Understanding Pain When Dealing With Injuries

There are two main components that need to be addressed when dealing with pain.

One is the physical aspect of rehabilitation, and the other is the psychological aspect of healing. The latter for most people depends on the extent of the injury, if it impairs them from activities or sports they enjoy, and how long the injury has been present. We will talk about these two aspects especially in dealing with the concept of pain and how it should be cared for in rehabilitation.

Like Cardiovascular disease and eating right, I’ve found an excellent study proposal that discusses how to deal with pain in injuries. I’m going to go through that and summarize it in layman’s terms.

Evidence based practice Protocol

Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial

Adrian C Traeger1,2, G Lorimer Moseley2,3, Markus Hübscher2, Hopin Lee1,2, Ian W Skinner1,2, Michael K Nicholas4, Nicholas Henschke5, Kathryn M Refshauge6, Fiona M Blyth7, Chris J Main8, Julia M Hush9, Garry Pearce10, James H McAuley1,2

This is the study title, and its overview and methods are excellent in summarizing the current pain research.

Introduction

Low back pain (LBP) is very common1 ,2 and the leading cause of disability worldwide.3 Not everyone who gets LBP will develop chronic LBP (more than 3 months’ duration), in fact, most do not.4 Although 60% of people who have LBP recover in a few weeks,5 and often with minimal intervention,6 for the other 40%, recovery is slow and the risk of long-term symptoms, or chronic LBP, is high. For patients who develop chronic LBP,7 research has consistently shown that treatments are seldom effective in returning them to a pain-free or productive life.8–11 These people face a downward spiral of increasingly lengthy periods of pain and disability with substantial social and personal disadvantage.1 Most of the costs associated with LBP can be attributed to patients with chronic symptoms.12

In general, there are several differences between acute pain and chronic pain. Generally, pain after an acute injury tends to go away as the injury gets better and rehabilitation work is performed.

However, some cases of acute injuries may develop into types of chronic pain syndromes. These types of chronic pain syndromes may not have anything wrong with the body from a physical perspective, but the nervous system of the body is enters a dysfunctional state for various reasons which can propogate disability, social, and personal disadvantage.

I’m skipping a couple of sections on evidence for preventing LBP and identifying patients at risk for LBP, so if you want to check out then click here.

Pain biology education

International guidelines recommend educating patients with acute LBP to reduce fear and concern about their LBP, and to promote an active recovery.27 Education is a treatment option that is simple, inexpensive and readily used by primary care practitioners.

One educational approach that has not been tested to prevent chronic LBP is pain biology education, or ‘explaining pain’. Explaining pain aims to reconceptualise pain as a protective output of the brain, rather than an accurate measure of tissue damage. It presents a conceptual framework that is based on biological processes that are accepted in the pain science community, but only recently introduced to people in pain. This framework integrates the various cognitive, social and contextual factors that modulate pain, and the appropriateness of a biopsychosocial approach to management and rehabilitation.28

Experimental studies have shown that pain biology education changes pain-related attitudes and beliefs29 and reduces catastrophising (holding a overly pessimistic interpretation of one’s symptoms and prognosis) in people with chronic or sub-acute pain and in pain-free individuals.30–33 A blinded randomised experiment showed that pain biology education increased pain threshold during a straight leg raise test, in contrast to explaining lumbar spine physiology and anatomy, which decreased pain threshold during the same test.29 Pain biology education can also reduce pain and disability in people with chronic pain.33 ,34 These findings have been replicated in distinct chronic pain disorders in different language and cultural groups by independent researchers,33 ,35 ,36 and are supported by systematic review and meta-analysis level evidence.34

In general, educating patients about their pain is important to reduce fear and promote active recovery. The key is to help people understand it so that they don’t “catastrophize” their pain into something that is going to “destroy” their life or “never get better.” In fact, informing people about their pain can reduce their pain.

Guideline care

All participants will receive current guideline care from their primary care providers in addition to the study interventions. Participating clinicians will be given a booklet and trained on the delivery of care based on the Australian National Medical and Research Council guideline for recent onset LBP.40 In general, the guideline recommends that after performing diagnostic triage, first-line care should consist of advice, reassurance and analgesic medication. Participants will be reassured of the benign nature of LBP, advised to remain active and avoid bed rest and instructed in the use of simple analgesics to manage their symptoms. The practitioner may consider second-line options such as spinal manipulation if the participant does not respond to first-line care.

