University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Life Events

When a person gets a spinal cord injury, it is an event that can create changes in almost every aspect of life, not only for that person, but for their friends and family as well. It is one example of how a "life event" can cause stress, feelings ranging from worry to anger, depression, changed family relationships, financial challenges, changes in health status and other interruptions of the lifestyle and habits someone is used to. What we mean by "life events" in this sense are major changes that are either unexpected or that throw life out of balance. There are many types of life events that fit this description, events that can happen to anyone, such as the death of a loved one, divorce, loss of a job, or moving to a new home. Believe it or not, an upsetting life event can even set the stage for developing a pressure ulcer (which means the same thing as "pressure sore" or "bedsore") or slow down healing of an existing pressure ulcer for people with spinal cord injuries, as many of our study participants experienced for themselves.

One way to get an idea of what types of things are considered highly stressful life events is to look at the Holmes and Rahe stress scale, a list that was developed by Thomas Holmes & Richard Rahe of the University of Washington School of Medicine. Interestingly, these researchers found out that the life event that causes the most stress for most people is the death of a spouse, followed by divorce, marital (or relationship) separation, going to jail, death of a close family member and major illness or injury, such as a spinal cord injury. To try to give people an idea of how much stress they have because of life events, points were assigned to each of these events.

By this time, you might be wondering what the extreme stress caused by life events has to do with pressure ulcers. Actually, there are a few ways that life events can lead to pressure ulcers. One of the ways that pressure ulcers can be avoided is by maintaining an overall high level of health. Did any of your older family members (maybe your mom) ever tell you to "keep up your resistance," or that if "your resistance was low," you might catch a cold? Well, they were referring to an overall level of good health that is supported by getting proper nutrition, enough sleep, moderate exercise, and participating in activities that give a sense of satisfaction or accomplishment. All these good health habits help keep the body's immune system strong, which is what "your resistance" really is. When a person runs into chronic stress (that is, ongoing or long-term stress that lasts for extended periods every day for weeks or months), whatever the source, the ability of the immune system to fight off disease is weakened, and it's harder to get well again once you are sick. (This effect is called "immunosuppressive" 1.) For example, among workers who report they feel stressed, annual health care costs are 46% higher (or $600 per person) than employees who say they don't feel stressed 2. This harmful effect applies to fighting pressure ulcers as well; a strong immune system helps to protect against pressure ulcers, and stress can lower your resistance, or make it take longer to heal one that you already have. And life events certainly produce chronic stress; that is one way that life events might lead to getting a pressure ulcer. For example, one of our study participants, Odel, who was always very careful about doing skin checks, developed a pressure ulcer on his left heel when his father was dying of cancer; he really could not identify another possible cause for this ulcer other than the stress of his father's death. Another study participant, Chris, learned that his job was being eliminated and saw his relationship with his girlfriend break up while he was having several hospital stays to treat a pressure ulcer; his recovery was difficult, possibly delayed by the stress he was feeling from these life events.

Apart from just the stress caused by life events, these kinds of upsetting or unexpected happenings can also make life very confusing. As some of our study participants learned in their own lives, confusion and chaos in life can lead to developing a pressure ulcer. Probably a strong explanation for this is that when there many distractions in a person's life, taking time for self-care activities that prevent pressure ulcers, like checking skin for redness, doing regular pressure reliefs, and being careful to keep clothing and bedding smooth and free of wrinkles, just doesn't seem very important. And how can you keep medical appointments when you have a lot of other things to worry about? When preventing pressure ulcers becomes a low priority, the danger of getting a pressure ulcer increases. Some examples of chaos and confusion that our study participants went through included being homeless, something Charlie experienced, and moving frequently within a short period of time, which happened to both Billy and Gary.

Life events sometimes force people to take time from their usual daily lives and habits to deal with them. For example, Alley checked herself out of the hospital twice, once to help take care of her best friend, who was dying, and then again a few weeks later to recover belongings that were stolen from her late friend's home and to settle financial problems of her own. Brenda was so worried when she found out that she might have breast cancer that she stopped using pressure ulcer prevention practices while waiting to hear the outcome of her tests. Helen, already feeling stress and sadness from the deaths of her father, aunt and boyfriend within a year of each other, found herself spending hours up in her wheelchair sorting through their belongings to distribute to surviving family and friends. And three of our study participants developed pressure ulcers while they were serving time in jail. For all of these participants in our study, dealing with life events meant they didn't have time to do their usual pressure ulcer prevention activities, and they couldn't get medical treatment, either because there was no time available or because they were literally not able to see a doctor. So the time spent dealing with life events can also cause a pressure ulcer, or make recovery from one harder.

