Why Unexpected Pain Hits Different

Researchers out of Japan wanted to take a closer look at a phenomenon they call “Bayesian surprise” in terms of pain perception. The concept refers to how our brains process pain when the reality of the situation doesn’t match our expectations. Pain varies from person to person and even within the same person, as sometimes an injury hurts significantly, while other times it is much less intense. Researchers believe part of this difference in pain experience within the individual is tied to an individual’s perception and expectations of pain.

This phenomenon isn’t exactly new, as there have been countless studies on the placebo effect and how our brains work when they believe they are being medicated for a condition. Similarly, the “Bayesian surprise” seeks to explain how our expectations of pain can impact our actual experience.

For the study, researchers had participants wear a virtual reality headset and manipulate a virtual knife with their left hand. Participants were directed to stab the virtual knife into their right forearm when they heard an audible beep. Meanwhile, a thermal device applied real heat to the corresponding spot on their actual arm.

Researchers first tracked how pain experiences changes by varying the timing of the heat simulation. Sometimes the heat was applied as soon as the virtual knife made contact, while other times it was slightly delayed. Occasionally, the knife would disappear in the virtual world right before contact was made with the arm. Researchers tracked brain processes to see how these actions led to different responses within the brain.

Participants reported much higher pain intensity when the heat simulations were delayed and when the knife would unexpectedly disappear. Essentially, patients reported more pain when it came as a surprise. This suggests that our brains perceive pain not just based on the physical stimulus itself, but also by how much that stimulus violates our expectations of pain. When a painful stimulus surprises us, like getting a paper cut or stubbing your toe, the surprise factor may amplify our pain experience.

On a larger scale, this study also suggests why it is so important that doctors work to help their patients have realistic pain expectations during the course of their care. We never want you to be afraid of pain or discomfort that you might experience, but at the same time, if discomfort will be present, we want you to be aware of this. If you underestimate pain or assume painkillers will drown out all your discomfort, you may actually find that your pain levels are amplified because of the surprise factor!

For more information, reach out to Dr. Silverman by filling out this contact form.

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Continued Pain After Surgery

There are a number of different reasons why you may still be experiencing pain in the wake of your foot procedure. Here’s a closer look at some of the most common reasons, and what steps you should consider next.

Still Rehabbing – You may still be experiencing pain and discomfort in your foot region following surgery simply because recovery hasn’t fully run its course. We bear an immense amount of strain through our feet when we walk and run, so it’s not uncommon for recovery after surgery to take 6-12 months or longer. The pain you’re experiencing may be completely normal, and it may just be a byproduct of your foot working to become the strongest version of itself following your operation. Talk with your doctor if you are concerned about lingering discomfort, but know that this could be completely normal depending on your rehabilitation schedule.

Mismatched Expectations – Sometimes there is so much arthritic degeneration or bone malformation that surgery simply isn’t going to be able to fully resolve all of your discomfort. We’re confident that your feet will feel better than they did prior to the operation, but perhaps total pain elimination was never an expected outcome. Make sure you’re on the same page with your doctor when it comes to goals and expected outcomes so that you don’t have any mismatched expectations after your procedure.

Misdiagnosis – While incredibly rare, we do want to touch on the possibility that the underlying issue was not addressed during surgery because of a misdiagnosis. This is why physical exams, imaging tests and conservative treatments are all used prior to surgery to ensure that the provider has a complete understanding of the issue and how to best treat it. If you’re concerned that your underlying issue may not have been addressed during an operation, seek out a second opinion.

Surgical Issue – There’s also the possibility that surgery did not go exactly as planned. Nerve damage or an infection could cause localized pain and discomfort following a procedure, and again, your surgical team will work tirelessly to reduce the likelihood of these possible complications, but they can never be completely prevented. If you suspect that your discomfort is due to a surgical site infection or a problem with your incision, reach out to your care team right away. If you suspect that there is an underlying nerve issue, consult with your care team or seek out a second opinion.

In the vast majority of instances, pain or discomfort following a surgical procedure is due to one of the first two reasons. Either you’re still in the rehabilitation process and soft tissues are healing, or there was a possibility that the goal was to improve pain, not eliminate it. Whatever the underlying issue, if you are concerned about the pain or want to learn more about the recovery process, please reach back out to your care team. They would be more than happy to provide answers and do what they can to keep your rehabilitation on track.

