Injury rehabilitation and pain management - three critical principles.
(Below is rough transcription of the above video)
First of all, for sake of clarity, let’s differentiate three scenarios where you can experience pain:
1. You are in pain due to some structural compromise – like fractures, joint sprains and so on
2. You are in pain, but do NOT have any structural compromise – like headache, repetitive strain injuries, fibromyalgia, or irritable bowel syndrome
3. There is some level of structural compromise but how much it contributes to pain is unclear – arthritis is a very important example of this, and so is chronic back and neck pain
Regardless of on which scenario or scenarios your pain might fall, or how simple or complicated it might be, injury rehabilitation can be explained in very simple principles. But behind these simple principles, the science is very complex and still not very well understood. Today, we’ll focus on the simple principles.
The three principles of injury rehabilitation or pain management are:
1. Settle the acuteness
2. Let structures heal (only if there’s a structural compromise)
3. Get on with your life
First, settling acuteness means settling two physiological processes that are crucial but if unnecessarily sustained, can prolong pain. These are:
- Inflammation and
Inflammation is a chemical process that naturally occurs if something is compromised, and generally shows up as swelling (although not always). Sensitisation is a process where the nerves become extra-sensitive to pain(1). Like inflammation, it’s a normal process, and a good example is being sore to touch on the area where you've hurt yourself.
Method of settling down these processes can vary greatly, depending on your condition. Settling down a wrist fracture is going to be vastly different from settling down a carpal tunnel syndrome. Sometimes, you will have to rely on a competent health professional to guide your way.
Once the acuteness is settled, then we must consider the second principle - letting any compromised structures heal. But with this, comes a big disclaimer:
This principle ONLY applies when there actually IS a structural compromise that is RELEVANT to your condition.
Sounds quite obvious doesn’t it? But trust me, I've seen countless people WAITING for something to heal up when there was no relevant structural compromise to begin with.
(People often hang around here far too long before moving onto the next principle).
And while all three principles are important, this third one is the most pertinent point for patients because this is the only principle that is absolutely and entirely up to you. And this is also by far the most underestimated aspect of recovery. What I’m talking about is the third and final principle, "getting on with your life".
There have been countless researches investigating FACTORS that turn an injury into persisting pain, or continuation of persisting pain that disturbs quality of life (2,3). And it’s not the severity of injuries, it’s not age, and it’s not even degeneration or arthritis. It’s fear(4).
It's fear of pain that stabs you when you lift something or turn your head. It’s fear of not recovering from pain if you return to work. It’s fear of returning to normal life because the pain would get worse.
However it’s the very fear of pain getting worse if you returned to your life, that is actually perpetuating the pain, resulting in poor outcome of injury rehabilitation. And I’m not talking about “pain all being in head” or “imaginary pain” sort of thing. Or often-used but very incorrect (in my opinion anyway)"somatoform" or "non-organic" pain. It is actually a real physiological process.
When a person experiences an injury of pain, there are adaptive changes that occur at neural level. That is how your brain and central nervous system controls the body. From muscles to hormones, from movement to respiratory. These changes are ok or even beneficial in the early stages of injury rehabilitation, like protecting a fracture, but these adaptive changes do NOT help you at all once the fracture is healed, and they are downright destructive if there were NO relevant structural compromises to begin with.
They’re MAL-ADAPTIVE, at celluluar, neural, cogtive, behavioural, and in every facet of your body. Much of the rehabilitation that we do for fibromyalgia or chronic pain condition is to identify and untrain these maladaptative changes.
So the point that I want to get across is, getting on with what you’d consider “normal” life is incredibly important if you’re working on improving your condition.
(Unless your normal is doing "nothing"; then clearly you need to recalibrate what is normal).
Now I’m in a great danger of sounding like someone who tells a person struggling with depression, to “just get over it”. That’s not my intention at all. However, in a way, if you’re having chronic pain, it’s actually NOT unlike recovering from depression. And just like managing depression, it’s very helpful or sometimes necessary, to have a competent health professional who will guide you, encourage you, sometimes challenge you, and help you to be resilient to adversity.
And this “getting on with your life” or “returning to normal life” can actually begin VERY early. If possible, you can go to work with your broken bones, you can still go to your gym with migraines, you can still do housework with back pain. It might be difficult at times, but in a long-run you’ll be much better off.
Again, I stress, it all depends on YOUR condition. That’s why a good health professional is so important when it comes to injury rehabilitation or pain management. But just remember, maladaptive changes need to be eliminated as soon as possible. How that can be done, whether you use a brute will or gentle pacing or somewhere between, that’s the important question.
Let me summarise again. Three principles of injury rehabilitation or pain management, unusually, but not necessarily in order:
1. Settle the acuteness
2. Let structures heal (only if there’s a relevant structural compromise)
3. Get on with your life
1. Marchand S. The physiology of pain mechanisms: from the periphery to the brain. Rheumatic Disease Clinics of North America. 2008;34(2):285-309.
2. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745-58.
3. Kjogx H, Kasch H, Zachariae R, Svensson P, Jensen TS, Vase L. Experimental manipulations of pain catastrophizing influence pain levels in patients with chronic pain and healthy volunteers. Pain. 2016;157(6):1287-96.
4. Rudy IS, Poulos A, Owen L, Batters A, Kieliszek K, Willox J, et al. The correlation of radiographic findings and patient symptomatology in cervical degenerative joint disease: a cross-sectional study. Chiropr Man Therap. 2015;23:9.