Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Holistic Approaches to Pain Management with Professor Romy Parker
Unlock the secrets of pain management in trauma care with our enlightening discussion featuring Professor Romy Parker from the University of Cape Town. Discover how understanding pain as a biopsychosocial construct can transform patient care. From nociceptive to neuropathic and nociplastic pain, we explore the complex relationship between physical injuries and the individual's mental, emotional, and social environments. Learn how physiotherapists can enhance trauma care by considering the holistic context of each patient.
Join us as we navigate the intricacies of tissue healing and pain phases, from acute to chronic states, and the vital interplay of the immune, autonomic nervous, and endocrine systems. Our conversation takes us into the heart of the ICU, where we highlight the importance of monitoring pain as a vital sign, its connection to sleep quality, and how stress affects recovery. Professor Parker sheds light on the essential role physiotherapists play in crafting personalized, non-pharmacological pain management strategies that prevent chronic pain and improve patient outcomes.
Empower your approach to pain management with insights into patient empowerment and multidisciplinary collaboration. Discover how physiotherapists use empathetic communication and strategic planning to create a sense of safety and address pain effectively. Explore the promising potential of non-pharmacological treatments that focus on reactivating patients and helping them return to meaningful life activities. With a focus on the latest research and practical applications, this episode is your guide to advancing pain management in trauma settings.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
‘Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
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Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. Today we are discussing pain and pain management in trauma, and I am joined by Professor Romy Parker from the University of Cape Town in the Department of Anesthesia and Perioperative Medicine and the Director of the Pain Management Unit. Romy, thank you for joining me this morning.
Speaker 2:Thanks, Helene. It's great to be here. I'd love to talk about your book.
Speaker 1:Thank you. So, Romy, won't you tell our listeners a little bit about yourself and how you ended up in pain management? Sure so?
Speaker 2:so I might be in the department of anesthesia and perioperative medicine, but I'm very much a physiotherapist, um, and physios have an enormous role to pay in in pain management, um, because pain is the ultimate biopsychosocial construct. Yes, it's, it's complex, it's about human beings and those physios. We've got multiple tools to engage with people yeah when they've got pain.
Speaker 2:You know, um, and I got into pain management because I was working in the field of rheumatology um, and you would think that when people have joint damage and joint disease, that all our treatments should focus on the joints. Yes, but then I met patients who had terrible joint disease and no pain, and patients who had very mild joint disease and terrible pain. So I started asking myself the question what is pain then? Because it didn't seem to be directly correlated to the joint disease. Yes, so, yeah, I got into pain and understanding that pain is not directly correlated to tissue damage. The pain is something that our is not directly correlated to tissue damage. The pain is something that our brains create when our brains come to the conclusion that we're in danger.
Speaker 2:Okay, yeah, and sometimes the joint had something to do with it, but a lot of the time it was all the other things going on in people's lives that contribute to pain. And I think in your field, in trauma, the same applies. You know, know, we've all seen people with awful polytrauma, but their pain doesn't seem to be that bad exactly and then the person in the bed next to them doesn't have that bad an injury, but they've got screaming pain.
Speaker 2:You're like what's going on? And? And that's what fascinates me about pain and what draws me to it as a physio because as physios, we're good at engaging with our patients, right? Yes, and seeing the whole person and thinking about getting them back to living their lives, and pain management is all about that.
Speaker 1:Yeah, definitely yeah. So when someone has a traumatic injury, it's often very unexpected in nature. So what do you think would be important for physios to understand in this context of unexpected injury inflicted on the body?
Speaker 2:I think it's so important, helene, to think about the fact that if somebody has been hospitalized because of a traumatic event and it was unexpected, it's the equivalent of the worst day of their lives, right? So if you think about stabbing your toe, like we've all stabbed our toes, right Agony. But if you stab your toe on a good day, you know it's a beautiful day. You've got all your friends and family around, everyone's brought food, there's wonderful music, everyone's talking and enjoying each other's company. As you walk outside, you catch your toe on the door and it does that. Yes, that's four, but how long is it? Her four?
