Understanding and Managing Delayed Recovery Post-Trauma: A Comprehensive Approach
Author: Gloria Gilbert, PT,M.Sc.
Diplomate, Canadian Academy of Pain Management
In the not-so-distant past, patients who struggled to recover after trauma were often dismissed with diagnoses such as “chronic pain”, “malingering”, or “exaggerating.” Dealing with the medical and legal aspects of these cases was undoubtedly challenging. Currently, it is better understood that the “delayed recovery post trauma” can be caused by many factors such as physical, psychological, and emotional.
Among the physical reasons, is the possibility that a mild traumatic brain injury may have occurred at the same time as trauma to the body.
The effect of those traumatic events are likely to be “invisible” (unless the patient has sustained a fracture etc) and may cause significant problems at home or work (now referred to as ADL)
Before we can assess the patient adequately and provide treatment guidelines, it is incumbent on us as health providers to be knowledgeable about the effects of trauma, what could be within our scope of practice to manage, and what issues, in time, should be delegated to another health provider.
So, why are we still using the word pain in clinical practice? What does it mean?
The Evolution of Pain Understanding:
In 1965, Drs Melzack and Wall described the Gate-Control Theory which provided a framework to better understand the integration of the physical and psychological experiences of pain.
The McGill Pain Questionnaire (McGill Pain Index) developed by Melzack and Torgerson in 1971 used descriptors to better delineate physical from emotional from ‘other’ ‘possible’ sensations people could be experiencing (feeling) when they are in pain.
The International Association for the Study of Pain was established in 1970
It was not until 1979, that IASP published a definition of pain: ’An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’
The IASP definition was updated in 2020 when IASP added ‘notes’ (which essentially were the associated biopsychosocial factors that could affect the experience of the person in pain)
The Current Definition of Pain:
The Current IASP definition of Pain is: An unpleasant sensory and emotional experience associated with or resembling that of actual or potential tissue damage:
Pain is always a personal experience that is influenced to varying degrees by biological, psychological and social factors.
Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
Through their life experiences, individuals learn the concept of pain.
A person’s report of and experience of pain should be respected.
Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.
Verbal description is only one of the several behaviours to express pain; the inability to communicate does not negate the possibility that a human or non-human animal experience pain.
Promoting Accurate Expression of Sensations:
As clinicians, should we not encourage our patients to describe WHAT and HOW they are feeling and whether or not they can CHANGE what they are feeling? Perhaps it is NOT a pain word, but a sensation or symptom they do not like or understand, and because we have not provided a vocabulary for them to use.
For example:
PHYSICAL WORDS: aching, stabbing, shooting, burning
EMOTIONAL WORDS: stressed, worried, anxious, sad
And now let’s introduce the possibility that this patient has also sustained an Acquired Head Injury (or mild traumatic brain injury mtbi), which may or may not have been diagnosed or investigated thoroughly.
According to the Framework developed by the Ontario Neurotrauma Foundation, we can now add descriptors and ‘separate sensations’ into other categories.
PHYSICAL: tinnitus, sensitivity to light or noise, headache, nausea/ vomiting, dizziness, vision/blurred or double, balance problems
EMOTIONAL: confused, sleeping more than usual, depression, drowsiness, irritability
COGNITIVE: memory, comprehension, concentration, feeling in a ‘fog or dazed’, feeling ‘slowed down’.
Furthermore, we must be realistic that there are many biopsychosocial factors (e.g. Gender, Age, Lifestyle, Culture) that affect our patients’ ability to both understand and manage their problems.
Before we can assess and implement a treatment program for our post-trauma/ABI patients, we must ensure that we ourselves have accessed reliable and appropriate educational and assessment resources.
Resources for Further Reading:
Ontario Brain Injury Association: www.obia.ca
ECHO Ontario www.echoontario.ca ( Many programs including Concussion and Chronic Pain Evening Series)
Ontario Neurotrauma Foundation: www.braininjuryguidelines.org/concussion
Gloria Gilbert, PT,M.Sc. is a dedicated physiotherapist with over five decades of experience. In 1982, she established The Downtown Clinic in London, Ontario, to provide personalized care for patients with persistent pain and chronic conditions. Recognizing the challenges faced by individuals with limited access to treatment, Gloria developed the comprehensive Encompass program, combining various healthcare disciplines to address patients' unique needs. After 33 years of service, Gloria closed The Downtown Clinic in 2015 but remains an active and licensed member of the College of Physiotherapists of Ontario. Today, she continues to make a difference by offering assessments and treatments through a secure online platform. For more information, contact Gloria at gloria@dontgototheouch.com or connect with her on LinkedIn here.
You can purchase the e-book version of Gloria’s book “Don’t Go to the Ouch!” here.
