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.