The recommended practices for acute LBP specifically are:

• Analgesic medication
• Advice and reassurance of the benign nature of LBP
• Remain active and DON’T do bed rest
• Manage symptoms
• Manipulation, if needed

In general, bed rest is bad because of the nature of bed rest leading to atrophy and weaknesses of the muscles.  It is better to be active, manage the symptoms, and seek proper treatment while knowing that most back pain goes away over time.

Postural studies have shown that LBP is correlated not with lumbar lordosis, pelvic tilt, leg length discrepancy, and length of abdominal, hamstring, and hip flexor muscles. Rather, lack of endurance and lack of strength in muscles is correlated with increased LBP.

RESULTS: Among all the factors tested, endurance of the back extensor muscles had the highest association with LBP Other factors such as the length of the back extensor muscles, and the strength of the hip flexor, hip adductor, and abdominal muscles also had a significant association with LBP. CONCLUSION: It appears that muscle endurance and weakness are associated with LBP and that structural factors such as the size of the lumbar lordosis, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles are not associated with the occurrence of LBP.

Therefore, it is important to try to attempt to maintain a regular routine if at all possible.

Pain education

Participants randomised to the pain education intervention will participate in 2× 1 h sessions of pain education by the specifically trained study physiotherapist. The educational programme includes the following three broad components: (i) reframe any unhelpful beliefs about the nature of LBP; (ii) present key concepts of pain biology; (iii) evaluate understanding and discuss recovery.

Current pain education is broken down into 3 steps.

Part (i). Reframe any unhelpful beliefs about the nature of LBP

The study physiotherapist will identify any unhelpful beliefs, those that have been found to be associated with poor recovery from LBP, such as poor recovery expectations, intentions to avoid activity due to fear of damage and beliefs concerning a reliance on passive treatment approaches.26 These beliefs will be addressed by discussing any potentially unhelpful diagnostic, prognostic or therapeutic conclusions that the participant might have made. For example, a participant may express concern about a ‘disc slipping out’ with bending tasks at work. This belief will be identified to the participant as understandable, but inaccurate and unhelpful. Less threatening, evidence-based information will then be provided about the nature of the intervertebral disc, its inability to ‘slip’ and its relationship to LBP. The inherent strength and stability of spinal structures will be emphasised.41

Basically, knowledge of how the body works is immensely useful. Because people hate pain and want to avoid it at all costs, it’s easy to take any pain and make it seem worse than it is. Knowledge of anatomy and physiology to explain what is going on and emphasis on the rehabilitation process involving strength and stability is important to help dispel these beliefs.

Part (ii). Present key concepts of pain biology

Part (ii) introduces the key aspects of pain biology and is designed to complement part (i) as well as explanations given by the primary care provider. Topics have been adapted for the acute LBP population from previous work on pain education.29 Pain will be presented as being a protective output of the brain that is influenced by many factors, rather than being a robust signal of tissue damage. More specifically, participants will be taught that: nociceptive input is modulated at the tissues, spinal cord and brain; the brain evaluates many inputs before selecting a response; pain is the conscious part of the response. This explanation provides support for current guideline instructions. For example, instructions such as ‘hurt doesn’t equal harm’, ‘stay active’ and ‘return to work as soon as possible’,27 will be discussed in the context of evidence from pain biology.

Research has shown that the concepts of pain education can be understood by participants from a wide-range of socioeconomic and educational backgrounds31 and that metaphors and stories are a useful way to present complex and new information.42 Metaphors are meant to provoke contemplation and increase the potential for re-organisation of previous thoughts about pain. Metaphors will be used to both reframe unhelpful beliefs (part i) and present new concepts, in accordance with established principles of conceptual change (see ref. 43 for review).