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How Doctors Should Prepare Their Patients For Post-Op Pain

Your doctor plays a key role in helping you get past any post-op pain, and this begins well before you go under the knife. For starters, your doctor needs to help ensure you have realistic expectations about the operation and your projected outcomes. Not only should doctors explain what to expect from a pain standpoint, but they’ll also want to cover rehab expectations. For example, while physical therapy may be painful in the short-term, it can help to improve flexibility and decrease pain in the long-term, so these trade-offs should be discussed so the patient knows that some parts of their rehab may be uncomfortable. If a patient has unrealistic expectations or isn’t willing to commit to their rehab, their pain may feel stronger or linger longer.

Another thing doctors will want to do is to ensure the patient knows that they are there as a resource during the patient’s recovery. If the patient feels like something is wrong, like their recovery is stalling or they aren’t sure on how to best manage their medications, all you need to do is reach out to a member of our team. We’d be happy to answer any questions you might have, and education is a great way to help deal with pain because it’ll help you understand how to best manage your condition.

Finally, doctors should also consult with their patients to see how they have managed pain in the past, especially if they have undergone previous surgeries. What areas of pain care did you struggle with, or how were you best able to control pain? Learning from your past experiences can help us alleviate pain as you progress through your next rehab.

How Patients Can Prepare

Patients can also do some things prior to surgery to help them manage the pain that will persist in the future. Aside from getting on the same page with your doctor by following the above points and understanding how to manage your medications after surgery, you’ll also want to:

Prepare some distractions – Mentally engaging exercises like crossword puzzles, reading or even conversation with loved ones can help take your mind off your pain. Have some distractions nearby so you can help take your mind off your discomfort as you recover.

Stick to your rehab – Even though physical therapy and your rehab exercises may be painful at the moment, they are great for pain control and mobility in the long run. Make sure you understand what will be asked of you after surgery so you can mentally prepare for it afterwards.

Express your concerns – Also, if you have any concerns about potential painkillers, be it about allergic reactions or a possible dependency issue, bring your concerns up to your doctor. We may not have access to certain medical records, so if you are afraid that painkillers could lead to a relapse, talk to your doctor about alternatives to pain medications.

Get healthy – Finally, while you may not be able to change your total body health in the short time before surgery, any little bit helps when it comes to pain care and your recovery. If you can drop a few pounds and ensure your body is getting a range of healthy vitamins and minerals, it will be better able to handle the trauma of surgery. Every pound you drop takes pressure off your recovering joints and muscles, so work towards a healthy weight prior to your operation.

If you keep these tips in mind, we’re confident you’ll be best able to control pain after an operation. For more tips, head on over to the AAOS’s website.

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To determine if time affects our perception of pain, researchers asked 127 marathon runners to report their pain levels immediately after running a marathon. Researchers also asked runners to recall how much pain they were in during the race one week and one month after marathon completion.

After looking at the results, researchers found that runners underestimated their memory of pain as time went on. For example, a runner who claimed to have a pain score of “6” immediately after the race is more likely to rate that pain a five or a four when asked to recall how much pain they were in one week or one month down the road. Researchers say underestimating past pain is more common when the pain is associated with a positive event, like completing a marathon or getting a tattoo, instead of a negative event, like falling on ice and breaking your ankle.

“Suffering in a situation that is perceived as positive and desirable may be remembered differently than the pain associated with traumatic and poorly controllable events such as illness, injury or surgery,” lead researcher Przemyslaw Babel said.

Recollection Of Pain

It’s certainly an interesting study, and it makes sense that pain that is associated with a positive event or an accomplishment is often underestimated, especially when compared to pain associated with a negative event. It’s the same reason many runners sign up for another marathon shortly after completing the last one, even though it was painful. Pain is temporary, but the feeling of accomplishment last longer, and it leads to us underestimating “in the moment” pain when we look back on the event.

It would be interesting to take this study and bring it into the operating room. I would like to see how people estimate pain and discomfort levels before and after surgery, and then how they perceive it down the road, especially if we could track the outcomes after surgery. I’m sure we’d seen something similar, with people who experience the most healing and best outcomes underestimating their discomfort before and after surgery, while others who don’t experience as favorable of outcomes having a more accurate estimation of their past pain.

