Welcome back to the Healing Pain Podcast with Laura E. Keyser, PT, DPT, MPH

Chronic pain cannot be treated by simply focusing on its symptoms and root cause. Beyond these things are social determinants that directly impact health and disease. Most of the time, these can go back even from a person’s childhood. Dr. Joe Tatta is joined by Laura E. Keyser, PT, DPT, MPH to discuss how to embed such factors into the PT practice and education to vastly improve health treatment and patient experience. Laura explains how clinicians, educators, and research should focus on interdisciplinary collaboration and the impact of different social determinants in an individual’s lived experience. She also shares how PT practitioners can engage with the government and large corporations to provide better services by sharing all about her consulting firm, Mama, LLC.

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Social Determinants of Health in Physical Therapy: Challenges and Opportunities with Laura E. Keyser, PT, DPT, MPH

In this episode, we discuss how social determinants impact health and disease. My guest on this episode is Dr. Laura Keyser. She is a physical therapist and a public health consultant with expertise in pelvic health and child health and development. She is a seasoned researcher, writer, speaker, and educator with an interest in reducing health disparities, improving population health literacy, and advocating for gender equity as well as human rights.

She received her Master’s and Doctorate degrees in Physical Therapy from the University of California in San Francisco, and she completed a Master’s of Public Health from the John Hopkins School of Public Health. She holds international experience in healthcare capacity building in India and multiple countries across Africa. In this episode, we discuss how clinicians, educators, and researchers can improve health by reducing health disparities in individuals as well as populations. Without further ado, let’s meet Dr. Laura Keyser and discuss the social determinants of health and disease.

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Laura, thanks for joining me on the show.

Hi Joe, it is great to be here.

I’m excited to speak with you. For those who have purchased the book, Integrative and Lifestyle Medicine in Physical Therapy or who is going to soon purchase the book, you pen the chapter with Dawn Magnusson on social determinants of health, which is the first chapter of the book. It sets the tone not only for the whole book. It also sets the tone for integrative and lifestyle medicine. First, thank you for doing that and contributing to that important work, along with Dawn. Give me some background on how you became interested in this particular topic, social determinants of health, in and around the healthcare and physical therapy world.

It is something I had always had an interest in, even before I had all the language that I have now to describe it. As part of my background, I pursued a Master’s in Public Health. That was probably the first time that I formally studied this field. This was an opportunity to revisit some of the things I had learned during my studies and dive a little bit deeper into some emerging research around this topic, which there has been a wealth of data and literature that has come out in the last several years that contributed to our understanding.

The research around social determinants is exploding. The pandemic added fuel to the fire. I’m not sure when you did your Master’s in Public Health, but it has been around for a while. It was almost called something different a few decades ago. As the literature has built, we solidified some of the vernacular around. These are social determinants. The word determinant, we can hang on to that for a minute because we hear all the time the factors, risk factors, and contributing factors. What is different about a determinant versus a risk factor?

All of us in medicine have always thought about what causes disease. We often use the word cause. As we have learned, it is not that easy. When we think about determinants, it implies something a little more complex. It is not A plus B equals C, but it is D, E, F, and G that interact at different levels to get a certain outcome. The language has been refined as we have started to synthesize literature from a variety of disciplines.

For a long time, there were different disciplines operating in silos. Maybe the field of sociology would start to pull something together, or in the field of medicine, but there weren’t always people weren’t talking to each other. We have recognized the importance of pulling this all together to create a better picture of what leads to or developing helps us to develop our health and function over time.

As you go through a Master’s program in Public Health and you are starting to be introduced to these concepts, are your alarms going off with regard to our profession specifically or physical therapy? Are you starting to say, “This speaks to some of the work I’m doing with women in the world?” What was happening in your mind at that time?

I would say two things. One, what I loved about my MPH program was that I got to take a little bit more of a bird’s eye view. I enjoy reading about policies and these bigger things that you can pull together in your clinical practice, but you usually are doing a one-on-one treatment. That was interesting and exciting to me.

