenagers are leukemia and lymphoma. Thankfully, most cases of these cancers are curable.

Researchers and doctors have discovered a link between stress and disorders of the immune system. Studies have shown that long-term stress, particularly when those experiencing it can not see any ending to it or have no hope of escaping it, weakens almost all aspects of the immune system, making those affected more susceptible to a variety of problems. Some researchers believe this is due to the presence of cortisol, a stress-related hormone that may affect the cells within the immune system and limit their ability to fight off diseases.

Continued research is occurring as scientists and doctors learn more about the ways in which stress affects the immune system. It has been observed, however, that people exposed to long-term stress are more susceptible to a variety of problems, ranging from colds to cancer. Addressing overall health is extremely important when con­sidering the immune system and how to keep it at peak functioning levels. Proper nutrition, sufficient exercise, and keeping stress under control are all factors that affect how efficiently your immune system works.

There is no proof that stress, by itself, causes cancer. Studies con­ducted over the past three decades, however, have suggested a rela­tionship between psychological factors, including stress, and cancer risk, according to the National Cancer Institutes, a branch of the National Institutes of Health.

While some studies have indicated that stress might actually increase the risk of developing cancer, others have suggested that high stress levels may lead to faster progression of the disease once it occurs. Still other studies have linked stress to certain types of virus-related tumors that occur when the immune system is compromised.

This is a complicated topic, because, as with high blood pressure and heart disease, it’s not known whether stress is a factor in the development of cancer, or if it contributes to the effects of other cancer factors, such as obesity, smoking, and alcohol abuse. Someone with a strong family history of cancer may experience a great deal of stress worrying that she too will get cancer, raising the question of whether the stress may contribute to the likelihood of the cancer occurring. And, researchers wonder, once cancer has been diagnosed, could the stress that accompanies such a diagnoses contribute to the progression of the disease?

Most scientists believe that cancer is caused by a combination of factors, including genetics and environmental and behavioral factors. As more research is conducted, we should get a better understanding of a possible link between stress and cancer. We do know, however, that stress can negatively affect the immune system, and the immune system is an important tool in fending off cancer.

A common stress response for many people is to eat. And, gener­ally, when you’re feeling stressed out and looking for relief, a celery stalk is not the first food you reach for. Most people who seek stress relief through food gravitate toward foods high in fat, sugar, and salt—pizza, fried chicken, and donuts, rather than fruits, vegetables, and whole grains.

Many people eat when they are bored, happy, sad, angry, or frus­trated—not just because they are hungry. Researcher Brian Wansink claims that the average person makes about 200 decisions pertain­ing to food every day, most of which are made with little thought or awareness, and most of which have hardly anything to do with hunger. Eating habits, Wansink asserts, depend largely on who we’re with, where we are, and how we’re feeling at the time we decide to eat. So, if you and friend always take a different route home from school on Fridays because you stop at the café for a water ice or gelato, you’re likely to indulge, even if you’re not particularly hungry. If you’re feeling stressed or upset, you might indulge even more than you normally would.

There’s a lot of truth to jokey mottoes such as “When all else goes wrong, reach for chocolate,” because that’s exactly what many people do. Some people use food for escape, just as others might use alcohol or drugs.

A recently released study of more than 1,000 low-income adoles­cents in Boston, San Antonio, and Chicago revealed that kids who reported high levels of stress based on five factors experienced an obesity rate almost 10 percent higher than their peers who did not feel overly stressed. The five factors considered were: academic problems, drug or alcohol use, depression or poor mental health, aggressive behavior, and lack of future orientation.

The increased obesity in the highly stressed kids could be caused by behaviors adopted in response to stress, such as overeating and not exercising, researchers said. Or, obesity itself may be a stressor, leading to a vicious cycle.

In addition to stress-affected eating habits, scientists recently dis­covered another connection between stress and weight gain. A study led by Georgetown University Medical Center revealed that a mol­ecule called neuropeptide Y (NPY), which helps in new tissue growth, is released from certain nerve cells during times of stress. The NPY molecule has been linked to appetite and obesity, leading researchers to suspect a link between stress and fat growth. The body of a per­son who experiences stressful situations on a regular basis could be releasing this molecule often, promoting the production of fat.

Diabetes is another disease which, although not caused by stress, may be affected by it. And, stress may be a contributing factor in the presence of the disease. When someone has diabetes, his or her body doesn’t produce insulin (type 1 diabetes), or doesn’t use insulin properly (type 2 diabetes). Insulin is a hormone necessary to convert sugar, starches, and other foods into energy. Nearly 8 percent of the American population has diabetes, and the incidence of the disease is rising. Both genetics and environmental factors, including obesity, play a role in the development of this disease.