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Feeling pain makes you pull your hand off a hot pot before a bad burn or come in from the cold to prevent frostbite. It also tells you when you have a cut, broken bone or eaten something you should have not eaten. We never forget these events because they “hurt!” Your body is very smart and ‘Mother Nature’ has created the nerves that “feel” pain. These special nerves are called ‘pain fibers.’ The real answer is PAIN is the way your brain understands the signals from those nerves. Your brain then stores these memories to stop you from repeating a painful event. So there is always a reason for pain every time you experience it. There is an old joke and it’s true, “It hurts when I do that.” And your doctor says, “So don’t do it.”

Pain has many benefits. It helps the body release special chemicals that are needed for healthy healing. Pain also tells us when we are overdoing it. In addition, pain is an early warning system for most medical complications. Using too much pain medication can override Mother Nature’s messages. Therefore masking pain completely with a drug is never ideal. It can lead to failure of fracture repair, increased swelling, delayed healing and missed complications.

When injured, pain should be addressed by first fixing the reason for the pain: cast the fracture, stitch the cut, fix the bone or start an antibiotic. Then we can use treatments to decrease pain at the source like anti-inflammatories for inflammation, elevation and ice for swelling.  Narcotics are never the only treatment for pain. Medications should never mask pain so completely that your own body’s ways of helping you heal cannot work properly.  A dog never walks on a broken paw until it stops hurting. Only people take possibly addicting medications so they can walk, run, work or drive while having a painful limb.

Still, after an injury or surgery, pain medications are often prescribed. Pain medication can help get people moving after an injury and movement has great benefits. Therefore, we don’t want to have too much pain and at the same time no one wants their doctor to miss the early signs of a preventable complication because of too much medication.

Anxiety, stress, fear, muscle spasm, swelling and not resting or elevating an injured body part can all worsen pain. Fortunately, stress, anxiety and muscle spasm can be treated with non-narcotic medications. For each problem, the full choice of treatments should be considered before increasing or continuing a narcotic in place of solving the real problem.

Whether the patient is an adult or a child, having family or friends become part of the team to deal with pain from an injury or surgery is important. Bring someone along to make the plan with your doctor, and to help stick to the plan once you are home.”

As doctors, our goal is to help ‘Mother Nature’ do her job, not help our patients hurt themselves more. Always choose appropriate treatments over narcotic pain medicine as a first choice and help us stop the National Narcotic Addition Epidemic! We can only do it together.

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Here are some examples of so called “Opioid” or “narcotic” pain medications:

Morphine, Vicodin (Hydrocodone), Percocet (oxycodone), Codeine, Oxycontin, Dilaudid, Tylenol with codeine and others. Approximately 100 people die in the US per day from overdoses. Not starting these medications when they are not the first choice for a problem is our first step to saving these lives. The USA uses the majority of the world’s oral Narcotic (opioid) medications and we are 5% of the world’s population.

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1)  Not wearing the right footwear

The majority of people who decide to take up running as a new hobby want to go out and try a short run right away.  While a short run is a good way to build up endurance, doing so in the wrong footwear can put you in the doctor’s office in no time.  Not only are running shoes built to provide support for your ankles and feet, but they are also designed to give you enhanced traction with the ground.  Running without proper footwear can lead to sprains, strains, slips, and a slew of related maladies.

2)  Overdoing it early

Another common problem for amateur runners is that try to run too much, too soon.  Overworking your muscles and bones can lead to overuse injuries like blisters, stress fractures, and shin splints.  Don’t try to up your mileage from three miles to five miles in the course of a week.  Also, if you’re training during the week, be sure to take at least one day off.  Try to make it during the middle of the week instead of running Monday-Thursday and taking Friday off.  Consider working on your upper body muscles or abs during the week to give your legs a break.

3)  Failing to stay hydrated

Staying properly hydrated is important for runners of all skill levels, but it’s the novice ones that usually don’t understand how much fluids they lose during a run.  A general rule of thumb to consider is to consumer six ounces of fluids for every 20 minutes you run.  You should also consider replacing some fluids with sports drinks like Gatorade or Powerade during runs lasting longer than an hour, as your body will be losing some key nutrients and minerals during the extended run.  Runners should also properly hydrate before a run by consuming 16-24 ounces of a non-caffeinated liquid.

4)  Poor form

Although we’ve already discussed the proper form for each part of your body while running, it’s important to reiterate the significance of using the right running technique.  If your hips are out of line or your stride is too long, you can develop significant problems in your knees and ankle joints.  Run with your chest and head facing forward, and make sure your arms don’t cross in front of your body.  If you are running correctly, your feet should land directly underneath your body with each step.