Speaker 2:Probably not that much, and you get back to being with your friends and your family pretty quickly and it's okay, yeah. But what about stubbing your toe on a bad day, you know, when you've worked two weeks in a row because everyone else has been all sick and the weather's terrible, and had the worst fight ever with the person you love the most in the world, and you're just not sure why you have to get out of bed and go to work again today, but your bank account's in a miserable place and life just feels overwhelming and it's all terrible. And as you walk into the bathroom you catch your toe on the door and it goes how much does?
Speaker 1:it hurt yeah, no very different perception of pain completely different experience.
Speaker 2:It's not just the pain, but I mean, I sat on the floor and cried for half an hour once when I stubbed my toe because it was a bad day, yeah, and it was so painful. Bad day, yeah, and it was so painful. And it's not just that it was so painful, but when you were having a bad day, we're also pro-inflammatory, so you have a bigger inflammatory response. Your toe might swell up on that day, okay, and it didn't swell up when you were having a good day, yeah. Yeah, the tissue issues, what happens in your toe, might be exactly the same on those two days. But pain is about more than the tissue issues. Yes, so we think about somebody who's having trauma. We've got to think about more than their tissue issues, right? Yes, we've got to pay attention to the tissue issues. Don't get me wrong, don't ignore that. But who's this person? What are they worried about? What are they scared of? Who's this person? What? Are they worried about what are they scared?
Speaker 2:of who's supporting them. What are the consequences for them? Does this mean they're going to lose their job? Maybe they don't know and they're worried about that? Did their cell phone get smashed in the car and they haven't been able to speak to anybody that they love since it happened? What are all the other things contributing to it being a bad day? Yeah. And that's holistic, biopsychosocial pain management.
Speaker 1:Yes, no, and I think it's so important that you mention those things because often in the trauma ICU setting, or even a busy trauma ward setting, we as physiotherapists don't always think about asking these additional questions when we first meet and assess our patients. So, yeah, very important to keep in mind.
Speaker 2:I mean, we don't necessarily need to do a 20-minute history taking, because that's not appropriate and relevant, but just one or two questions of how are you doing? What are you worried about you? Questions of how are you doing, what are you worried about? Yeah, you know how are you feeling when it hurts. What worries you about the pain is a critical question to ask in that environment. Let's say, someone's got rib fractures and it's sore for them to breathe deeply. But I need them to breathe deeply, yes, and I know it's safe for them to breathe deeply. They need to know that, although it hurts, it's not dangerous, yes. So asking them when it hurts, what worries you about that pain? Let me reassure you that that's not dangerous. It's safe for us to do this. Even though it hurts, it can make a significant difference to it actually hurting.
Speaker 1:Yes, that's very true. So let's talk a little bit about the neurophysiology around pain. So we know that there are several role players, which is your peripheral nervous system, the spinal cord, the brain, and then the others. We've taken to calling them the synergistic systems, just to give them a little umbrella name because they all feed in? Yeah, and we also know that there's terms like nociceptive pain, neuropathic pain and the other one. Yeah, what is it?
Speaker 2:Nociplastic pain, nociplastic pain. What's that?
Speaker 1:Nociplastic pain. Could you maybe just talk about all of that?
Speaker 2:All of that, yeah, all of that. No, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no on earth is a nociceptor. So nociceptor has its root in noxious, okay, okay. So a nociceptor is a receptor, a nerve that fires when something potentially noxious, potentially dangerous is happening. Okay, all right. So nociceptor pain is pain that I'm experiencing when something potentially dangerous is happening in my body or if I've had an injury, something actually dangerous. Yeah, Okay, it's important to remember that they fire for potential danger. Everyone's experienced that If you put your hand on something hot, right, sometimes you get that ow, but you look at your hand and it's not actually burnt. Yeah, so brilliant. The pain system did its job. It set off the alarm so that you didn't get burned. Yeah, that's really the point of a pain system. It's a protective system, okay, it's not a tissue damage measurement system. Yes, okay, okay. So nociceptors are firing because something potentially dangerous has happened. If you've had trauma, something actually dangerous has happened, yes, okay. Trauma something actually dangerous has happened? Yes, okay.
