David Ring, MD, PhD is an Orthopaedic Hand Surgeon at the Massachusetts General Hospital, Boston, specializing in arm fractures, post-traumatic reconstruction, hand surgery and elbow surgery.
Some fractures frustrate us. Adverse events always affect us. But nothing takes the wind from our sails more than a patient who has greater pain and disability than expected. We are used to having answers and knowing what to do. For diagnoses like open fracture, compartment syndrome, or an elbow that will not stay reduced, we feel like we can make a difference. But when our patients have stiff fingers, a stiff elbow, or persistent disabling pain the answers do not always come easily (1).
Coaching, encouragement, and reassurance can backfire. To the injured it may seem like we are not listening, we are dismissing their concerns, or we feel they are not trying hard enough. Telling a patient something encouraging and optimistic like, “no pain, no gain” seems to say that we think he or she is a wimp. Without trying to do so, we can dig ourselves into a very deep hole.
It is tempting to give up. The bone is fixed. My work is done. This is not my problem. Perhaps the physical therapist, pain doctor, or alternative practitioner will have the answer. Unfortunately, these experts are often at as much of a loss as we are. Giving patients stronger narcotics, injections, or alternative treatments often disappoint them and can seem like a step backwards. It stinks. There must be some hope.
On the other hand, once you have been in practice for awhile you realize that most patients eventually figure it out and complete the recovery – even after many months of little or no progress. We also are afforded the privilege to see the patients who recover much more rapidly and completely than we expect, and patients who make the best out of their situation when the injury is severe. If we could just figure this out and bottle it!
Psychologists call it self-efficacy (2): “I can do it”; “I have got this”; “I will be fine.” The key to health and wellness is within. The opposite is catastrophic thinking and passivity: “Someone needs to fix this or I will never be able to rely on my hand again”. With insight, some guidance, and lots of practice, catastrophic thinking can be replaced with self-efficacy (3).
Trauma surgeons see this all the time. As patients recover, the natural protective state where our worst thoughts are convincing (“If I push it any more I will rip the plate out;” “I will never play tennis again”) gives way to increasing confidence in self-stretches and trust in the hand. We can all likely recognize this process in some of the rougher patches of our own lives.
Dr. David Ring examining a patient’s hand at the Mass General Hospital
One formal method for coaching and accelerating this process is what psychologists call cognitive behavioral therapy, which is learning to separate thought from fact (4). This is particularly useful for relatively intuitive people who can navigate through what is real and what is irrational. Those who are used to trusting their gut feelings often find it particularly difficult to change mindset. One day soon patients and providers will seek out this kind of fitness for their thoughts and behaviors like they seek out physical fitness today. A coach or trainer can be invaluable.
But what can we do today? It all starts with empathy. To paraphrase Osler: Patients do not care how much you know until they know how much you care. Language that acknowledges the patient’s thoughts and emotions is key: “Does it feel like you can’t depend on the hand?” “… like you’re going to do harm?” “… like the exercises are not going to work?” When you get a nod, you know you have connected.
Acknowledge how difficult and counterintuitive it is to do a painful stretch after injury. Normalize it: “This is how we are built. It is an evolutionary advantage to react to pain protectively and prepare for the worst;” “Pain sets off the ‘alarm’ like smoke sets off the fire alarm. Just like in the kitchen, it’s usually a false alarm.” Analogies can be easier for the patient to absorb and seem less confrontational – even when the message is counterintuitive.
Celebrate small improvements and insights. Be patient. Explain things that are counterintuitive, but do not try to convince — just offer your expertise. One of the most common misconceptions is that swelling blocks motion. If patients trust you and are prepared, you can encourage them in a self-assisted stretch and show that this is not true – particularly for stiff fingers.
Be aware of your own thoughts and emotions. Stress contagion is when the patient’s stress transfers to the provider. It can make you say or do something counterproductive. Do not be overprotective. I find therapists tend to do this almost automatically or as part of their profession: “Work to pain, but not beyond;” “Do not overdo it, you will cause inflammation.” As we all know, you are not doing the stretch correctly unless it is uncomfortable, and the more stretching the better.
Recovery is not just about new bone bridging the fracture line. Recovery is regaining confidence in your arm or leg and knowing that things will be okay – in spite of permanent impairments. Our expertise facilitates the biological aspects of recovery, but we can play an important role in the cognitive and emotional parts of recovery as well.
Opportunities for Empathy
The patients says:
“I have a high threshold for pain, but…”
You say:
“It probably feels like the wrong thing to do”
The patients says:
“It’s unbearable”, “It’s excruciating”
You say:
“You’ve been through a lot;” “Your reserves are probably tapped”
The patients says:
“This is as far as it will go”
You say:
“Does it feel like your going to prevent it from healing or maybe pull out the plate?”
The patients says:
“I’m trying as hard as I can”
You say:
“I know that you’re giving this your all. The stretches are so counterintuitive”
The patients says:
“I’m dropping things”
You say:
“It probably feels like you won’t be able to rely on your arm”
References
1. Ring D, Barth R, Barsky A. Evidence-based medicine: disproportionate pain and disability. J Hand Surg Am. 2010 Aug;35(8):1345-7. PubMed PMID: 20684932.
2. Arnstein P. The mediation of disability by self-efficacy in different samples of chronic pain patients. Disabil Rehabil. 2000;22(17):794-801.
3. Vranceanu AM, Barsky A, Ring D. Psychosocial aspects of disabling musculoskeletal pain. J Bone Joint Surg Am. 2009 Aug;91(8):2014-8.
4. Vranceanu AM, Safren S. Cognitive-behavioral therapy for hand and arm pain. J Hand Ther. 2011 Apr-Jun;24(2):124-30; quiz 131. Epub 2010 Nov 4. PubMed PMID: 21051204.
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Filed under: Hand, Trauma, Trauma Rounds | Tagged: fracture healing, fractures, Hand, Trauma | 1 Comment »
John Kwon, MD is an orthopaedic surgeon at the Massachusetts General Hospital, Boston and a member of the Foot & Ankle Service, as well as the Partners Orthopaedic Trauma Service. Dr. Kwon specializes in foot & ankle fractures, sports injuries and correction of foot & ankle deformities.
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