Ninety to 95 percent of people suffering from diabetes have type 2, in which their bodies don’t use insulin properly. Traditionally, type 2 was known as “adult diabetes,” because it usually didn’t occur until well into adulthood. Today, however, children as young as seven have been found to exhibit early signs of type 2 diabetes, and, alarmingly, the number of children being diagnosed with this type of the disease is increasingly rapidly. Overall, the incidence of diabetes in the United States increased by 13.5 percent between 2005 and 2007, according to the American Diabetes Association.

Experiencing frequent stress poses particular problems for some­one with diabetes. When the fight-or-flight response kicks in, so do stress hormones. The hormones allow stored up energy in the body to be released into the cells to get the body into shape for fleeing or fighting. A person who has diabetes may not have insulin to help that stored-up energy get into the cells—the glucose and fat that makes up the energy gets stacked up in the blood. For such a person, stress occurring on a regular or constant basis, can result in long periods of high levels of glucose in the blood.

Also, people who have diabetes and find themselves under stress may not take care of themselves as well as they should, which can have a negative effect on their health.

As you have read, long-term stress plays a role in a number of very serious diseases, as well as causing less serious problems such as headaches, digestive problems, neck and shoulder pain, sleeping problems, and skin rashes. If you are already experiencing any of the physical problems associated with stress, you should make an appointment to see your doctor. If you haven’t had a physical exami­nation for two years or more, it’s advisable to try to schedule one. If you don’t have a family doctor or can’t afford to see a doctor, there may be alternatives available to you. You’ll read more about that in this post, Paying for Care – Health care coverage for Stress.

> While short-term stress can be useful, long-term stress can cause a variety of problems, including serious physical conditions.

> Many people become accustomed to living with ongoing stress and no longer recognize that the stressful situation exists.

> If you’re already experiencing physical symptoms of stress, you should address the situation now so it doesn’t continue to worsen as you get older.

> Stress is believed to play a role in high blood pressure, heart disease, stroke, problems of the immune system, cancer, obe­sity, and diabetes.

> While stress doesn’t cause these serious diseases and condi­tions, it might contribute to their presence or make them worse once they are diagnosed.

> If you believe you may be experiencing stress-related physical problems, you should consult with a doctor or other health professional.

The Role of the Physical Therapist in Life Care Planning

Physical therapists serve as facilitators of health. They treat patients with a broad range of potential participation from other professionals, family, and friends. An open mind-set to any given patient and situation is crucial to the enhancement and facilitation of health. The treatment of signs and symptoms, pain, irritation, lesions, catastrophic injury, and dysfunction are given viable solutions from the unique perspective of balanced deliverance of effective physical therapy skills. This cre­ates a synergistic application of physical therapy with the patient’s willingness to be responsible toward maximizing health and function.

Cooperation with all professionals, financial supporters, family members, and friends contributes to the overall facilitation of health. Insight to innovative and new techniques as applied to a specific patient’s needs is an opportunity to promote physical therapy skills with positive participation by the patient. It is vitally important that the well-being of each patient be considered in long-term and short-term care.

In dealing with life care issues, there are fundamental questions and paradigms of thinking to be asked of the physical therapist and others involved in the care of the patient or client, such as the following:

¦     What was the level of health, function, and lifestyle before the injury, disease, lesion, or dysfunction?

¦     What level of health, function, and lifestyle can be achieved given the present status of the patient and his or her physiological, social, psychological, financial, and spiritual environment?

¦     What are the ideal, hopeful goals and plans, balanced with the real goals and plans?

¦     What are the integrated thoughts on parameters and boundaries of the patient’s thinking in relationship to the process of healing and health?

The physical therapist and all persons involved in life care planning should integrate their plans with the following concepts being interwoven in their health care delivery process:

¦     “Seek first to understand, before you are understood.” (Covey, 1989, p. 239)

¦     “Walk a mile in my shoes.” (Song performed by Joe South)

¦     “Do unto others as you would have them do unto you.” (Matthew 22:39 paraphrased, KJV)

¦     “Understand the patient’s languages of love—care and receiving”. (Chapman, 1995)

As we examine life care goals and priorities for the patient, we are building a foundation of true principles to develop our skilled delivery of physical therapy. Therefore, we return the patient, as much as possible, to full health and function with basic human dignity, rights, and privileges. If
full health and function are not attainable, then at the very least we should create a plan, delivery, and environment of highest quality and dignity of life, minimizing suffering and creating a door of hope for tomorrow. This also allows us to participate in one of the greater values of life, the opportunity for fellowship and to relate to a person’s unique experience of life, a form of shared enlightenment.