Speaker 2:So the nociceptors are firing in the peripheral nervous system. They come along and they deliver the message in the spinal cord. If the message is loud enough, the spinal cord hears it and sends it up to the brain. Nociception gets to the brain. The brain gets nociception. 200 different parts of your brain interpret all of that information, not just the nociception. 200 different parts of your brain interpret all of that information, not just the nociception. Your brain also goes where are we? What's going on? Has this happened before? Do I remember anything dangerous? Do I smell anything? Do I see anything? Do I hear anything? What do I know about? This Puts it all together and if your brain comes to the conclusion that you're in danger, it generates pain. Okay.
Speaker 2:And that's nociceptive pain. So you bang your funny bone, you stub your toe, you cut your finger. That's nociceptive pain.
Speaker 2:It's not always painful, though. Sometimes you cut yourself and you don't notice, right, true? So what happens then? So what happens then, we think, is that you cut yourself. The nociceptor sends the message to spinal cord. Spinal cord goes yeah, okay. Sends the message up to the brain. Brain does the processing, goes ah, we're in the garden, the man loves the garden, the birds are singing, it's a beautiful day. Don't worry about that danger signal, it's fine. So, so, no suspicion comes in, but your brain might go no, in the bigger picture, we're not in danger, it's fine. Okay.
Speaker 2:What happens later, helene? When somebody goes, you're bleeding and you look at it. What happens then?
Speaker 1:You get a fright and and you think, oh, my goodness, I need to do something about it. And does it hurt?
Speaker 2:Then it might. Sometimes it stings. Then, yes, it's a bit confusing, right. You're like you didn't hurt a minute ago, but now you're seeing and now I need to do something about this yes, right, what changed? What's changed is your brain's got more information now. Now you've looked at it, you've seen the blood. Someone said blood. Now your brain's got information. Oh, maybe that is dangerous. Yeah, oh, maybe Helene does need to do something about this. Hello, have some pain. It gets your attention right. Pain interrupts us, interferes with what we're doing to get us to change our behavior. And so then we wash our finger, put a plaster on it.
Speaker 2:We're all good, okay, finger, put a plaster on it, we're all good, okay. So nociceptive pain is probably the most common pain that we're going to see in trauma. Okay, okay, because those nerves are firing and the brain has decided we're in danger. Then we have neuropathic pain. You're also going to see that in trauma. Neuropathic pain is pain which arises because of pathology in the nerve. Okay, so the nerves get damaged. We see that right. Neuropathic pain when nerves are damaged occurs because those danger nerves now start firing spontaneously like little electrical bursts. So neuropathic pain how do our patients describe it? Electrical shooting pins and needles tingling, burning. Down here in Cape Town my patient says dwarf pain. It's kind of numb that it hurts. Yeah, that kind of dwarf pain, okay, yeah, that's all pretty typical of neuropathic pain. Yeah, and it's not that I move the rib that it hurts, it's just that the nerve next to the rib got a bit irritated or inflamed and it's firing spontaneously.
Speaker 1:I see.
Speaker 2:Okay, and my brain receives it as exactly the same as the nociceptive message. My brain doesn't know how to tell the difference. It just goes, ow, that's no neuropathic pain, okay. Nociplastic pain probably less relevant in the acute trauma situation, unless somebody had a pre-existing nociplastic pain condition. Okay. But where we do need to pay attention to nociplastic pain is if we're not managing people's acute traumatic pain appropriately, we're really increasing their risk of nociplastic pain. Right, okay. So nociplastic pain is when the whole nociceptive system becomes so sensitive that it starts setting off the alarm despite the fact that nothing dangerous is happening.
Speaker 1:Okay, so I can see the difference there.
