Blog 7: Making a mountain out of a ‘pain’ hill

Making a mountain out of a mole ‘pain’ hill.

I often use the metaphor of a ‘pain hill’ when I am describing what is needed to be done to improve and achieve a ‘normal’ degree of protective pain again. And because I have the sort of mind that keeps making weird connections, I often think to myself of things like song lyrics to further metaphorise (I think I just made up that word) my metaphor.

So who better than the ‘king’, and in his most excellent gospel style. The song I am thinking of is a haunting one that can be seen and listened to on You Tube via this link:

 

The chorus lyrics:

♫  ♪  “But this time, lord you gave me a mountain
A mountain you know I may never climb
It isn’t just a hill any longer
You gave me a mountain this time.
♫  ♪

These words are rather dramatic but apply at various points in injury rehabilitation and always in persistent pain. The hill can really seem like a mountain that can’t be climbed.

But it still needs to be climbed; trying to go around it is not a reliable method and not going over it means you are stuck on the wrong side.

With chronic pain, the idea is to first understand pain comprehensively then start up the hill confidently with exercises and re-gaining fitness. It is important to choose a slope up that mountain that suits your particular situation. Originally, I used to advise people in pain that if they chose a slope too steep it could result in too much pain and the risk of sliding back down the slope was higher. However, I have altered my original views based on my own observations and an interesting program I have discovered*. The reality is that once actual structural harm to the body is taken out of the equation, those who choose a steeper slope actually do better overall and recover more quickly despite the initial pain! Standard rehabilitation exercises provided along with normalising everyday activities do not logically represent harm; there is only ‘perception of harm’ which is precisely the reason why the pain is persisting in the first place.

However, as stated, the steepness of the slope up the pain mountain has to suit the individual’s particular preferences because ‘perception IS everything’. Whatever method is chosen, steep or more gradual, what is needed is to take steps forward and upwards to the top of the mountain and then the easier downward slope to recovery can be reached.

Exercise programs are a component of current pain management programs but there is all too often still  inadequate confidence due to a continued focus on faulty structures that are seen on scans that have very little real, if any, significance. The message often then given is ‘learn to live with your pain, but do these exercises as they will help you’. Therefore the perception of ‘danger’ can easily still exceed the perception of ‘safety’ increasing the pain slope again. Whoooa, there I go, back to the bottom again – fix me doc … please!!

But, the major point of this blog is to point out how easily the same process can apply to critical points in standard injury rehab programs. This then sets the stage for a persistent pain outcome. And to illustrate this point, I will relate a personal anecdote.

My youngest daughter was playing netball one night as a 16 year old. I received a call saying that she had “dislocated her knee” and figured out fairly quickly that this was a patella (kneecap) dislocation. I arrived at the court about 20 minutes later and my daughter had ‘frozen’ with fear and pain. I distracted her and gave the patella a push back into place. There was the anticipated scream, then tears, then relief. I took my daughter home and applied the treatment basics over the first few days, then the next few weeks, then over the next few months. No x-ray, no scan; just clinical assessment and monitoring responses to increased loads etc. I have just cut a long story short because this is not the important part of the anecdote.

It wasn’t easy and there were a few times when my daughter’s apprehension needed much encouragement and gentle coercion, but eventually she regained excellent functional control and powerful distal quadriceps (muscles around the kneecap) tone. She returned to netball at the end of that season for a few games and then played out the next season, continuing her high level exercises with dad annoying her frequently, as dads do.

The season afterwards she travelled in a different sporting direction and focussed on ‘cheer’ which is becoming very popular. To my mind, I thought that the physical requirements weren’t quite so demanding as netball, so I got ‘off her back’. As is probably typical among teenagers, she admitted later that she had slackened off on her program substantially.

