The walking accident zone…


Luke (not his real name – you know I disguise details to protect confidentiality) is a man in his mid-20’s who is a walking accident zone.  He tells me he’s broken ‘every bone’ in his body – and while it’s not exactly true, he has certainly broken a few of them!  The reason he came to see me was because he has neck and shoulder pain.  He describes it as burning, tingling, deep and aching pain over his neck and down the back of his arms to his elbow.  Sometimes he has tingling in his fingers, and sometimes he has headaches.

The story is that he loves high risk sports – rock climbing, sky diving, mountain-biking, snow-boarding, the lot.  And the problem is that he falls down a lot.  And not slowly either!  He also seems to fall from heights – twice at least he’s fallen about 8 – 10 metres.  His work doesn’t help, he works in construction and spends a lot of time on scaffolding – hence the falls.

This time he’d fallen and sustained fractures of his vertebrae, and needed surgery to stabilise the area.  Unfortunately he also tweaked some nerve roots, and had some post-surgical neuropathic pain around the surgery site as well.  Hence the burning, tingling pain.

What’s the problem for rehabilitation?

Well, the problem isn’t really his fault.  He listened very carefully to his surgeon who told him not to move his neck.  So he didn’t.  That was some months ago.  Now he hardly does anything during the day, sleeps poorly, and isn’t feeling very happy in himself.  His fitness level is pretty low, and while he does have some loss of grip strength and power in his arms, this isn’t just due to the accident.  He’s basically stopped doing everything.

The other problem is his natural tendency to want to push himself and go, go, go!

So when he does do things, he over-does – and pays the price with a large increase in pain.

Luke hasn’t really had to cope with long-term pain much. Most of his fractures and cuts have laid him up a month or so, then he’s been back on the adrenalin track.  So this time, with this pain that doesn’t go away, and the surgeon’s very stern words about not doing anything, he’s struggling to know how to cope and how to get back to ‘normal’ at the right pace.

Luke represents a fairly typical young male sports rehab prospect.  Most of the time someone like Luke will rehabilitate without much input from health professionals.  He isn’t afraid of pain, he knows that fractures take a while to heal – but they do heal, and he’s happy to pick himself up, dust himself off and get back on the skateboard again.

The problems arise, it seems to me, when the pain doesn’t go away, or when someone gives him well-meaning advice that he over-interprets (like ‘don’t do anything’).  Now probably the surgeon thought he was saying ‘just moderate your high risk sports for a while’, but Luke thought he was saying ‘sit on the couch and don’t move’.

So Luke sat on the couch until he got fed up and decided to go and do something. His typical way of doing things is full-on – but in this case, he got a back-hander from his pain, reminding him that he had done not just a simple fracture, but also some nerve tweaks.  This scared him a bit, and he got back on the couch, and stayed there.  But every now and then he’d get up and have another attempt – too much, too fast – and got a back-hander from his pain!

With too much time on his hands, and not a lot of patience, Luke worries about his pain and finds it really difficult to distract from it.  He gets irritable and cranky.  He starts to feel useless and isolates himself from his friends and family.  His friends can’t understand why he’s so irritable, and leave him to it until he ‘gets right’, and his parents – well they’d given up on trying to get him to settle down a bit and stop taking these stupid risks, so it’s kind of nice to see that he’s not heading off on his mountain bike or jumping off rocks for a while, so his mother spends a lot of time making sure he’s OK.  Luke goes back to adolescence momentarily and grunts when she asks him how he is.

What to do, what to do.  Here’s my thoughts on what might help Luke.

Remembering that Luke has heeded the words of his surgeon, but perhaps a little too much, it would be helpful for me to talk to his surgeon and clarify just what movements Luke can do, rather than what he shouldn’t do. It would also be great to find out whether he can start to return to work, because Luke is keen to do so.  Notice I said ‘start’ to return to work – it would be good to find out which movements Luke can do and then help Luke decide which parts of his work he can start to do.

Then because Luke is bored and has found out that he feels worse when he’s not doing anything, it might be helpful to get him to start doing some daily walking and perhaps some general exercise. In view of Luke’s tendency to over-do things, developing a program of exercise that he must record every day might help him to regulate his activity level.

