A Simple Question – “What Happens When the Pain is Gone?”

We get this question periodically. The simple answer is that you want to keep the pain gone, right? How best to do that is a matter of debate.

Some of the strategies below seem simple, but in practice are much, more difficult to execute. Despite this obstacle, we (patients & health care providers) should at a bare minimum recognize these factors play a role in healing long after the pain is gone. Best case scenario is that the patient and health care provider are able to execute many these strategies together. Executing a specific plan tailored towards the patient’s goals helps drive down the chance of recurrence.  Reducing recurrence avoids unnecessary medical costs. Unnecessary medical procedures cost our health care system over $210 billion annually.(1)  Over $765 billion in medical expenditures are wasted annually. (2)

Several strategies to keep the pain gone are outlined below:

1.Complete A Comprehensive, Thorough Rehab Program That Reduces Compensations

Common compensations patterns include low back flexion, knees caving inwards (valgus) and rotation of the lower body down and inwards (pronation)

It is well known at this point that a risk factor for re-injury or secondary injury (injury to a separate but related body area) is incomplete rehab. (3, 20) Patients can form compensation patterns of movement despite significant pain reduction and some improvement in function in the initial phases of rehab.  The body learns to adapt and therefore cheat.

Compensations can aggravate the initial problem or cause secondary issues. An example of compensations occurs when glut (butt) muscle strength changes following an ankle sprain. (4) Fast forward months down the road and it is possible that the lack of gluteal strength leads to other problems such as decreased performance in athletes or increased chances of ankle, knee, hip, low back or other kinetic chain injury.

Follow your health care provider’s advice. Stick with the indicated treatment plan as long as it seems reasonable. Stick with the treatment plan as long as you are making progress towards your goals in the expected time frame. Following through with the recommendations of your health care provider gives you the best chance of reducing compensations. Following through with your health care provider’s recommendations limits the chance for re-injury and secondary injury.

2. Focus on General Health

General health advice helps avoid chronic disease. Chronic disease impacts musculoskeletal (MSK) healing.

Doctors are seeing increased rates of chronic disease such metabolic syndrome, type 2 diabetes, autoimmune diseases, fatty liver, high blood pressure, high cholesterol, high levels of triglycerides, heart disease and cancer. Combine these chronic diseases with a culture that eats inflammatory foods, is subject to high levels of stress, doesn’t sleep enough and does not get sufficient exercise  setting the table for never resolvingsimple MSK (musculoskeletal) injuries.  The conditions above all impact healing cells. So back pain, shoulder pain or knee pain may not “heal” to the level it should.

It is a good strategy to ask your doctor or health care provider about some good general health tips on topics such as nutrition, hydration, weight loss, stress reduction, sleep and exercise. It is a better strategy to improve your health with small, daily changes to your lifestyle habits that can stand the test of time.

3. Consider a Comprehensive Review of Your Medications

Don’t be afraid to ask your medical doctor, osteopathic doctor or pharmacist about your medications

Many Americans are over-medicated. (5, 6, 7) The rate of over medication is staggering when compared to other industrialized countries. Medications can be prescribed:

  • without clear clinical benefits
  • for symptoms rather than diagnoses
  • with overlapping clinical benefits
  • with overlapping side effects
  • without doses adjusted to a patient’s current health status.

All treatments come with risk.  Medication is no different here. There should be a clear and favorable benefits with minimized risks. A review of your medications once the pain is gone is warranted. Once your health status changes so should your medication status, in theory. Ask your physician for a comprehensive review at the appropriate time.

The most common medications in the MSK (musculoskeletal) realm are pain medications (opioids), non-steroidal anti-inflammatory drugs (NSAIDs), steroidal anti-inflammatory drugs and muscle relaxers. Each of these types of medications have benefits and risks.

Opioids come with the risk of poor outcome and addiction. NSAIDs  can affect soft tissue healing as well as increase the risk for stroke, heart disease, heart attack and ulcers. Steroids may spike blood sugar, cause weight gain and affect the body’s immune system. Muscle relaxers can cause drowsiness. Drowsiness can be a big problem when operating motor vehicles or with tasks that require memory, concentration or awareness. This is just a sample of the most common side effects from the most commonly prescribed medications for MSK conditions.

