Chronic pain Chronic pain in sportin sportRichmond StaceRichmond StaceMCSP MSc (Pain) BSc MCSP MSc (Pain) BSc (Hons) (Hons) Specialist Pain Specialist Pain PhysiotherapistPhysiotherapistHonorary Clinical Honorary Clinical Lecturer QMULLecturer QMUL

Chronic pain in sportChronic pain in sport

The problem of painThe problem of pain The problem of persisting pain in sportThe problem of persisting pain in sport Tendinopathy as an exampleTendinopathy as an example What can we do?What can we do?

Messi injuryMessi injury

Messi Messi

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

Was there an injury?Was there an injury?

Pain and injuryPain and injury

Poorly relatedPoorly relatedRelationship can be absentRelationship can be absent

Phantom limb painPhantom limb painHamstring ‘pull’Hamstring ‘pull’

Pain and sportPain and sport

Normal in sportNormal in sportExpected Expected Occupational hazard ~ accepted riskOccupational hazard ~ accepted riskTraining painTraining pain

Post exercise aches and painsPost exercise aches and painsReward Reward

MeaningMeaning

Injury and pain implications:Injury and pain implications:CareerCareerIncomeIncomePerformancePerformanceImpact on team Impact on team

What is pain?What is pain?

Unpleasant sensory and emotional lived Unpleasant sensory and emotional lived experience emergent in the person in the experience emergent in the person in the face of a perceived threat, motivating face of a perceived threat, motivating actionaction

Body systems in protect & survive mode Body systems in protect & survive mode ~ no pain system or pain signals~ no pain system or pain signals

Protection Protection Adaptive and normalAdaptive and normal

The problem of chronic The problem of chronic painpain

Chronic pain & depression ~ top 2 global Chronic pain & depression ~ top 2 global healthy burdenshealthy burdens

Back pain, neck pain, OA, Back pain, neck pain, OA, headache/migraine ~ in top 12headache/migraine ~ in top 12

Figures quoted:Figures quoted: 100 million Americans100 million Americans 20% of the population20% of the population 1:5 children1:5 children

Chronic pain: a societal Chronic pain: a societal problemproblem

Problem across societyProblem across society Public health issuePublic health issue Huge cost to society and individualsHuge cost to society and individuals Lack of understanding across societyLack of understanding across society

Reliance on drugs ~ belief that drugs, Reliance on drugs ~ belief that drugs, interventions are the answerinterventions are the answer

Biomedical modelBiomedical model Wrong messages ~ low expectations Wrong messages ~ low expectations

Chronic pain in sportChronic pain in sport

What is the prevalence?What is the prevalence?How many do you see?How many do you see?

What is considered to be a chronic What is considered to be a chronic problem versus regular aches and problem versus regular aches and pains from training/playing?pains from training/playing?TendinopathyTendinopathyRecurring hamstringRecurring hamstringBack painBack pain

The storyThe story

VulnerabilitiesVulnerabilitiesGeneticsGeneticsPrior experiencePrior experienceFunctional pain syndromesFunctional pain syndromes

Protect modeProtect modeInjury moment or moment of Injury moment or moment of

pain ~ differpain ~ differ

The injury momentThe injury moment

The moment of painThe moment of pain

Reaching a protect lineReaching a protect line Gradual onset ~ vague start pointGradual onset ~ vague start point Priming ~ kindling Priming ~ kindling

Worsening episodes, closer togetherWorsening episodes, closer together Pain impacting ~ limiting choices, Pain impacting ~ limiting choices,

affecting performanceaffecting performance Temporal summation?Temporal summation?

Influences on the Influences on the momentmoment

Context Context Where we are ~ Where we are ~

environmentenvironment Been here before?Been here before?

What we are doingWhat we are doing Action ~ Action ~

mechanismsmechanisms Who we are withWho we are with

Emotional stateEmotional state MoodMood StressStress Anxiety Anxiety

Initial thoughts?Initial thoughts? CatastrophisingCatastrophising Beliefs about pain & Beliefs about pain &

injuryinjury Current health and Current health and

wellbeing statuswellbeing status

More or less likely More or less likely to respond with to respond with protect?protect?

Shaping the trajectory Shaping the trajectory

Early pain control Early pain control The right messagesThe right messages

Understand painUnderstand pain Explain injury ~ Explain injury ~

problemproblem Working Working

knowledgeknowledge DirectionDirection

Desired outcomeDesired outcome Action Action

What is going on behind the What is going on behind the scenes?scenes?

