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February 2015
Persisting pain in sport
Richmond 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
? ?rst thoughts?

..and then she
says this..
? 8 year h/o migraines
? disturbed sleep
? widespread tenderness
? high-?yer 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 de?nition:
? 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 in?uences 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
? In?ammation
? 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
? In?ammation -- immune
? Behaviours based upon beliefs
? Normal to hurt

There is no
pain system
Or pain signals
Or 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
? In?uences 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 + in?uences = how much it hurts
? Whole person | multi-system | multi-dimensional

? painphysiolondon@gmail.com
? Twitter @painphysio
? www.specialistpainphysio.com

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