We should also be aware that many of our patients are also on cholesterol medications, blood pressure medications, anti-anxiety medications, anti-depressant medications, anti-seizure medications, immune suppressing medications (autoimmune disease) or anti-coagulant medications (blood thinners). All of these medications come with complications that can impact the outcome of many of the MSK (musculoskeletal) diseases that we treat. Please check with your prescribing physician, physician’s office or a pharmacist about benefits vs. risks of prescribed medication(s) after the pain is gone.

4. Check Out Your Healing Environment

The healing environment is multi-factorial. It’s more than just tissues physically healing!

We are finding more and more that a patient’s “healing environment” is not purely limited to tissues physically healing. The psychological environment plays a HUGE and underappreciated role in resolving an injury. This is particularly apparent in injury worker’s returning to their occupation. (8, 9, 10) Patient’s social interactions with their family, friends, colleagues, co-workers and medical providers all matter.

Recent studies indicate that what doctors say to patients and how they say it to patients facilitate or impede the healing process. An ill-timed or misplaced suggestion or recommendation by a health care provider can set the patient back quite a bit. (11) Healthcare providers must be honest, approachable and stay positive. Patients feed off of that.

5. Social Re-Integration 

Injury affects your physical, mental and emotion state. Health care providers often deal with physical healing, but forget about the mental & emotional component.

Patients may have trouble re-integrating back to their environment following resolution of pain. If you’ve ever worked in athletics, you realize there is a psychology component associated with rehabbing athletes. Athletes are often scared to perform their sport because of fear. They fear re-injury. Fear can be a big obstacle!

Fear of re-injury as an obstacle to re-integration is acknowledged in the sports realm. Seldom do we talk about average Joe/Jane reintegrating back into their social environment. Examples could be a recreational athlete like a runner, that feels the effects of social withdrawal like depression, anxiety, angst or nervousness when rehabbing. Later when  making the transition from pain (injury) to performance (running/racing) they may still be fearful. Another example is the elderly patient at a nursing home that fell months ago. The elderly patient is now scared to balance for any length of time without use of walker, cane or a helper. Our last example is the 45 year old woman that sprained an ankle in the yard. She has become increasingly sedentary as a result. She no longer goes for her morning walks with her friends for fear that she could re-injure the ankle. There are other examples, but you get the point.

Re-integration back into your normal daily environment is not often discussed during treatment. Unintended consequences like fear, anxiety, stress, social isolation can develop serving as obstacles in the rehab process. MSK providers need to do a better job in addressing this obstacle. Consider guiding your patients through this process after the pain is gone with a positive attitude and graded exposure.

Good barbecue is done “low and slow!” Low heat over a long period of time. Sometimes small exposure to the patient’s activities over an extended period of time (“low and slow”) is the only way to overcome fear.

Graded exposure is exposing patients in small doses back to pre-injury activity levels. Slow cook this, like good barbecue if necessary (“low and slow”)! Develop and implement a specific plan that slowly reintegrates the patient back into their pre-injury life and pre-injury activities. Slow cooking the reintroduction to activities in the presence of fear may lead to superior outcomes.

6. Build Up Your “Emergency Fund” by Building Adaptability, Resiliency and Capacity

The t-shirt says it all! Building resiliency, adaptability and capacity makes you bigger, stronger, faster and harder to kill.

This is a fun area. This is where human performance enters into injury rehab. Performance measures are specific to the patient’s demands. Performance is for everyone from everyday Joe/Jane to weekend warriors to elite athletes.

Everyday Joe/Jane picks up their kid from the ground (dead lifting), takes out the trash (sled pulls, farmer’s carry or suitcase carry), puts objects on the shelf (overhead press), takes objects off a shelf (overhead pulls),  sits down and gets up from a toilet seat (“potty squats”). The average person needs the capability of performing daily routine tasks efficiently over and over again to sustain a certain quality of life.