Mature organism model Mature organism model (Gifford)(Gifford)

Biology in the darkBiology in the dark

Predictive processing ~ a Predictive processing ~ a contemporary model (Clark, Friston)contemporary model (Clark, Friston)

What we experience: What we experience: Brain’s best guess about the causes Brain’s best guess about the causes

of the sensory informationof the sensory informationBased upon prior experienceBased upon prior experience

Body systems ~ Body systems ~ protectprotect

Nervous systemNervous systemImmune systemImmune systemMusculoskeletal systemMusculoskeletal systemAutonomic nervous systemAutonomic nervous systemEndocrine systemEndocrine system

Persisting (chronic) Persisting (chronic) painpain

What happens when we continue to protect?What happens when we continue to protect? Habits ~ thoughts-perceptions-actionsHabits ~ thoughts-perceptions-actions LearningLearning

Increasing vigilance and response to range of cuesIncreasing vigilance and response to range of cues Circular causalityCircular causality Deterioration in health & wellbeing of the personDeterioration in health & wellbeing of the person Generation of a pain state with no external cause Generation of a pain state with no external cause

The personThe person

Oliver SacksOliver Sacks The person as much as the conditionThe person as much as the condition

The person feels pain ~ in a locationThe person feels pain ~ in a location Embodied, lived experienceEmbodied, lived experience Entirely subjectiveEntirely subjective

What changes?What changes?

Everything…Everything… PerceptionPerception ThinkingThinking MovementMovement Body senseBody sense

The biology of painThe biology of pain

Where is it?Where is it? There is no specific pain biologyThere is no specific pain biology

No pain signalsNo pain signals No pain centresNo pain centres

What is there?What is there? Detection of threat ~ salience Detection of threat ~ salience Orientation towards the perceived threatOrientation towards the perceived threat Protection ~ thinking + action Protection ~ thinking + action

Trajectory of painTrajectory of pain

Poorly related to Poorly related to tissues ~ tissues ~ Wall 1979Wall 1979

Depends uponDepends upon Person ~ Person ~

genetics + priorsgenetics + priors Working Working

knowledgeknowledge ContextContext Messages taken Messages taken Treatment Treatment

ExpectationsExpectationsAdherenceAdherenceOutlook Outlook DeterminationDeterminationEnvironmentEnvironmentPeople aroundPeople around

TendinopathTendinopathyy

The problemThe problem

Tendon pain has a significant impactTendon pain has a significant impact Time factor Time factor Recurrence Recurrence PersistsPersists

Costs ~ individual, societyCosts ~ individual, society Why don’t tendons get better?Why don’t tendons get better?

The debate: how tendons get The debate: how tendons get betterbetter

ExerciseExerciseInjectionsInjectionsBiomechanicsBiomechanicsThe brain ~ me!The brain ~ me!

Conclusion?Conclusion?Where was the Where was the

focus?focus?

Tendon painTendon pain

Where is the predominant Where is the predominant focus for treatment?focus for treatment?

How do tendons get better?How do tendons get better?

What is getting better?What is getting better?

Debate conclusionDebate conclusion

Exercise and movement ~ Exercise and movement ~ which?which?Eccentrics?Eccentrics?

Biomedical model Biomedical model predominatespredominates

Reasons for pain?Reasons for pain?

Systemic inflammatory condition?Systemic inflammatory condition?Rule outRule out

Locally, something happens?Locally, something happens?What has happened?What has happened?Mechanism ~ sudden, intermittent, Mechanism ~ sudden, intermittent,

gradualgradualBody systems adaptBody systems adaptThe person is in protect mode – not CSThe person is in protect mode – not CS

Why do we have pain?Why do we have pain?

To compel thoughts, perceptions and To compel thoughts, perceptions and actions that promote protection and actions that promote protection and survivalsurvival The lived experience ~ unified thoughts-The lived experience ~ unified thoughts-

perceptions-actionsperceptions-actions

Pain is a response to Pain is a response to perceived threatperceived threat Pain is a measure of the need to protectPain is a measure of the need to protect Pain and injury poorly relatedPain and injury poorly related

Who perceives the Who perceives the threat?threat?

The person The person ~ embodied cognition~ embodied cognition Biology in the dark ~ is not separate from Biology in the dark ~ is not separate from

the personthe person Sampling in and around based on priors Sampling in and around based on priors

Hypothesis ~ what I experience nowHypothesis ~ what I experience now Is there a threat? Is there a threat?

Threat Threat

Unique perceptionUnique perceptionSalient networkSalient networkHow salient is How salient is

this?this?Perceived threat Perceived threat

necessitates a necessitates a responseresponse

Even ‘just in case’Even ‘just in case’Becomes a habitBecomes a habit

The protect lineThe protect line

The point when we feel painThe point when we feel painPain is part of protectionPain is part of protection

Altered perceptionsAltered perceptionsAltered movementAltered movementAltered sense of bodyAltered sense of bodyAltered thinkingAltered thinkingAltered emotional stateAltered emotional state

What takes us to the What takes us to the line?line?