Luke doesn’t really understand what this pain is all about, so although he’s not especially fearful of pain, nor particularly avoidant, he could do with learning about neuropathic pain and why this pain is different from other accidents he has had. I’d probably give him a book to read on pain, something like ‘Explain Pain’ by David Butler, or perhaps sit down with him and go through his anatomy and physiology.  Knowing something about the neuromatrix model might be good too, so he can understand why he’s been given certain medications, and why normal movement will be helpful.

It would be great to help Luke understand about gradually increasing his activity level – there is a nice section in Butler’s book about activity pacing and re-setting the pain threshold.  This explains why it’s important to start at a low level of activity, then gradually increase.

I forgot to say that Luke’s sleep is shocking!  He’s developed a very erratic sleep pattern, and this could be contributing to his irritability and low mood.  So it would be useful to review his sleep habits, and establish why his sleep has deteriorated, moving to sleep hygiene and behavioural sleep management once any other problems have been eliminated (like inappropriate use of sleeping pills).

I think someone like Luke has a high potential to recover very rapidly once he’s got the ‘green light’, and learns to  regulate his activity level and adjust his expectations accordingly.  I also think he is at high risk for developing ongoing pain and disability if this episode is not managed well.  Because he’s a risk-taker the chances of him having another accident are pretty high.  And he could well develop another neuropathic pain problem then too.  If he develops good coping skills now, and learns that he can and will recover, albeit slightly more slowly than he hoped, then he’ll be in a good position then next time he has an accident.  If he doesn’t develop these skills this time, the risk is that next time he’ll have more trouble managing, and start on a downward spiral.

Risk factors need managing comprehensively and early.  A stepped-care approach means stepping up when the risk factors are present and the person doesn’t respond.  Let’s hope that Luke, and people like him, get the level of input they need early, and don’t simply get a medical or acute pain management approach.

9 comments

  1. I think that doctors quite often do not give enough information in language that is common to both surgeon and consumer of surgical services. In fact, quite often I find that people with whom I speak have very little idea of human physiology and anatomy. So it would be important to almost everyone to be given rehab help that is in everyday language and has a feedback loop built right in. People rehab more easily and quickly when they can participate in their care. This is a very timely post!

    1. I agree with you – and we as healthcare providers are often prone to using jargon, forgetting to ask our patients what they understand from what we’ve said, and forgetting they’re often anxious and not taking as much information in as usual. I just read an article about writing information pamphlets (Hirsh, Clerehan, Staples, Osborne & Buchbinder, in press, Patient assessment of medication inforamtion leaflets and validation of the Evaluative Linguistic Framework. Patient Education and Counselling, doi: 10.1016/j.pec.2009.03.011) – good stuff to read!
      Thanks for taking the time to comment, it’s always a pleasure to know there are people out there!!

  2. I would imagine extreme sports people / adrenaline junkies would be in a minority within a chronic pain service. I get the impression (not being one myself) that there is something of a badge of honour for the breaks and scrapes that come with the territory. Hopefully Luke has some positive role models, ie probably all his peers, that experience ongoing pain (or other disabilities) yet continue to participate in their chosen pursuits.

    This sounds as much to do with poor communication than anything else. Presumably getting his surgeon to clarify his plan and a timeframe would be the green light to get up and get on.

    Does Luke have previous success in recovering from his various accidents? Surely a history of successful rehab, positive attitude to work and low fear avoidance (?) adds up to a good prognosis? He’s just doing what he thinks he was told to do.

    A bit devil’s advocate – but taking it back a few steps I’m struggling to see the yellow flags flying!

  3. Hi Mary
    Yellow flags don’t just refer to the individual, but also to the systemic issues (ie ‘social’ part of psychosocial) influencing the person – and I’m afraid, iatrogenic influences are incredibly prevalent in chronic pain! There were two things his surgeon didn’t do well – check that Luke had correctly interpreted his advice, and the surgeon advised him NOT to return to his job. Both are not good prognostic indicators!
    The other aspect that is definitely a risk factor is Luke’s tendency to boom and bust – booming, or over-doing is a slightly better-disguised problem than under-doing. It can be positive, if the person doesn’t overload, but the risk is that the activity pattern becomes saw-toothed – over-active part of the day, under-active the rest. This doesn’t lead to gradual build-up of activity tolerance.
    Over-activity is often associated with strong beliefs or ‘rules’ about how much someone ‘should’ do, or in the case of Luke, with the adrenaline-junkie pattern. When people like this lose their activity (because they misinterpret information, or sustain another illness on top of the original one), they can become depressed, and often don’t allow themselves adequate time to recover.
    I think we do see this type of person often in our field, but only after they’ve moved beyond this stage and into the depression/deactivation or fatigued point. The good thing was to see this guy early enough to do something positive.