Since most life events can't be prevented, what is the best way to deal with them when they happen, especially if your goal is to avoid getting a pressure ulcer? When the unexpected happens, there is no one answer that fits everyone. Some good ideas to try include looking for emotional support from friends and family; informing your doctor or care attendant what is going on and asking their advice: asking your doctor for a "referral" (a prescription to see a doctor who is a specialist) to a counselor or therapist; or talking to a leader in your community or religious group. Don't be afraid to ask for support; some people may not realize you need help, or might not know if offering to assist you would be embarrassing or awkward. If you need financial help to deal with life events, ask for that, too, although sometimes it could be harder to find a loan than to find a sympathetic ear to listen to your troubles or shoulder to cry on. Some people might also have a "Plan B" in mind; that is, a different way of doing things when the preferred way is not possible or not working out. For example, Tom had to move from the small town he lived in to a large city because there wasn't a clinic or hospital in the small town that could provide proper health care for pressure ulcers.

"Life happens." There's no doubt about it, and no avoiding it. But when the events in life cause stress, try to keep in mind that it's still a good idea to do what you can to avoid pressure ulcers. You may even need to do more than usual, because life events make pressure ulcers even more likely.

If you'd like to use the Internet to learn more about how life events can cause stress and lead to health problems like pressure ulcers, you might find that typing "life events" into an Internet search engine such as Google brings results that aren't exactly related to this topic. For example, a lot of the websites that come up from such a search belong to insurance companies trying to convince people to buy more life insurance when they get married or have a baby! It might help to type in the particular life event that you might be experiencing, and maybe also type in a word like "stress" or "spinal cord injury."

A recommendation for a good place to start an Internet search about "life events" is the web page with the Holmes and Rahe stress scale, which was mentioned near the beginning of this article. Another useful article about stressful life events is When Disaster Strikes, on the website of Mainstream, an online magazine that supports the rights of people with disabilities, or, as the magazine says, "the able disabled." Mainstream's article talks about natural disasters, such as fires, earthquakes and hurricanes, explaining that in some ways, people with disabilities are better at handling them than other people because they are used to dealing with "barriers" in daily life, but that anyone who is in a natural disaster must remember to keep emergency supplies with them, such as medications, assistive equipment, and so on. (Speaking of emergencies: if you want some suggestions about how to get out of a building safely in an emergency, try the Evacuation Preparedness Guide by June Isaacson Kailes, on the website of Center for Disability Issues and the Health Professions at Western University of Health Sciences.

The Cleveland Clinic Health System (CCHS) has a number of helpful articles about how life events cause stress, and suggestions for coping with stress, which is sometimes called stress management. If you'd like to find a website that lists life events that cause stress, and ways to stop stress, in a clear, easy-to-remember list, Coping With Life's Stressors, on the CCHS website, is very good. CCHS even has an article called Coping With Holiday Stress, which has suggestions for dealing with the stresses that come up at holiday time; for some people, holiday reunions or parties can be stressful life events. If you like "medical-sounding" language, you might like The Phases of Stress, another article by CCHS, which explains the phases of stressors as their effects increase, and offers solutions to contend with each phase.

Another idea on the Internet for dealing with stressful life events comes from an online newsletter with an article, Forgiveness and Spinal Cord Injury, about a study that found something very interesting: people who have had a serious injury (which, of course, is a very stressful life event) but who are willing to forgive themselves and forgive others tend to feel better about their lives and to have better health than people who hold onto anger and stress. (Look for the article on page 7 of the newsletter, which is from the University of Michigan Medical School.) An abstract of this research into forgiveness and stress reduction in very technical language, Forgiveness linked to spinal cord injury rehab, is also available.

Any of these websites might be helpful for keeping in mind that no one can change life events when they happen, but people can change how they react to life events. Remember: taking good care of your health is more important than ever during stressful times!

1 Dhabhar, F. S. (2002). A hassle a day may keep the doctor away: Stress and the augmentation of immune function. Integrative and Comparative Biology, 42, (3), 556-564.

2 Schwartz, J. (2004 September 5). Always on the job, employees pay with health. The New York Times. Retrieved September 5, 2004