Again, the attitude for delivery is based on how we would want to be treated in any given situation. This attitude counteracts selfish goals and stirs physical therapists to strive for the best scenario and outcome, for the goal is quality of life. This way of life care planning requires com­mitment to the process. It includes active responsibility and participation of both the physical therapist and the patient.

The physical therapist has the unique capability of providing a large spectrum of evaluative techniques as well as evaluative protocol. The evaluation process is a multilevel course of action. Full detailed evaluation processes can occur on various levels or may be specific parameters, as well as being appropriate to special situations.

In the general areas of medical studies and patient situations, a physical therapist is presented with a variety of evaluative techniques. These include the areas of orthopedics, neurology, soft tissue dysfunction, wound care, sports medicine, hand therapy, industrial medicine, and cata­strophic injury to specific or multiple areas. The physical therapist can also specify evaluative techniques by age groups, including pediatric, youth, adult, and geriatric populations. Besides the areas of physical dysfunction and areas of given diagnostic diseases, lesions, or injury, a compara­tive evaluation and preparation for return to life evaluations can be delivered. Evaluations that involve return to life skills, including activities of daily living (ADL), function, work-related skills, ergonomic analysis, sports-related skills, and overall total life skills can be offered with the appro­priate parameters in order to be specific or holistic in nature.

The evaluation process involves consideration of the adaptability of the patient and the circum­stances in which the patient is placed. Evaluations can involve specific areas of spine, extremities, and body systems, as well as specific areas of dysfunction and injury. General areas of consider­ation and evaluation involve the following.

Review the existing medical history and subjective information.Interview the patient. This involves a general subjective overview, including verbal con­tributions from the patient, type of injury, surgical history, disease process, and dysfunc­tion. Other areas involved in subjective information include present job situation, activity level before and after injury, previous types of physical therapy received, and medical care received.Consider psychosocial questions and interview as they relate to the present dysfunction. Other professionals may have covered psychosocial issues, but it is always appropriate to establish a baseline of understanding of other involved issues in the patient’s dysfunction.As appropriate, communicate with family and friends about observed subjective and objec­tive information.

The subjective information and input obtained from the client are established as the baseline for other evaluation considerations. Pain evaluations using standardized questionnaires as well as various tests have benefits for cross-correlation and reliability of subjective information. These essential baseline data of pain characteristics assist in leading the therapist toward establishing present dysfunction and potential for further dysfunction and other complicating factors.

General characteristic complaints of pain are to be established, such as:

¦     The location, duration, and frequency of the pain.

¦     The specific qualities of the pain—constant, intermittent, diffused, localized, sharp, numb, burning, dull, tingling, radiating, quick, or sustained.

¦     Examples of specific pain (e.g., night pain, pain upon arising in the morning, pain with activity, or pain throughout the day).

¦     Clarifying the pain intensity by using a scale—0 being no pain and 10 being acute pain.

¦     Examples of activities that increase pain and activities that decrease pain (e.g., sitting, stand­ing, walking, lying, bending, massage, ice, or heat).

¦     Is the pain getting better, getting worse, or remaining the same?

¦     What is the maximum length of time the patient can perform any particular function, such as sitting, standing, walking, and driving?

Pain questionnaires should also reveal relationships between how much function the patient can perform and at what level the pain occurs, such as how much can the patient lift and carry? What provides relief? What positions and body ergonomics or equipment assist in decreasing pain and promoting function? Pain drawings and various standard pain scales are other informative tools to be utilized for comparative information, with coordination of other data.

Past medical history and personal information also are important to understanding the direc­tion of evaluation, treatment, and plans for function and health care. The new standards and parameters established under the Health Insurance Portability and Accountability Act (HIPAA) have to be considered in all aspects of care and planning.

Referral questions such as return to work, work duty load, time load, consistency testing, and impairment ratings are also directional in the evaluative and care process.

An objective evaluation will analyze basic functional activities, such as the patient’s gait; sitting, standing, and rolling activities; and appropriate supportive devices.

Observation of the basic structure of the anatomy, weight-bearing capabilities, and appropriate body landmarks is an essential part of this examination. One should note appropriate posture, compared to the correct anatomical position, and specific noted deviations. Considerations for historical body habits, adaptive shortening, and contractures are important data. Also note the self-limiting or compensated functions and adaptations the patient has made. These can occur voluntarily or involuntarily.

