Issues Magazine

Rehabilitation and Pain

By Geoffrey Speldewinde

Rehabilitation is part of the common approach to managing pain conditions. Each experience of pain is unique, and calls for the expertise of several health disciplines.

Rehabilitation is all about learning to function better with a particular problem. Where pain is concerned, rehabilitation may reduce its severity.

In health practice, rehabilitation is defined as the planned formal process of improving, and hopefully maximising, the restoration of one or more of the physical, psychological, occupational, social, domestic and recreational functions of an individual impaired by a health condition. Conditions include fractures, sprains and strains from work, motor vehicle accidents and sporting injuries, nerve damage, stroke, head injury, depression and chronic fatigue.

Rehabilitation is generally a time-limited process, being goal-directed, problem-oriented, patient-directed and patient-centred in its delivery.

In 1974, the International Association for the Study of Pain adopted the following definition of pain: “an unpleasant sensory and emotional experience described in terms of tissue damage or described in terms of such tissue damage”. By defining pain as an experience, one can understand that there can be multiple dimensions of the underlying experience of pain.

Painful states can also occur as part of the rehabilitation process and for seemingly pain-free conditions such as a stroke or after the wounds of injuries or operations have supposedly healed.

The rehabilitation process in pain management can occur in several different phases. This may depend on the duration that the pain condition has been present. The goals and therapies soon after the onset of a condition are usually somewhat different to those much later, and will depend on how that condition has evolved, the priorities for the individual and resources available.

One of the dilemmas that people suffering with pain face is being able to describe their pain to other people and have them understand it. Thus as the complexity of someone’s pain unfolds, so may the rehabilitation strategies alter over time. Although it is common that painful conditions such as fractures and operations and sprains and strains settle down in days if not weeks, for significant numbers of people significant pain persists and can take at least months if not years for full recovery. Some pain conditions can be permanent, such as the pain that commonly occurs after the amputation of a limb.

The range of disciplines that are applied in the rehabilitation of someone with pain may vary over time depending on the specific needs of that person. For example, if after an injury someone in hospital has to be able to climb 15 steps to get back home then that will apply a different focus to the immediate rehabilitation process compared to someone who has no steps to deal with.

Pain Physiology

Part of the rehabilitation process is determining, if not confirming, causation in order to develop a specific and relevant program. Pain can be thought of as always arising from an injured or diseased structure such as a joint, ligament or nerve. The signals then travel from the peripheral nervous system into the central nervous system, which includes the spine and brain. In the spine and brain there are numerous important information processing centres, the first of which is at the entry area (the dorsal horn) in the spinal cord (such as a nerve arriving from, say, the big toe entering the lower spinal cord). There are numerous other processing centres as the signals travel up the spinal cord into the brain. These centres are in the lower part of the brain, the interior part of the brain and then finally around the cortex or surface of the brain.

There is no single pain centre in the brain: the experience of pain is generated by the totality and the overall balance of signals as they are processed and distributed and come to the individual’s conscious awareness. Most of these discrete areas of the brain also function in other “states” such as depression, anxiety, euphoria and pleasure, and thus one can understand how pain is more than just a sensation but an overall experience.

Not only is pain described in terms of structural cause, such as a fracture or nerve injury, but also as nociceptive or neuropathic. In nociceptive pain, the pain arises directly from an injured structure and signals are transmitted through the peripheral and central nervous system directly to the processing centres in the spinal cord and brain. In neuropathic pain, the nerve path itself has been damaged, whether it be the peripheral nerves in the body (e.g. an injured or cut nerve) or central processing pathways in the spinal cord or brain (as can occur in multiple sclerosis). These two types of pain have many differences in their processes, and this is reflected in differences in medications and therapies used.

Sometimes the rehabilitation process is affected by processes that are amplifying the pain signals. This may suggest that central processes are hypersensitive: pain may spread beyond its initial source of pain. For example, an injured toe can sometimes cause great pain involving the whole foot, or the toe pain can worsen in the hours or days following the initial injury even if there has been no additional injury.

These features of pain spreading beyond its initial source, or worsening over time, represent central sensitisation and central pain hypersensitivity. The patient describes and demonstrates pain that seems far out of proportion to the condition that they have, at least to observers. It may warrant specific assessments and interventions such as medications, additional pain counselling, or management of anxiety, depression or post-traumatic stress. By this means it is possible to reassure and educate the patient or utilise other innate brain-based strategies, such as specific relaxation techniques or meditations.

There is one more important manifestation of pain, and this is of central neuroplasticity. This arises as a result of the processing of the sensory stimuli by the multiple pain pathways and processing centres around the brain. This may manifest in unusual ways, such as feeling pain before any movement has happened, or in a part of the body being gently stroked in a normally non-painful manner.