Athletes need to train the requirements of their sport. Does the athlete need short, powerful bursts? Does the athlete compete over a prolonged length of time (endurance)? What are the athlete’s shortfalls? Is it strength, symmetry, quickness, flexibility, mobility, stability, balance, coordination, lateral agility, recurring injury, etc.?

Everyday rehab typically never touches this area of building adaptability, resiliency or capacity. Inadequate rehab occurs in both everyday Joe/Jane and in elite athletes. Everyday Joe/Jane will stop treatment once the pain is gone. Athletes are likewise rushed back onto the playing field before adaptability, resiliency and capacity are restored. Building adaptability, resiliency and capacity is building your “emergency fund.”

Your physical emergency fund is analogous to your financial emergency fund. Your financial emergency fund is the sum of money you keep around so that when bad things happen in life, you’ve got something to cover your behind. The financial emergency fund fixes a broken car, patches a leaky roof, replaces a washer or dryer that’s gone bad, etc. The physical emergency fund for your body is building up strength, stamina, mobility, stability, endurance, mental fortitude and confidence. A targeted strength and conditioning program is the tool by which to build up your physical emergency fund.

Yes, that’s exactly what we are saying. Exercise is good for you. It helps with the baby fat (pun intended).

Exercise is not just the emergency fund for the MSK system. (12, 13) Exercise deposits into the fund for the cardio-respiratory system (heart & lungs), nervous system (brain, spinal cord, peripheral nerves), gastrointenstinal-digestive system (stomach & intestines), genitourinary (GU) system (kidneys, bladder, ureters, urethra), vascular system (blood vessels), immune system, integumentary-exocrine system (skin and glands), endocrine-metabolic system (thyroid gland, pituitary gland, adrenal glands, pancreas, ovaries, testes, etc.) and reproductive system. Exercise gives towards your emergency fund. Sedentarism (sedentary lifestyle) takes away from that fund.

We want a robust fund. We want that fund to provide for you when the demand is necessary. We want that fund to insulate you against abnormal stresses to your body. We want the fund to protect you from injury and sickness. We want to make you leaner, bigger, faster, stronger, more confident and basically “harder to kill.” We can implement this strategy of building adaptability, resiliency and capability once the pain is gone.

Why Did I Write This Blog? 

I wrote this blog for 3 main purposes, outlined below:

1. Informational: I want to inform you about another level of care. I want you to have additional strategies to keep the pain gone, reach and surpass your health goals after treatment ends.

2. Explain how you could be sabotaging your own outcome!: We are seeing more and more patients stop care early once the pain is gone. Three major reasons that patients stop care early include financial, cultural and other reasons.

Financial Factors: Let’s face it. Patients are paying more and more out of pocket these days. Patient’s may be forced to make a tough decision whether to continue with care or stop based on finances. Good, caring health care providers sympathize with you. They don’t want patients to incur additional expenses, BUT they also don’t want you to sabotage your own outcome. You’ve worked hard for this! Don’t throw it away by stopping your treatment plan too early.

Remember, incomplete and inadequate rehab is a risk factor for re-injury or secondary injury. Also, consider  the topic of “muscle memory.”  Tissues can heal, but the body can remember.

The body is like a computer with hardware (muscles, tendons, ligaments, fascia, cartilage, bones & joints) and software (brain, spinal cord and peripheral nerves). Hardware is easy to conceptualize. Software is a lot harder to understand. The nervous system stores programs that run the computer’s hardware. Health care providers are becoming increasingly aware that software matters as much as hardware. (14) The body’s software remembers the injury and develops patterns to avoid re-injury. Software reprogramming may take longer than expected following an injury, Hardware may heal faster than the software can catch up. Failure to address the software adequately can lead to re-injury, secondary injury or chronic pain. Failure to fully heal both hardware and software may sabotage your outcome costing you more time, money and headaches.