I also felt so much of what this topic highlight is stuff that we already do as physical therapists. So much of what we do is evaluate someone’s environment. We are not thinking as in-depth as this chapter goes, but we are thinking about who is there to support this person and what their job duties is. Things like that can be helpful because this is a little bit of an overwhelming topic. As I reread the chapter, I was like, “There is a lot in there. It can pack a punch.” It is not to get too overwhelmed and recognize we already do a lot of this stuff. We can now layer on this additional information and research that we have.

Have you started to integrate this into your physical therapy?

I have stepped away from clinical practice in the last several years, which was a hard decision to make. I’m leveraging both my clinical expertise and my public health background and thinking more about a health systems approach. I have worked globally with a number of nonprofits. We are looking at capacity building. We are working one-on-one with physiotherapists and other providers but thinking a little bit more about the system and all the factors at play there so we can improve healthcare delivery.

Are you teaching some of this content in the PT program at this point?

Only a little bit. I’m on the faculty at Andrews University. I have done a few guest lectures. I have taught a Human Rights course and a Leadership course. We embedded some of this, but not an overt class on social determinants of health.

Someone will come around after this interview and say, “This is an important topic.” When you are looking at the evolution of social determinants, which is starting to show up in PT programs and some of the frameworks that we use, what framework specifically does this speak to that is potentially embedded within DPT education or DPT practice?

The introduction of the biopsychosocial model is something that most PT students have been immersed in that. That is not a bad thing. It speaks to the factors at an individual level. It acknowledges it is not biology, but it is these social factors and your mental health. Where the leap needs to be made is taking a little bit bigger. It is thinking about how health develops over time, from birth to all the way through old age, and thinking a little bit more about this multi-level perspective. Outside of this individual, what are all these spheres of influence from the family, community, and the country that you live in?

Over time, you are talking about the life of an individual. That can be big for professionals. A physical therapist is seeing someone, not always, but typically for a more defined period of time is more than a life course view of health than approaching that more from we can use this to improve treatment for a patient, or is it more from a health promotion perspective?

The health promotion perspective is a little bit easier to sell. In terms of treatment, it can influence our expectations for treatment outcomes and maybe guide treatment in such a way that you might identify that this person might not be ready for PT. Maybe they need some case management or community resources. You can provide those linkages to resources in their community or work together as a team so you are able to identify what other things this person might need, or you can provide that as a PT. It pushes us to work together with multidisciplinary teams. No one person can tackle all of these issues. That is a great thing, and I have always loved interdisciplinary collaboration in my work. I encourage students and other PTs to take that on. It is more fun. It leads to better outcomes for our patients.

When you say expectation, the expectation you are referring to is the expectation of the provider if I’m tracking with you here. Explain that to me. Someone comes to you for physical therapy treatment, and you are aware of a particular social determinant they have. How would that impact the provider’s expectation of the outcome? Is that expectation could influence the expectation in a positive way or a negative way?

There are both possibilities, and that is a great point. I was at Johns Hopkins for several years, treating a variety of patients. We were nested in Baltimore City and had a large Medicaid population. I did a lot of individual advocacy for certain patients, where I knew this patient was going to need a longer course of therapy because there are many things going on in their life and educational barriers. I have to spend more time talking to them. That alone has value. We don’t need to jump into exercise, but we need to get their buy-in and help them understand what their experience is and what their goals are.

Often, I would advocate for maybe a longer duration of therapy for a chronic condition, maybe up to six months. It wouldn’t be that person that comes in that everything is great in their lives, and they need a few sessions. They could go that way. It could also feel overwhelming for some providers. They feel like they may discharge early because they feel like they are non-compliant or something like that.

That is something we have to check ourselves and think through. I have seen it. I’m sure you have seen it too, where people are like, “This person is not compliant. They are not coming to therapy.” I would advocate my managers at that time to say, “I know you want me to discharge this patient because they have missed three visits, but they take the bus or walk five miles across town to get here. There are reasons they haven’t been coming.” At some point, you have to discharge that patient, but it’s being able to understand those things rather than making some of those judgments without that understanding.

