Category Archives: Pain Sciences

Let’s Talk About Stress: A Reason Why Your Patients May Not Be Healing Faster

Think of the last time you were under aSl_StressBrain lot of stress, whether it be work/school related, financially driven, relationship troubles, or some other component of your life not going exactly as you intended.  How did it make you feel? Were you having trouble eating, sleeping, or concentrating? It’s amazing how this emotional response can have such an impact on us physically.

Now think of the last time you had a patient say that they WERE NOT under a lot of stress (I know personally these individuals are few stress boomand far between). In addition to the previously mentioned stressors, our patients may have a few more on their mind (duration of symptoms, unable to return to work, previously failed treatments, increased pain, etc). In addition to all of these things, they now need to find the time in their already stressful day to do their home exercises, which may make them feel like they’re about to explode.

But why should we, as physical therapists, care about our patients’ stress levels? Well, it may play a huge reason behind why your patient is not getting better as fast as you thought they would. Now if your next thought is that “it’s all in their head,” first of all you should be ashamed of yourself, and secondly, please check out my recent post about how to talk to patients regarding their pain. So if it’s not “all in their head,” how do you talk to your patients about the role of stress in their recovery?

That’s where research comes into play. Back in 1998, Marucha et al examined the effects of stress on wound healing. Who were the lucky subjects? Dental students of course, because learning how to put your hands in other people’s mouths without getting your finger bitten off wasn’t stressful enough. The researchers created punch biopsy wounds on the hard palate of the students during two different scenarios; one during summer vacation (couldn’t think of any better way to spend your summer), and the other three days before their first huge exam. scumbag-dentist_o_656833 Now if I remember back to the first exams of the semester during PT school, I’d say that tensions were high and my classmates were just a little bit more stressed out than usual, so I can imagine how happy these dental students must have been. The researchers then tracked to see how long it took each of the wounds to heal, and compared them between the two scenarios.

What did they find? The wounds that were made days before the big exam took nearly 40% longer to heal. Once again in case you missed it, it took FORTY PERCENT LONGER TO HEAL. Same type of wound, same person, all that changed were the situational stressors. Now why is that important? Remember all of those potential stressful events going on in our patients’ lives; how do you think they will help their tissue healing rates? As I have said before, pain does not always equal tissue damage. There are a variety of reasons which can exacerbate someone’s symptoms, and stress can be one of those many factors. Helping the patient make the realization that their stress can impact their tissue healing may actually be a huge breakthrough in your ability to treat the patient.

But think back to the specific scenario in the study; the wound was made BEFORE the actual stressful event occurred. Now granted the students were most likely starting to get test anxiety several days in advance of the actual exam, but this concept can be a game changer in regards to your subjective history taking. When a patient comes in for an evaluation reporting some insidious flare up or onset of symptoms, I often ask them what else was going on around that time in their life. Now this can be a touchy subject, so do not pry if they do not want to share, but often I’ve had patients tell me about a loved one passing away, a recent change in their job situation, or that they were moving into a new home around the same time that their symptoms increased. For them, this may be their “first big exam,” and this stressful situation could play a role in their persistent symptoms.

So what’s the take home message? Well, there are several. First of all, realize that your patient’s pain does not always have to be due to some type of pathological tissue issue. There are a variety of factors that can exacerbate an individual’s symptoms, and stress is one of them. By helping your patient identify these potential stressors, it may allow for them to take the appropriate steps to start managing their stress. Secondly, patient education is crucial. Tell them about the study with the dental students, and let them know that research shows changes in your immune system functioning during stressful periods of times which can impact your tissue healing rates. While you’re at it, maybe tell them about the Red Light/Blue Light study, and use that as an avenue to talk about pain sciences. Finally, and most importantly, remember to stay within your skill set. Like I said earlier, some of these topics can be very difficult to discuss with a patient, and you need to be comfortable enough with your pain science education techniques to not make the patient think you are telling them “it’s all in their head.” Remember, pain is in your brain, not in your head. You also need to recognize when a situation may be outside our scope of practice, and be willing to refer a patient to the appropriate professional if need be. So long story short, by identifying the potential stressors in your patients’ lives they may heal as fast as if they were hurt during summer vacation. Trust me, that’s a good thing.