5)  Not warming up or cooling down

Although there have been recent articles that question whether stretching before a run is actually better for you, any expert will tell you that it is important to warm up before going for a run.  Starting out with a light jog will increase your heart rate, warm your body temperature, and increase blood circulation in your body, all of which are beneficial before starting to run.  A similar technique should be used at the end of a run.  Cool down with a 5-10 minute walk, and do some light stretches to aid in muscle recovery.  Your muscles become contracted when you run, so stretching after a workout will help re-lengthen them.

Related source:  About.com

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1. Offer Rides

Ask if your family member or friend needs a ride home from the hospital after the procedure.  You might volunteer transport and even go to the surgical center and wait during the recovery period after the surgery.  Rides will be something your family member will need for quite some time, so consider offering rides at other times as well.  They might need rides for work, errands, or other occasions.

2. Help with Instructions

When someone has surgery, they might be a bit foggy on exact instructions.  You can help by figuring out what the person needs to do and then helping them do it.  Doctors will send post-surgery instructions home with their patients, and from those instructions you can create a schedule that includes medications, doctor’s orders, physical therapy exercises, and other items so your family member can keep it all in order.

3. Offer Alternatives to Crutches

Crutches can be very helpful for getting around, but they can also be very hard for some people.  Offer your family a few options as shown on GoodbyeCrutches.com.  Items like the Hands Free Crutch, the Knee Walker, or the Seated Scooter could greatly improve the mobility of your family member after his foot surgery.

4. Offer Specific Help

Think about the things you normally do around your house that would be hard to do on one foot and then offer to do those things for your family member.  You could mow the lawn, do the laundry, cook, clean, etc.  Keep in mind that it is easier for someone to accept help when you are specific about what you are offering.  Instead of telling him to ask for what he needs, offer something specific.

5. Watch for Issues

If you will be around your family member for an extended period, study some of the adverse affects someone can have after a foot surgery and then watch for those signs.  You will want to call the doctor, for example, if the patient has a fever of 101 or higher.  Keep an eye on the swelling in the foot as well as its color.  Also, make sure there is not too much drainage coming from the surgical incision.  It is important for you to watch for these issues because your family member, having just come from surgery, may not be alert enough to notice the danger signs.

There are plenty of other things you can do for someone after a foot surgery, but these ideas are a great start to help your family member along their road to recovery.

Author Bio:

Brooke Williams is an award winning writer for Goodbye Crutches, the largest distributor of modern alternatives to crutches that serves those who can’t bear weight and can’t bear crutches.  A former radio announcer turned freelance writer she contributes to many other websites.  She has authored four complete books as well.  Brooke has been married for 10 years and has two daughters, Kaelyn, who is nearly 4 and Sadie who is one month old.

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Joint hypermobility at age 14, sometimes commonly referred to as “double jointedness”, led to increased musculoskeletal pain four years later in the ankle and foot, the knees, and the shoulders.

Even more interesting, the likelihood of musculoskeletal pain was significantly greater if the teens were considered obese.  Researchers for Arthritis & Rheumatism found that double-jointed teens were 10 times more likely to suffer musculoskeletal pain if they were considered clinically obese.

For the study, British researchers enrolled over 14,000 pregnant women during the early 90’s, and asked that their children be examined for hypermobility around the age of 14.  The children were then asked to report on their pain history when they were 18.

To determine if a child was hypermobile, they needed to score a 6 or higher on the nine-point Beighton scale, which measures mobility.

According to data, girls were five times more likely than boys to exhibit double jointedness.  Of the participants who were considered hypermobile, 45% of them reported experiencing pain for at least one day in the past month.  Similarly, girls were more likely to experience pain (47.5%) than boys (41.3%).  The pain most commonly occurred at the ankle/foot, knee, shoulder and spine.

Regardless of sex, when compared to pain data for adolescents without hypermobility, researchers found that double jointed teens were almost twice as likely to suffer from musculoskeletal pain.

In addition, teens with hypermobility suffer from more intense pain.  Researchers asked both groups to rate the pain on a scale of 1 to 10, with 10 indicating immense pain.  Double jointed teens reported average scores of 5.92 for their worst pain in the past 6 months, while non-hypermobile teens reported a score of 5.41.

