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

Blog 3: “Sorry, but there are SO many more than 50 shades of grey in pain”

Medical experts love getting together and negotiating consensus positions for diagnostic and treatment guidelines and definitions. For example you are considered to have persistent (previously known as chronic) pain when you pass the three month mark from the onset by the official consensus-reached-by-many-experts conclusion. Furthermore you are entitled to ‘normal’ pain due to proportionate nociceptive (electrical signalling) stimulus in the early injury phase always, and there is no reason to have any concern unless that pain persists.

ie- like this lovely commonly used graph picture:

(It is easier to see the details if you click on it)

New Picture

I suppose this makes practical sense, for example  so that epidemiologists (researchers in health statistics) can analyse things.

The actual guidelines are more intricate if you read them carefully ie via: http://www.apsoc.org.au/PDF/Position_Paper/apa_position_statement.pdf but I can tell you from multiple conversations with a biomedical model obsessed therapeutic community that there is a problem. What is actually practically remembered by most is that somehow maladaptive pain is only really a consideration after 3 months and even after that the scan changes seem to dominate anyway until everyone gives up on ‘fixing’ things a long way down the track.

What inevitably happens is that people then think the consensus derived definition is sacrosanct and direct more energy into defending the definition and pigeon-holing people into it than managing the actual highly complex situation in front of them.

Now let me show you how easily this approach comes unstuck.

Let’s keep on track and consider that lovely graph above. (Again, it is easier to see the details if you click on it)

Graph2

Keep the thought of those red and yellow lines running perfectly together in the early phase following “the moment of injury” and now have a look at what I call – “A tale of two nails”.

A tale of two nails – ‘Perception is everything’

nails

Reference: A Biological Substrate for Somatoform Disorders: Importance of Pathophysiology. Joel E. Dimsdale, MD and Robert Dantzer, DVM, PHD. Psychosom Med. 2007 December; 69(9): 850–854:“Two brief case reports involving construction injuries with nails demonstrate the phenomenon beautifully. In one report (6), Fisher et al. described the case of a builder who jumped down onto a 7-inch nail, which pierced his boot at the toe level (Figure 1, left panel). The man was in pain and required intravenous sedation in the emergency room. However, when the boot was cut away, it turned out that the nail had fortunately passed between his toes as opposed to its apparent impaling of the foot. The man’s agonizing pain was elicited solely by his misperception—a case of somatic amplification. On the other hand, a report in USA Today described a construction worker who had unknowingly shot himself in the head with a nail gun (Figure 1, right panel) and who was unaware of the injury. He perceived a toothache and went to a dentist 6 days later, wherein the cause of the rogue toothache was discovered. In this case, one would conclude that somatic deamplification was at work. The patient was unaware of the injury and attributed the sensation to more familiar sources.”

In plain speak all this translates to the first dude thinking he was injured and having severe pain until he realised he wasn’t actually injured and the second dude being injured but because he wasn’t aware that anything happened, he generated no acute pain response.

This makes a bit of a mess of the lovely early bit of the graph, doesn’t it?

Another lovely example of this is Lorimer Moseley’s ‘snake bite’ story (check out the you tube video directly or via the ‘For Patients’ page on my website if you haven’t been to one of his lectures yet).

So, you may be saying – Why is this important? Why can’t I have my lovely little graph and definitions? Why are you making my professional life so difficult? Please go away and leave me alone!

The problem is this – firm adherence to linear definitions in what we know is the extraordinarily complex and multi-factorial construct of PAIN is in itself a contradiction in terms. The biomedical model view is based on a fundamental flaw which is the absence of a linear relationship between structural changes and pain. I urge the pain fraternity not to inadvertently make the same fundamental error. NB: People rarely read the fine print, so the message has to be very clear. The pain is either positively adaptive or negatively maladaptive and the earlier that is considered perhaps the better, albeit being cautious not to miss any ‘red flags’.

A practical example of this problem is a conversation had recently with an eminent spinal surgeon who advocated earlier surgical intervention for back pain on the basis that he was trying to avoid the persistent pain ‘phase’ after 3 months!!

Practically this problem is also manifest so very commonly by cases that I am involved with in compensation reviews where the ‘punishment just doesn’t fit the crime’.

These cases regularly involve minor mechanisms of injury with extraordinary long term and tragic pain outcomes. These problems are even potentially cross generational and the flow on effects in terms of social breakdowns, costs to the health system etc, etc, etc are well known.

In fact, it is my regular observation that, paradoxically, those with more severe traumatic injuries seem to recover better (in the absence of an acquired brain injury component) than those with minor ‘eg: I tweaked my back’ type injuries. There is that contextual and motivational influence again …

In an alarmingly large number of cases the original mechanism of injury leading to persistent pain in a ‘someone to blame’ context is almost the equivalent pathophysiological trauma of being blown over by a feather. There is a stark contrast to similar and very much more severe trauma occurring in a sporting environment.

Now that is not to say that there is no electrical signalling input to a protective pain response at all, ever. That is not what I mean at all. I am sure that even in the first nail case above, the electrical signalling from the nail passing frighteningly close to the tissues was appropriate to create that protective response saying ”help!!’ It is just that it proved to be a maladaptive response right at the very start of the problem and luckily it could be proven objectively once the shoe was removed.

To conclude, please consider an analogy with the first nail case. Imagine the shoe to be the external body covering of the spine. Then imagine the nail to be the ‘tweak’ of sudden pain lifting, bending or similar in the back, stretching briefly those poor little previously well adapted nerve roots or similar. Imagine the same early protective pain response. Imagine further that instead of being able to take the shoe off and prove that there was no reason for alarm and further protective pain, someone told you that the nail was stuck in your foot, or in spinal terms, you have got a disc ‘bulge’ / ‘pars defects’ or ‘fractures’ / ‘spondylolisthesis’ / ‘instability’ (isn’t that a common one these days?) etc, etc, etc ………….

Actually, you don’t have to imagine this at all; it can be seen so very often.