QMUL MSc SEM | pain in sport lecture

February 2015

Persisting pain in sportRichmond Stace MCSP MSc (Pain) BSc (Hons) | Specialist Pain Physiotherapist

Thursday, 5 February 15

Behind every pain...

✤ ...is a story

✤ Know the person to know the pain

✤ “It’s as much about the person as the condition”. Oliver Sacks

✤ When a person gets better, their pain gets better


Picture this...

✤ 16 year old girl with pain in both shins

✤ 2 years; worsening

✤ continues to play sport at school most days + training

✤ exquisitely tender to touch

✤ occasions when unable to walk

✤ first thoughts?


..and then she says this..

✤ 8 year h/o migraines

✤ disturbed sleep

✤ widespread tenderness

✤ high-flyer at school

✤ thoughts?

✤ who is this a case for?


Puzzled by a lack of signs?

✤ is it an injury?

✤ is it sensitivity?

✤ hamstring ‘re-injury’

✤ damage or feels like damage?


Acute pain

✤ is it an injury?

✤ "I sincerely thought it was the last ball I would be touching for a long time because of the pain," Messi (2012)


Acute injury

✤ damage?

✤ damage = pain?


Pain is...

✤ normal

✤ unpleasant

✤ alerts us to danger in the body

✤ motivates action

✤ a vital survival device


My definition of pain is...

✤ _________________________


Pain definition

✤ IASP definition:

✤ An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.


Pain is a huge global health burden

✤ A systematic analysis for the Global Burden of Disease Study 2010

✤ Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality (Vos et al. 2012)

✤ Most burdensome global health issues

✤ Number 2 -- depression

✤ Number 1 -- chronic back pain


The problem

✤ Pain is poorly understood

✤ Pain is poorly communicated

✤ Chronic pain outcomes often low

✤ Expectations low

✤ WE MUST CHANGE THE UNDERSTANDING OF PAIN


✤ A problem in sport -- yes!

✤ Professional vs amateur

✤ Stops return to full participation

✤ Financial/career

✤ Affects performance

✤ Playing with pain

✤ No pain, no gain

✤ Is this different to non-sporting population?

✤ Context

✤ End goal

✤ Should we think differently about pain in sport vs non-sport?

✤ NO

Persisting pain in sport


What can we do?

✤ Understand pain

✤ Reconceptualise pain

✤ Neurobiology

✤ Neuroimmunobiology

✤ Neuroimmunoendobiology

✤ What influences pain biology?


What is pain? What does it involve?

✤ Protection in the body region deemed to be under threat

✤ Perception of threat + normal biological response

✤ Multi-system

✤ nervous, immune, autonomic, endocrine

✤ there’s no pain system, message, receptors...

✤ Multi-dimensional

✤ physical, cognitive, emotional

✤ Biopsychosocial model in sport


Reconceptualisation story

✤ Melzack & Wall

✤ Melzack -- pain matrix theory

✤ Pain as an output

✤ Mature Organism Model (Gifford)

✤ Pain is emergent

✤ Salient network


✤ Consider:

✤ Pain is not an accurate indicator of tissue damage -- phantom limb pain

✤ Pain is allocated a ‘space’ - cross the midline

✤ Pain is dynamic

✤ Accuracy of recall -- how well do we recall a pain?


Influences on pain

✤ Context/Situation

✤ ‘the meaning’

✤ Emotional state

✤ Anxiety

✤ Stress

✤ Fatigue

✤ Prior experience of pain and injury (they are different)

✤ Environment

✤ Who we are with

✤ Attentional bias

✤ Beliefs


Pain in sport

✤ Normal

✤ Expected

✤ Part of training and playing

✤ Accepted risk of injuries that hurt, BUT....

✤ What about the pain that doesn’t get better?


Injury

✤ First observations?

✤ First thoughts?

✤ First questions?


Injury moment

✤ Context

✤ Mechanism

✤ Meaning to the person

✤ Body responses

✤ Pain intensity

✤ Stress/anxiety/traumatic

✤ Early care

✤ Treatment choice

✤ Messages given

✤ Investigations

✤ Others’ responses

✤ facial

✤ verbal


Injury -- not in isolation

✤ The story

✤ The person

✤ Circumstance

✤ Priming factors

✤ Genetics -- epigenetics, vulnerability

✤ Fitness

✤ Body sense -- e.g. hypermobility

✤ Pre-existing sensitivity

✤ Fatigue

✤ Inflammation

✤ General health

✤ Prior experience of injury

✤ CLIMB OUT OF THE TISSUES


Responses to tissue damage

✤ Thoughts

✤ Acts

✤ protective

✤ Pain

✤ Change in motor control

✤ Healing

✤ Autonomic responses

✤ Inflammation -- immune

✤ Behaviours based upon beliefs

✤ Normal to hurt


There is no pain systemOr pain signalsOr pain receptors


Pain persists

✤ Why?

✤ On-going perception of threat

✤ What are the perceived threats?

✤ Tissues are healing but pain persists

✤ Pain is not an accurate indicator of tissue damage

✤ Biological mechanisms e.g./ neuropathic pain --> central sensitisation

✤ Influences upon pain biology


Persisting problems

✤ Tendinopathy

✤ Anterior knee pain

✤ Back pain

✤ Repeated muscle ‘strains’

✤ Hamstring

✤ Groin


Functional pain syndromes

✤ IBS

✤ Pelvic pain

✤ Migraine

✤ TMJ dysfunction

✤ Anxiety/Depression

✤ Gender -- females predominate: immune/endocrine factors + reporting


Persisting pain features

✤ Pain

✤ Altered body sense

✤ Altered motor control

✤ Beliefs - Behaviours

✤ Thinking


Modern approach

✤ Consider whole person

✤ Understanding

✤ Skill development

✤ Coaching

✤ Pain dimensions

✤ Physical - cognitive - emotional

✤ How they interact

✤ Adaptations

✤ Cortical

✤ Loss of precision (disinhibition)

✤ Body systems that protect:

✤ Sensorimotor

✤ Nervous - immune

✤ Autonomic


Summary

✤ Pain is not an accurate indicator of tissue damage

✤ The meaning and context are key

✤ Early messages are vital

✤ Biology of pain + influences = how much it hurts

✤ Whole person | multi-system | multi-dimensional


✤ [email protected]

✤ Twitter @painphysio

✤ www.specialistpainphysio.com


mailto:[email protected]

mailto:[email protected]

http://www.specialistpainphysio.com

http://www.specialistpainphysio.com

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QMUL MSc SEM | pain in sport lecture