Other observations should include:

¦     Basic soft tissue evaluation

¦    Appropriate understanding of joint position

¦     Intervertebral movement

¦     Normal joint movement

¦     Range of motion (ROM), including cardinal and diagonal planes

¦     Gait analysis

¦     Flexibility

¦     Manual muscle testing

¦     Strength testing with technologies and instruments

¦     Functional test

¦     Sensory tests

¦     Special tests

Special tests can target specific examination of any given extremity or body part. These tests rule out various complications and evaluate appropriate function and dysfunction.

Other appropriate evaluations include:

¦     A neurological exam would include basic reflexes as well as appropriate strength measuring, with manual muscle testing and sensory examination. It should be noted that during the evaluation any cross-correlation with a basic generalized assessment can be made with more specific evaluations, including functional aspects of a work capacity assessment (WCA), functional capacity assessment (FCA), and isokinetic, neurological, and balance testing and sensation tests.

¦    Joint mobility evaluations include the normal ROM, correct anatomical position, appropriate accessory movements, and physiological movements.

¦     Soft tissue evaluations include palpation of tissue, noting restrictions, trigger points, pliabil­ity, and plastic and elastic responsiveness. The evaluation of soft tissue and tender points should include restrictive qualities and tenderness nature and the response of the tissue (Jones et al., 1995). The evaluation of articular structures should include pain, irritation, and inflammation status as well as movement patterns being evaluated. The functioning of soft tissue and joint structures as a synergistic pattern should be noted. Functioning activities such as sit to supine and return, rolling to supine, side lying and return, and overhead reach are part of the evaluation. The evaluation of functional positions and assuming positions, including the quality of movement as well as any centralization or peripheralization of pain, signs, and symptoms should be considered in this process.

¦     Other palpation skills include evaluating muscle play, restriction, guarding, reflex contractions, soft tissue restrictions, trigger point, and referred pain. Intervertebral movement evaluation is based on a numerical scale set between 0 and 6, with 0 being ankylosed and 6 being unstable; 3/6 is normal. The intervertebral movement can also be classified as hypomobile, hypermobile, and painful. The general evaluation can be broad or specific.

The terms work capacity assessment and functional capacity assessment are sometimes used synonymously (Polinsky, 1983; Blankenship, 1989). They can also be more definitive, with WCA being an evaluation used for baseline of work capacities. The FCA would involve a more direct study of basic, functional activities of daily living, with the potential of also evaluating work-related activities. The WCA/FCA can be done at the beginning, middle, or end of any
treatment evaluation process, or as part of a total perspective of life care planning depending on what is needed. There can also be varying degrees of specific details in the WCA, since the parameters are determined by the physical therapist’s understanding of the goals of the evaluation process. The WCA/FCA can occur during the initial stages of the life care planning process or can be extended throughout the span of the life care plan. Follow-up assessments are to upgrade and adjust the goals and plans for the patient, as well as to update the baseline data for reevaluation. All physical therapy evaluations are done in coordination with other professionals and their evaluations. Integrating the results of other health professionals’ assessments into the physical therapy plan allows for a more holistic approach in achieving the goals for the individual patient.

There are a number of evaluative techniques in the areas of WCA and FCA that are effective and appropriate for any given situation in the life care planning process. According to Blankenship (1989, p. 122), “the WCA or the FCA is an evaluation of physical capabilities and limitations as they relate to work, recreation, and ADL. It describes the optimum and maximal capabilities in terms of strength, endurance, related joint problems, fine and gross motor coordination, limiting factors and methods of functional and task performance.” Therefore, in order to make a more accurate assessment, the WCA/FCA should involve measurements of different activities.

General areas tested in basic functioning include:

¦     Lifting, which includes level lift, floor to table, and carrying

¦     Pushing to maximum tolerance

¦     Pulling to maximum tolerance

¦     Standing, sitting, and kneeling tolerance

¦     Bending, stooping, and squatting

¦    Walking, climbing, and balance

¦    Coordination activities, including the upper and lower extremities with gait analysis and gait function

¦     Pivots, forward reach, overhead reach, etc.

The evaluation often requires an assessment of time and repetitive parameters specifically defined as not required, occasional (up to one-third of the time), frequent (one-third up to two- thirds of the time), and constant (over two-thirds).

These tests can take on specific work or functional aspects. Various lifting tests have been developed to improve consistency, reliability, validity, and standardization of data to be applied to evaluation and supportive conclusions, results, and directions of rehabilitation.