Cultural Factors: Culturally, our medical system is largely based on intervention rather than prevention. Health care providers typically intervene once there’s a problem rather than acting in advance by reducing risks leading to both injury or disease. Intervention is more costly than prevention. Interventions in the MSK realm typically address pain. Conceptually, the “job” is often seen as completed once the pain is gone.

The third party payer system of health insurance influences our health care culture. Health insurance companies have inserted themselves “in the game” for better or for worse. Health insurance companies aren’t going anywhere. Health insurance companies carry huge economic and political clout. Health insurance companies have shaped health care culture through policy and practice standards. Policy decisions have been made that once pain is gone, care may be seen as complete. Insurance companies typically don’t like to approve nor pay for care after the pain resolution phase unless legitimate objective deficits remain.

Culturally, we live in the Burger King society of “Your Way, Right Away.” The expectation for many patients whether realistic or not is that the pain will be gone almost immediately. Care is seen as complete once the pain is resolved.

Pain with many MSK conditions is a low hanging fruit. There are treatments available that can readily reduce or abolish the pain. Pain therefore becomes a quick and easy marker of treatment success. Don’t be fooled! There are other relevant markers towards treatment success like how are you adjusting to normal daily activities, are you playing sports again, how’s your social life, are you able to do your job effectively, etc. Some of these things can be impacted despite reports that the pain is gone.

Other Factors: Other things can sabotage your outcome without your knowledge. These are listed and discussed above. The saboteurs are poor general health, over or under medicated, bad healing environment, failure to re-integrate, failure to build up an emergency fund. Failure to understand the importance of these variables sabotages outcomes.

3. Prepare you for a dirty little secret in the MSK realm:  Most MSK injuries resolve but can have a high rate of recurrence! You read that right. Nobody really talks about this. Pain often goes away very quickly and most if not all function returns. Rapid pain resolution and functional restoration can fool the patient and health care provider that the job is done; however, research says having an injury is a big risk factor for another injury. This is particularly true in the athletic realm. (15, 16, 17, 18, 19, 20, 21, 22)

Going through the steps outlined above reduces the chance of recurrence, BUT you can never completely eliminate the risk of re-injury. Good health care providers set this expectation for the patient up front. Your health care provider should assist you in taking steps to reduce risks as much as possible. Your health care provider should empower you. You should be able to independently manage a recurrence or know when to seek treatment at the conclusion of care.

Conclusion

I hope by now you are seeing the bigger picture. There is so much more to rehab & performance than pain leaving. When the pain is gone, your quality of life may still not be where it should be! That is frustrating for both patients and health care providers! Health care providers can’t stop you if you choose to end care early once the pain is gone, but just know that choice could come with risks such as relapse or secondary injury.

Please don’t think  of this article as a scare tactic. It’s not intended to do so. The intent is having honest conversation about the benefits vs. risks. Do the benefits of stopping care outweigh the risks? Health care providers often fail to even have this conversation with the patient. I was guilty of this early in my career.  My focus as a young chiropractor was building my practice by building patient rapport. I wanted patients to like me. At certain points, I forgot that they could like me and still respect that I had an obligation to their health. “First do no harm!”  Not knowing that there are risks of stopping care early once the pain is gone, isn’t the patient’s fault. It’s the fault of the health care provider for not broaching this subject.

Health care providers, namely the good ones, that care about patients want you to succeed. We want you to be pain free as soon as possible, but we also want you to finish the job. We are your advocate. We are your cheerleader. We are pulling for you even when the pain is gone.

References

1. https://newsatjama.jama.com/2017/09/27/jama-forum-the-high-costs-of-unnecessary-care/

2. https://www.npr.org/sections/health-shots/2017/11/28/566782829/epidemic-of-health-care-waste-from-1-877-ear-piercing-to-icu-overuse

3. https://www.ncbi.nlm.nih.gov/pubmed/6874174

4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421486/

5. https://www.consumerreports.org/prescription-drugs/too-many-meds-americas-love-affair-with-prescription-medication/

6. http://www.businessinsider.com/infographic-america-is-over-medicated-2012-2

7. https://www.globalresearch.ca/pill-nation-are-americans-over-medicated/5367349