Speaker 2:You can see that straight away, right? So just flexing and extending my elbow might be painful, despite the fact that there's no tissue damage. It's healed, it's done, all right. Okay, we might get nociplastic pain with somebody who's had rib fractures healed. You know, we're three months down the line. We've got beautiful evidence of tissue healing. They're doing fantastically, but they still hurt, with coughing and sneezing, okay. Okay, that is because the nerves in that area have become sensitive from the injury, which they should, but they haven't desensitized with the healing.
Speaker 2:Okay, so there's still that background pain the whole time, that background sensitivity. The alarm keeps going off, going oh, careful, careful, we're vulnerable here, careful when actually there's no need for it to be careful. So it's plastic. The plasticity has changed right of the nociceptive system. Okay, okay, yeah, so those are the three kinds of pain, and all the way through we always think to ourselves when someone has pain, what's going on in the peripheral nervous system, what's going on in the spinal cord and ultimately, what's going on in the spinal cord and, ultimately, what's going on in the brain yeah because it's the brain that creates pain.
Speaker 2:Oh yes, of course, no brain no pain.
Speaker 1:Okay, okay, that's really interesting um. So, in relation to trauma, um, how is the timeline regarding tissue healing defined for the acute period of pain, subacute and chronic?
Speaker 2:Great question and it links to what I said just now. Someone had a rib fracture more than three months ago, right? So timelines are really important. And timelines are important because of tissue healing times. Okay, so… I always say that my students see, I know you learned this in first year or second year. See if you can remember it. So tissue healing phases your first phase of tissue healing, the inflammatory phase, okay, tends to last 10 days to two weeks. If somebody's got severe polytrauma and maybe a lot of comorbidities, it may last a little bit longer than that, but typically around two weeks we transition out of the inflammatory phase.
Speaker 2:Okay, okay, inflammatory phase peaks at 72 hours, which is something everyone forgets. So if it's bad on day one, day two is going to be horrible. Okay, 72 hours it peaks, settles down and by two weeks we transition out of the inflammatory phase. Okay, so the so in the inflammatory phase we've got lots of pro-inflammatory cytokines around. Okay, immune systems up.
Speaker 2:What's your endocrine system doing in the inflammatory phase? Big sympathetic nervous system, big cortisol release, lots of save activity going on right in that inflammatory phase. Okay, and all of that sensitizes the nervous system. So the peripheral nerves get very sensitive, spinal cord and brain all get very sensitive. So in the inflammatory phase pain is severe, okay, okay, um, and it's not necessarily directly in relation to the amount of inflammation we can see, because there are all of these other synergistic factors going on that might be adding to somebody's pain. Okay, then we move into our second phase of healing, tissue regeneration phase, and that lasts up to six weeks, Okay, six weeks, right, okay. And those are the first acute inflammatory phase and tissue regeneration phase, from zero to six weeks, where there's lots and lots of cellular activity, lots of stuff going on, okay. But pain in that second phase, between two weeks and six weeks, gradually settles down. Okay. Now, when pain is behaving the way we expect it to with tissue healing processes in that first six weeks, we call that acute pain, okay. Okay, now, when pain is behaving the way we expect it to, with tissue healing processes in that first six weeks, we call that acute pain. Okay, I kind of think of acute pain and nociceptive pain as pretty much mirroring each other. Yes, okay, okay. Is pain behaving the way you expect it to doing the things that you want it to protecting you when the tissues are vulnerable? As the tissues heal and become more robust, the pain settles down.
Speaker 2:Yes, yep, the third phase of healing six weeks to three months. We regard that as the subacute phase, that's your tissue remodeling phase. You remember remodeling from fracture healing, right, okay. So at six weeks we've got union, but from six weeks to three months we've got remodeling. So there's still stuff going on and pain in that phase not necessarily there all the time, but if you push the tissue hard it's going to go.