In summary, the key concepts to be presented by the pain education are:

~ Pain is a protective mechanism, not necessarily a symptom of damage
~ In acute LBP, the system can become overprotective (sensitisation)
~ How one makes sense of their pain is an important factor for recovery

These are the key concepts:

• Pain will be presented as being a protective output of the brain that is influenced by many factors, rather than being a robust signal of tissue damage.
• For example, instructions such as ‘hurt doesn’t equal harm’, ‘stay active’ and ‘return to work as soon as possible’,27 will be discussed in the context of evidence from pain biology.
• Pain is a protective mechanism, not necessarily a symptom of damage
• In acute LBP, the system can become overprotective (sensitisation)
• How one makes sense of their pain is an important factor for recovery

In general, the body operates by the SAID principle — specific adaptation to imposed demand. Unfortunately, sometimes during rehabilitation the pathways that modulate nociceptive (pain sensation) can be over sensitized. What this means is that the pain pathway can be “strengthened” to an abnormal state such that you may feel pain during normal movements, even after the tissues are fully healed.

Most people often believe that pain is a bad thing, a sign of harm to the tissues, or an indicator that something is wrong. This tends to be true for an acute injury such as an ankle sprain, but the further out from an injury you go the less it is likely to be true. Hence, pain that persists and sticks around is not an indicator of harm but rather typically sensitization along with potential other beliefs.

Part (iii). Evaluate understanding and discuss recovery

The final component of the intervention reinforces the concepts outlined in part (i) and (ii), and discusses recovery within these concepts. Understanding the cause of the symptoms and their variable relationship to tissue damage is discussed as the most important starting point for a good recovery. Emphasis is placed on the reliability of the tissue healing process, and the necessity of gradually returning to all activities. The explanation of pain biology in part (ii) provides evidence that rehabilitation approaches such as pacing are safe and effective. The participant is encouraged to discuss more specific aspects of rehabilitation (eg, goal setting) with their primary care provider.

The goal is to eventually return to activity and emphasize the safety and effectiveness of rehabilitation. Obviously, pain is a part of that, but it is not overemphasized or under emphasized; just a realistic part of the process.

Models of pain

In general, the gate control theory of pain has been replaced by the biopsychosocial model and neuromatrix theory of pain.

The biopsychosocial model of pain asserts that there are biological, psychological, and social factors which influence pain within the body. Indeed, there are other factors as well that may play into the model as well.

• Biological — pain from repetitive stress, injuries or trauma, nerve damage, illnesses, and similar phenomena that effect the body itself.
• Psychological — the effect of emotions and thoughts, mood, attention, sleep, anxiety, depression, fear, trust, and other factors that may result in altered behaviors.
• Social — Both biological and psychological inputs with pain can play a role in altering your social activities, relationships, work and occupation, and may lead to more isolation.
• Others — These factors usually are external factors that alter any of the above three areas such as medications, lack of available medical care, financial issues, and so on.

Similarly, the neuromatrix theory of pain looks specifically at the various biological and psychological factors more in depth. The general 6 areas, verbatim, are:

• Cognitive issues — memories of past experiences, meaning, and anxiety
• Sensory issues — the nociceptive (pain) inputs from cutaneous, visceral, and musculature senses.
• Emotional issues — limbic system and stress mechanisms. The limbic system regulates threat response in the brain.
• Pain perception — sensory, affective, and cognitive dimensions. How our brain interprets pain.
  Actions — both voluntary and involuntary actions. Smash your knee and you may voluntarily or involuntarily rub it to alleviate some of the pain.
• Stress — the immune system, cortisol, and other stress hormones.

All of these things play a role in how one experiences pain. In general, simply knowing about how pain works and how it is not a primary factor in rehabilitation is important.

Rehabilitation and pain

As you now know, education and understanding the process of rehabilitation with strength, endurance, and stability are important.

Typically, conditioning or graded response will work for those with chronic pain. You have to take these things slowly and introduce the movement back. Preferably as stated before the small amounts of movements and mobility work will only have lower levels of pain or stiffness. However, as the body begins to learn again how to differentiate between them you can increase the movement.

Cardiovascular activity to increase the blood flow to the brain and endorphins are also a good idea to use with people who experience chronic pain.

It has been shown in studies that “chronic pain” is less in countries where there is no such thing as time off work or workers compensation. The mindset of the person is very critical to overcoming any type of chronic pain, so you really have to believe that you can do it along with the other protocols.

For a more in depth discussion of some of these concepts see Anoop’s article on pain here. I honestly do not see this as a revolution (in his words) at least in the injuries world, but information is not as widespread as other types of treatment and application for acute injuries.

Also, here is an interesting article from Todd Hargrove on how taping can help with pain and/or injuries.