When Theresa May became prime minister she released a statement including the following message. “If you’re from an ordinary working class family, life is much harder than many people in Westminster realise. You have a job but you don’t always have job security. You have your own home, but you worry about paying a mortgage. You can just about manage but you worry about the cost of living and getting your kids into a good school.” Since this message, the situation has dramatically worsened, and this has serious knock on effects on our health.
In my blog post on homeostasis, I explained the codependence of our biological systems and how healthy, robust systems act as reservoirs for each other, increasing the resilience of all. In this post, I’d like to explain why psychosocial environments are accurate predictors of health and illness.
Physiotherapists assess and record barriers to recovery by taking a social history as part of our examination. Our flag system has been developed to help us understand why people respond differently to illness, not in order to give up on them, but to be aware that in some parts of their lives, patients do not have the power to change aspects of their environment that adversely affect their health by making their systems more inflammatory. We need to be smarter, finding where they do have agency, respecting their lower tolerance for short term effort and setting achievable goals for long term improvements in health. Remember, adaptation takes time: 3 months is a decent rule of thumb.
As a less experienced clinician, I didn’t understand why psychosocial environments would prove a barrier: after all, a sprained ankle is a sprained ankle and will recover in time and return to activity as the body heals itself. Right? Wrong. It depends on your immutable characteristics such as age (which I will cover separately) how fit you were before the sprain and whether you have the power to control your environment to allow optimal recovery. For example do you work on your feet and were you able to take adequate paid time off in the acute stage to let the ankle rest? Do you have caring responsibilities: young children, ageing parents?
With less autonomy, the likelihood is that your patient was less fit before the sprain and for the same reasons. Those with less personal agency at work (blue flag) and who are compelled to return before they are fully fit (black flag) live in poorer health and have worse outcomes. They are more likely to be injured in the first place, too: the same life stressors will leave them precious little energy to look after themselves.
A lack of personal agency and many competing obligations are likely to cause distress, a feeling of helplessness and a negative attitude causing another barrier to recovery (yellow flag). This is often compounded by societal blame and stigma when commentators apportion blame for the outwards manifestation of their predicament. “They don’t look after themselves” “they’re overweight and lazy”, when often they only reach for maladaptive coping mechanisms to self medicate their challenging lives.
Poverty, in and of itself, is unlikely to be the sole driver of this. In my opinion, agency is the defining factor. Wealth affords more choice, and so wealthy individuals are less likely to have obesity, for example. But it doesn’t mean all poor people are necessarily unhealthy or that wealthy individuals lack psychosocial drivers of ill health.
I work in private practice so most of my patients can afford a healthy diet. For exercise, my patients often pay for personal trainers, outsourcing the motivation required to be physically fit other than the time taken to diarise it. Or they pay for expensive gyms easily accessible to them. Outwardly, these individuals appear physically well. Yet they often work at the absolute limit of their tolerance, their brain doesn’t switch off, they don’t wind down in the evening and they sleep poorly.
In both these environmental circumstances the individuals are working at the limit of their tolerance without enough downtime to relax and repair. Their overloaded systems are always ‘on the go’ and whilst they can function in terms of work and personal obligations, there is nothing left in the tank for healthy physical or mental health behaviours. They have too many spinning plates on canes: the healthy food and exercise behaviours the office worker can afford only give more capacity for work, not self care.
What has been interesting for me ever since I became a clinician has been the manifestation of musculoskeletal pain in those without the physical trauma to explain it. These so-called insidious conditions seem to appear out of nowhere, yet on closer questioning there may have been a lifestyle change several months before that moved the dial from just about managing into the acquisition of health debt. Their illness was in the post from that point on.
Or those with recurrent conditions who function so close to the edge of tolerance that a slight change in their environment will result in symptoms. Individuals will often have a weak link, the first thing to ‘go’ when the balance in their lives becomes unhealthy. This is particularly true of autoimmune illnesses: understandable as the body becomes more inflammatory and thus these conditions are triggered. Irritable bowel, headache, neck pain for example.
But if this is unhealthy equilibrium is a constant, resulting in chronic low grade systemic inflammation, it dramatically increases the risk of all serious disease states including cancers and cardiovascular illnesses. It also becomes a driver for illnesses we may previously have assumed to be solely biomedical.
Osteoarthritis is a good example. Previously thought of as wear and tear, we now understand that evidence of ageing does not mean inflammation and pain: you can have two identical X-rays or MRI scans and you do not know which patient will have symptoms. We ‘treat the man, not the scan’, and osteoarthritis has become a clinical diagnosis, not a radiological one. And for the assumption that weight bearing would increase disability through acceleration of radiological deterioration? The opposite is now known to be true. If you want to keep your joints functioning for longer, with healthier articular cartilage, you need to load them. Physiotherapists fight with this mindset on a daily basis since many patients give up exercise as a result of a radiological diagnosis. ‘I haven’t done x because of my arthritis’.
In summary, those patients who are ‘just about managing’, living at the limits of their tolerance, with no off switch, do not enjoy a healthy quality of life and are only one short step away from illness. It is therefore no surprise that, for example, the cost of living crisis has caused such an increase in people out of work due to long term sickness.
Our obligation as health care professionals is to find where people have agency and turn this vicious cycle into a virtuous one, understanding and advising that the adaptation required to live in better health does not happen quickly. We need to set achievable, flexible goals, starting with just a little more than they are doing now. And this needs to be within the limits of their tolerance or our best efforts will only make them sicker.