Considerations of Pain Management in Physical Rehabilitation

In this Clinical Insight, we reflect on, and link together, the importance of pain management principles in the rehabilitation of traumatic musculoskeletal injury.

Rehabilitation under conditions of high pain is extremely challenging. When a rehabilitation plan is built without adequately addressing the underlying pain drivers, engagement is reduced, movement is limited and outcomes are not optimised.

Pain management in trauma rehabilitation

Pain management is a critical component of major trauma care. It is a key enabler of definitive treatment and rehabilitation, it supports psychological recovery from the event, and it offers a locus of control to the patient, reinforcing effective behaviours and functional reablement.

In the acute phase, severe, unrelieved pain has physiological consequences that can worsen injury. Acute pain drives a powerful stress response such as tachycardia and hypertension. Effective early pain management – whether via systemic analgesia, regional techniques or multimodal regimens – helps modulate this stress response and supports early medical and surgical recovery. Challenges remain, of course, with issues such as dependence, adverse effects and polypharmacy, all of which must be carefully risk‑assessed and managed (Hsu et al. 2019).

As the acute phase resolves, we are then left with the challenge of rehabilitation in a highly painful situation.

What is rehabilitation in this context?

It can be understood as a process of self‑actualisation: enabling a person to reach their potential after major trauma. Effective pain management sets the scene for aspirational goal‑setting by offering a credible vision of the future. In physical rehabilitation, this defines the plan, the milestones and the expected gains, all of which become achievable rewards. These rewards are endogenous and help drive a positive response to tasks and activities.

Rehabilitation activity will often be painful. However, when that pain is managed within a framework of control, the patient can engage with and tolerate the necessary stress of therapy while still achieving the desired outcome. Without this, we lose capacity across multiple systems – particularly respiratory, musculoskeletal and neurological – and rehabilitation stalls. In contrast, good pain management offers a clear multi‑system benefit.

The impact of pain on recovery and movement

Without effective pain management strategies, the physiology of recovery is negatively affected. From the most basic components such as joint movement, soft tissue excursion and the health of the nervous system, everything depends on our ability to restore and tolerate movement. This is the ripple effect of returning to function, and then to life‑supporting activities that underpin social and emotional wellbeing.

Bone and soft tissues require movement, load and controlled stress to heal and remodel effectively. If this process is inhibited peripherally by pain or fear of movement, we see poorer functional outcomes. Centrally, the nervous system can adapt in maladaptive ways, altering movement prediction, the expression of sensation and the way sensory feedback is processed. These central and peripheral changes combine to limit recovery and reduce the effectiveness of rehabilitation.

A whole-person approach to rehabilitation

The symbiotic relationship between physical and psychological wellbeing means that a whole‑person model is essential to achieve optimal results. Interdisciplinary care is vital and may extend to vocational rehabilitation, social support and the voluntary sector (Stanos et al. 2012).

In summary, pain management is a balance of external support, cognitive strategies and careful calibration of desired outcomes against fear and distress. To do this effectively in physical recovery and rehabilitation, an interdisciplinary, whole‑person approach is key, while goal‑setting within an aspirational but realistic framework can be particularly advantageous.

References:

Hsu, J.R., Mir, H., Wally, M.K. and Seymour, R.B., 2019. Clinical practice guidelines for pain management in acute musculoskeletal injury. Journal of orthopaedic trauma, 33(5), pp.e158-e182.
Stanos, S., 2012. Focused review of interdisciplinary pain rehabilitation programs for chronic pain management. Current pain and headache reports, 16(2), pp.147-152.