"Since the time of the ancient Greeks, we have felt that there was a close relationship between a strong, vital mind and physiological fitness."
- John F. Kennedy
When we think of fitness, we frequently focus on physical fitness, yet mental fitness is also an important component of wellness.As doctors of chiropractic, we can assess - and guide patients to maximize - mental and physical fitness, in order to help them achieve true wellness. A partnership relationship that characterizes patient-centered care promotes the trust necessary to help patients modify self-defeating behaviors and destructive attitudes.
Mental fitness is a state of successful mental functioning, resulting in productive activities, fulfilling relationships and the ability to adapt to change and cope with adversity.1 Mental fitness is as indispensable to our well-being as physical conditioning. It affects family and interpersonal relationships, and the ability to contribute to society.1 Strategies to enhance coping skills are a large part of mental fitness and can be taught.2 A sense of personal control can be developed and can contribute significantly to mental fitness. Mental fitness is related to successful stress management. The ability to control stress, both psychologically and neurochemically, is a critical variable in stress management and is emphasized in chiropractic wellness care.3
Assessment of Psychosocial Stressors
Psychosocial stressors can be assessed through a history of the patient's family and home circumstances, occupational and recreational status, spiritual and community life, and financial situation. In addition, a rating scale that assesses life events for the previous year can determine the level of accumulated stress.4 The importance of life events, and the response to them, impacts overall well-being. As chiropractors, we are acutely aware that the response of the autonomic nervous system to excessive stress over time leads to an imbalance between the sympathetic and parasympathetic nervous systems, which is detrimental to health and wellness.
Anger as a Stressor
Unresolved anger significantly affects health and well-being. Negative anger results in hostility and is self-destructive when aggressive impulses are internalized. Anger turned inward increases personal stress and leads to depression. Patients with severe unresolved anger should be referred for anger management. Coping with stress is a life skill.
Dealing with angry people is as much a potential source of stress as unresolved anger. Listening to what the other person is trying to convey, rather than responding, often can defuse the situation.5 When a patient is in an abusive relationship, care must be taken not to directly tell them to steer clear of their situation. Instead, they should be encouraged to think about their situation and whether it is affecting their health. It is difficult, if not impossible, for patients to be healthy if they are faced with mental or physical abuse.
Pain as a Stressor
Poorly controlled pain leads to mental and physical changes that severely compromise mental well-being. Central sensitization which provokes an exaggerated response of the central nervous system (CNS) to a peripheral stimulus that is mildly painful can become exaggerated through hyperexcitability and hypersensitivity of the CNS neurons.6 Characteristic of central sensitization is the persistence of pain that can lead to mental distress, such as depression and anxiety. Noxious mechanical and chemical stimulation of nociceptors show dramatic expansion of neuronal activity in the spinal cord.6 Similar processes have been described in the osteopathic literature by Korr,7 and later Patterson,8 referring to the neurophysiologic effect as the "facilitated state." The current view of the cellular mechanisms underlying neuroplastic changes indicates that sensitization is caused at least in part by changes in the intrinsic characteristics of the spinal neurons involved, in addition to changes in the damaged peripheral tissues.9 The process appears to be dependent on an initial activation of nociceptive afferents and the subsequent release of excitatory amino acids and neuropeptides.6 Central sensitization that magnifies chronic pain can result in conditions such as fibromyalgia and irritable bowel syndrome that can be prevented and treated by chiropractic care. Psychological distress from chronic pain may manifest as depression or apathy. Psychic pain can lead to self-medication with alcohol or drugs, which can then become a problem in itself if dependence occurs.
Psychosomatic syndromes have often been dismissed as "all in your head." Fortunately, the mind-body connection has become better understood in the past two decades. The holistic approach to patient care acknowledges and addresses the mind-body connection. At the physiological level, stress is viewed in terms of disruptions of bodily functions. Psychosomatic disorders can affect a number of different organ systems (Table 1). The complex interplay between the functions of the autonomic nervous system and the endocrine system produces the "emergency adrenalin reaction" that produces a diffuse response to stressful situations. When prolonged through demanding conditions, a breakdown in the body's overall ability to adapt occurs.10 Stress management strategies which address the underlying psychological component that perpetuates organ dysfunction must be addressed, in addition to treatment directed to specific target organs as appropriate.
|Table 1: Organ Systems Affected by Psychosomatic Disorders|
|the respiratory system, by triggering hyperventilation syndrome, chronic bronchitis, or asthma;|
|the cardiovascular system, with high blood pressure, migraine headaches, or irregular heartbeats;|
|the gastrointestinal system, with aggravation of peptic ulceration, irritable bowel syndrome, or anorexia nervosa;|
|the genitourinary system, with menstrual disorders or frequent infections; and|
|the musculoskeletal system, with backache, neck pain or tension headache.2|
|Source: Jamison J. Health Promotion for Chiropractic Practice. Maryland: Aspen Pub, 1991;167-172.|
Acute stress and environmental disturbances can cause transient and short-term insomnia. More problematic is chronic insomnia that can develop in response to physical or psychosocial stressors. Sleep assessment may begin with a sleep diary. Factors that can affect sleep habits include psychological stress, physical problems, shift work, jet lag, restless leg syndrome, excessive intake of caffeine, and compromised breathing (sleep apnea). Poorly controlled pain also can prevent falling asleep and, in turn, awaken sufferers once they are asleep. Narcolepsy is a chronic sleep disorder that produces severe problems with persistent sleepiness. This can be as distressing as insomnia. Severe sleepiness can cause impairment comparable to that caused by alcohol intoxication. Sleep patterns and causes of sleep disturbance must be assessed to successfully formulate the patient's sleep regimen.
