Ikke alt, som gør ondt, er en skade!
Af Morten Høgh, Ph.D. M.Sc.Pain, specialist i sportsfysioterapi | Adjunkt på Aalborg Universitet, Musculoskeletal Health and Implementation, Health Science and Technology, Medicinsk fakultet.
Kontakt: msh@hst.aau.dk / Twitter @mh_dk
Mange atleter oplever, at smerte forringer eller begrænser dem i deres sport. Og såvel atleter som professionelle kan have svært ved at adskille idræts-relaterede smerter fra idræts-relaterede skader. Traditionelt er smerte blevet opfattet som et udtryk for en skade, der kræver specifik behandling. I dag ved vi, at behandling af smerte og skade adskiller sig fra hinanden, og at smerte både kan og vil opstå uden skader i bevægeapparatet. Som professionel skal man derfor kunne forstå, forklare og håndtere såvel skader som smerte, herunder kunne vejlede atleten til at reagere forskelligt på smerter, der opstår sammen med hhv. uden en vævsskade.
Baggrund: Sammen med Michael Rathleff, Kristian Lyng og Sabina Vistrup undersøgte vi hvordan ”idrætsskade” (eng. sports injury) var anvendt i de randomiserede lodtrækningsforsøg, som var publiceret i BJSM fra oprindelsen til marts 2021. Vi fandt at smerte (pain) og skade (injury) bliver brugt i flæng, endda i samme manuskript (se appendix 1). Derfor satte vi os sammen med prof Steven Z George (US) og a/prof Tash Stanton og lavede vi en Infographic (produceret af Madeline Thorpe, AUS), der efterfølgende er blevet publiceret i BJSM (1). Denne artikel er en narrativ gennemgang af rationalet bag publikationen.
Baggrund (boks): Sammen med Michael Rathleff, Kristian Lyng og Sabina Vistrup undersøgte vi hvordan ”idrætsskade” (eng. sports injury) var anvendt i de randomiserede lodtrækningsforsøg, som var publiceret i BJSM fra oprindelsen til marts 2021. Vi fandt at smerte (pain) og skade (injury) bliver brugt i flæng, endda i samme manuskript (se appendix 1). Derfor satte vi os sammen med prof Steven Z George (US) og a/prof Tash Stanton og lavede vi en Infographic (produceret af Madeline Thorpe, AUS), der efterfølgende er blevet publiceret i BJSM (1). Denne artikel er en narrativ gennemgang af rationalet bag publikationen.
I denne artikel vil jeg argumentere for 1) at smerte ikke bør betragtes som en skade, 2) at smerte er en naturlig konsekvens af skade, 3) at smerte kan og vil opstå i fravær af skader, 4) at væv kan gå i stykker, men ikke gøre ondt og 5) at ovenstående er klinisk relevant.
Smerte og skade er ikke, og bør ikke anses som, synonymer
At skade ikke er afgørende for, at man oplever smerte har været kendt i mange år og indgår bl.a. i definitionen af smerte (2). Ikke desto mindre bruger mange forfattere smerte (pain) og skade (injury) synonymt, ligesom der er inkonsistens i, hvornår man burde bruge det ene eller andet til at afrapportere, hvorfor atleter ikke kan deltage i deres sport (se appendix 1). Vi foreslår, at man anvender begrebet sports-relateret skade, når undersøgelsen viser vævsskade, samt når der er en stærk, klinisk mistanke om en skade (fx tegn på inflammation, kendt skadesmekanisme eller visuelle fejlstillinger/forandringer).
Overordnet set er det den professionelle, der bedst kan vurdere, om atleten har fået en skade: I mange tilfælde kan den professionelle afgøre om der er tale om en skade på baggrund af en grundig klinisk undersøgelse, selvom parakliniske undersøgelser kan være nødvendige. Omvendt er smerte en oplevelse, som kun atleten kan redegøre for.
Figur 1: Sports-relateret skade vs sports-relateret smerte
Figur 1 illustrerer at skader (blå) og smerte (rød) er forskellige og at skade i udgangspunktet altid vil medføre smerte, men at smerte kan eksistere helt uden skade. Størrelsesforholdet er fiktivt, men det formodes at forekomsten af sports-relaterede smerter er markant større end forekomsten af sports-relaterede smerter. En partiel ligament-ruptur (type II) er et eksempel på en skade, der også medfører smerte i den akutte fase hvor der er inflammation. Og patellofemorale smerter er et eksempel på en smerte, der ikke er relateret til en skade på vævet.
Som det fremgår af Figur 1 formodes smerte at kunne opstå uden skade, mens skade i udgangspunktet vil medføre smerte. Og derfor skal klinikeren være i stand til at vurdere, om vævsskaden er den bedste/eneste forklaring på atletens smerte, og derfor om smerten vil forventes at forsvinde helt når skaden er helet. Hvis vævsskade er den bedste forklaring på smerten, vil det være rationelt af fokusere på, og lade behandlingen være styret af, helingen, samtidig med at atleten kontrollerer smerten (som må forventes at være aftagende og sandsynligvis helt fraværende lang tid før en vævsskade er helet). Hvis atletens smerter ikke kan forventes at blive mindre i takt med forandringer i vævet, bør behandlingen primært fokusere på at smertelindre og på at støtte atleten i at få kontrol over smerterne, sideløbende med at denne vender tilbage til sport. Hermed ikke sagt, at vævsrettet behandling (fx træning) er irrelevant, men blot at øget styrke ikke kan forventes at lede til fuld og varig bedring (3,4).