Isometric lift test, strength test with one repetition, repetitive loads, dynamic and static, grip test, and other integrated techniques utilizing new technologies, programs, and standardized tech­niques and databases are part of the evaluative tools available. These tests are also cross-correlated often to arrive at reliability, validity, and consistency of effort parameters. Many tests, for example, EPIC (Employment Potential Improvement Corporation, developed by Matheson, available at www.epicrehab .com), have criteria and standards for application, databasing, and analysis.

Establishment of proper body ergonomics and posture during functional ADL, as well as work- related activities, is important not only in establishing and facilitating present health, but also in preventing further dysfunction and injury. It is important that ergonomics be applied in the evaluation process as a tool to determine the patient’s capabilities (physically and mentally) in comprehending the issues of proper body mechanics. In the evaluative functional capacity/work capacity arena, proper ergonomics and posture will need modifications based on equipment handling capabilities and the use of adaptive equipment.

Functional aspects of ADL, such as personal grooming, hygiene, and dressing, are issues that are often considered in the FCA (also see this post on the occupational therapist’s role). Areas of nutrition and speech can also be evaluated by a qualified physical therapist with appropriate training. Some aspects of the FCA, as well as other aspects of WCA, are often overlapped in the expertise area with the occupational therapist, speech therapist, recreational therapist, ergonomic specialist, and appropriate physician specialist. In any evaluative process, standard body mechanics are to be evaluated by the therapist during the lifting task portion, as well as basic functional activities task, in order to ensure the most advantageous body mechanics for handling basic ADL functions and work functions.

Evaluation for sports and other specific recreational skills needs to be considered in the evaluative process. There is a correlation between functional skills, work skills, and sports or recreation skills. Collating these concepts provides for efficiency of movement, as well as promoting correct body function and health, within the parameters of the given dynamics of the patient’s physical challenges.

Evaluation of body mechanics is crucial to determine potential for wear and tear on the patient. Appropriate alternatives, suggestions, and varying procedures and skills for handling any given dysfunction should be understood. Full comprehension of these procedures and skills will enhance the development of proper use of strength, as well as minimize irritation and pain. Also, with proper evaluation of the patient’s present knowledge and skill, the need for further training or education can be developed. The role of the physical therapist from the basic evaluative process or WCA/FCA can essentially be refined or specified for any catastrophic impairment.

When performing the evaluative process and listing objective findings, substantial data are important to assist the delivery of health care to the patient. Gathering of data and information in the objective format also plays an important role in defending the patient’s present situation and in presenting the plan for future services. Skilled assessment is vital in giving direction for the best possible outcome for the patient’s return to health, as well as providing long-term care. It is appropriate to develop parameters allowing for changes in the patient’s function and health and in the patient’s environmental situation and basic home lifestyle. Adaptability and changes in preparing the patient for return to work or work activities are crucial in understanding the format for performing the evaluative FCA or WCA.

Isokinetic testing provides a technologically advanced approach to human performance testing, rehabilitation, and exercise. The test allows all major joints of the body, including the upper extremities, lower extremities, and trunk, to be evaluated and compared. Bilateral testing, as well as comparative testing, can differentiate between muscle groups in the isokinetic test. Isokinetic exercise is performed at a constant speed throughout the range of motion. As the muscle applies
force, it is resisted by appropriate proportional opposing force. Therefore, the speed of movement is kept constant. The isokinetic evaluation process or exercise provides an excellent means of qualifying many aspects of movement and function, including muscle torque, work, fatigue, ROM, and peak torque levels. As the sophistication of technology improves, more accurate and appropriate measuring devices will allow for basic data and parameters in which to assess body function. The isokinetic test can also be used in a cross-correlation with functional measurements being taken, as well as manual muscle testing and basic lifting capabilities. This cross-correlation can help define the patient’s present level of activity and assist in determining symptom magnification and inappropriate illness behavior parameters.

As in the general evaluation given earlier, the neurological examination can be an expanded appraisal involving specific parameters. It involves specific emphasis on neurological and neu­romuscular mechanisms of the body, including muscle test and evaluations, sensory tests, functional and neuromuscular developmental sequencing and evaluations, and specific injury evaluations to the central nervous system or peripheral nervous system. Associated dysfunction as in gait, transfers, dressing, grooming, hygiene, sports, and work can also be neurologically evaluated.

