Does God have a place in physical therapy?

Wow Rod...getting a bit deep aren't we?

Yeah I know...I have to admit to some trepidation in writing today's entry for a few reasons. Firstly, the issue of spirituality in medicine has only recently come under more of a spotlight and not many health care providers are comfortable discussing this rather personal issue. Secondly, I am no one's spiritual sextant and wouldn't assume to begin starting today.

However, the more I sit and think about how to approach this difficult topic, the more I begin to question my initial trepidation, and feel more strongly about addressing spirituality. Why not? If you examine Gallup poles and a growing number of medical journals, most of our patients consider themselves to be spiritual individuals. This makes religion an important component of our patients' value system, which is one of the pillars of Sackett's definition of evidence-based care. This makes spirituality one of the many 300-pound gorilla some of us in health care have simply gotten used to ignoring.

After a recent online discussion that swerved into the topic of spirituality and clinical research bias, I finally decided to work on this blog entry. I usually begin with an Ovid search of relevant studies or commentary before I go shooting my mouth of. I think it payed off in this case as I found a real gem of an article titled: "Religion, Spirituality, and Medicine: Implications for Clinical Practice" by psychiatrist Harold Koenig of Duke University. Believe me, it is worth reading.

Koenig presents a well organized and perhaps surprisingly well-referenced overview on the role of spirituality in medicine. Religiosity and spirituality are both operationally defined and distinguished early-on to avoid the inevitable semantic debate following these discussions. Koenig then goes on to discuss the role of spirituality in our patients' lives. There is compelling evidence that religion plays a clinically significant role in patients attitudes, coping strategies, and even clinical outcomes for chronic and/or terminal dysfunction.

Religious Beliefs and Practices: Mental & Physical Effects

Intuition always led me to believe religiosity and spirituality played a mediating role in our health. Koenig provides a pretty solid literary basis for this intuition. Religious beliefs and practices can have a profound effect on well-being. Specifically, there is strong evidence suggesting spirituality and religiosity exert the following effects:

• Lower rates of depression and suicide
• Less substance abuse
• Higher social support during an illness
• Stronger immune function
• Lower rates cardiac and cancer mortality
• Improved wellness behavior such as exercise and tobacco avoidance

The mechanisms underpinning these relationships is clearly in question, but the data are hard to ignore. There appears to be some connection between spiritual and religious behavior and physical health.

Spiritual Beliefs and Medical Care

As it turns out, these behaviors play a significant role in how our patients view and manage their utilization of health care. According to Koenig's findings, religious and spiritual beliefs may:

• Affect medical decision-making
• Generate beliefs not consistent with the care being delivered
• Induce struggles and stress that impair the healing process
• Interfere with patient compliance and early disease detection

Not only do religious and spiritual beliefs affect the patient's health, they likely affect how patients navigate our health care system, seek, and respond to medical care they receive.

Handling Spirituality and Religion with Patients

You probably don't have to stretch your imagination too far to realize health care providers are not overly eager to dive into a patient's spiritual belief system. While not directly applicable to all cases, Koenig proposes collecting a spiritual history in certain patients over the course of one or several visits. While the information may be difficult to broach with the patient, some very important information can be gleaned from answers to the following questions:

1. Are religious beliefs a source of comfort or stress?
2. Are religious beliefs a potential source of conflict with medical care?
3. Are there some religious beliefs that could affect medical decisions and how?
4. Does the patient have a support system within their faith community to monitor the patients recovery?
5. Are there any other spiritual needs that need to be addressed?

Obtaining a spiritual history has not become the standard of care for most physicians, Koenig suggests that physicians often don't feel comfortable, don't have time, and sometimes don't even know why they don't obtain this information from their patients. However in light of the established effects of religion and spirituality on our patients health and health-behavior, we may want to keep our patients beliefs on our radar.

Implications for the Physical Therapist

Koenig indicates that spiritual beliefs often become more relevant to patients during periods of chronic or terminal disease. Some orthopedic therapists, such as myself, don't frequently encounter patients with chronic disease as the primary reason for their visit to my office. I'm not sure I'll be jumping into taking the spiritual history of a 17 y/o female soccer player one day after her high-ankle sprain. However, I do see an increasing number of patients with chronic disease that is indirectly or directly associated with their primary complaint. Breast cancer survivors with shoulder pain, diabetics with chronic heel pain can be found in my office with increasing regularity.

While I often don't treat these primary conditions, it would be foolish for me to assume that religious or spiritual beliefs are not affecting the patients health. How will I handle this from now on? Good question. As I said before I'm no spiritual guide. However I don't believe the purpose of Koenig's article was for us to mobilize our patients' spiritual belief system. Simply being aware and open-minded to spiritual belief may be sufficient to elevate our patients trust in our ability and provide value-driven care. As with much of my personal and professional development, it will likely be a work in progress.

Have a great Sunday.

Koenig HG. Religion, Spirituality and Medicine: Research Findings and Implications for Clinical Practice. The Southern Medical Journal 2004; 97:1194-1200.