A holistic approach to stress management includes relaxation, exercise, sound nutrition, cessation of smoking or other forms of tobacco use, and a balance between work and play. Relaxation can be promoted through techniques such as meditation, visualization, tension release and progressive muscular relaxation. Regular exercise designed to reduce stress and improve mental fitness should be individualized for each patient. Consideration must be given to the patient's body type, level of physical functioning and a choice of activity the patient enjoys.11 Prescribe an exercise regimen that is not pleasurable to the patient and they will not follow it for long. Outdoor activities such as gardening or spending time in a park can be inexpensive ways of reducing stress. Sound nutrition is essential for a healthy mind as well as a healthy body, and should be tailored to individual needs. Excess alcohol and caffeine consumption, and smoking or other forms of tobacco use, should be addressed. A balance between work and play is often the most successful way to promote mental fitness. A realistic recreational program based on age, temperament and level of physical fitness should be recommended and developed through a partnership with each patient.3
Efficient use of time depends on prioritization of daily tasks and life goals. Time can be wasted as a result of unnecessary personal behaviors, adding to mental stress. Patients with perfectionist tendencies often set unrealistic goals that increase daily stress levels. They should be encouraged to understand why they are performing a task and to set realistic goals. Indecisive patients need to learn how best to reach desired goals. A common stressor comes from work overload when patients attempt to do too much in the time available. A guide for assessing work stress is outlined in Table 2. Procrastination can become habitual. Putting off a task so it will "go away" is a stress-inducing behavior that should be curtailed. Learning to deal effectively with interruptions and distractions that can prolong tasks can reduce frustration. Patients often need to be reminded that being unable to say no leads to stress from overload. By saying yes to one task, they may be actually saying no to something else. This must be understood in order to make their desired choice.5
|Table 2: Assessment of Work Stress|
|cannot finish work in time available;|
|too many interruptions;|
|infrequent work breaks;|
|work schedule is inflexible;|
|too much overtime; shifts are too long;|
|too many days without time off from work;|
|too much paperwork;|
|colleagues or co-workers not available;|
|too many job duties to manage; and/or|
|work is incongruent with training and experience.|
|Source: Adapted from Muldary TW. Burnout and Health Professionals: Manifestations and Management. California: Capistrano Press, 1983.|
Refining Coping Skills
Mental fitness can be enhanced by refining coping skills. Wellness promotion needs to be tailored specifically to each patient's needs and abilities. Commitment to lifestyle changes that promote mental fitness is a prerequisite of a successful wellness program. Patients with long-standing negative attitudes toward themselves and others may require referral for cognitive therapy, which can be effective in relieving depression and underlying anger. Cognitive therapy works to change thought patterns and can help patients deal with difficult situations in specific and realistic terms.11 Changing perspectives and attitudes toward others can have a dramatic effect that improves mental fitness. Wellness is not only a consequence of what one does, but also of what one thinks.3 Chronic psychosocial stresses affect the central nervous system and the immunoresponse.3 Immunological health may be modulated by an awareness and cognitive control of situational variables.5 Perceptions are a direct mediator of wellness and can influence health that can be promoted through lifestyle choices.
Greater understanding of the relationship between mental fitness and physiological health has led to the rejection of the mind-body dualism that has too often led to dismissal of patients' suffering on the grounds that it was "all in their head." Addressing mental fitness is just as important as the physiological processes that lead to health and wellness. The uniqueness of human beings is the conscious, deliberate and creative aspects of their adaptation.12 Lifestyle changes that foster healthy adaptation and greater mental fitness should be promoted. The old axiom that ignores the mental aspect of a patient's fitness is just as mistaken as dismissing a patient's complaint as all in their head. Fitness is as much in the mind as in the body.
- Healthy People 2010: Understanding and Improving Health. U.S. Department of Health and Human Services, November 2000.
- Gatterman MI. Chiropractic and Health Promotion and Wellness. Massachusetts: Jones and Bartlett, 2007; p 30.
- Jamison J. Health Promotion for Chiropractic Practice. Maryland: Aspen Publishers, 1991:167-172.
- Rahe RH. "Subject's Recent Life Changes and Their Near-Future Illness Susceptibility." In: Lipowski ZJ. Advances in Psychosomatic Medicine: Psychosocial Aspects of Physical Illness. New York: Karger, 1973:2-40.
- Jamison J. Maintaining Health in Primary Care: Guidelines for Wellness in the 21st Century. London: Churchill Livingston, 2001.
- Baldry P. "Relevant Neurophysiologic Mechanisms." In: Myofascial Pain and Fibromyalgia Syndromes. London: Churchill Livingstone, 2001:3-15.
- Korr IM. The neural basis of the osteopathic lesion. J Am Osteopath Assoc, 1947;47:191-8.
- Patterson MM, Steinmetz JE. Long-lasting alterations of spinal reflexes: a potential basis for somatic dysfunction. Manual Med, 1986;2:38-42.
- Gillette RG. Spinal Cord Mechanisms of Referred Pain and Related Neuroplasticity. In: Gatterman MI. Principles of Chiropractic: Subluxation. St Louis: Mosby, 2005:349-370.
- Muldary TW. Burnout and Health Professionals: Manifestations and Management. California: Capistrano Press, 1983.
- Gatterman MI. Chiropractic Management of Spine-Related Disorders, 2nd ed. Baltimore: Lippincott, Williams & Wilkins, 2004.
- Dubos R. "The Credo of a Biologist." In: Mental Health and Chiropractic. New York: Sessions Pub; 286.
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