Persistent pain signals can result in subconsciously disturbed and distorted pain processing, which modulates the person’s perception of the pain and their physical, emotional and cognitive (thinking) reactions to that nervous system input of that pain. Recognising all of these components (nociceptive and neuropathic pain modified by central sensitisation and neuroplasticity) is important in order to develop an efficient and efficacious rehabilitation approach, particularly when someone’s recovery is more troublesome than expected.

The many different areas of the brain subserve differing functions, so the “meaning” of that pain becomes altered as pain interacts with each one. For example, if anxiety is elevated in an individual then that will influence how they perceive a given pain issue and how they develop their coping strategies.

Medications for Pain Relief

Many people are familiar with more common pain-related medications such as paracetamol, ibuprofen and codeine phosphate (which provides pain relief by being metabolised to morphine in the liver). Morphine and other opiates are certainly useful in acute pain, but all may have limited usefulness in chronic pain. In long-term use they are associated with physiological tolerance, drug dependency and, on occasion, addiction behaviours. However, this is a minuscule problem compared to the lack of real efficacy of long-term opiate use for persistent or long-term pain.

Particularly for persistent pain, but sometimes also for pain of shorter duration (“acute” pain), a range of pain-modulating medications are used. Some of these medications are also used in the treatment of anxiety, depression or epilepsy. This is because, as described earlier, not only does pain activate similar brain centres (after all, one aspect of any sort of pain is that it can provoke anxiety or cause stress) but also because the chemicals involved in the processes are overlapping. These chemicals includes the biogenic amines noradrenalin, serotonin and dopamine.

Another group of medications used in some acute and chronic pain conditions are also used for the treatment of epilepsy. Some of the chemicals involved to control epilepsy are similar in pain transmission.

Diagnostic and Therapeutic Procedures

A significant component of the rehabilitation of pain may involve seeking a more specific diagnosis as a means to directly reduce the pain intensity by treating its cause. By reducing pain intensity, people may be more effectively and productively engaged in a pain management program with physical therapists, psychologists and work therapists. This may seem logical, but for many causes of pain a specific diagnosis is not necessary: maintaining a general approach will quite often facilitate a satisfactory improvement or resolution of the pain. This is seen very commonly in people with back pain, whereby the best thing is a rapid reactivation of physical and psychological function despite continuing pain.

Frequently, pain intensity can remain so intrusive that the person is unable to reasonably progress in their recovery. This pain can be reduced by achieving a more specific diagnosis and offering more specific types of therapeutic procedure. A fine needle procedure under X-ray (at a low radiation dose) or ultrasound guidance is commonly used to diagnose some specific joint, ligament or nerve problems and deliver a more effective treatment solution along with other therapeutic disciplines. Such modalities are certainly useful for assessing or investigating for a cancer or infection but have been found to be less specific and useful for the more common persistent pain conditions of a joint, ligament or nerve injury.

Role of Different Health Professionals

Because of the multifaceted experiences of pain, rehabilitating someone dealing with a pain condition can involve a multidisciplinary approach. Usually, a range of health disciplines work together to achieve desirable goals that may have been set with initial assessment or become defined as a patient progresses through the recovery process. The team will meet regularly for a “case conference” to discuss the progress of each case. This is generally coordinated by a medical doctor, most commonly in Australia by a specialist in rehabilitation medicine.

In the context of pain management this process is often directed by a specialist in pain medicine. The medical doctor, who may have the traditional roles for prescribing medications or organising relevant investigations, also facilitates the team of professionals who may be used for a given individual.

Many people may only require limited involvement of one or two therapists for a short period, such as a few visits over a few weeks. However, some people suffering with their pain may benefit from an extended period of therapy, including participation in various types of pain education sessions within a small group.

The common health practitioners involved are physical therapists (physiotherapists and rehabilitation exercise therapists), nurses and psychologists. However, there is growing use of educational specialists, as well as therapeutic massage and acupuncture.

Physical therapists will focus on getting the injured part, as part of the whole person, moving again in a structured and progressively self-managed manner by that individual. Techniques used may include hands-on soft tissue mobilisation or occasionally manipulations, and exercise approaches such as stretching, strengthening, endurance, aerobic and anaerobic training. Increasingly employed is graded motor imagery using lateral recognition, imagined movements and mirror box movements. Hydrotherapy is often valuable because the heated water may facilitate a relaxation response and motivation. Therapists recognise the broader dimensions of the pain experience of their patient and discuss their progress and consider any impediments to their progress.

Psychologists play an important role in determining the contribution of other lifestyle and personal stressors such as depression, anxieties, post-traumatic stress and personality styles that may be impacting on the recovery process. These factors can reinforce the negative experience of living with pain or actively impede normal recovery and healing processes.

Assessing significant psychological factors and then addressing them through counselling, medication, meditation and physical reactivation will facilitate recovery. Psychologists are often the driving force in pain management programs that utilise education, insight development, behavioural change, and recognition and alteration of maladaptive thoughts of the individual to assist them improve their ability to function with their pain with less difficulty.