December 13, 2020
Pain is the gift nobody wants. To prevent pain, one relies on different means to manage it. Based on the intensity, their coping methods, cultural influences one may choose a method over another. The threat of an injury activates a range of responses in the brain and results in behavioral changes.
When does opioid come into play in hand and upper extremity? Usually after an acute injury or a repetitive stress injury. Pain following trauma persists in many: one in four have moderate to severe pain 12 months following trauma, and up to one in three have significant pain and disability 3 years later. Predictors of pain were found to be lower socioeconomic status, pain severity, and injury severity. It is not known if the predictors of chronic pain 3 years out are the same as those at the onset or if other items are added to create lifelong pain.
If we have a better understanding of those pain factors, we may be able to provide early intervention and reduce the chances of chronic pain. Poorly controlled pain in the 1st week following injury increases the risk of severe pain one year later by 2-3 times. Pain is more than just a sensation indicating tissue damage, it is a multidimensional experience. Numerous areas of the brain are activated. Thus, a multidisciplinary approach is needed to manage such injuries.
One of the easiest and most common method to manage pain is opioid. Physicians offer this as one of the most common ways to help their patients. They are trained in med school in such method partly because the education system in this country is sponsored by big pharma, promoting their ways and means to alleviate pain. However, opioids never take the pain away completely, partly due to the poor understanding and assessment of the origination of pain. Severity of pain in early phase could be due to multitudes of reasons. From edema, nerve involvement, open wound, psychological effects of trauma to functional Limitation. If the early factors are not accurately assessed and treated no opioid medications can help, as opioid is not the answer for all of these factors.
If these factors are not relieved in the early phases it may result in chronic pain. Factors for chronic pain are a lot different from the early stages. These are usually the result of poor early management resulting in adhesions, thus causing limitations in motion and use, resulting in disuse and atrophy. Which may result in compensatory patterns resulting in completion of the cycle of chronic pain.
Anxiety associated with patient’s financial condition results in a different psychological pain, and those pains are not resolved with opioid but rather counselling or anxiety medications.
In the early phases of a physical injury, therapy can play a huge role, in education about the injury, the prognosis, the process of recovery and ways and means to manage pain with modalities and exercises when done correctly.
Simple additions to the maximum protection phase have the potential to decrease primary impairments associated with surgery and immobilization. Studies have shown that one can maintain and improve Strength via contralateral extremity training. They can prevent excessive ROM Loss via motor imagery and manage pain and preventing CRPS via aerobic exercise.
Chronic pain may require some medications but therapeutic modalities like biofeedback mechanisms, counselling can be used in addition to medication to decrease reliance on pills. Constant neuropathic pain may result in central sensitization and therapies may assist in preventing the development of chronic pain through central sensitization.
For patients who think taking opioids will get rid of the pain need a good conversation or understanding what is to be expected from medication or even marijuana. Education of what a pain medication can do and when to use it along with the side effects can help patients make educated decisions as to when to take the medication rather than taking it every 4 hours because that is what was instructed to them.
As mentioned earlier, certain cultures deal with pain differently. Some consider it as an enduring quality whereas others do not want to experience any. For any pain to go away one must assess the reasons for it. Mechanism of injury, for example a one-time trauma must be treated very differently than an ongoing repetitive injury. Early management of injury is advocated by all, however, it should not just be by medications but by using modalities, ceasing the activities and removing the causative factor. If the factors are not assessed correctly and alternative options are not provided, then patient starts relying on medication to relieve the discomfort and to continue with their daily activities. Therapeutic options to avoid opioid dependence must not just be offered but emphasized to the patient with formal training and ensuring understanding of the problem by the patient. Education should emphasize on treating the cause rather than the symptom. A blanket prescription for opioid must never be offered, time should be taken to educate patients on an independence to wean off of the medication. Education on withdrawal symptoms from opioids must also be provided and strategies to manage pain and its withdrawal symptoms.
There is a time and place for medications like opioid but that must not be the only option provided. Instead a multidisciplinary team approach to ensure accurate treatment plan must be the way forward if we are to tackle the opioid epidemic, making therapists an integral part of the team to assists in providing relief. Communication between members must be the highest priority to prevent a patient from becoming dependent and ensuring other team members brought in like a psychologist as and when needed to manage psychological conditions after an injury. Having an open mind ensuring patients betterment must be the goal of each person on the multidisciplinary team.
Thus, if therapists are brought in the early phases of injury management, the likelihood of opioid dependance would decrease dramatically. Medical training must re-introduce a multidisciplinary approach. And if this is the way forward, introducing a 9% cut in payments when such therapies can be at the forefront to manage this crisis, is the worst thing Medicare can do.
Do they not see these therapy services as beneficial and important in managing this epidemic produced by the pharma industry, promoted by physicians who only propagate it? They seem to be failing the patients by refusing to see therapy as the missing link, what the therapy industry can provide and instead of rewarding the industry they are cutting their legs and rewarding those who created it.
I strongly urge Medicare to review their decision about the payment cuts in a time when patients need these services more than before. Therapists can help prevent, manage, and assist in ending this crisis in the multidisciplinary approach proposed above.
With a perspective,
Sincerely,
Saba Kamal, OTR, CHT