EXPECTATIONS OF PAIN, AND THE PSYCHOLOGY OF RECOVERY.
Are we as clinicians and movement specialists doing a good enough job with post-operative patient education? Maybe. Or, maybe we just think we are.
Many patients who are planning on undergoing an orthopedic surgery do so to get away from the pain, depression, and poor quality of life they are experiencing. Whether it’s pain due to a chronic condition such as osteoarthritis, or an acute injury that ruptures ligaments, tendons, or bone, patient’s expectation following surgery is to improve function, decrease pain, and get back to the things they love doing.
With that said, are we doing enough to provide top-notch patient education to live up to our patient’s expectations? Let’s dive into it.
Acute vs. Chronic Orthopedic Injuries:
Movement specialists such as physical therapists, as well as physicians and surgeons, may underestimate the psychological toll that pain and decreased function have on their patients.
Examples of common acute injuries requiring surgical intervention:
Typically these occur as a result of a trauma, which may have been perpetuated by poor movement patterns, motor control, strength, and mobility.
- Achilles tendon rupture
- Anterior cruciate ligament tear
- Fractures, most common include those of the foot/ankle and hand/wrist
- Hip labrum or shoulder labrum tear
- Ulnar collateral ligament (UCL) tear/rupture (acute or acute-on-chronic)
Examples of chronic injuries and surgical intervention:
The onset of chronic injuries in multifactorial. Like acute injuries, these may have been perpetuated by poor movement patterns, motor control, strength, and mobility, without the sudden trauma. They may also be exaggerated by poor overall health, obesity, smoking, and sedentary/inactive lifestyles.
- Achilles tendinosis with severe Haglund’s deformity
- Osteoarthritis (OA) of the knee, hip, shoulder, foot/ankle, or spine
- Spondylolisthesis and subsequent spinal stenosis, both lumbar and cervical spines
- Non-traumatic rotator cuff tears
- Bunions, hallux valgus, hammer toes, and pes planus deformities of the foot
Anyone who has undergone surgery has questions regarding expectation of mobility, pain, and returning to their previous level of function. These are all big question marks, that may get touched on briefly, or not at all, in pre-operative counseling. For patients suffering from chronic disorders, electing to have surgery usually means they’ve reached a tipping point with their pain, dysfunction, or both. They may look at surgery as a way to restore function they had years, even decades, earlier. Patients should most certainly expect an improvement in disability, however expectations of returning to running marathons after a 10 year history of knee OA, and subsequent Total Knee Arthroplasty, is far reaching.
What about returning to prior level of function/sport for some of the common sports injuries? We’re not doing as well of a job as you may think. Hewett et al described that outcomes are widely varied following ACL reconstruction, and unexpectedly poorer than previously reported. They state that less than half of athletes who undergo reconstruction are able to return to sport within the first year after surgery, and for those athletes who successfully return to activity, it is estimated that approximately 1 in 4 will go on to a second knee injury3,4,6,8,9. Expectedly, the outcomes after a second ACL injury and subsequent ligament reconstruction are notably less favorable3,4,6,8,9. Poor prognosis is also seen in returning to throwing following shoulder and elbow surgeries1.
While our goal as movement specialists is to get these patient’s back to their prior level of function, it is worth the time to educate your patients on the data surrounding their particular injury. This is not meant to scare your patient, but enlighten them to the seriousness of rehabilitation and set the expectation for hard work.
Let’s just get this out there: Pain after surgery is NORMAL!
Ok, now that that’s out there, let’s explain. Many patients I’ve treated do not expect the amount of pain associated with their surgery. I’ve seen many patients that are similar in demographics (age, sex, sport), mechanism of injury, have the same surgery by the same surgeon, yet their pain and eventual level of function are drastically different. This is obviously multifactorial, taking into account things such as pain tolerance, intrinsic/extrinsic motivation, psychological distress, tissue health and quality, surgeon experience, among other things. But what can help you determine if your patient will be able to push through the normal post-operative pain, to get them to their eventual goals?
Lentz et al suggests maybe there needs to be a more comprehensive screening for yellow flags when dealing with musculoskeletal pain. Lentz and his colleagues set out to describe a concise, multidimensional yellow flag assessment tool for application in orthopedic physical therapy clinical practice. What they came up with was a 17 question outcome measure, called the Optimal Screening for Prediction of Referral and Outcome (OSPRO-YF)5. These questions were whittled down from 136-item yellow flag item bank developed from validated psychological questionnaires across domains related to pain and disability. They found that these questions help identify patients that may have an elevated vulnerability or decreased resilience to pain, with 85% accuracy5.