Cardiovascular fitness evaluations incorporate a range of specifically applied stress testing under the supervision of the physician and appropriate professionals, including a physical therapist. The cardiovascular appraisal is often involved in the FCA/WCA, which establishes a minimal level of conditioning protocol that could include treadmill, bicycle ergometer, or step-climbing evalua­tions. All these tests have basic guideline parameters. Often a cardiovascular clearance evaluation is needed before other evaluations, WCA, and FCA can be performed. The pertinent physician or professional may give appropriate parameters under which the cardiovascular system may be stressed or tested.

The neuromuscular skeletal function is evaluated in specific areas or systems and holistic body systems and functions. This evaluation can involve the study of the balance system of the body in relationship to gait and functional activities. Proper consideration for a proprioceptive feedback system in static and dynamic functional activities is measured. This evaluation can involve specific job activities, sports activities, and ADL, with coordination, balance, and skill being integrated into foundation data. The criteria involve general standardized tests, as well as specific tests designed by the physical therapist to the given situation based on age, developmental sequencing, and specific goals of the functional or life care demands.

Gait evaluation involves specific or general evaluations of the patient’s ambulatory status in a variety of environment situations. Consideration for adaptive equipment, tools, and prosthetics is part of this evaluative process.

Return to work and physical demand categories as published by the Department of Labor, in combination with consistency of performance, positional tolerances, and lifting tests and other evaluative procedures, create a viable tool to have a “systematic process of measuring and develop­ing an individual’s ability to perform meaningful tasks on a safe and dependable basis” (Hanoun Medical, 2002).

The role of the physical therapist as a facilitator in health care is to treat, train, condition, and assist in the direct structure and setting of goals for the patient. Basic communication to the patient, family, professionals, and financial parties serves as a primary directive of achieving the life care planning process. It should be understood from the physical therapist’s point of view that his or her establishment of feedback into the life care planning process is crucial in developing a long­term solution for the patient’s care. Proper structured treatment, evaluation, follow-up physical therapy, and training involve clear communications among the professionals involved so that all forms of facilitation to functioning are utilized.

An attitude of openness and understanding should be the goal while preparing the patient for the highest level of independence. This same directive should be applied when providing options for those who will need long-term or lifelong physical therapy. Examples of this attitude and structure are as follows: a patient who is in need of a wheelchair and is dependent upon the wheelchair for most of her life will develop other dysfunctions. Typically there is greater wear and tear on the upper extremities, cervical, neck, thoracic, and spine, due to having to handle a greater load of total body function in the upper extremities and upper trunk and neck areas. It is important to understand that lower extremities that are not functioning do not provide support and therefore cannot be used in functional skills. This greater demand of activity and function is placed on the remaining working cardiovascular, neuromuscular, and skeletal systems. These patients or clients are susceptible to greater breakdown of all involved systems and structures. Effective planning involves addressing the immediate dysfunction in preparing the patient to develop a higher level of independence and future preparation. It should also be understood that the patient would in all probability have an increased ratio of wear-and-tear factors and greater susceptibility to further lesions and insult in his remaining systems and structures.

The dysfunctional areas of the body and mind will still need suitable care and support. These would include areas of strength, ROM, hygiene, wound care, tissue function, and basic vascular and neurological functional considerations. Sometimes injured areas become hypersensitive, even though not functional. Phantom and referred pain can occur in the dysfunctional area.

As in any treatment or evaluation process, the therapist should be open-minded and aware of any new studies or opportunities to increase the function and promote the facilitation of health in the injured area. This especially applies for adaptive equipment. The progressive use of equip­ment, awareness of advanced technology, and foresight to predict need are essential. For example, a lower-level tetraplegic patient would commonly require a primary power wheelchair for basic ambulating. However, there are occasions in which an additional manual wheelchair would pro­vide the patient with a variety of sitting postures, backup to the power chair, and an opportunity for the wheelchair to be used as a piece of exercise equipment. The manual wheelchair provides an
excellent source of exercise potential and opportunity for the patient to develop some control and direction in ambulating.

Thoughtful modifications and supplements to the patient and the given situation, with appro­priate equipment, should be considered for both short-term and long-term care. This allows the physical therapist and the life care planning team to develop a full perspective in returning the patient to the highest level of independence and an appropriate, dignified lifestyle. Motivating, encouraging, and challenging the patient to use equipment and supportive devices are part of the evaluative, training, and treatment process.

Financial considerations include original equipment, maintenance, modifications, and replace­ment equipment. All these factors are to be considered over the patient’s life span. As the patient changes and various challenges are presented, considerations for equipment should be appropriate to the life care plan and goals. Financial support for equipment and the evaluative process should be based on the highest goals and principles presented.

