Exploring the Management of Pain following Traumatic Injury
Being in the business of rehabilitation following complex traumatic injury, whether this be limb loss, complex and/or multiple fractures, nerve injuries, and soft tissue injuries and often a combination of these, one common feature is pain.
When working in rehabilitation, managing a patients' pain is integral to enable them to engage and achieve their rehabilitation goals. We must understand why our patients experience pain and when we can continue to load structures and tissues safely.
Is Pain helpful?
Did you know there is a rare condition where people do not experience pain? It’s called Congenital Insensitivity to Pain. That might sound great, but sadly these individuals suffer a short life expectancy. Imagine bursting your appendix and not feeling the pain, so you just carry on as normal - it wouldn’t take too long to become seriously unwell.
So, pain is helpful, as it lets us know when the body is in trouble, and normally its whereabouts. It makes us take some action; ease up or stop what we are doing, seek medical attention, move etc. It’s there to protect us. But do we all experience pain in the same way? The simple answer is no. I always wonder why a football players seems to experience agonising pain from a minor knock versus a rugby player being hit by a someone double their size. The important thing is, your nervous system is constantly sampling what’s happening in the rest of the body, and if it's worried, you can experience some degree of pain.
Pain is not equal to harm
I’ve treated many amputees in my career, and most at some point experience phantom limb pain (PLP). Phantom limb pain is pain experienced in the limb that no longer exists. I am sure I’ll do a separate blog on this at some point as it’s an interesting topic and something our patient and team experience frequently. The point here is that PLP is a good example of pain not always being equal to damage.
The pain people experience following injury is impacted by more than the tissue injury itself. Our pain system is not an isolated system we can target, it’s much, much more complex. The nervous system responsible for pain interacts with other systems, including the hormone and immune systems. Have you ever noticed a headache when you are stressed at work, or that old back ache plays up when you’re sick with the flu or run down?
So, the amount of pain isn’t necessarily related to the amount of damage - this makes it more challenging to treat.
Peeing and pain
Have you ever needed a pee, and got up and headed off to the bathroom, only to be distracted and completely forget you needed to pee, and suddenly an hour later you’re busting so bad it hurts? Your brain knew your bladder was full and it would be a good time to empty it but when you got distracted, that other thing became more important, and the bladder issue wasn’t so urgent. The brain continued to get the information that the bladder was full, but for a while it was less bothered so allowed you to focus on something else. So, what’s this got to do with pain? Well, the pain system works in a similar way. You can cause damage to tissues and your pain system can turn things up or calm things down. Over time it has learnt when it should be worried and ramp things up and be less worried and calm things done and this continues to change over time. Imagine spraining your ankle, running out of a burning building. It’s no use your brain alerting you to your ankle injury, making you roll around like a football player, your pain system will let you be a bit more like a rugby player and keep moving. Once you are out of imminent danger, you may feel instantly calmer and suddenly the pain in the ankle is severe, your brain always knew there was danger in the ankle was there, but it needed you to get out of danger first.
Back to your bladder. Ever, noticed needing to pee urgently after a cup of coffee? That’s because caffeine can increase the sensitivity of the system, or ever met anyone who can hold their pee like a camel and others who seem to need to go every 30 seconds? Like the pee system, the pain system can become more sensitive, like a footballer or less sensitive like a rugby player. It’s a complex bit of science impacted by many factors, but the fact is your nervous system can change right from the nerve endings in the area you feel your pain, through changes in the spinal cord and in the brain. It’s useful after a complex injury to be ramped up a bit for a while to stop you doing too much while things are healing, but for some people it can get a bit stuck on high alert, even after healing. These are our patients who suffer with more persistent pain problems.
I’m not 100% sure where this term comes from, but my patient tell me it’s because physios inflict pain. I admit sometimes with mobilisations or exercises, pain can result but be reassured it’s not our goal. I think the important point here is, as rehabilitation clinicians, we understand when joints and tissues are safe to mobilise and load. Pain is, as I’ve said, not necessarily equal to harm. A weak muscle that starts to be trained will ache, a joint that hasn’t moved for months with protest a bit when we try get it moving. This doesn’t mean by any means that our patients should just grit their teeth and endure the pain (although some are willing). At Remedy Healthcare we ensure that we understand the injury, the pain, and ensure that this is managed as best we can, and find ways to make the rehabilitation programme as effective as possible. The last thing that I or my colleagues want to do is to stop patients moving forward.
We have many patients who want to push on through the pain and we must help them understand pacing and graded progression, so as they don’t ramp up the pain system or cause harm. Others need reassurance, and a good understanding of what the pain means. When pain is more of a barrier, we have to problem solve how to adapt our rehabilitation approach, to continue to achieve patient goals. So, pain matters as much to us as to patients. Sometimes rehabilitation hurts, but doesn’t harm.
Did you know that it’s estimated in the UK we get through 3600 tons of paracetamol each year? So they must do something, right? Pain killers can be very useful, especially for patients who suffer acute pain, like the early stage following their accident or surgery. Pain medication is often an integral part of assisting in rehabilitation, especially with individuals suffering with complex injuries. We understand that different pain medications are better for some types of pain versus others and some people will respond better than others and suffer different side effects. Unfortunately, it’s not an exact science and getting the balance right is often a challenge. At Remedy Healthcare we want to ensure pain is managed as best as possible, with minimal side effects, so pain medication needs to be constantly monitored. We also look to introduce other strategies that can help.
A broken heart
The expression 'a broken heart' comes from the pain felt in your chest when you’ve lost a loved one. It even has clinical name 'Broken Heart Syndrome' when symptoms are so severe. In these instances the heart is fine but at the time it doesn’t feel this way. Thoughts and emotions impact the pain we experience - they can cause pain to either increase or decrease. We know that suffering with a complex injury can have a life changing impact. It comes with a baggage of things, like juggling appointments, loss of independence, unable to work, litigation, fear of the future, changes in appearance, unable to sleep and much more, all of which contribute to stress, anxiety and mood changes. It makes sense if this is all going on that your body responds in the same way as a broken heart, with increased pain associated with injuries – sensitivity of the system is ramped up.
What has shopping got to do with pain?
A very well-renowned physiotherapist called Louis Gifford, who we can thank for helping us understand pain better, came up with the idea of a shopping basket. The same way we can have a unique selection of food in our shopping basket, we can have a unique set of factors that contribute to making up our pain experience. In the same way one shopping basket might have more of one type of food, a pain shopping basket might have some factors that contribute more.
At Remedy Healthcare, we understand the complex nature of pain associated with complex injury and the impact this has on peoples’ lives. We work as a team to determine what patients’ individual shopping baskets looks like and, like your real shopping basket, this may change over time. This helps us to work out the best approach and when we need support from different clinicians and specialists.
If you have any questions regarding the above blog, please contact the Remedy Healthcare Team via the website.