Speaker 2:Oh, we're not strong enough for that yet. Yeah, it's. It's still a little bit sore, okay. And again, that's normal when we regard that as sub acute pain. Okay, again. And no susceptive pain, right, okay. But three months is the magic line. Okay, three months is when most tissues in the body are healed. Helio, finished, doesn't matter if it was a slipped disc, fractured tibia, surgery. Three months, most things are healed, we're done, we're good to go, okay, okay. Three months, most things are healed, we're done, we're good to go, okay, okay. So if you still have pain after three months, we call that chronic pain, and that's not normal, healthy pain. Okay, that is essentially nociplastic pain, right, okay, that is pain where the system has got stuck being sensitive despite the fact that it doesn't need to be sensitive anymore because the tissues have healed.
Speaker 1:Okay, wonderful. Thank you for that beautiful description. You touched a little bit on the synergistic system. Could we maybe just talk a little bit about what that is made up of and how that influences pain?
Speaker 2:Okay, so you know you talked about pain as the neuroscience of pain. We're now talking about the psychoneuroimmune pain mechanisms, recognizing the synergistic systems and, to make it kind of manageable, the synergistic systems that I encourage people to pay attention to are the immune system, the autonomic nervous system and the endocrine system. Okay, okay, and if you think about managing trauma in the intensive care situation, those three are big. Yes, right, so we know that if somebody develops an infection or has come in with an infection, their pain will be worse. Definitely okay. And one of the reasons why we encourage people to monitor pain as the fifth vital sign is that if you start seeing temperature spiking and pain spiking, you've got an infection on board yeah all right, whereas sometimes, when you see a temperature spike on its own, you know, sometimes my anesthetists are saying, well, maybe that's just a post-anesthetic spike, yes, right.
Speaker 2:But if you see it going with pain, you've got an immune system that's kicking up into gear. You've got lots of TNF-alpha, interleukin-1-beta, all of your pro-inflammatory cytokines, immune system cascade kicking in and that is going to push pain up. Okay, so pain is useful then to tell you what's going on in the immune system. But also, don't be surprised if you're treating somebody for I don't know a fracture, and then they've got a bladder or respiratory infection. Their pain is worse. It doesn't mean something's gone wrong with the fracture.
Speaker 1:Yeah, and I think that's important to remember really important to remember.
Speaker 2:So I had a patient years ago who had this chronic knee pain and she phoned me and said I've done all my homework and my knee's so bad, please can I come and see you.
Speaker 2:And I was, yeah sure when you come into that. Well, I've got this terrible bladder infection. So I've got to come to the UTI clinic tomorrow and I said, you know what? Let's get the bladder infection under control and see what happens to your knee. And a week later she's, like my knee's, fine. So it's really important for us as physios to remember that if there's another infection going on in the body somewhere and I'm rehabbing something that has pain, that pain may be worse. And it's not that I've got a back off on my rehab. Yeah.
Speaker 2:Yeah, I'm remembering that Autonomic nervous system. Oh, in ICU doesn't it do some funky things, right? I mean, you know this way more than I do, but some of the autonomic dysautonomia things that happen when people have had long, long stays in the ICU, or even a short stay, but three or four days ventilator support, you start seeing that autonomic disruption going right. So if you're seeing autonomic disruption, if you're seeing unstable blood pressures or you're mobilizing your patient and they're dizzy and they're all over the place, or you're seeing some of that bladder sensitivity starting to kick in, those kind of autonomic nervous system disruptions, their pain may flare up as well. Okay, not because of the injury, but because of the autonomic nervous system. Yes, right. And then endocrine system Just keep it simple and think about stress, right. And then endocrine system Just keep it simple and think about stress. Okay, if I'm stressed, cortisol, endocrine consequences. Yeah.
Speaker 2:Okay, so anything that's going to disrupt the endocrine system is going to also sensitize neurons. Okay no-transcript.
Speaker 1:One other thing that we will leave as a topic for discussion for another episode is sleep and sleep quality in the ICU, and particularly in the trauma ICU as well, and how lack of sleep impacts on pain experienced and several other things, and so is sleep quality also part of the synergistic system Absolutely so we particularly think about sleep in terms of autonomic nervous system.
