How understanding pain can empower patients to become more resilient

I recently found an infographic on Instagram from a sports medicine article that highlighted my approach to musculoskeletal pain that does not seem to result from tissue damage or injury. I had generated my own approach by reading pain articles but this infographic and article highlight my new approach to these pains! I think all people who treat any pain or have experienced any pain can benefit from these principles.

Physics and mechanics were my favorite science subject in high school and college. When I went into medical school, I loved sports medicine due to my enjoyment of sports and history of injuries, and the discipline’s tie to mechanics. It was interesting to think of the injury mechanism for acute injuries and how that resulted in stressing the bone or ligament to failure. Overuse injuries also are a symptom of chronic and acute load changes!

However, when going out on practice on my own, I saw much more musculoskeletal pain that didn’t seem to be caused by an injury. There was no mechanism of injury or pain lasted much longer than expected. I started reading more on pain management and pain theory ( I highly recommend all of Lorimer Mosley’s books! ).

 I started incorporating different discussions into my sports medicine clinic, including focusing on the fact that often pain does not mean there is tissue damage. This means that we can do every type of imaging or lab study and not find the cause of the pain. Further muddying the water, sometimes we find imaging abnormalities that may be asymptomatic and not causing the pain as well. That also means that injections or invasive therapies aimed at aiding healing are unlikely to be helpful. These talks often are challenging and cannot occur in one visit.

My way of conceptualizing this to patients is that this doesn’t mean the pain is in your head. It may have started with an injury, or it may not have, but regardless, there is now pain. Pain experience can be generated anywhere from the tissue where you feel the pain, the peripheral nerves in the limbs or spine, or at the central nervous system level. Our body is good at sending pain signals as it is protective and a way to keep us safe. As we send pain signals, we get better at sending pain signals, just like we get more efficient doing a task that we practice. Our goal now is to decrease the bodies sending and experience of pain. We want the patient to get better at not experiencing pain again through practice! I think the great thing about these techniques is they work for people who do have pathology. I broke my arm recently, and the same methods can be used to improve my pain and get me moving afterward!

My first goal is to separate the idea that pain equals tissue damage in these cases. We go over the normal results to lower the fear of worsening the injury. Sometimes people have degenerative changes on imaging. Instead of focusing on these, I try to frame them as signs of aging. “The skin on your face doesn’t look the same as it did when you were 17, well neither does your knee or your AC joint. ” But I make sure that they know that these changes do not mean they should sit at home and be inactive. Depending on where the person is on the fitness and activity journey, I have them decide on an activity they would like to do, do pain-free activities, focus on physical therapy, or focus on imagery of going through painless motions or activities. As time goes on, I focus on increasing their activity and thus their movement tolerance. 

If people are focused on the pain or results, I discuss how vital self- talk is. Lorimer Mosley’s books discuss loading your imaginary backpack with concepts that help you feel good and decrease your pain; these are your pain toolbox. I usually have my patients focus on identifying negative self-talk and on reframing it. I try to ensure that my patients aren’t telling themselves that they have something wrong with them and are destined for a life of pain as this negative self-talk can become a self-fulfilling prophecy.

Almost all of these patients I get into physical therapy. I think therapists help to get the patient beyond the idea that they can’t move. They work on strength, flexibility, and sometimes the tissue work and modalities can be incredibly helpful. Laying hands on someone in a therapeutic way can make a difference. I stress that the majority of physical therapy is active and not passive treatment. I do not want my patients going somewhere and just getting a massage or a back cracking. They need to work on their functional deficits. They need to work on their activity tolerance, strength, proprioception, and flexibility. They need to learn to trust that their body was built to move. 

I also evaluate the psychosocial factors that impact pain. Is there stress around the sport or a coach? Was there a recent divorce? How is the patients’ mood, anxiety, or sleep? Are they obese or chronically inactive? Is there excessive stress placed on the athlete by a coach or family member? These all significantly impact pain and need to be addressed.

I agree with this editorial; however, this requires a paradigm shift. Patients are often scared by well-meaning health practitioners that if it hurts to stop doing it. This is helpful if there is an injury but is not necessary for all types of pain. We know that exercise and movement is one of our most potent treatments for chronic health issues. Thus anytime a physician or health care practitioner takes someone out of activity, they may be putting doubt in the patient as to the safety of being active. These thoughts can have many downstream implications for people, both young and old.

Additionally, the current health care model does not help much in incorporating this paradigm. Short visits with little time to coach patients through makes this approach difficult and requires multiple visits. Additionally, due to various factors, the musculoskeletal biologics and interventional musculoskeletal medical fields are growing. While these treatments have their place, they may be over-used for musculoskeletal pain. In the setting of pain that doesn’t appear to originate from tissue damage, these interventions often fail to be a quick fix, much to the patient and the practitioner’s chagrin. I have even had a friend have multiple injections around her ankle, seeking a cure for her chronic ankle pain. What a frustrating and expensive experience for her!

While interventional sports medicine and the more traditional tissue damage paradigm of sports medicine have a place, I look forward to more utilizing these principles as pain does not always mean tissue damage. Not addressing other aspects of the patients’ biopsychosocial components will mean that many athletes and patients will be sub-optimally treated.

Further reading on pain:

The current editorial in the BJSM ” There is more to pain than tissue damage: eight principles to guide care of acute non-traumatic pain in sport“https://bjsm-bmj-com.libproxy.uthscsa.edu/content/early/2020/09/08/bjsports-2019-101705

Short review article on the types of pain and how they correlate to sports injury and athletes: Pain in elite athletes—neurophysiological, biomechanical and psychosocial considerations: a narrative review: https://bjsm-bmj-com.libproxy.uthscsa.edu/content/early/2020/09/08/bjsports-2019-101705

Tame The Beast: A video and Q&A podcast series created by Dave Moen (pain phsyiotherapist) and Lorimer Mosley (pain researcher) to engage patients in rethinking their pain experience.

Permission to Move: Tools for clinicians and patients on understanding and treating chronic pain. They do have courses and certification but I just downloaded the book.