The Pain Game: Changing the Perception of Pain

painLet’s play a word association game. When you hear the word “pain,” what do you think? Are they positive or negative thoughts? Since birth, pain has been associated with being injured, damaging tissue, danger…the list goes on and on. So when a patient comes into your clinic complaining of pain, odds are they are associating these symptoms with some of these previous thoughts. But what if there was a way to change how your patients perceive pain? I don’t mean adopting the “no pain, no gain” philosophy on treating, just maybe reinforcing the concept that, “pain does not equal tissue damage.”

shin bruiseHow many of you have found a bruise on your leg, but cannot remember how it got there? Did you damage tissue? Of course you did, you can see the reminisce of ruptured blood vessels, so obviously something has been damaged. But the bigger question is the following: did you experience pain? Or what about a paper cut? How much tissue damage occurs? Not a lot, yet it can hurt like crazy. Being able to talk through examples like this may help your patients make the connection that although there may be “pathological” findings on imaging, it does not mean that those “issues in their tissues” are the source of the pain.

Now let’s go back to that bruise on your shin. What if you got the bruise scoring the game winning goal to win the championship; would it change your perception of the tissue damage? The pain typically associated with the injury may not have such a negative connotation anymore, because every time you look at it you are reminded of that game winning goal. And what if the role was reversed…what happens if you got that bruise while losing the championship game, think your perception of the injury may change?

A recent study by Benedetti et al dove a little deeper into this concept of changing our perception of pain. What if you were rewarded for your pain? That’s right, what if the negative emotional experiences you have when you feel pain were actually encouraged? Well the researchers in this study did just that. The source of the pain? A blood pressure cuff, inflated to the point in which it would create an ischemic pain. blood pressure cuffThe lucky participants? Two different groups of subjects were used, both instructed to try and endure the pain as long as possible. The game changer? One group was told that cutting off the blood supply would be beneficial to the muscles and help them get stronger, whereas the other group was simply told to try and withstand the pain. The findings? The group who was told that they’d get stronger was able to keep the blood pressure cuff on nearly 50% longer than the control group. That’s a pretty significant difference!

Now the researchers go into talking about, “a positive approach to pain reduces the global pain experience through the co-activation of the opioid and cannabinoid systems.” Instead of getting into the neurophysiological significance of these systems, let’s talk about how we can use this study  in a clinical setting. What if you have a patient who just had a total knee replacement, and is afraid to bend it. Instead of just telling them that they need to work through the pain, maybe you set small milestones for each week (ex: our goal is to reach 90 degrees of flexion at the end of the week), and praise them for all of their hard work once they accomplish these goals. Maybe you acknowledge how difficult it is right now, but reinforce the fact that better motion will allow for them to do things they’ve been wanting to do. Besides, motion is lotion after all.

So what’s the big take home message? The way our patients perceive their pain can significantly impact their lives, and as physical therapists, we play a huge role in educating our patients about their pain. Take the time during your next treatment session to talk a little pain science with your patients, whether they are a high school athlete with an ankle sprain or an elderly woman with chronic back pain, because everyone can benefit from knowing more about why they may be in pain. Remember, knowledge is power.knowledge-is-power-41

 

Red Lights or Blue Lights: What Color Do You See?

Can you think of a time when your thoughts influenced how you felt about a situation? For example; have you ever heard a sound at night while you’ve been home alone? In a matter of seconds you can go from being relaxed on the couch to having a mild panic attack thinking that there is an intruder in the house with you. Did you actually see something? No, but your brain processed that information as potentially dangerous and kick started your body’s “fight or flight” response just in case.

This hypothetical situation can be applied to a variety of scenarios, including our perceptions of pain. In fact, Mosely and Arntz published a study in 2007 looking at how the context in which a noxious stimulus is delivered can alter the way people perceive pain. During the study, a cold metal rod (-20 degrees Celsius) was applied very briefly to the subject’s hand while they received various contextual information about the stimulus. This information was in the form of a light: red or blue. The subjects were told that the red light meant “hot” and the blue light stood for “cold.” The subjects were then asked to rate their pain intensity, pain unpleasantness, and the temperature that they perceived (on a 0-10 scale, with 0 indicating both no pain/unpleasantness, as well as being extreme cold).

Now the study was a little more complicated than just looking at the color light; the subjects were given different scenarios in which they rated their perception of the stimulus. For example, they either were provided a warning as to the color of the light versus no warning, or were allowed to look at the application of the rod versus being blinded to it (see the image below for a representation of the different scenarios).

 

blue light study

So what did they find? Well long story short, the subjects rated their pain intensity and unpleasantness as higher when looking at the red light versus the blue. In case you forgot…THE STIMULUS NEVER CHANGED! The rod stayed the same temperature; all that changed was the color of the light (see the graph below for the results of the study).

blue light graph

So what does this mean? Well Mosely and Arntz made the following conclusion, “the tissue damaging meaning of a noxious stimulus, warning about the stimulus and visual attention to the stimulus all affect the evoked experience.” That being said, our perceptions about an injury (whether they are accurate or not), can play a huge role in regards to our pain. This can be a game changer for us as physical therapists, as we have the opportunity to educate our patients not only about their injury, but about other factors that may be exacerbating their symptoms as well.