Speaker 2:Right, okay, right, and you're parasympathetic. Yes, you don't get any parasympathetic balance without good sleep. Yeah, we used to think the relationship between sleep and pain was bidirectional. So when you're in pain, you don't sleep, and if you don't sleep, you get more pain. Right, right and off it goes. But actually the recent evidence from our colleagues at FITS is that sleep drives it. From our colleagues at FITS is that sleep drives it. So if you're not sleeping, that's the bigger driver of pain, rather than pain disrupting sleep. Okay, that's interesting. Sleep is a primary focus in appropriate pain management. Okay, and I relate to that. I mean, if I've stayed awake for 72 hours, I have fibromyalgia, I'm in pain all over my body, I can't think, my memory is gone, I'm miserable and grumpy and in pain, and that's what sleep deprivation does for pain.
Speaker 1:Okay, yeah, so yeah, not sleeping in the ICU, that we know that pain management during this acute phase of pain is often driven by pharmacological management like opioids and paracetamol and several other methods of managing pain. But coming back to physiotherapy, what do you think would be the role of a physiotherapist in that context?
Speaker 2:Enormous. Okay. So the first thing is, if we're recognizing that pain is something my brain generates when it perceives that I'm in danger, then the physio has an enormous role to play in creating a sense of safety with the patient. Right, and we all do this right. We all make sure we make contact with our patient. Hi, yes, my name is Romy. This is who I am. This is what we're going to do today. Okay, but then the next thing is, before you just start doing your rehab with them, is to say how are you you feeling? What are you worried about? Is there anything on your mind that you'd like to chat to me about? What questions do you have? What are you scared of? Okay, and being very clear that in my physio session that at any time they can say stop, that actually they're in charge, yes, yeah.
Speaker 2:To give them that control, because one thing that we know about pain is that if we have pain but we feel like we're in control of it, it doesn't bother us that much Okay, but when we don't have control of it, that's when our distress goes through the roof. True, okay. So if you think about having a sore tooth, if your tooth is only sore when you stick your tongue in it, you don't go to the dentist. Well, I don't go to the dentist. It's only sore when you stick your tongue in it, because you're actually in control of it yeah.
Speaker 2:When you go to the dentist, when it's sore all day and all night and you don't have control of it anymore, you go to the dentist, True, and the dentist says to you why didn't you come to me months ago? This has obviously been going on for a long time, yeah, but it wasn't bothering me that much. Okay.
Speaker 2:So if, in the ICU setting, as a physio, I can give my patient some sense of control they might not have control of the bigger picture, but give them choices and a sense of control of what's happening and what's going to happen next. That then gives them a bit more control over the pain and reduces the threat of the situation. Okay, so communication strategies and how we engage with our patients make a huge difference. Yes, okay, then we have treatments, we have tools in our toolbox. Definitely Touch cold in our toolbox.
Speaker 2:Definitely Touch cold heat TENS. Some lovely new evidence coming out on TENS oh, that's great Acute traumatic pain for perioperative pain management. In fact, in Europe and in the UK TENS is now part of post-operative pain management. That's brilliant, right. So lots of things that we can do. And how great is TENS actually. If your patient is conscious enough and is able to have the power and control of their TENS machine, that's also going to feed into how well they respond to their pain?
Speaker 1:Yes, and I think in the ICU context that would be absolutely wonderful to be able to introduce to them. So I'm glad you mentioned that there's new evidence coming out for that specific modality as a pain management strategy post-operatively. You mentioned earlier in our discussion that it's important during the acute phase of injury that we as physiotherapists ensure that we manage pain adequately so that it doesn't escalate into chronic pain later on. So if we think about strategies that physiotherapists can use in order to ensure that we are aware of the patient's pain experience and that we manage it appropriately, any thoughts about that?