8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4979741/

9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444584/

10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671916/

11. https://www.ncbi.nlm.nih.gov/pubmed/25811262

12. https://www.cdc.gov/physicalactivity/basics/pa-health/index.htm

13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1402378/

14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4331171/

15. https://www.ncbi.nlm.nih.gov/pubmed/8680943

16. https://www.ncbi.nlm.nih.gov/pubmed/6874174

17. https://www.ncbi.nlm.nih.gov/pubmed/11394599

18. https://www.sciencedirect.com/science/article/pii/S2095254612000452

19. https://www.jstage.jst.go.jp/article/jpfsm/3/1/3_139/_pdf

20. http://bjsm.bmj.com/content/38/1/36?ijkey=46efafe451f3e1f74df35b2e38e1a66c0c8cf134&keytype2=tf_ipsecsha

21. https://www.ncbi.nlm.nih.gov/pubmed/22724435

22. http://bjsm.bmj.com/content/40/9/767?ijkey=b315339faa82e12b8a0aed7497f64b8ff1b06ade&keytype2=tf_ipsecsha

About The Author

Dr. Dino Pappas

Dr. Pappas is a chiropractic physician, certified athletic trainer and certified strength and conditioning specialist. He recently has moved from Tinley Park, IL to Austin, TX. He works for Airrosti Rehab Centers. Airrosti is a health care company focused on rapid resolution of soft tissue and joint injuries delivering exceptional care and cost savings to patients. His goal is to provide the Austin community of NW Hills with the best conservative orthopedic, sports medicine, rehabilitation and soft tissue based care possible.

Dr. Pappas blends the best of physical medicine with the best of integrated medicine to help patients and athletes of all shapes and sizes. He utilizes tools such as chiropractic manipulation, soft tissue mobilization, functional movement based assessment, the McKenzie Method, strength training and conditioning, kinesiology taping, diagnostic imaging and specialty laboratory testing when needed.

Dr. Pappas’ sports medicine interests are endurance athletes, overhead athletes (pitchers, throwers, volleyball players and tennis players), tactical athletes (police, fire department, first responders and military), contact sports athletes (football, rugby, lacrosse, field hockey, soccer and basketball) and Crossfit athletes. He has worked with athletes at all levels from professional to amateur.  He has provided sports medicine services to the University of Illinois, Indiana University, the Chicago White Sox, the Joliet Slammers (Jackhammers) minor league baseball team, the Windy City Thunderbolts minor league baseball team, Victor J. Andrew High School and Carl Sandburg High school.

On a personal note, he reads and interprets the medical literature daily to stay abreast of cutting edge advances in his field. The doctor is an avid runner and aspiring triathlete having completed 5 marathons, 5 half marathons and numerous 5 and 10k races. He has goals of qualifying and competing in the Boston and New York Marathons, the Ironman in Kona, Hawaii, and climbing Mt. Kilimanjaro in Kenya, Africa. He recently completed the Pikes Peak Ascent, a half marathon to the 14,115 foot summit of Pikes Peak.  He is currently training to complete the Go Ruck Tough Challenge as well as ruck Rim to Rim across the Grand Canyon. One day he hopes to serve his country as a team chiropractor for the United States Olympic teams and serve as a team chiropractor for a high level collegiate or professional sports team.

The doctor practices in the Northwest Hills area of Austin approximately 7 miles from downtown Austin, TX. The office is located within a multidisciplinary surgical hospital. His mantra is “Why Put Off Feeling Good?” He can be reached by email at drdinopappas@gmail.com and drdpappas@airrosti.com.  His business cell phone is 210-243-5734. Call 1-800-404-6050 to schedule an appointment with Dr. Pappas.  Please make sure to request the Northwest Hills, Austin-TX office when calling to schedule an appointment.***

*** Disclaimer: The views and opinions above represent that of the author, Dr. Dino Pappas. They do not reflect the official policy or position of any agency or company that Dr. Dino Pappas may have a relationship or affiliation with. ***

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