Pain in sportRichmond M. Stace MCSP MSc (Pain) BSc (Hons)

Specialist Pain Physiotherapist

Behind every pain……is a story…a personKnow the person to know the pain It’s as much about the person as the condition –

Oliver SacksWhen a person is better, the pain is betterPeople with persisting pain often fall in the cracks

Picture this..16 year old sporty girl with shin pain2 years and worseningContinues to play sport most days at schoolVery tender to touchSometimes very painful to walkFirst thoughts?

Then….8 year h/o migrainesDigestive disturbancesDisturbed sleepWidespread tendernessPerfectionist & demanding schoolThis a case for……

A lack of signs? Puzzling?

Is there an actual injury?Is there sensitivity?e.g./ hamstring ‘re-injury’What’s the story?

is there damage or does it just feel 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 Is there actual damage? Does more damage =

more pain?

Pain is…NormalPart of protectionImportant for survivalUnpleasantA motivator compelling action

Pain definition

IASPAn unpleasant sensory and emotional experience

associated with actual or potential tissue damage, or described in terms of such damage

Pain is the No.1 global health burden

Back pain, neck pain, headache, migraine, OA All in top 12 depression

Persisting pain What do you think about?

Is persisting pain in sport?

The problem

Pain misunderstoodSocietyHealthcare

Wrong messages communicatedLow expectations

Even morphine affected by expectationPoor outcomes

Persisting pain in sportYesHow common?Impact – this is the ‘lived experience’

PersonProfessional vs amateurParticipation PerformancePlaying with pain

What can we do? Develop understanding of

pain Answer the question:

what is pain really? This answer leads to a

route onwards Different thinking

Neurobiology Neuroimmunobiology neuroimmunoendobiolog

y

What is pain?

What is any experience? The brain’s best guess! Making sense of the world

now Generates & constructs

explanations for its sensory input

Generates predictions of sensations

Generates hypotheses to try to explain what is happening in the outside world

Mature organism model (Gifford)

Important principles

Change We change ‘Neuroplasticity’ Which direction?

There’s more than one direction

If you think there is… Your choice

Whole person ‘I’ think ‘I’ feel (pain, thirst,

hunger) My ______ does not feel

pain, I do What do we treat? Or who do we treat?

Embodied cognitionThe body an extension of the mindWe are more than a brainOur bodies in the world do much of the work

needed to achieve goals (not just the brain)e.g mechanics of walkingGestures reduce load on brain

I think with my whole personWhere do you feel anxious? Hungry?

Embodied athletesIdentify with body & performanceTheir sense of self encompasses body &

performance‘gestures’ part of their cognition

AutomaticPredictions not responses – otherwise miss the

ball!Injury => loss of sense of self

Pain Consider…

Pain is a lived experience Pain is not an accurate

indicator of tissue damage

Pain is about perceived threat

Pain is allocated a space Pain is dynamic

What influences pain? The meaning – what do

you tell yourself? The context

Where you are What you are doing What you are planning to

do What you have just done

Emotional state – anxiety, stress

Tiredness

Prior experience Beliefs about pain/health Attention bias Who we are with

Pain in sport Expected Part of training & playing Accepted risk ‘no pain, no gain’ What if the pain

persists……or injuries recur?

New injury

What do you want to know?

The injury moment Context Mechanism Meaning Body responses Pain intensity Current health Early care

Initial management Messages given Investigations Other’s responses

Facial Verbal

Injury – not in isolation Why? Pain vulnerabilities

Pre-existing sensitivity Functional pain

syndromes Injury patterns

Fatigue Health Prior injuries & pain

Circumstances The person Priming factors

Pain vulnerability Genetics Body sense

e.g. hypermobility

Persisting painBegins at the moment of injury

VulnerableUncontrolled painWrong treatment

Pain beyond a useful time?Or are there health issues?Habits of thought and action

What have you seen?Features?

What do we see? Loss of sense of self Change in body sense Altered movement

patterns Altered thinking

Outlook? Altered planning Change in perception of

the environment

Sickness responses Other aches and pains Poor sleep Varied emotions

What are we trying to do? Restore a sense of self as

defined by the person Resume a meaningful life Matching what is

expected with what is happening

What does that look like? Ask the person? Their vision

How do we do it? Working knowledge of pain

Reduce threat Take healthy action

Develop body sense Sensorimotor training Motor imagery visualisation

Focus on health (not pain) What we focus on, we get

more of… Deal with distractions from

the vision

Programme must be lived Moment to moment

Build tolerance for activities Graded exposure General fitness

Sleep habit Meet basic needs! Pain Coach

Strengths based coaching Become their own coach

Key pointsPain is whole person: when the person gets

better, the pain gets betterEarly messages are key!Understanding pain is vital – working knowledgePain is a lived experience, which the programme

must reflectPain is temporary, each moment uniqueChange is certain; direction can be a choice

Thanks!@painphysiowww.specialistpainphysio.compainphysiolondon@gmail.com07932 689081UP | understand pain – www.understandpain.com@upandsing