Category Archives: P.A.I.N

Should rehabilitation exercises be painful?

There seems to be two, somewhat group-specific although not equally wrong – general opinions on this:

The “Crossfit”-group, for the people who proudly wear the “No Pain No Gain”- tshirts and think that it has to hurt to work. All that nonsense; you are either one of those or you have heard it. The former is obviously worse and this view undoubtedly represents the “most wrong” opinion.

The “Personal Trainer”-group, for the people who have attended at least one expensive course/workshop/coffee meeting. Mantras such as “do not move into pain” and “pain is bad, mkay” rule the atmosphere of beliefs, and – not unlike the CF-group, they take pride in being part of this… better-knowing group of educated individuals. Once upon a time I too probably belonged somewhat to this group, so – because of social “reasoning” – that makes it okay for me to say it.

 

If you noticed the SP-ref and the sarcasm at the end there, there might be hope for you yet.

 

Now to the point. Both groups are most likely wrong.
Here´s why:

A 2017 meta-analysis titled “Should exercises be painful in the management of chronic musculoskeletal pain?” looked at both the acute and long-term effect of exercises where pain is allowed/encouraged compared with non-painful exercises. Based on the conclusion shown below, it would appear that both groups are wrong and that a moderate and controlled (in time) level of pain during (rehabilitation) exercises is okay, and perhaps even something to strive for. Good news for the sadists and masochists out there.

Conclusion: Protocols using painful exercises offer a small but significant benefit over pain-free exercises in the short term, with moderate quality of evidence. In the medium and long term there is no clear superiority of one treatment over another. Pain during therapeutic exercise for chronic musculoskeletal pain need not be a barrier to successful outcomes.

 

What makes your pain better/worse?

 

It is now well established in the literature that factors like poor sleep (Schuh-Hofer et al. 2013), negative expectations (Bingel et al. 2011; Kessner et al. 2014), worry, anxiety, depression (Ligthart et al. 2013; 2014), fear (Crombez et al. 2012) , stress (Chen et al. 2011; Fagundes et al. 2013; Scott et al. 2013) and negative beliefs about the injury (Wiech et al. 2008; Wertli et al. 2014) all have the capacity to amplify the danger messages. Therefore the brain is alerted to more “danger” than there actually is and the pain response may not reflect the degree of tissue injury.

- Running Physio.

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Neuroplasticity 101 – infographic

Neuroplasticity is one of the more important buzz-words these years. It´s well established that our brains are plastic until our last day, meaning that the capacity for change is always there.

This is good news in the sense that it means that your 10y+ pain isn’t necessarily chronic/permanent, and that your bad habits can indeed be changed. That said; plasticity is neither only good nor bad. – with practice, you can become very good at something very bad, so make sure to chose your skill set wisely.

 

Rewiring_the_Brain_Infographic_1

Source: Alta Mira

PAIN-videos

Nedenunder er 3 videoer, alle omhandlende nyere smerte-videnskab.

Den første omhandler generelle “do and dont´s” i forbindelse med længerevarende smerte, mens nr. 2 er specifik ift. smertestillende medicin i denne situation. Den 3. og sidste er en re-post af en populær og anbefalelsesværdig TED-talk, som tager dig igennem store dele af smerte-videnskaben på letforståelig vis.

 

 

 

 

Biomedical Pain Model; Hitler parody

Simon Roost Kirkegaard har lavet en fremragende lille video, omhandlende “The Biomedical Pain Model” og hvordan den er håbløst outdated.

Videoen opsummerer mange af de ting som allerede er at finde i PAIN-sektionen, og udgør dermed en fin reminder til hvad vi rent faktisk ved omkring smerte fra litteraturen, samt de utallige fejlagtige tilgange og myter der ingen ende vil tage.

 

 

The Health Governor pt. 1 – who is he, and why is he making you sick?

  • Hvorfor strækker forkølelsen sig ofte over flere dage om vinteren end om sommeren?
  • Hvorfor er en “do-good” sprøjte som er synlig for patienten, ofte mere smerte-lindrende end sprøjten som ikke er synlig?
  • Hvorfor har vi et øget immun-respons når vi ser/omgås mennesker som er syge?

 

“The little man in your brain”, aka. the Health Governor, er et udtryk for et indbygget “health management system”, som kort sagt har til formål at vurdere pros vs. cons ved en given situation (Humphrey, 2002; 2004). Som det ses er idéen altså ikke ny, men velkendt.

 

 

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Humphrey & Skoyles, 2012

In effect, the health governor acts like a good hospital manager who, with finite resources, has to try to provide a service that maximizes patient satisfaction in the short-term while minimizing long-term risks. Crucially, he needs to be able to make an informed guess about future needs and opportunities, so that he can budget accordingly.

 

Smerte udgør et fremragende eksempel på hvordan denne lille kaptajn (jeg arbejder stadig på et navn til min) i vores hjerne fungerer: En forstuvet ankel gør først ondt efter den vigtige finale.

Et andet eksempel er ift. en immun-reaktion: Under “normale” omstændigheder er det hensigtsmæssigt at inducere feber (øget temperatur for at bekæmpe bakterier/parasitter), mens det ville være en dårlig idé under perioder med lav mad-beholdning, deadline på arbejdet og udeblivende social støtte.

 

Vi er altså vanvittigt dygtige til, ubevidst, at analysere de nuværende og sandsynlige fremtids-konsekvenser, for på denne måde at kunne eksekvere et passende fysiologisk respons. Næste indlæg vil bl.a. berøre placebo; aka. hvodan man snyder kaptajnen til at igangsætte et selv-helende respons.

When you really understand your PAIN

 

På nuværende tidspunkt bør det stå forholdsvist klart for de fleste, at længerevarende smerte har en betydningsfuld kognitiv komponent. Det er tidligere blevet nævnt, at blot dét at undervise/informere en person omkring smerte-biologi, kan have en positiv effekt på smerten.

Nedenstående illustration viser hvor mange studier der, til dags dato, dokumenterer effekten på forskellige fronter, blot ved at kende en smule til fysiologien bag smerte. Når det kommer til at brede budskabet, tyder det ligeledes på det er fordelagtigt at bruge analogier frem for kolde facts (Gallagher et al., 2012).

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Data fra L. Moseley, September 2013.

 

PAIN perception and the neural basis for endogenous pain modulation, placebo and nocebo effects.

Illustrationen omfatter bl.a. hjerneområder involveret i den decenderende inhibition og smerte-oplevelsen samt responset til nocebo og placebo (Tracey, 2010). Figur B viser faktorer (som tidligere diskuteret), som kan have en modulerende effekt på smerte.

Illustrationen bør bruges som verbal røvfuld, til den næste som omtaler (længerevarende) smerte som noget simpelt og vævs-lokaliseret.

Pain perception and neural basis for endogenous pain modulation, placebo and nocebo effects.

Pain perception and neural basis for endogenous pain modulation, placebo and nocebo effects (Tracey, 2010).

 

The Drug Cabinet in the Brain

Lorimer Moseley har fået meget plads den sidst periode. David Butler er samarbejdspartner, ligeledes smerte-forsker, og medforfatter til den anbefalelsesværdige bog “Explain Pain“.

I nedenstående video (5:44) forklarer han - på letforståelig vis - det fysiologiske rationale bag hvordan førnævnte faktorer som erfaring, forventninger, kontekst mm., kan forøge eller formindske oplevelsen af smerte.