Bono’s arm

Bono’s arm — Anyone who has read Bono’s recent post will know that he believes that he may not play his guitar again. As a rock and roll icon, this is a strong message that reveals the mortality of man.

Many times I have heard people tell me that they cannot do what they used to do. This is usually because of pain or a physical limitation. Often this pain and limitation has been in existence for some time before they come to see me, and hence the body has physically adapted, thinking has narrowed and avoidance assumes the default position. For this reason, the early messages about pain and injury are a vital because they set the scene for the action taken.

I do not know the full details about Bono’s arm aside from reports in the media. The injury sounded complex and nasty, requiring surgery to fix the damage. Healing always ensues, pain usually accompanies healing as do a range of other biological mechanisms such as change in movement, change in thinking and responses to different environments. Additionally we can feel unwell (the sickness response), our mood can vary, sleep is disrupted with knock-on effects, appetite may change and thinking can lose clarity. There is a very individual response to an injury, especially when it affects something very important to our self.

When helping patients to understand their pain I often tell them about the pain threshold differences in violinist’s hands — lower on the left because of the meaning of the left hand in terms of playing. If a carpenter cuts his finger, this may not be a great problem. It is certainly not unexpected. If a violinist cuts his left index finger, this could be a significant problem in terms of being able to play. Same type of injury, different meaning, therefore a different outcome: more pain, more negative thinking, more worry. This would be similar for a professional vs an amateur footballer who injures a knee ligament — the financial consequences, the loss of a place in the team etc.

The way in which Bono’s body responds to the injury will be unique to him, will reflect his health and the way he views his situation. This is the same for everyone. The uniqueness of the injury, the context, the environment and the person. For treatment and rehabilitation, this is how it must be viewed to optimise the outcomes.

Hypothetical case study

When a patient comes to see me with a complex injury, I focus on the person as much as the problem (this is one of my overarching principles). This is because it is the person who tells and lives their story, and it is the whole person I am treating, training and coaching back to a state of well-being.

Assessment would include:

  1. Exploring the narrative: gathering all the information about the injury — e.g./ the circumstances, how it happened, health status, lifestyle status, past experiences, beliefs about pain and injury
  2. Pain types: e.g. nociceptive inflammatory (possible neurogenic), neuropathic
  3. Protective measures that have beenĀ adopted: e.g./ guarding, avoidance
  4. Adaptations: e.g./ altered body sense, altered movement patterns
  5. Influences upon pain: stress, thoughts/beliefs, fatigue, emotions, other health factors, rumination

Then —

Pain understanding:

  1. This is the start point. Making sure that the person understands their pain, relevant to their condition and the action needed to overcome the pain.
  2. Getting their thinking in alignment with what we really know about pain and what it means to them to overcome pain. Achieving success is about the meaningful return to living; what is this to the patient?
  3. Cultivating the belief that their pain can be overcome and that they CAN do things with the right knowledge and ‘know how’. This is the pain coach concept.
  4. Develop the growth mindset — you may not be doing things YET; NOT YET rather than ‘I will never’. Never say never. Give it your best shot. Dedicate yourself to the fullest recovery and a return to wellbeing. Sign a contract stating this is need be, and know that you will be supported and motivated at every step.

Treatment & rehabilitation:

Depending upon the pain types (biology) and the influences upon pain, specific training is designed to achieving normal body sense, normal movement and confidence in being active and engaging in life again.

If playing the guitar is what they want to do, from word go that is how the training begins; even in plaster! Sensorimotor training begins immediately, or even before an operation. Working the sensorimotor areas is vital from a top-down perspective with specific exercises and can be started whilst immobilised with a range of imagery and visualisation techniques that work the motor centres.

When the immobilisation period ends, actual movement begins to nourish the stiffened, healing muscles and joints. After immobilisation it is normal for the area to appear different — perhaps red and swollen, a different skin quality, hair and nails can change too. Movement and sense of the area is altered and needs specific attention in the early stages because a normal perception of the body is key for healthy movement.

An early focus on function for a guitarist would include thinking and training dedicated to the fine control required to play. The actual movements are partĀ of a sensorimotor feedforward-feedback loop that must be addressed. Adopting the right mindset is key for rehabilitation and should be practiced from the outset: a coaching model for a growth mindset.

We often do not know our full potential, so until you have given it your full dedicated attention, never say never.

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