  4. Thanks for the speedy response!

    I guess my point is that if the surgeon has his communication ‘faults’ brought to his attention, and addresses them, then many of the risk factors go away. The almost mythical ‘green light’!

    Does a young (previously athletic) man with a predisposition to ‘booming’ present with sufficiently significant risk factors to move away from a more straightforward rehabilitation approach?
    Would you expect to influence his overall approach for the sake of a more consistent gradual progressive model?

    I note from your original article that you identify Luke as having ‘high potential to recover very rapidly’ albeit with the risk of spectacularly failing too! I agree, and think that my bigger question is how to determine the most appropriate approach for patients who may just get better anyway.

    I don’t work in primary care, and in a ‘tertiary’ setting I have the enormous benefit of hindsight from every other clinicians unsuccessful attempts. But in primary care how would you pick out this chap from any other ‘extremer’ who rolls out of surgery? All he has done is be very obedient!

    Loving the blog by the way (trying to get back in your good books) although remain rather unnerved at the sheer breadth and depth of your knowledge and passion!!!

    1. That’s exactly my point Mary – risk factors CAN be reduced by looking not just at the person and his or her actions, but also at how we (ie health care providers) can do it better. In this case I don’t know about the surgeon and amending his ways (some things are harder to do than others!!), but we can address the effect of this specific risk on Luke.

      Your second point about when is the right time to ‘escalate’ a (relatively) low risk patient – well, the simple answer is when the lower level interventions are not making an impact. God bless review points! Anyone in the health care team could provide him with the input to talk about activity regulation and looking at his expectations, it’s not the province only of psychologists, or indeed of physiotherapists or occupational therapists or GP’s!

      As to whether it’s a good idea to influence his overall approach to life for the sake of a more consistent gradual programme, yes I think so. This chap has had a previous episode of chronic pain, plus this one, so the potential for him to develop another is increased. I think it’s a principle of rehabilitation generally to gradually increase activity level rather than going at it with high intensity. My colleagues in sports medicine say that the problem with people like Luke is just that, they go for it and don’t give things time to settle – or they hold off and don’t do anything at all…

      Thanks for the compliment (*blush*) – pain and pain management is something I’m very committed to, as is trying to provide practical information to clinicians who may not have much opportunity to find out the ‘how to’ or application of some of the more esoteric research that gets published!

  5. Hi

    thanks for that – I submitted a response last night, but it seems to have disappeared, and I was in a bit of a rush to watch House!

    The gist of it was about personalising treatment so that the person’s personality isn’t lost in the mix. We see such a diverse bunch I get worried that we try and force them all into one ‘box’ and risk losing compliance in the process (patient centred and all that).

    Probably need to think it through and then put it down in writing!

    Thanks again.

    1. I watched House too!! Great episode!
      Yes I agree that we need to personalise treatment – and we have to hold onto good rehabilitation practice. The problem is trying to meet both aims when they seem contradictory.
      I do believe that case formulation is the best way to personalise management: this means identifying the specific factors that influence the person’s presentation and responding to these. For example, in Luke’s case, his specific risk factors around adrenaline rush and high activity suggest that this might be worth helping him review and moderate so he knows when it’s the right time to adopt this approach, and when it’s not. The risk factor from a biophysical point of view is the development of neuropathic pain – and this needs to be identified to him so that he responds to it differently from when he has a common old sprain or strain from skateboarding. It’s really teaching him to be flexible in terms of his approach so he can achieve what he values in his life.

  6. Great – thank you. I think flexibility and options / choices in different scenarios makes a lot of sense. Reading back through this discussion has helped me to narrow down the questions I want to ask, and definitely draws a focus on how case formulation needs to reflect the patients rehab plan (rather than just their diagnosis / presentation).

    Ta!

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