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Pain and Injury - you don't always have both.

 

 

 

2019 Pain Revolution Tour rider Nathan Green

explains how you can have pain

and you can have injury -

but they don't always

occur together.

Professor Lorimer Moseley delivered Musculoskeletal Australia’s annual Koadlow Lecture in 2019. He talked about “Pain, the Brain and your Amazing Protectormeter.” There was a lot of critical information in that to help people move towards recovery from persisting pain. We’ve asked some of our expert clinicians and researchers (who are part of the 2019 Rural Outreach Tour in Tasmania) to add some more details to the short video clips, so you can fully understand the reason these concepts are so important for people in pain.

Watch the video below and read the post written by Exercise Physiologist, Nathan Green. Nathan rode in the 2018 Rural Outreach Tour, and enjoyed it so much, he's coming back to do it again in 2019. Nathan proudly represents AIA Australia, one of the Platinum sponsors that gets us out on the road for the Rural Outreach Tour.

Wow, what an incredible story Lorimer shares in the video above! It's entertaining, and cleverly told, and it also contains two very important messages to assist in the understanding and management of persistent pain.

  1. Tissue damage/injury does not always result in pain.

And, I think more importantly when considering how to assist recovery, the flip side to this:

  1. Pain is often present without significant tissue damage.

Every clinician who has worked in the area of persistent pain will have stories that demonstrate this variable relationship between tissue damage/injury and pain. Certainly a few come to mind for me.

A Common Story of Persisting Pain

I remember one gentleman quite vividly. He attended 4-week multi-disciplinary chronic pain program I worked on early in my career. He was in his early 40s working in a labour-intensive role in a remote mining community. He described the onset of his low back pain whilst performing some heavy lifting. He went to see the visiting GP, who diagnosed a “low back strain” advising rest and simple analgesia.

The pain persisted, and his diagnosis and prescription remained unchanged apart from escalating medication over the next several months. At some point, he was referred to a Neurosurgeon and underwent the usual extensive imaging, which revealed age-related degeneration with no significant lumbar spine pathology. The Neurosurgeon referred back to the GP noting surgical intervention was not appropriate.

Some 12 months later, now 18 months since the onset of his pain, with ever deteriorating function and increasing pain, this gentleman arrived at our facility from the airport in a wheelchair, unable to walk due to escalating pain from his 2 hour flight and with a troubling narcotic analgesic intake. There was no doubting this gentleman’s suffering and debilitating pain experience, despite the minor triggering event and resultant minimal tissue damage.

The story so far is not at all unique. Such presentations were all too depressingly common in that program. What sticks with me about this fellow, and what I struggled to understand or explain at the time, was the level of improvement he displayed over the course of the program.

The program was focussed on education and graded exercise, with limited emphasis on specific anatomical structures. The pain physiology education presented was very basic, with the underlying message being one of reassurance and eventual recovery.

By the end of the 4 weeks, this gentleman had ceased all analgesic medication, was reporting very intermittent mild low back pain symptoms, was walking upwards of 4km a day and managing a quite demanding daily stretching and strengthening program. Post-program follow-up at 3, 6 and 12 months revealed a full return to his work, domestic and recreational activities with no recurrence of significant symptoms during this period.

There are Many Reasons Why Pain Persists

Whilst this dramatic improvement is not the “normal” journey for those with persistent pain, this story, and others like it, exhibit to me the powerful effect of context on the pain experience.

Context is certainly more telling than the level of tissue damage or seriousness of diagnosis. This gentleman had received very little to no education about his condition, had been prescribed ever increasing levels of medication with no other treatment advice apart from rest, had been provided with no positive prognosis and had been told by a Neurosurgeon “there is nothing I can do”.

All the while he was at home alone in an isolated community, with little or no social contact, and on medical recommendation had ceased all work and recreational activities. He had never suffered an injury like this before and had no recovery expectations or experience to draw on.

Presented with some basic education around the physiology/anatomy of his condition, an alternate treatment path and daily reassurance and support from an array of allied health and medical professionals, this gentleman was able to significantly alter his pain experience.

Treating Persisting Pain Well

I remember at the time trying to rationalise these outcomes and was at a loss to fully grasp how such profound improvements were possible in such a short time frame. With a deeper understanding of pain physiology, I now appreciate how the education, encouragement and graded activity integrated into the program were sufficient to change how this gentleman viewed his pain.

With a better and less catastrophic understanding of his condition, an expectation of recovery and more positive management strategies he was able to reconceptualise his symptoms and reduce his pain experience.

As mentioned above, the pain education provided to this gentleman (20+ years ago) was quite rudimentary, and certainly not as well informed by scientific research as we are today. Armed with a much greater body of knowledge around the human pain experience, contemporary clinicians are even better placed to provide appropriate education, guidance and support to those living with persistent pain.

In the battle to treat persistent pain, the concept that pain and injury have a variable relationship is an important one, allowing for reassurance that despite pain it is safe to move, safe to gradually increase recreational and vocational activities and safe to return to life.

All our riders on the Rural Outreach Tour pay their way for the ride, take a week off work AND we make them fundraise to support the Local Pain Educator Program. Nathan's almost made it to the $3000 target we set for each of the riders, and if you liked this post, you can add your donation to his account.

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