In the life care planning process, an evaluation establishes the baseline for treatment through­out the process. In many situations, specific treatment by the physical therapist is required and involves not only therapy, but also ongoing evaluation. Physical therapy treatment may involve eight basic categories:

EducationConditioningPhysical medicine treatmentFunction-specific and ADL-specific treatmentOccupational and industrial physical therapySports physical therapyTotal life relationship skills and integration treatmentBoundaries and communication skills

Education involves an emphasis on ergonomic principles applied to posture and body mechanics, and essential principles for carrying out assisted or independent programs of conditioning, strengthening, ROM, and functional care. Education in ADL, functional, sports, and work- related skills is delivered to all parties involved. It is important that these skills are developed in the patient’s real-world setting and that there is ample opportunity to implement them in an appropriate manner—with supervision, leading toward independence as a baseline goal. The appropriate support of professionals and family members in the real-world setting will require adaptive thinking.

Establishment of specific patient potential in any given area needs to be determined and understood by the patient and team members. An understanding of the patient’s situational life­style, critical work demands, task analysis, functional activities, and recreational plans is impor­tant. The patient’s understanding of educational information presented and the development of a functional delivery by the patient in handling basic nonmaterial ergonomics and essential material ergonomics should be considered. Material handling and nonmaterial handling ergo­nomics are matters not just of work-related issues, but also of functional ADL and the total environment.

Integration into the whole aspect of the patient’s life care with the life care planning team on an as-needed and program-developmental basis will be required. This will probably require the physical therapist to coordinate with the patient/client, other professionals, and family members to follow through with essential concepts of physical therapy education.

Conditioning involves aerobics, cardiovascular, and physiological conditioning. It should be noted that in conditioning, appropriate adaptations to the patient’s/client’s needs will be made and evaluated, as well as developed into a working solution by the physical therapist. Strengthening, which will incorporate specific muscle dynamics, will be used to increase strength levels for performing functional activities, work activities, sports activities, and ADL. Specific areas of strengthening can involve techniques in cardinal and diagonal planes, which can involve singular movements or multidirectional movements. The physical therapist has at his disposal the use of many strengthening techniques, including isometrics, isotonics, isokinetics, plyometrics, and proprioceptive neuromuscular facilitation (PNF). Strengthening could involve rotational, multidirectional facets to prepare the patient for a variety of lifestyle situations. Mobility, stretching, and flexibility categories are used synonymously to describe appropriate mobility exercises to ensure basic principles of full functional ROM in both physiological and accessory patterns. Using balanced concepts of strengthening without strain or further injury is of vital importance in designing a program specific to the individual patient and situation.

The integration of all conditioning factors with functional skills, ADL skills, work skills, and sports skills should be considered and integrated into life care planning. Specific neuromuscular, balance, and coordination activities allow the integration of the central nervous system and the peripheral nervous system to handle ADL, functional, work, and sports activities. Ballistics and dynamics are stresses to be applied to prepare the patient to handle a variety of velocity forces and changes that occur in any lifestyle situation. This can involve specificity of training at various speeds and various levels of physical performance.

Physical medicine treatment includes the use of appropriate medications, modalities, manual therapy, and specific exercises. Physical therapy medicine is used for basic signs and symptoms, which may include pain management, wound care, and improving function. Physical medicine includes the areas of specialized program development or treatment, which could include relaxation techniques, weight control, and appropriate uses of supportive devices, equipment, and braces.

Function-specific and ADL-specific treatment are specific treatment programs the physical therapist can use to encourage increased functional capabilities, such as in gait, transfers, personal hygiene and grooming, speech, and general ADL.

Occupational and industrialphysical therapy involves the process of creating a situation in which a patient/client may progress from a beginning level of handling any job task to the actual per­formance of the job. The job-specific program can involve a program starting in the clinic and being transferred to the on-site job location. Work hardening, work conditioning, and work start are synonymous terms to describe this process.

Sports physical therapy involves the direct relationship of physical therapy in establishing appro­priate conditioning and training, structure, and protocol. This skilled development of parameters and goals creates an atmosphere that develops independent training techniques, as well as inde­pendence to continue higher levels of sport or sports-specific performance.

Total life relationship skills and integration treatment involves the physical therapist working with the patient, family, and total environmental in developing a workable plan structured for assisting the patient in facilitating her full health at the highest level possible. This total life care integration involves a coordination of all previous physical therapy treatments and evaluations with the potential for upgrading, changing, and adapting any given treatment plan and program.

Boundaries and communication skills involve personal and relationship effort and education, utilizing appropriate psychological consultation and study. The skills and techniques gained will enhance the positive effectiveness of a caring serving professional.