While visiting Tasmania with my wife (isn’t that MONA place weird??!) earlier this year, and just before leaving for dinner one night, a phone call was received from Melbourne advising that a rather vigorous cheer manouvre went wrong and the patella was out again. My then 18 year old daughter froze again due to fear of pain. My telephone recommendation to give it a quick push or simply straighten the knee went unheeded. Dad was a plane trip away this time and so the patella was finally relocated over an hour later after transfer to a local ED and a bit of sedation, then crutches, zimmer knee splint, recommendation to see an orthopaedic surgeon etc…

I oversaw a similar injury treatment program over the initial period including discarding the splint and early isometric (contraction alone) distal quadriceps contractions, but at about two weeks I started getting worried. The pain apprehension was worse this time and there was no ability to do the simple exercises, let alone any others.

To scan, or not to scan, that was the question.

Prior to doing this, we both sat on the carpeted floor one night (approx 3 weeks post injury) and I must have spent about 2 hours trying everything I could think of to get her muscles ‘activated’. There were tears and fears, half attempts, pain complaints and early fatigue. We took regular rest breaks, and then started again. The focus was on the quality not the quantity but we weren’t getting much of either for a long time. But then it started to happen – the kneecap started to move up and down and the very wasted quadriceps muscles around it started to wake from slumber. We continued until I really felt she had it sorted out reasonably and then repeated the process over the next few days focussing on the quality and varying the speed of the muscle contractions.

That was the turning point.

The effusion (knee fluid) settled proportionally as the function and strength was regained. Further rehab progressions, VMO focus (muscle on the inside of the kneecap which helps it stabilise), bike, higher intensity exercises, plyometrics etc… Full range of movement regained. no fluid responses to increased load; all coming good. No need for a scan. Functional stability gained again with the help of a nagging dad.

She returned to cheer with lots of high intensity exercises in addition to her training and a careful but vigorous warm-up routine. I watched her just today on her 19th birthday at a national cheer competition and she was easy to pick out from a distance because she was wearing a black patella stabilising brace (only used during high demand activity). Her team came second out of seven teams in that section. I think she will now do her ongoing functional stability program more diligently because there may not be too many more chances. I will still annoy her frequently though, just in case. That’s my job as a dad anyway.

I have never been impressed with the results of surgical pathways in recurrent patella dislocation patients. Interestingly a friend of my daughter followed such a path, had several operations with a poor outcome and this helped convinced my girl to stick with the plan.

She had quite a few hills to go over in her rehab on both occasions that eluded being described in this blog to shorten it. But that night on the floor, she faced a pain ‘mountain’, and we went over it together.

The difficulty of that process impressed me.

There are probably many similar mountains faced in injury rehab situations where the perception of danger continues to exceed the perception of safety.

And rather than go over the mountain, the limited time and available patience for patients in current practices leads to an expedient scan, a surgery referral, higher doses of painkillers and a ‘fix me doc’ pathway. Not only is the mountain not climbed but the road that led to the mountain is travelled backwards again. And somehow the longer that mountain is there in the way, the larger it seems.

I don’t know the details of why Elvis Presley developed chronic pain which apparently led to a fatal medication dependency. Perhaps he tried to go around the mountain instead of over it.

PS: From today’s competition:

IMG_1571

 

*”Boot Camp” – Chapter 13 in the book Watch Your Back by Richard A Deyo MD. Cornell University Press. Dr Deyo is renowned for his excellent widely published research in the massive first world problem which is back pain. I highly recommend this book which is available online.

Deyo

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kalfried

I attained Fellowship of the Australian College of Sports Physicians in 1995 and have gained extensive experience in this field both before and after that milestone. I worked for five years in the Victorian snowfields, before joining the Melbourne Football Club (AFL) in the mid 1990's. I was a medical officer there for a total of 15 years with Dr Andrew Daff, as well as another 2 years with the Collingwood Football Club in the VFL. I was appointed as the AFL Australian International Rules team doctor in 2011 and 2013. I have also supported other elite sporting teams including the Australian Diamonds netball team in 2012. My main current appointment is with the TAC and WorkSafe as a medical advisor on the Clinical Panel and on various projects, and I am also an Independent Medical Examiner. In addition to general sports medicine I have developed a particular interest in the neuroscience of pain, the potential to 'de-sensitise' persistent pain, the biopsychosocial management model and exercise & conditioning prescription.

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