Perspectives on Pain

Jeffrey Cowdry

Pain is common to most of the patients that we treat. It is easy to develop a calloused attitude toward pain when you treat it every day. We may in fact laugh with our patients who, having progressed through a pain phase of their treatment, refer to us as their physical “torturer.” But eventually we stop laughing. Either we experience pain ourselves or we treat an individual whose pain will not go away despite our best efforts to conquer it. Indeed, hand pain has been identified as “one of the most acutely stressful aspects of traumatic injuries and their treatment.”¹

Pain is one of the first things that we ask patients to rate or describe. We use pain to establish boundaries on exercises and stretches. Without pain to guide us, tendons would rupture, ligaments would tear, and wounds would not heal. Indeed, “pain protects us from destroying ourselves.”² In his book, Pain: The Gift Nobody Wants, Dr. Paul Brand describes the fate of those with Hansen’s disease (Leprosy) who, lacking the ability to feel pain, slowly lose fingers, toes, ears, their nose, and often go blind (forgetting to blink). I highly recommend this book to all therapists treating patients with pain. The book serves to stimulate both our scientific and our humanitarian natures. Several box inserts will be used as pearls throughout this chapter to highlight insights from Dr. Brand’s book.²

Clinical Pearl

“Touch…conveys to my patients a sense of personal concern that may help calm their fear and anxiety—and thus help reduce their pain”²

Finding the origin of pain can be difficult. For example, compare parts A and B in Fig. 12-1. Look at the thumb carpometacarpal (CMC) joints in these radiographs. It may seem clear that Fig. 12-1, A, is of a patient who has severe CMC pain and the patient in Fig. 12-1, B, is pain free. In reality the hand in Fig. 12-1, A, is that of a woman I know who has no thumb pain at all. Fig. 12-1, B, is my hand that from time to time gives me bouts of severe CMC pain.

FIGURE 12-1 A, Patient with thumb CMC arthritis but no pain. B, Patient with painful thumb CMC but no significant radiological findings. (Courtesy of Jeffery Cowdry.)

Consider also a gentleman I treated for a crush injury to the hand. The initial surgical repairs included a carpal tunnel release. Long after the wounds healed and after many weeks of therapy this man had unrelenting pain and stiffness. The diagnosis was changed from crush injury to reflex sympathetic dystrophy (RSD). No treatment helped this man until a different doctor performed a revision carpal tunnel release. The surgeon’s suspicion that an incomplete carpal tunnel release was the problem was correct. Once the nerve was completely decompressed the patient’s pain went away immediately along with much of the stiffness.

Sometimes the origin of pain can be determined but not successfully treated. An extreme example of this is a patient who I saw for stump desensitization. He had an above the wrist amputation with a hypersensitive stump. His history included an original trigger finger release, neuromas, neuroma surgeries, and finally complex regional pain syndrome (RSD) of the hand. He told me that prior to the amputation, the hand pain was so intense he could not stand for even water to touch the hand. The hand eventually became filthy and then infected. The pain was so severe and the infection so bad that the man elected hand amputation. The sad ending to this story is that this patient eventually went on to have two more amputations (one below elbow and one above elbow). The last I heard about this patient was that he was suing his fourth surgeon who operated on his frozen shoulder, which made the pain worse.

Fortunately most of our patients respond well to over the counter or prescription analgesics to control pain. I find that hand patients who are on pain medication longer than two weeks are the exception. Many patients tell me that they only took their pain medication one or two nights to help them sleep after their operation. From a therapy standpoint some of the techniques used to control pain are: rest, immobilization, physical agent modalities, elevation, soft tissue massage, active range of motion (AROM), functional activities, joint protection education, adaptive equipment, and ergonomic education.

Although pain is a guide, in the United States we usually try to eliminate pain as fast as possible. If pain is not controlled quickly, patients will change doctors and therapists just as quickly. I learned this myself when treating my own tennis elbow (lateral epicondylalgia). When one treatment did not work, I would quickly try another. I tried many things, including joint taping, manual therapy, eccentric exercises, swimming, physical agent modalities, a cortisone injection, orthoses, and straps. I even tried a method that purposefully induces pain in order to stimulate the inflammatory process of the healing cycle. Just like my own patients, I shopped around and experimented until I found something to take away the pain.