There could be some bias there that when you take into consideration a social determinant of health, it could negatively impact someone’s clinical decision-making if they are not aware of the bias they have when they approach the patient with the care plan. It is interesting to think about that.

I hadn’t considered it until you brought it up. It is important not to see this as fatalistic because you have all of this stress in your life and social factors that are barely conducive to your health. You are doomed to have whatever it is that you have got. To see if that person wants to change or if you can help create opportunities for them to build a healthier life, there is still hope there. It is not a fatalistic course.

The chapter you mentioned is quite dense. There is a lot of great information in that chapter. It is a lot to digest if you haven’t been introduced to social determinants of health. As you mentioned, the biopsychosocial model, that social part, starts to pull in these social determinants into the whole conversation that we are having. PTs are aware of the biopsychosocial and social aspects.

Can you make the connection for us on the social part? The social almost feels like it is in the environment. It is almost “far away” from anything I’m interacting with in the clinic. Can you give us an idea or explain to us how the social, which is outside our skin, can get under our skin and impact our biology and start to make that biosocial cycle connection?

This is where this field of research has taken off now that we have got a lot of data to show that connection. Prior to this research, we had the biomedical model, which was mechanistic. We talked about social stuff, but it was over here. We have data that shows that our experience of our physical and social environment affects our physiology.

We all have stress in our lives. We all adapt to stress in our day-to-day. That is how we are functioning humans. Someone that is exposed to chronic stress over time that doesn’t go away can give rise to dysregulation of these different physiological processes. From animal studies, we have evidence that certain areas of the brain shrink. That gives rise to states like chronic hypertension, cardiometabolic diseases, chronic pain, and even learning and behavior or deficits and things like that.

You are talking about, in some way, allostatic load and how that impacts someone’s health.

The term allostasis means achieving stability through change. If you are familiar with the term homeostasis, allostasis is the way the body gets us back to homeostasis. It is not a bad thing. If something stressful happens, we are all familiar with the fight or flight scenario. That is a good thing. You need to run for your life. We also need a period where our body gets back to baseline. Individuals are exposed to an abusive home environment, gun violence in their neighborhoods, inadequate schools, and all of these things. That, over time, has this cumulative effect where that process of allostasis becomes maladaptive.

People call them psychosocial variables, but a lot of times, they are talking about the psychological variable. It is wonderful. I have been a proponent of psychologically informed care, but what you are starting to talk about social determinants is socially informed care. You can maybe take into consideration fear or fear of avoidance in someone who has chronic lower back pain.

If you look further upstream to that, there might be a social determinant potentially carrying more weight in that person’s lived experience, which affects stress mechanisms, pain mechanisms, trauma mechanisms, and their ability to thrive in their environment. We have this biopsychosocial model using it in PT practice. How would you like to see professionals start to implement more of the social into their practice while still taking into consideration the biological as well as the psychological?

There are a couple of thoughts. One, in terms of resources, there are some resources in the chapter that would help a clinician or even a group of clinicians to start to evaluate the social risk factors that their patients are experiencing. A lot of those resources will guide either a linkage to a community resource or something like that can help because we certainly don’t expect physical therapists are going to be addressing food security issues. We can certainly be familiar with what resources are in our area to help with that particular stress.

You can screen for them first before the evaluation.

American Academy of Family Physicians has The EveryONE Project, where they were promoting this team-based approach to addressing social determinants of health. Centers for Medicare and Medicaid are starting to embed some of this. We see a shift in practice in this way.

I have seen that CMS has an evaluation tool or screen. Parts of it have been validated, but they pull from other places. Have you seen that assessment form?

They launched a five-year initiative. It is finishing in 2023. I can’t recall the dates, but my guess is that they will take all of that and come out with their own tool. It is great to see they are recognizing all the things affecting health outcomes.

What they have now is pretty simple. It is 10 or 15 questions, potentially. I can’t imagine it will be much longer than that once they are complete with it.

For most of us in healthcare, unless you are a social worker where you want to do an hour-long intake and you want to get into the meat of it, 10 or 15 questions, something that you add onto your intake form can help. You can take note of it. It can inform some of your clinical decision-making or the resources and things that you offer.

