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Chapter 8. Relieving Orthopedic Injury Pain

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Pain or Injury?Pain or Injury?

• Coaches ask if the distress is the result of torn tissue or simply in the athlete’s head.

• Torn tissue could be aggravated if athlete continues practice.

• If pain is only in the athlete’s head, the athlete could suck it up or gut it out.

• Attend to her pain or return her to practice?

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Philosophy and Principles of Pain ReliefPhilosophy and Principles of Pain Relief

• Drugs, psychological techniques, surgical procedures, and physical therapy techniques result in varying degrees of success.

• No one method is consistently successful.

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Philosophy and Principles of Pain Relief (cont.)Philosophy and Principles of Pain Relief (cont.)

• Successful clinicians are directed by a core philosophy.

• Principles are more important than tools.• Therapy is truly an art.

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Conditioning vs. RehabilitationConditioning vs. Rehabilitation• Athletic success requires sacrifice.• Sometimes the athlete must ignore

discomfort—push through difficult challenges, push beyond previous best effort.

• Sometimes the athlete must persist in spite of pain—conditioning.

• Some types of injury pain must be ignored.

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Conditioning vs. Rehabilitation (cont.)Conditioning vs. Rehabilitation (cont.)

• Other types of injury pain cause neural inhibitions that decrease neuromuscular functioning—range of motion, strength, agility, etc.

• Persistent painful activity enhances neural inhibition.– Can become permanent physiological block

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Pain: Good or Bad?Pain: Good or Bad?

• Demanding disciplinarian or benevolent benefactor?– Payback for pushing body beyond limits

(demanding disciplinarian)

OR – Protective mechanism to keep from causing

further damage (benevolent benefactor)?

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Pain: Good or Bad? (cont.)Pain: Good or Bad? (cont.)

• Both!• Body often mishandles pain.

– Great memory for what it wants to do but not for why it is doing it

– Pain often persists long after cause resolved

• Must respect pain– Use it to guide you.– But be tough on it when necessary, so it

doesn't take on a life of its own.

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No Pain No Gain?No Pain No Gain?

• During conditioning: Yes!

• During rehabilitation: No! No! No!– Ignore the pain

equals no brain.– Pandering to pain

propagates pain.

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Ernst Dehne Ernst Dehne

• Father of modern orthopedic rehabilitation

• Revolutionary thinking set stage for great advances in rehabilitation during the past 30 years

• Ideas thought way out in the 1940s and 1950s

• Now standard thinking

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Dehne's Spinal Adaptation SyndromeDehne's Spinal Adaptation Syndrome

• Afferent nociceptive impulses from traumatized tissue alter the integration of central nervous excitation at the spinal cord.

– Decreased response to volitional stimuli– Increased response to otherwise subliminal peripheral

stresses

• Results in involuntary muscle action• Alters repair• Responds adversely to additional stress,

favorably to reestablishment of central control

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In EssenceIn Essence

• Nociceptive impulses from traumatized tissue inhibit motor functions and tissue repair.

• Voluntary activity can reestablish CNS control and prevent this inhibition.

• Prolonged inactivity after an injury will lead to neural inhibition that may become permanent.

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Resetting Central Control during RehabilitationResetting Central Control during Rehabilitation

• Not enough to just get rid of the pain sensation

• Must also get rid of the effects of the pain– That is, reset the system (or reset central

control)

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Chicago Plane AnalogyChicago Plane Analogy

• A tire blowout occurs during takeoff.• The runway is shut down so the damaged plane and

debris can be removed.• The runway reopens after 6 hr (pain removed). • However, thousands of passengers are stranded

because of canceled flights (Chicago and elsewhere).• Meetings and business activities must be

rescheduled; hotel reservations and leisure activities must be changed.

• It may take months to fix the effects of the blown-out tire (reset central control).

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Example: Ankle Sprain in GymnastExample: Ankle Sprain in Gymnast

• After weeks of rehabilitation, the athlete is pain free while walking, has good muscular strength, but feels pain on dismount.