So what can we do about it? How many times have you had a patient tell you that they have imaging that shows they have arthritis, a torn rotator cuff, or a disc herniation? And obviously since there is evidence of these pathological tissues it must be the source of their pain, right? WRONG! One recent study published in 2015 by Nakashima et al examined the prevalence of abnormal findings on cervical spine MRIs. Over 1,200 healthy volunteers (key word, healthy, aka no symptoms) ranging in ages from 20 to 70 years were imaged. The findings? Over 85% of the subjects presented with disc bulges (even those subjects in their 20s, with over 70% of this population having evidence of some degree of bulging). Why is this information important? Well if you were a patient and you were told by a medical doctor that your MRI found degenerative changes, disc protrusions/herniations/bulges, narrowing, etc…what would you think? All of these words have such negative connotations associated with them, which may also serve as a “red light.” Could these “issues in your tissues” be causing the pain? Maybe, but we just saw how many “abnormal” findings were associated with individuals without symptoms. In fact, since the majority of the individuals presented with disc bulges wouldn’t it be “abnormal” not to have these changes…? Think about that.

Be mindful of how you talk to your patients, because the way you communicate to them may have the potential to change a few red lights to blue. For example, I love reviewing lumbar MRIs with my patients, because I feel that this can be a “make or break” point in regards to their fear of their prognosis. Often the images look like the following:

lumbar mriI choose my words very carefully at this point, and instead of pointing out the disc protrusions at L4/L5 and L5/S1 or the degenerative disc disease that they have, I may say that they have some “grey hairs” in their back (metaphorically speaking) which can be found in individuals without any symptoms at all. Now a once potentially red light may be slightly bluer. What I may highlight a little more closely would their multifidi, as you can see in the following example:

multifidi

The above image shows fatty infiltration of the lumbar multifidi; a common finding in individuals with low back pain. Now I tend to describe these changes to their multifidi in regards to hamburger meat (once again, metaphorically speaking); image on the left has the good stuff, high quality lean beef. Image on the right on the other hand, may be closer to 60/40 beef. Which would you prefer to eat? Why do I show them these muscles? If their impairments include lumbopelvic stability (not all patients with low back pain need “core” exercises though, see the following post), then we can address this through physical therapy. BLUE LIGHT! The once depressing, scary MRI now shows the potential for an improvement in their symptoms, and you may have a better adherence to your plan of care now that the patient understands more about their “tissue issue.” Remember, knowledge is power.

Check out the following statements that I’ve heard used by patients or other medical professionals, and see how they could potentially switch from a red light to a blue:

  • “I have bone on bone arthritis that the doctor said was the worst he has ever seen.”
    • Thank you for instilling fear avoidant behaviors. Educating the patient that arthritic changes are a normal part of the aging process, and that they probably have had these changes for several years. Maybe discussing some of the research behind “abnormal” imaging findings in asymptomatic individuals can drive home the point that pain does not always equal tissue damage.
  • I hurt my back 20 years ago lifting a box off of the ground, so my doctor told me never to lift anything over 10 pounds again.
    • Sounds like a red light to me. Using words like “never,” “always,” or “worst,” really stick in a patient’s mind, so try and be mindful when making suggestions or recommendations (even if it is regarding something like posture or exercise technique). This would be a perfect patient to talk about tissue healing rates, and dive into some more pain science education (ex: their tissues have healed at this point, but their nervous system may still perceive lifting as a dangerous stimuli…aka red light).
  • “That knot in your muscle is as hard as a rock and keeps coming back.”
    • So now the patient thinks of their muscles as rocks, and that there symptoms are resilient. I often have patient’s ask if things “feel tight” when I’m performing soft tissue mobilizations, and if applicable, I tell them how it is normal for certain muscle groups to be “tighter” or “stiffer” than others (ex: upper trapezius when doing myofascial work, or thoracic spine when performing joint mobilizations). While each patient is special and unique, we do not necessarily want to verbalize that their tissues are that way.
  • “I was told that since I tore my rotator cuff I’d never be able to swim again.”
    • A few things to address in this one. Once again, discussing the normal “abnormalities” found during imaging would be a good start. Also, never say never. Never. Automatically the thought of not being able to return to a sport, work, or life activities can prove to be a huge blinking red light. Now this patient may not be able to swim for hours, but talking about the benefits of addressing the potential impairments that they may have, and relating that back to their ability to achieve their goals may increase their confidence.

Each time a patient walks into your clinic, they may have a few red lights in the back of their mind. While some may be brighter than others, cumulatively they can add up, and when they do, your patient’s symptoms may go through the roof. Thankfully we have the potential to turn these lights off, and maybe switch on a few of the blue ones while we are at it.