Preparing the exit program involves a combination of compiling all previous evaluations, treat­ment, data, and observation processes in communication with the associated team members to arrive at a conclusion of the involvement process in the patient/client. During the exit program, appropriate recommendations and postdischarge plans are made from the physical therapist’s point of view with preferred sequencing, as well as postdischarge plans for status to returning to full lifestyle situations. Options and variations of any program, as well as reentry into a program, are open for consideration, as is proper application of newly found situations.

Follow-up care resolution is a broad category involved in interpreting the appropriateness and efficacy of the evaluative and treatment process from the patient’s perspective. It also involves the physical therapist’s perspective in the areas of physical ergonomic integration into basic life, con­cepts of preventative physical medicine, appropriate concerns for future update and recheck, and any issue of compliance. This involves a process of communication between the patient and all team members in restoring the patient to the highest level of function and a dignified lifestyle.

Symptom magnification or inappropriate illness behavior is an issue that can be present in the life care process and involves many complications and issues. Physical therapists, as well as other professionals, have attempted to arrive at appropriate systems, tests, and evaluative procedures for giving suitable feedback and baseline data to establish appropriate behavior in any given situ­ation. General considerations for inappropriate illness behavior and symptom magnification are behaviors that are out of proportion to the impairment. It should be understood that symptom magnification is a behavior that is improper but does not implicate a reason or motive for that behavior. Furthermore, it should also be understood that there could be a psychosocial basis for some behaviors that do not necessarily originate from a physiological or organic basis.

In determining symptom magnification or inappropriate illness behavior it should be under­stood that there are often degrees and levels at which it is expressed. Some of these levels are extreme and can impede the appropriate fair process of assisting a person to achieve a healthy lifestyle. In addition, there are forms of symptom magnification that exist on a low level that are intrinsic to basic lifestyle teachings. Therefore, appropriate considerations for establishing objec­tive information, as well as objective treatment, require skill and fitting consultation from the team of life care planners and associated professionals.

If the physical therapist is involved in the identification of the type of symptom magnifier, which could be classified in the areas of an experimenter, a refugee, a game player, and a psychogenic type of magnification, consultation with the appropriate professional should be performed and used (Blankenship, 1989). Appropriate test questionnaires and scales administered by the physical therapist, or previously by associated professionals, can be considered as part of the evaluative
process. It should also be noted that in understanding, evaluating, and commenting on appropriate and inappropriate illness behavior, one should have an open mind and be alert to cross-correlation factors in the evaluative and treatment processes.

An example of this would be a patient being asked to perform a cardinal plane ROM by lifting his arm over his head, but the patient states or demonstrates that he cannot lift his arm above 70° of shoulder flexion. Then when asked to take off his shirt, he is able to demonstrate taking his shirt off over his head, thus demonstrating his ability to flex his shoulders above 100° or more of shoul­der flexion. Cross-correlation of specific evaluative techniques and functional techniques assists in determining the reliability and validity of the patient’s status. In communicating this information, the physical therapist should use the expression “The data presents itself.” Another way to express performance is to use the phrase “The patient demonstrated (this or that).” Therefore, the therapist avoids conjecture and judgment when communicating.

Basic rates in physical therapy for services rendered are wide and varied. Each profession and professional has his or her requirements and specific insights into delivery of any evaluation and treatment process. The following numbers are given as a broad perspective and are estimates for considering lifelong life care planning issues and are subject to change with all basic life situational economics, as well as specific professional demands.

¦     Basic physical therapy treatment and conditioning range from $65 to $200 per hour.

¦    General evaluative techniques, depending on the extensiveness of the techniques, range from $60 to $1000.

¦    These techniques could involve anything from a beginning basic physical therapy evaluation of $65 (average charge) to more specific exams running $200.

¦    WCAs and FCAs range from a modified WCA/FCA costing $200 to a more extensive WCA/FCA costing $1000.

Again, there is such a wide variety in pricing that it is best to be specific to the physical thera­pist involved in the analysis, evaluation, and treatment processes to determine the best life care planning situation. As in other life care planning areas, considerations for “how I would like to be treated” and what is fair should be a basis for appropriate structuring for financial reimbursement.

The physical therapist should establish an appropriate information system in order to accomplish the following:

Provide a means of examining the specific case issues as a professional.Establish appropriate correlations between injury and patient types. Establish appropriate protocol for returning the patient to his or her lifestyle and life situation.Establish appropriate modifications for further patient assistance and study.