– Frustrated• We began a series of graded skill activities to reset central

control.– 50% speed, sit on horse– 75% speed, straddle horse, land without a flip– Repeat at 90% speed– 90% speed, simple flip over horse, land on mat– 90% speed, easiest vault that would score points

• All pain free• That evening at meet: normal warmup with limited vaulting

(repeat afternoon sequence)• Athlete scored a 9.2 and had no pain thereafter.

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Must Reset Central Control after InjuryMust Reset Central Control after Injury

• With prudent exercise

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Placebo and Pain ReliefPlacebo and Pain Relief

• Placebo: Latin for “I shall please”• Medically inactive substance given for its

suggestive effect• To satisfy patient’s demand for medicine• Often thought of as a mock intervention

(sugar pill)• Patient thinks he receives medicine.• Psychological effects of patient’s

expectations responsible for results.

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Placebo: Positive or Negative?Placebo: Positive or Negative?

• Powerful influence on therapeutic interventions

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Placebo: NegativePlacebo: Negative

• Quackery abounds.• Snake oil salesmen dupe the gullible into

thinking they have powerful medicine.

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Placebo: PositivePlacebo: Positive• Half the strength of the true procedure in

double-blind studies• Placebo: relief to 35% of people with

postoperative pain, diabetes, chronic headache

• Ulcer patients – In one study

• 76% obtained relief with Tagamet• 63% obtained relief from placebo

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Placebo: GuidePlacebo: Guide

• Don't use unproven treatments on gullible patients.

• Do maximize proven treatments on believing patients.

• When clinician and patient believe in treatment, high probability of successful outcome

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Placebo: Guide (cont.)Placebo: Guide (cont.)

• Educate patient about the modality intervention.

• Be positive.• Set reachable goals.

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Mind Control (Psychological) EffectsMind Control (Psychological) Effects

• Same as placebo

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Pain and RehabilitationPain and Rehabilitation

• Many tools to decrease pain– Immobilization– Therapeutic modalities– Cryotherapy – Exercise

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Pain and Rehabilitation (cont.)Pain and Rehabilitation (cont.)• Exercise should be relatively pain free.• Activity can be mildly uncomfortable; however, more

than this is a warning from the body that something is wrong.

• Do not evoke injury pain.• Pain must be monitored throughout the rehabilitation

process.• Pain during activity indicates the activity is too

strenuous or complex. • Residual pain, or pain the next day, indicates that the

previous day’s activity was too much,• Activities that result in pain during rehabilitation will

hinder the rehabilitation process by inducing neural inhibition.

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Sources of Athletic Injury PainSources of Athletic Injury Pain

• Nociceptor stimulation• Relay impulse to spinal cord• Nociceptor is stimulated by

– Injured tissue (mediator release)– Edema pressure– Stretching injured tissue– Otherwise normal activity in a tissue that is

sensitized from disuse after injury

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Direct vs. Indirect Pain ReliefDirect vs. Indirect Pain Relief

• Indirect: get rid of source of pain (reduce swelling)

• Direct: deal with pain itself (TENS to gate pain or release opioids)

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Use a Variety of TechniquesUse a Variety of Techniques• Change methods as necessary (the body

sometimes adapts to the treatment method, rendering it ineffective).

• Differences in patient response• Differences in injury

Tools– Therapeutic exercise– Counterirritants– Analgesic balm (Ben Gay, Icy Hot)– Ice packs

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Heat and PainHeat and Pain

• Effective for reducing general aches and pains

• Chronic pain

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Electricity and PainElectricity and Pain

• Reduces muscle spasm• Releases endogenous opiates at pain

receptor sites• Stimulates nonpainful nerves to gate the

pain

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Cold and PainCold and Pain

• Acute pain• Surgery (Allen et al., 1940s)

– Ice packs and immersion for 1–5 hr– Total analgesic for amputation

• Less postoperative pain medication• Immersion better than massage

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CryotherapyCryotherapy

• Reduce pain to allow exercise– Joint sprains:

cryokinetics– Muscle spasm:

cryostretch