Both groups reported that the most immense pain was felt in their foot/ankle region, as their pain scores were 8.17 for hypermobile teens, and 6.98 for non-hypermobile teens.

“Certain joints may be more susceptible such as the shoulder (due to lack of inherent stability) or knee and ankle/foot (due to high forces exerted by weight bearing),” the researchers concluded.

Researchers suggested that obese children were at an increased risk to suffer pain because more weight was being placed on their knee and ankle joints.

Dr. Silverman comments

This is a very interesting study.

Hypermobility is a condition in which joints are loose.  Some people refer to this condition as “double-jointedness.”  They’re not really double-jointed, but their ligaments are loose and can stretch more than normal.  Having increased ability to move your joints can have significant advantages during some athletics such as dance, gymnastics and skating.  However, there is a healthy balance between excessive laxity and flexibility.  Having hypermobility leads to problems.

In my practice, I see many patients with ankle ligament and hindfoot instability. These patients will roll their ankle on uneven ground, feel pain in the ankle when walking on many different types of surfaces, and develop arthritis and tendon tears over extended period of time.  During an examination, I always check for signs of hypermobility. Excessive elbow or knee extensions are good ways to identify the condition, but my favorite and most reliable test is wrist flexibility. If your thumb can touch your forearm, you have hypermobility.

It’s important to identify patients with hypermobility prior to treating them.  Surgical treatments have higher rates of failure if the hypermobility is not identified. Nonsurgical treatment, otherwise known as symptom modification, is also likely to fail.  I make modifications to my surgical plan for many circumstances, including the discovery of hypermobility.  For example, I will perform different types of bunion corrections, and I will be more likely to perform surgical arthrodesis for deformity corrections.

What is concerning about this study is that the most immense pain was in the foot/ankle region.  This means that treatment of foot and ankle pain is poor in comparison to treatment of other joints in this patient population.

Related source:  MedPage Today

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Plantar fasciitis occurs when the connective tissues on the bottom of the feet become inflamed. The injury is common for people that put a lot of stress on their feet, like runners or overweight individuals. Common steroids are sometimes used to address plantar fasciitis, but about two to six percent of steroid treatments can lead to a rupture of the plantar fascia.

Researchers at the Autonomous University of Nuevo Leon wanted to find an alternative treatment option for patients suffering from plantar fasciitis. They decided to see how botulinium toxin, commonly known as Botox, affected patients.

Botox works by blocking a neurotransmitter called acetylcholine, which leads to a weakened muscle state for several months. They believed the Botox injections would lead to less foot pain in patients and result in less fascia ruptures.

For their study, researchers divided 36 individuals into two double-blind groups. One group received the Botox injections, while the other group received the normal steroid injections. Both groups also participated in foot-stretching exercises, another common course of treatment.

Findings

During the recovery process, individuals who received the Botox injections reported less pain than those who received steroid injections. The people who underwent the Botox treatment also reported better foot function and alignment.

Conclusion

“We found that a combination of [Botox] applications into the gastroc-soleus complex and plantar fascia stretching exercises yielded better results for the treatment of plantar fasciitis than intralesional steroids,” said, Dr. Carlos Acosta-Olivo, who administered the study. Researchers hope to test their methods on a larger group to see if Botox can reduce the rate of fascia ruptures associated with common steroids.

Dr. Silverman comments:

Botox injections are very controversial, but I would be interested to see this study conducted with a larger sample size.

Cortisone injections cause plantar fascia tissue to degenerate and rupture (acutely or gradually). Regardless, the tissue can become incompetent. Some people tolerate this rupture as the foot has other supportive structures, but many don’t. I do not inject the plantar fascia on patients as I feel such treatment, while standard of care, violates the sense test (“If it doesn’t make sense, don’t do it”).

Cortisone denatures collagen and causes tissues under tension to rupture. Doctors do not perform cortisone injections into tissues that are tearing without expecting the tissue to tear anywhere else in the body except the plantar fascia. If they did they would be sued for malpractice. Injections of the Achilles and the patellar tendon were done in the past and many people sustained tendon ruptures.

So why does injection of the plantar fascia persist? Because rupture is only symptomatic in some and not in others, confounding the results.  This is where the study is most flawed. They compare cortisone in the plantar fascia to essentially a temporary paralysis of one of the largest, most powerful muscles in the body. Botox to the gastrocneumius passes the sense test and the early results lend support to this deduction

Related source: Science Daily

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