Influences on painInfluences on pain

Stress ~ unique Stress ~ unique perception of the perception of the situationsituation

AnxietyAnxietyTirednessTirednessEnvironmentEnvironmentMeaning given to Meaning given to

painpain Inner dialogueInner dialogue

Anticipation Anticipation Gender Gender Situation Situation MovementMovementPrevious Previous

experiencesexperiencesGeneticsGenetics

All those little things…All those little things…

……build upbuild up

frustrations + annoyances =closer to frustrations + annoyances =closer to protect lineprotect line

The 2The 2ndnd arrow arrow Hard on self Hard on self

What is the story?What is the story?

How were things when the pain was first How were things when the pain was first noted?noted? The injury or pain moment:The injury or pain moment:

General health, wellbeingGeneral health, wellbeing ContextContext Initial thoughts ~ initial messages & treatmentInitial thoughts ~ initial messages & treatment

What has happened since?What has happened since? Pattern of symptoms, impact, treatmentPattern of symptoms, impact, treatment

Story Story

PriorsPriors Previous pain and/or tendon problemsPrevious pain and/or tendon problems How have the body systems learned to respond?How have the body systems learned to respond? How has the person responded before?How has the person responded before? Are they vulnerable to an amplified response? Are they vulnerable to an amplified response?

Vigorous protection?Vigorous protection?

Other contributing factorsOther contributing factors Context, meaningContext, meaning A conversation A conversation

Pause for thoughtPause for thought

Tendon Tendon treatment treatment focus:focus:Where is it?Where is it?Where does Where does

it need to it need to be?be?

Consider…Consider…

Most of the biology of pain is Most of the biology of pain is not where the pain is feltnot where the pain is felt

The tissues need to be The tissues need to be healthyhealthy

Nourishment ~ Nourishment ~ motion is lotionmotion is lotion

Blood flowBlood flow OxygenOxygen MovementMovement Strength + Strength +

flexibilityflexibility

Systems behind Systems behind the scenes:the scenes: Immune systemImmune system Endocrine systemEndocrine system Autonomic Autonomic

nervous systemnervous system How are they How are they

impacted upon by impacted upon by stress?stress?

Stress and painStress and pain

Persistent pain Persistent pain stress stress Chronic stress => pro-inflammatoryChronic stress => pro-inflammatory Perception of situation => stressPerception of situation => stress Perception of isolationPerception of isolation

Beyond the tissuesBeyond the tissues

Chronic pain needs an approach Chronic pain needs an approach that goes beyond the tissuesthat goes beyond the tissues

Whole personWhole personLocal tissue healthLocal tissue healthOverall health & functionOverall health & functionInfluences on local & overall healthInfluences on local & overall healthMoment to moment decisions & Moment to moment decisions &

actionaction New habitsNew habits

Central sensitisationCentral sensitisation

Biological adaptationsBiological adaptations Largely a lab phenomenaLargely a lab phenomena When does it start?When does it start?

Females => ? Onset of puberty ~ Females => ? Onset of puberty ~ dysmenorhoeadysmenorhoea

More than CS needed to explain chronic painMore than CS needed to explain chronic pain Role in functional pain syndromesRole in functional pain syndromes

To address the To address the changeschanges

Set the sceneSet the scene Model of success & strengths based coachingModel of success & strengths based coaching Altered thinking ~ focus on pain; working Altered thinking ~ focus on pain; working

knowledge needed ~ knowledge needed ~ understand pain to reduce understand pain to reduce the threatthe threat

Active engagement ~ become their own coachActive engagement ~ become their own coach Fear state ~ anticipation affects movementFear state ~ anticipation affects movement Awareness of existing habits of thought-actionAwareness of existing habits of thought-action Keep the focus on the desired outcome ~ the Keep the focus on the desired outcome ~ the

visionvision Manage distractionsManage distractions Create a sense of safetyCreate a sense of safety

..continued..continued Mindful practiceMindful practice

Create calm and clear thinking, moment to momentCreate calm and clear thinking, moment to moment Develop insight into the influences upon pain & Develop insight into the influences upon pain &

create new habitscreate new habits Focus on trainingFocus on training

Altered body sense and movement ~ e.g./ Altered body sense and movement ~ e.g./ sensorimotor training to develop normal sensorimotor training to develop normal movement, motor imagerymovement, motor imagery

Gradual build up of exercises & trainingGradual build up of exercises & training Specific ~ eccentrics, strength, flexibilitySpecific ~ eccentrics, strength, flexibility

Local treatment may help along the wayLocal treatment may help along the way

SummarySummary

Chronic pain is a huge and costly problem to societyChronic pain is a huge and costly problem to society Understanding pain is the first step to overcoming Understanding pain is the first step to overcoming

painpain We coach the person concurrent with any treatmentWe coach the person concurrent with any treatment Active involvement of the person is essentialActive involvement of the person is essential Pain and injury are poorly relatedPain and injury are poorly related Most of the biology of pain is not where it is Most of the biology of pain is not where it is

experiencedexperienced

UP | understand painUP | understand pain

Thank youThank you

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