Smerte er en naturlig konsekvens af skade
Inflammation er en fællesnævner for såvel sports-relateret skade og sports-relateret smerte, selvom sports-relateret smerte forekommer hyppigt uden inflammation og skade (5).
I forbindelse med skader er inflammationen en del helingen, men også afgørende for at vi får ondt (6): Dette illustreres bl.a. gennem relationen mellem prostaglandin og sensibilisering. Prostaglandin er et signalstof, der dannes gennem metaboliseringen af arakidonsyre via COX-1 og COX-2 (7). Prostaglandin E2 er særlig interessant fordi den påvirker nerveceller (”nociceptorer”) via EP2-receptoren, og som kan lede til ændringer af både receptorer og ion-kanaler (dvs. perifer sensibilisering). Sensibiliseringen anses for at være den primære grund til smerten, som patienten oplever i forbindelse med inflammation.
Væv kan gå i stykker uden at medføre smerte
Som det fremgår ovenfor, er det ikke vævsskaden, der i sig selv ”gør ondt”. Det er mere korrekt at sige, at smerten opstår som en konsekvens af reversible forandringer i nervesystemet. Det er med andre ord konsekvensen af skaden (især den inflammatoriske proces), der bedst forklarer, hvorfor en vævsskade medfører smerte. Det er således ikke blot semantisk uheldigt, men faktuelt forkert, at påstå at muskler, sener, led m.v. gør ondt. Vi anbefaler i stedet, at man beskriver strukturen (fx ACL), når man taler om skaden, og lokaliteten (knæet) når man taler om smerten. Dette tjener flere formål hvoraf de to væsentligste, i min optik, er at minde patienten om, at skaden og smerten er to forskellige ting, og at gøre det samme for klinikeren, så begge dele adresseres i relevant omfang.
Smerte kan og vil opstå i fravær af skader
Atleter har mindst lige så stor chance for at opleve uspecifikke smerter som baggrundsbefolkningen (8), og der er konsensus om, at denne type smerter ikke kan forklares blot som resultatet af én enkelt årsag, men derimod som resultatet af mange, gensidigt påvirkende faktorer (9). Ikke desto mindre er det biomekanik, der præger sportsmedicinens forklaringsmodeller (10), hvilket bevirker, at forekomsten af diagnoser af tvivlsom værdi er alt for høj (11). Det er imidlertid veldokumenteret at fx degeneration ikke er årsag til smerte (12–14), og at ensidigt fokus på at finde en ”smertegivende struktur” kan lede til overbehandling og måske have iatrogene konsekvenser i form af forlænget eller forringet tilbagevenden til idræt (15–18).
Inden for smerteforskningen forklares smerter uden kendt patogenese ofte som et resultat af forandringer i det centrale nervesystem (19). Disse såkaldte nociplastiske smerter (20) er udtryk for en ikke-veldefineret gruppe af mekanismer, inklusiv central sensibilisering, som ikke nødvendigvis er eksklusive for nociplastiske smerter, men som har det til fælles, at de ændrer på signaler fra kroppen således, at de fx ankommer med forstærket intensitet til hjernen, hvor de kan medføre øget smerteoplevelse. Nociplastiske smerter er derfor ikke en diagnose, men en teoretisk forklaringsmodel, der bl.a. skal gøre op med fejlslutninger som fx at smerterne har en psykisk årsag. Smerte er – i al sin kompleksitet – en oplevelse, som aldrig kan underkendes eller afvises, uanset om årsagen forekommer åbenlys eller ej (2). Når smerter opstår uden relevant skade, bør fokus i behandlingen rette sig mod at bevare atletens funktionsniveau (fx ved at undgå unødvendige pauser) og lære atleten at håndtere sine smerter med de midler, der har lavest risiko for bivirkninger og utilsigtede konsekvenser (21).
Hvad er nyt?
Smerte, som opstår ofte uden synlig/specifik skade, bør ikke behandles med de samme metoder, som man anvender til at behandle vævsskade. Derimod bør fokus rettes mod at fjerne eller lindre smerten, samt eliminere/reducere obstruktioner som smerten giver atleten. Et eksempel kan være tilpasset træningsplan ift at tillade atleten bedre søvn, hvis dette er en effektiv måde at tackle smerterne på, for den enkelte atlet. For den professionelle vil dette muligvis betyde ændringer i daglig praksis i det, fx i form af behov for at lære/rutinemæssigt anvende andre interventioner (fx uddannelse og vejledning i smertehåndtering) således at atleten bliver kompetent til at forstå og håndtere smerterne på egen hånd.
Vigtigste punkter for klinisk praksis:
En grundig klinisk undersøgelse med mulighed for parakliniske undersøgelser, når det er nødvendigt, er afgørende for at identificere specifik og/eller alvorlig patologi, som kræver specifik behandling. Men det tyder på, at flertallet af de muskuloskele problemer, som atleter henvender sig med, er smerte-relaterede. Smertelindring/-håndtering har mange facetter (fx hvile, varme, bevægelse eller distraktion) og behøver ikke omfatte regulering af atletens ”load”, selvom det ofte kan være et relevant.
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