Documenting baseline pain and performance is essential to helping patients get through their pain. Pain is a cardinal sign that is to be assessed by the therapist. Patients usually have poor recall about their initial pain. It is common after two or three weeks of therapy for them to say, “My pain is no better.” It is helpful to show them how they initially rated their pain and its effects. The baseline evaluation includes:

• Swelling (using circumferential or volumetric measures)

• Observations of appearance (color, use, dryness, or sweating)

• Sensory testing (monofilaments or two point discrimination)

• Pain assessment (visual analogue scale, pain diagram, pain questionnaire)

• Range of motion, strength, and fine motor testing

For more information on baseline evaluation and rating pain, please see Chapter 5.

When documenting pain there are terms that are helpful to know. Pain from the periphery that alerts us to damage or potential damage of tissue is called nociceptive pain, carried by the nociceptive fibers of the sensory nerves. Pain originating from damage to the nerve itself is called neuropathic pain. Allodynia is pain that occurs after a stimulus that is normally not painful. Painful light touch following sunburn is an example of allodynia. Hyperpathia is pain that is more intense than normally expected and/or lasts longer than normally expected. Pain lasting for hours after gentle passive range of motion (PROM) is an example of hyperpathia. See Box 12-1 for a summary of pain terminology.

BOX 12-1 Definitions of Pain Terminology

Allodynia: Pain in a specific dermatomal or autonomous distribution associated with light touch to the skin; a stimulus that is not normally painful.

Analgesia: Absence of pain in response to an insult that should produce pain.

Hyperalgesia: Increased sensitivity to stimulation (includes allodynia and hyperesthesia).

Hyperesthesia: Increased sensitivity to stimulation (pain on response to a mild noxious stimulus).

Hyperpathia: Abnormally painful reaction to a stimulus (especially repetitive); often includes extended duration of pain, frequently with a delay.

Hypoesthesia: Decreased sensitivity to stimulation.

Nociception: Response to an unpleasant (noxious) stimulus that produces pain in human subjects under normal circumstances.

Pain: An unpleasant perception associated with actual or potential cellular damage.

Sympathetic pain: Pain in the presence of and/or associated with over-action of the sympathetic pain fibers; by definition the pain is relieved by sympatholytic interventions.

(From Li Z, Smith BP, Smith TL, et al: Diagnosis and management of complex regional pain syndrome complicating upper extremity recovery, J Hand Ther 18(2):270-276, 2005.)

Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy

A day may come when you receive a referral diagnosing a patient with CRPS or RSD. CRPS/RSD has been described as “the most controversial and frustrating of all hand disorders.”³ It is a clinical syndrome in which there is extreme pain with allodynia and hyperpathia. There is usually associated edema, stiffness, skin color and temperature change (often red and warm initially, changing to blue and cold over time), excessive sweating or dryness, excessive or diminished hair growth on the arm or hand, and changes in the nails/nail beds and pads of the fingers. It affects all ages, all races, both sexes, and can occur spontaneously or be caused by trauma, cerebrovascular accident (CVA) also known as stroke, heart attack, and shingles.³ Because carpal tunnel syndrome and distal radius fractures are among the most common hand disorders, they are often cited as the event preceding the onset of CRPS/RSD.

The term RSD, coined in the 1940s, has been replaced by the term CRPS. RSD implies reflex to an injury causing a disease directly related to the sympathetic nervous system. CRPS conversely describes the complex nature of the disorder that attacks regionally (usually the arm or the leg), is severely painful, and is best thought of as a syndrome—not a disease. This is not the first time a new label has been used for this disorder. There are over 60 terms used to describe the condition (see Box 12-2). It is important to know that renaming RSD does not change the fact that there is no clear explanation, no precise way to diagnose, and no universally accepted treatment for this disorder.

BOX 12-2 Different Names Used for CRPS/RSD