Chapter 8. Relieving Orthopedic Injury Pain

1. Chapter 8. Relieving Orthopedic Injury Pain

2. 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?

3. Philosophy 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.

4. 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.

5. Conditioning 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.

6. 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

7. 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)?

8. 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.

9. No Pain No Gain? • During conditioning: Yes! • During rehabilitation: No! No! No! • Ignore the pain equals no brain. • Pandering to pain propagates pain.

10. 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

11. Dehne'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

12. In 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.

13. Resetting 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)

14. Chicago 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).

15. Example: 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.

16. Must Reset Central Control after Injury • With prudent exercise

17. Placebo 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.

18. Placebo: Positive or Negative? • Powerful influence on therapeutic interventions

19. Placebo: Negative • Quackery abounds. • Snake oil salesmen dupe the gullible into thinking they have powerful medicine.

20. Placebo: 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

21. Placebo: 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

22. Placebo: Guide (cont.) • Educate patient about the modality intervention. • Be positive. • Set reachable goals.

23. Mind Control (Psychological) Effects • Same as placebo

24. Pain and Rehabilitation • Many tools to decrease pain • Immobilization • Therapeutic modalities • Cryotherapy • Exercise

25. 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.

26. Sources 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

27. Direct 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)

28. Use 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

29. Heat and Pain • Effective for reducing general aches and pains • Chronic pain

30. Electricity and Pain • Reduces muscle spasm • Releases endogenous opiates at pain receptor sites • Stimulates nonpainful nerves to gate the pain

31. Cold 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

32. Cryotherapy • Reduce pain to allow exercise • Joint sprains: cryokinetics • Muscle spasm: cryostretch