In 2016, Louw and colleagues published an article entitled, “Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy.” There, the authors site that 25.3 million adults suffer from daily chronic pain, as well as 126.1 million adults in the United States experience some pain over a 3-month period7. That means more adults in the US experience pain than those who do not! Louw et al has shown in previous systematic reviews that PNE provides compelling evidence of reductions in pain, disability, and pain catastrophizing, as well as improvement in movement7. The authors call on physical therapists to use PNE as a cornerstone in treatment, with the clear message that pain is a normal human experience7.
Psychological Consequences of Surgery and Recovery
It is well documented that chronic pain not only affects someone’s physical state, but also their psychological state, willingness to move, emotional well-being, among other things. Add surgery, and the associated spike in pain that comes post-operatively, and we could potentially set ourselves up for poor results.
In one study, Slepian et al, looked into pain catastrophizing and it’s relation to mental health disorders for those patients in physical therapy. What they found was that the presence of mental health symptoms markedly reduces the effectiveness of physical therapy for reducing catastrophizing scores10. The findings argue for the inclusion of measures of mental health problems in the routine screening of individuals treated in physical therapy10. While many orthopedic/sports related surgeries are performed in hopes to regain normal function, those patients with a history of mental health disorders should be highly informed on the importance of pain neuroscience education to maximize potential outcomes.
Pain catastrophizing can lead to fear avoidance (FA) behaviors, and decrease the patient’s willingness to move. As movement specialists, we know that the human body is happiest when moving (of course, taking into account healing time, post-op restrictions, etc). So when a patient is fearful of movement, it can become a very difficult case. Gatchel et al do a great job of describing what fear avoidance does to our patients. They describe that the anticipated threat of intense pain will often result in the constant vigilance and monitoring of pain sensations, which, in turn, can cause even low-intensity sensations of pain to become unbearable for the person2. Just the anticipation of increased pain or reinjury can further stimulate avoidance behaviors2. A vicious cycle may develop, in which fears of increased pain or reinjury contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability2.
Post-operative pain is normal, and our patient’s should be highly educated on this fact. Providing your patients with meaningful information about their pain will help maximize their potential recovery. Patient’s whom have been experiencing chronic pain prior to surgery, may benefit best from pain neuroscience education, as well as the development of functional, achievable goals for patient buy in to their progress.
- Cohen SB, Sheridan S, Ciccotti MG. Return to Sports for Professional Baseball Players After Surgery of the Shoulder or Elbow. Sports Health. 2011;3(1):105-111.
- Gatchel RJ, Neblett R, Kishino N, Ray CT. Fear-Avoidance Beliefs and Chronic Pain. J Orthop Sports Phys Ther. 2016 Feb;46(2):38-43.
- Hewett TE, Di Stasi SL, Meyer GD. Current Concepts for Injury Prevention in Athletes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2013;41(1):216-224.
- Hui C, Salmon LJ, Kok A, Maeno S, Linklater J, Pinczewski LA. Fifteen-year outcome of endoscopic anterior cruciate ligament reconstruction with patellar tendon autograft for ‘‘isolated’’ anterior cruciate ligament tear. Am J Sports Med. 2011;39(1):89-98.
- Lentz TA, Beneciuk JM, Bialosky JE. Development of a Yellow Flag Assessment Tool for Orthopedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort. J Orthop Sports Phys Ther. 2016 May;46(5):327-343.
- Leys T, Salmon L, Waller A, Linklater J, Pinczewski L. Clinical results and risk factors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospective study of hamstring and patellar tendon grafts. Am J Sports Med. 2012;40(3):595-605.
- Louw A, Puentedura EJ, Zimney K, Schmidt S. Know Pain, Know Gain? A Perspective on Pain Neuroscience Education in Physical Therapy. J Orthop Sports Phys Ther. 2016 Mar;46(3):131-134.
- Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport. Am J Sports Med. 2010;38(10):1968-1978.
- Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2):246-251.
- Slepian P, Bernier E, Scott W, Niederstrasser NG, Wideman T, Sullivan M. Changes in Pain Catastrophizing Following Physical Therapy for Musculoskeletal Injury: The Influence of Depressive and Post-traumatic Stress Symptoms. J Occup Rehabil (2014) 24:22–31.