Speaker 2:so I think my first thought is sometimes, as physios, I think we, we think that if we treat the tissues and the injury, the pain will get better. Yeah, but it's important for us to treat the tissues and treat the pain separately. Okay, because it's a conscious construct in my brain. Yeah, okay, where do we start? We start with. Pain is about threat. So who's the person in front of me? What do they think is wrong? What are they afraid of? What are they worried about? Okay, so that cognitive reassurance, okay, is really important to reduce pain. Okay, what's also really important to reduce pain is validating someone's pain.
Speaker 1:Yes, and I think we don't always do that well. Yeah.
Speaker 2:And validating someone's pain doesn't have to take hours and doesn't go on forever. You know, I think sometimes it's busy, as we're worried that if I spend ages going, oh, I'm so sorry, it's so terrible that I'm never going to get into my rehab. You know, spend my whole session handing out tissues. But validation of someone's pain doesn't take long, it's a. I can see that this is really sore. I'm so sorry that this is happening to you. I can't imagine what it must be like for you. Okay, but here's what we're going to do to make the session manageable for you. Yeah, okay. So it's just a genuine touching down, if you like, of validating someone's pain experience.
Speaker 1:Yeah, and that you can do within a minute, exactly yeah.
Speaker 2:No, that's true, 30 seconds to one minute, it doesn't take long. But just sitting with it for a moment and going, I know this is sore and I'm really sorry this is happening to you. Yeah, and being genuine in that is really important. Yeah, because I don't know about you, but when I've been a patient in the hospital, setting you know, and people ask me about my pain and I say it's an 8 out of 10 and they just nod their heads and write it down, my reflex is but it'll be a 10. Just now, do you actually hear me? You know, it's kind of I'm sorry.
Speaker 2:That was really. I'm telling you it's quite bad. I need you to get it, yes, to acknowledge that, and sometimes we're being so professional and there's so much going on in our heads that we don't give the acknowledgement of it, and that's really important, yeah, okay.
Speaker 2:So treat pain separately. Treat the person, yes. Pay attention to what they're afraid of. Validate their pain, yeah, and then plan your treatment to address pain, perhaps before you mobilize them. So put an ice pack on and give it a good 10 to 15 minutes before you mobilize them, yes, or put the 10s on and give it a good 20 minutes before you mobilize them, or leave it on while you're mobilizing them, okay. So, thinking about the tools that you have, you know, get the extra pair of hands so that you can support the patient, teach the patient some mindfulness techniques, some mindful breathing techniques to use while you're doing other rehab with them. So, empower them with the self-management strategies. If you've got somebody who you know you're going to be working fairly passively, give them some virtual reality to engage in while you're doing that. Yeah, because that occupies the brain and distracts it, and now it's not worrying about the danger stuff yeah, I'm having a good time.
Speaker 2:So think about addressing the pain. What can I put in place before doing my physio, yeah, and then if there are analgesics, drug treatments, making sure that they've had the analgesia before you do your thing. You know, and they're working, you know. It's like how many minutes ago did you have that medication? Let's just wait a little bit until it gets to its optimum dose before yeah, I think that's very important, definitely.
Speaker 1:Um, just coming back to mindfulness therapy, um, and there's one method called imagery, um, I think I'm right where you ask your patient to visualize how they would do a certain activity, and I suppose that would also be useful in this context of pain and trauma and trying to mobilize and get active within all of this that the patient experiences Very useful, and imagery is useful for two things.
Speaker 2:So one thing is that when I imagine myself walking down the beach, I'm actually firing my premotor cortex, which then helps me fire my motor cortex. So if I'm about to get my patient out of bed and walking and they haven't for a long time it's useful for them to imagine walking first, because they'll do it more smoothly. Yeah, okay, it comes more easily. But imagery is also useful because it's a distraction technique. Now, when I say distraction, I'm not meaning just oh, don't think about it. I mean actively engaging your brain in something else so that it's not busy fretting about this danger thing, that's going on.