People say, “This is what a social worker does.” If you have someone who has multiple social determinants of health, an entire clinician can spend time with them working on those. There could be one that you might have to be aware of where your evaluation and treatment might improve your outcome.

Something to keep in mind, I like to speak to PTs about shifting our perspective on how we practice PT. It doesn’t always have to be one-on-one. We could start to think about how we can embed ourselves in the community. I’m not saying we become social workers or psychologists, but there is a lack of adequate healthcare providers in this country and around the world. I don’t think that is getting any better, unfortunately, for at least the foreseeable future. It’s being creative in how we are helping our patients, delivering care, and collaborating across disciplines when we can.

I love that train of thought and vision because it tells new physical therapists or existing physical therapists there are out there are opportunities beyond the one-on-one treatment approach if you want to venture into other areas where you start to look at groups of individuals, communities, or potentially even whole populations and how your knowledge and your skills can be used to better serve them.

We know burnout’s high with the traditional clinic model. As much as it is a scary leap into some unchartered territory, it is exciting. It gives us real opportunities to show up and show other professionals this is what our expertise is. We don’t need to see our patients one-on-one, though that is still important and will remain important. We can get a seat at the table to decide all kinds of things depending on what our interests are and what we are facing.

Even though they are called social determinants, there is a part of this that is wrapped up with political determinants or sociopolitical determinants. In many ways, the policies inform public health. You have a Master’s in Public Health. How much of that do you start to say there are opportunities here for physical therapists to engage with policymakers, government, and large corporations that potentially have influence over certain communities? Where is the opportunity for us there, as physical therapists and other health providers, to use our knowledge with that group?

We are at the tip of the iceberg there. I am seeing more PTs jumping into those arenas. Several years ago, when I would talk about advocacy, no one wanted to talk because you thought, “I have to go to Washington DC and lobby.” You can do that. If that is what you want to do, I highly encourage people to do that. There are a lot of other ways that you can have influence with even your local government or if you are working in a hospital system. You are pushing your way up to some of these positions where you have some decision-making power and influence over the decisions that are being made. There is also increasing interest from large businesses and things like that because they realize it is costing them money to not be addressing these things.

That might be the biggest factor in why people pay attention because there is a major cost driver in all this. Both big government, local government, and private businesses are starting to look at this and saying, “Every year, my health insurance premiums go up 20% to 30%.” How can we start to address that in a way that will not only impact our individual health but may impact the greater collective so that cost comes down and it has an impact on people’s pockets?

That starts to point people in the direction of once you understand the social determinants, you could go into things like not-for-profit organizations and find a role or a leadership position there. Talk to your local government about these topics, how it impacts health, and what your knowledge is, or maybe a local school system or a local business. Those are topics I don’t remember ever talking about in physical therapy school. From what I remember, there was a lecture on how to start a private practice, which was relatively small, but no one said that you could take this to the bigger community or population level, which is what is interesting about this.

It was not anything that I learned at all in PT school. It wasn’t until some of the global health work that I saw many patients and maybe worked with one physiotherapist to treat everything. In a tertiary care facility, there is no way she is ever going to get ahead. We got to think about other types of policies and things like that to reduce her burden and improve health for everyone.

You have started to do some of this work on a bigger level with the company. The website is TheMamas.World. People can go and visit it, but tell us about it.

My colleague, Jessica McKinney, is another physical therapist. She and I met, lived, and worked in the Eastern Democratic Republic of Congo for several years. I continued to go back. We had a shared passion and vision for this type of work. I’m focused on women’s and pelvic health in low and middle-income countries and low-resource settings.

Over time, we started to get engaged with some of the bigger nonprofits in USAID and formalize our partnership under MAMA LLC. We chose to go that route rather than a nonprofit for ease. We needed to make some money doing this work. It wasn’t all volunteer work, and that is an important point. Volunteer work is great, but we were committed to driving this as the main focus of our work.

