The most common mistake in injury rehabilitation and pain management

(Below is rough transcription of the above video)

On the previous video we talked about the three principles of recovery from injury or pain. These were:

1. Settling the acuteness
2. Letting structures heal (only if there’s a relevant structural compromise)
3. Get on with your life

In context of chronic or persisting pain, the principle that gets mishandled most frequently is by far the last one - getting on with your life. (And there are a number of crucial reasons behind that that we won't get into in this video)

And when this action of getting on with your life is delayed unnecessarily, MALADAPTIVE changes occur with your body. And we're talking about changes that occur at all levels of the body (1,2) - muscular, hormonal, neural, behavioural, cognitive, etc.

And these maladaptive changes are often the main drivers of the chronic, persisting pain, NOT your degeneration or arthritis, NOT the difference of your leg length, and certainly NOT because your spine is "out".

Today I would like to go through a typical example, a patient of mine, to clarify how such maladaptations can influence conditions.

The patient is 60 yr old male, with pain on his neck for about five months prior to our first appointmentSome 20 years ago he had a fusion of his C3-5 due to what he recalls as a disc prolapse. He had actually been reasonably good since, until gradual and significant increase of his pain some five months ago.
X-ray showed significant arthritis and degeneration on the vertebrae above and below the fusion site. This is reasonably common for those who had fusion. There were also signs of marked spinal cord and nerve root compression.
He has already been to a specialist, who recommended against any further surgery.
At the time of our initial session, he had been quite afraid of moving the neck for a number of months, due to his fear of permanent paralysis. He literally believed that every time he moved his neck into pain, he would be hitting onto his spinal cord and nerves and inching his way into a permanent nerve damage.
(Which is, from a patient’s perspective, fair enough. But paralysis and nerve damages simply don’t happen like that.)

So I explained:


His arthritis would have happened very gradually, let’s say over the course of at least ten years for argument’s sake. His pain really has been occurring for five months. The difference of arthritis between six months ago when he didn’t have pain, and five months ago when he did start having pain, would have been minimal. So what changed?

We could rationalize that there was a certain “tipping point” where the arthritis begins to be truly symptomatic. And I think that that's a valid explanation and this "tipping point" could have happened for this patient when he began to have a lot of pain some months ago.

However the presentation that I was seeing on the patient was not so much pain as a result of degeneration or arthritis, but it was consistent with his pre-emptive fear of worsening of his condition. We call this hypervigilence (3,4). How did I judge that it was more to do with hypervigilence rather than actual joint arthritis? I arrived on that conclusion only after a very thorough assessment and clinical reasoning.

So I rationalized that his condition was more to do with the fact he was hypervigilent and that was actually increasing stiffness and pain. He was pre-empting pain and moving like “this” when he could actually move upto here and here quite comfortably. He was operating within his self-imposed limitation, that was unnecessarily restrictive.

Not only is that self-imposed limitation unnecessarily restrictive, it would have actually resulted in maladaptation response from his body that results in pain. But THIS pain would be from maladaptation and NOT from the primary problem which was arthritis and degeneration.

Unfortunately patients cannot distinguish between these two and they think that the pain from the maladaptiation is from the arthritis. And this perspective simply but unfortunately, reinforces the original viewpoint that pain is worsening BECAUSE of arthritis, whereas in truth the pain might have been TRIGGERED due to arthritis but is PERSISTING or worsening because of his own hypervigilence.

It’s a vicious cycle in action: it’s sore, he doesn’t move because he’s afraid, it becomes sore because he doesn’t move, and he moves less because of worsening pain.

So I told him that while the state of his bones was likely to be responsible for some amount of discomfort, his presentation was consistent with maladaptation rather than arthritis. So I asked him to gently move his neck and try to function as normally as possible, like what he had been doing just prior to the onset of his neck pain five months ago.

I also assured him that his joints were deemed stable by not only myself but the surgeons as well, and any chance of permanent neurological damage such as paralysis was low, and his body is perfectly capable of creating a positive adaptation to minimize the impact of his degeneration.

And I did some manual therapy, with a purpose of demonstrating to him what his neck was really capable of and thankfully he really agreed with everything I had to say.

And he improved well. Really well. And most important of all, he gained peace within himself. This is the key to any rehabilitation, but especially something like chronic or complex pain.

We see these cases all the time. Where patients make less-than-ideal judgment on his or her own condition and the patient's experience of pain is more to do with maladaptation response that arise from consequences of such judgment, rather than actual primary condition.

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So, the key messages are:

1) The limitations that you put on yourself sometimes does more harm than good

2) That’s because of any shift that you have on your cognitive space, positive of negative, will result in behavioural changes, which results in concordant physical adaptations.

3) How you use YOUR body’s ability to adapt, positively or negatively, is up to you

4) Inner peace is important. It's a prerequisite for any successful rehabilitation and both patients and clinicians must strive to achieve it.

References

1. Adams RJ. Improving health outcomes with better patient understanding and education. Risk Manag Healthc Policy. 2010;3:61-72.

2. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. European Journal of Pain. 2004;8(1):39-45.

3. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745-58.

4. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30(1):77-94.

 

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