Stress

“ The greatest weapon against stress is our ability to choose one thought over another “

-William James

Stress is a normal part of human existence. Acute stress is a normal reaction to a threat. The “flight or fight“ response releases stress hormones such as cortisol that allow us to react and these hormones dissipate once the issue is resolved. Chronic stress on the other hand, results in the body being flooded by these hormones constantly. Chronic stress can be the result of things that are going on in life or due to thoughts regarding a traumatic past or a potential future. The end result is that these hormones increase chronic inflammation in the musculoskeletal system and can also increase the chance of cardiovascular disease, hypertension, stroke, diabetes, cancer, and obesity. 

In the past, Orthopedists rarely considered how stress may affect a patient's diagnosis. Doctor’s will notice a patient's pain level is greater than expected for the patient's diagnosis or radiologic studies. They may believe the patient is over reacting or has a low pain threshold which is just a polite way to say they believe the patient is a wimp. They often fail to consider that a patient may have far more inflammation, hence far more pain due to chronic stress. Chronic stress also causes mental health issues such as anxiety and depression which can further complicate medical treatment. An anxious or depressed patient will often have difficulty with minor injuries as well as challenges with rehabilitation and recovery from more major injuries. On the other hand, patients with less chronic stress or patients who have learned how to cope with their chronic stress will often recover quicker with better results. It is well known that the patient who enjoys their job or hobby will recover quicker than the patient who does not.  Western medicine with advanced diagnostic and treatment technologies and well trained  physicians has not often given much attention to the mind body connection. Eastern Medicine seems to be more in touch with the influence of stress and past traumas on the current disease. Research now supports the idea that certain cancers and many diseases are related to stress and even certain personality types.  

In the modern world, most patients have some level of chronic stress. If your stress is resulting in significant anxiety or depression you should seek professional help. Most people have learned some tools to cope with some of their own stress. Some of this self medication is positive but some of these techniques can be negative if taken to extremes. Some people are fortunate to fall into helpful habits while others are mindful of what decreases chronic stress in their life. For instance, some people have a great support system with a strong family and good friends that lower their stress levels while others need to eliminate toxic relationships and seek healthy ones in order to reduce stress. Some people are raised with healthy eating habits while others become aware as they mature what foods give them a long term sense of well being versus a short term dopamine hit or “mouth pleasure” but a lingering food hangover. 

Exercise is a great way to decrease chronic stress and it may be the best tool to use in the treatment of anxiety and depression for some. The stress hormones that cause chronic stress are actually released from the body when you exercise. At the other extreme, an exercise addiction could be detrimental to your health or relationships. A restful sleep may allow your body to recover from stress and also leaves you with more energy to use proper coping skills when stress arises. Even the foods you eat can affect your levels of stress hormones. Your hobbies can affect stress levels as well. What may be stress free for one patient may be highly stressful for someone else.

Unfortunately, some people self medicate their stress with harmful coping strategies. A few of these directly affect the practice of orthopedic surgery. Patients who abuse drugs and alcohol to escape the stresses in their life can have lower pain thresholds. This can result in higher pain levels than normal for a given injury. Higher pain levels are harder to treat and can affect recovery. People who abuse drugs and alcohol also have a higher frequency of accidents which increases the need for orthopedic treatment. It is now better understood that people may treat their anxiety and depression with overeating. Certain foods can increase chronic inflammation and extra body fat increases chronic inflammation as well. The truth is many orthopedists viewed overweight patients as lazy with bad eating habits. Now, we are aware of the role of mental health issues in unhealthy eating habits. If you struggle with building healthy eating habits you need to decide if the root cause of your overeating may be related to depression or anxiety. If it is, the next great diet or exercise fad is not likely the solution for you. You need to seek professional help and address the underlying stresses in your life. If you are successful at this you will see improvements beyond just the number on the scale. 

Stress management is a huge topic. If you are overwhelmed with stress you should seek professional help. In 2023, there is no stigma in asking for help. If you have a desire to learn other stress management techniques you can do your own research. Once again, all the information you need is on the internet. Many patients have found success with meditation or prayer, mindfulness, cognitive behavior therapy, and breathwork. Others just need a temporary escape from the stresses of daily life where they find an activity that allows them to find “flow” or be in “the zone”. This is when you are totally focused on the activity and all other thoughts leave your mind. This escape can help you be better prepared to meet the challenges of life, but it requires some work to find the activity. Ultimately, if you can improve the stress in your life, you will improve your mind, and ultimately improve your overall health.

The inability to manage stress appropriately can lead to addiction. Gabor Matte M.D. describes addiction as any behavior that a person finds relief in and therefore craves in the short term but suffers negative consequences in the long term which often leads to negative consequences. As physicians, we end up treating the negative consequences. Unfortunately as orthopedic surgeons, we learned how to treat the consequences but were never taught the underlying reason for the consequences. Many see the alcoholic or the drug addict as someone who took partying too far and built a habit they are too “weak” to quit. We have seen the obese patient as lazy with poor self control. Soon most physicians will understand that these patients are self medicating an underlying mental health problem and guide them to the appropriate help. We also see patients who have overcome one addiction such as drugs or overeating with a less harmful or even beneficial addiction like exercise/sports, arts/music, fishing/hunting or work. The physician needs to be aware when an injury interferes with their stress management plan or addiction alternative. This awareness is critical to an injury treatment plan. Associating mental health issues with physical issues in both the patients’ and the physicians’ mind will go a long way in improving the health of our population.