Our biggest partner to date has been EngenderHealth, which is an international NGO that receives a lot of USAID funding specifically for women’s health initiatives around the world. We are working in Nigeria. We are working with the Ministry of Health, National Social Work Association, and National Center for Population Health to think about how to build capacity for rehabilitation services, knowing that there are not enough physical therapists there. We are working with community health workers, nurses, and social workers to start to deliver pieces of care depending on the scenario.

You’ve applied what you have learned from the social determinants and your background in public health to women’s health or pelvic health for a whole population instead of seeing individual people.

I was on a call, and I was like, “I think you don’t understand what the work is that I do. I don’t go to Africa and treat patients. I do a little bit, but rarely. I try not to just see patients because that doesn’t feel like a sustainable model. I’m always working with providers or at an administrative level to think about how to roll out a program.”

Have you thought about modeling that program here in parts of the US where there are women with individual pelvic health issues that are underserved?

It is hard, as you can imagine, but we have, and it is our vision. If you see our website, we have both done work in the United States. This work is primarily in Sub-Saharan Africa. We see it as a continuum. It is not like, “All these poor women over there. There are plenty of poor women over here that are suffering and experiencing all kinds of pelvic health conditions.” We have percolated on some ideas, but we haven’t quite gotten the resources to grow it too much.

I can see a pelvic healing collective or a pelvic health collective as a way to educate and empower women with their health and wellness, which is incredible to think about. You can take all the skills you learn throughout PT school, maybe working one-on-one, and it is delivered to a much larger demographic.

One thing I haven’t mentioned is I also have a foot in digital health, and that is where I see, especially in a place like the United States, and I have done some work there. We haven’t quite grown in the ways that I envision. Maybe in several years, we will have this conversation again, and I can tell you all about it. Digital is certainly not a replacement for any in-person care but something that can leverage or help scale up things at a population level.

We have already seen some of that in musculoskeletal health, chronic pain, chron

ic low back pain, and arthritis. Some of that has been successful. You are right. We will see some of that spill over into every other aspect of physical therapy because everything that we do as professionals has an impact on someone’s life course, health, and well-being.

That is something that we need to get on the train as physical therapists because someone else will do it, and it won’t be as good. You come in and say, “This could have been so much better because I have all this knowledge.” The business folks don’t know what we do unless we tell them. I encourage all of our readers to think about that and strategically in terms of what your role could be.

In a lot of these areas, we can be the leaders and manage the system to make sure that it is evidence-based and helps the intended population that is intending to help. Laura, it has been great speaking with you about social determinants of health and disease and some of your work. How can people learn more about you and follow all the things that you are doing?

I’m pretty active on LinkedIn. I often encourage people to find me that way, as well as my website. We are going to migrate soon, but you can still find us at TheMamas.World and access some resources through that website.

You can reach Laura at her website, TheMamas.World. You can reach out to both Laura and me on social media. You can find us on LinkedIn. I spent a lot of time on Instagram, where you can find me @DrJoeTatta. I want to thank Laura for joining us to talk about the social determinants of health and disease. Make sure to check out her chapter in the book Integrative and Lifestyle Medicine in Physical Therapy, which you can find on the website at Amazon or OPTP.com. Thanks for joining us, and we will see you next episode.

Important Links

• Dr. Laura Keyser
• Integrative and Lifestyle Medicine in Physical Therapy
• The EveryONE Project
• EngenderHealth
• LinkedIn – Laura Keyser
• LinkedIn – Joe Tatta
• @DrJoeTatta – Instagram
• OPTP.com

About Laura E. Keyser, DPT, MPH

Laura Keyser, DPT, MPH is a physical therapist and public health consultant with clinical expertise in women’s and pelvic health and child health and development. She is a seasoned researcher, writer, speaker, and educator with interest in reducing health disparities, improving population-level health literacy, advocating for gender equity and human rights. Dr. Keyser holds international experience in healthcare capacity building in India and multiple countries across Africa and has published and lectured on this work. She received her master’s and doctorate in physical therapy from University of California, San Francisco and completed her Master of Public Health from Johns Hopkins School of Public Health.