Speaker 2:Okay, some precautions, though, are needed with imagery. Don't give your patient an imagery you know I might say to you let's imagine walking down the beach at sunset, but you were mugged on the beach at sunset a couple of years ago. That's not going to be relaxing for you. So ask your patient you know where's your favorite place to be. Tell me about it. Can you imagine yourself there? And then use the senses. What can you see? Okay, what can you smell? What can you hear? Okay, can you taste anything?
Speaker 1:What can you touch Right?
Speaker 2:So bringing in those senses, bring in the senses and immerse them in that imagination. Okay, and that helps to ground them. It's a grounding technique which then reduces the threat evaluation in the brain and the fear of movement.
Speaker 1:Exactly, okay, exactly, and you would do that before you then get them to do their knee flexion exercises or standing up with a frame and walking Right, okay, and I suppose what we've spoken about is very useful to use in patients who are awake and responsive, but those that are not awake in the ICU, I think it's important that physiotherapists are just more observant of any signals from the person that they are experiencing pain, so facial grimace or a sudden retraction of a limb due to what you've been doing to that limb, because there's so much evidence out there to show that patients are at different levels of depth of sedation, and one is consciousness. Exactly yeah.
Speaker 1:And often you hear stories after the ICU experience where patients say they recognized a particular voice. They were aware of discussions around the bed side, but they just couldn't respond to it.
Speaker 2:Um and imagine if they recognize that particular voice and they know what comes next exactly, it's like that voice means that's the physio. What's happened to the threat level of my brain? The physio hasn't even started and the brain's on high alert. Yes, of course that physio session is going to be more painful. Yeah.
Speaker 2:And I think with those patients, you know some strategies that we can use is talking to the family. What music does this person like? Okay, what's their favorite place to be, you know? And so that while we're treating them and engaging them, we might have that music playing, yes, you know. Or we might talk to them about, oh, yeah, you know. I hear that. You know you love going to the beach. While we're moving your feet, why don't we think about walking down that beach?
Speaker 1:Yes, I think that's great, thinking about engaging in that way, and I think the engagement with a patient that is not able to respond to you is so vitally important, because we often see physios walking into the ICU and never talking to the patient. That seems unconscious or not able to respond to them.
Speaker 2:So it's really important that that communication takes place anyway, whether the nurse is laughing at you or not, or we're laughing at ourselves, and I think also it's helpful for us to be talking to that person, even if they're not responsive, for us to remember that we're treating the person, yeah.
Speaker 1:And, of course, in all of this, just to come back to the trauma aspect, to know what the precautions for movement are, to have discussed it with a surgeon and the rest of the multidisciplinary team in the ICU, and to be really sure that you know what you can and can't do.
Speaker 2:Absolutely, and that's why you know, when you said to me what can the physio do for pain or where do we start, it's that I've got to treat the tissues. I've got to know what the injuries are and what's safe to do and what my precautions and contraindications are. I must know that. But then I must treat pain separate to that. And I've got to treat pain and know that pain is not an accurate measure of all of those tissue issues.
Speaker 1:Yes, yeah, and to keep that in mind, yeah, yeah, yeah. Okay, rami, as a last comment, anything that you want to mention, or are you happy that we've covered?
Speaker 2:I think that one of the key things that I want to say to physios is that the non-pharmacological treatments for pain are where it's at, yes, in modern pain research and where all of the research is going and where clinical development is going. The drugs yes, there's ongoing research in what drugs we can use for pain, but they have minimal effect. They just turn down the volume a little bit. The things that really make a difference is what we do as physios is engaging with people, is reactivating them, is getting them moving, is helping them engage in meaningful life roles and doing the things that they love and enjoy. And so you know, in your ICU trauma setting, partnering with the occupational therapist, working together and working with the person, we can make a massive difference.
Speaker 1:Yes, yeah, I know that's very true. Thank you so much for your time. It's been wonderful to have this discussion with you. Thanks, helene, and thanks for having me. You're welcome.
