24th November 2013

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

Pain

✤ An exciting time of rapid change

The problem

✤ Pain poorly understood

✤ Public

✤ Health professionals

✤ Sportsmen & women

✤ A problem -- yes

✤ Professional vs amateur

✤ Stops return to full participation

✤ Affects performance

✤ Playing with pain

✤ No pain, no gain

✤ Different to non-sporting population?

✤ Context

✤ End goal?

Persisting pain in sport

What can we do?

✤ Reconceptualise pain

✤ Neurobiology

✤ Neuroimmunobiology

✤ Neuroimmunoendobiology

✤ What influences this?

Pain definition

✤ IASP

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

✤ Dated?

Reconceptualisation

✤ Melzack & Wall

✤ Melzack -- pain matrix theory

✤ Pain as an output

✤ Mature Organism Model (Gifford)

✤ Pain is emergent

✤ Salient network

Pain -- emergent

✤ Shift from telling patients that pain comes from the brain

✤ “But it’s my back”

✤ Pain emerges from the person

✤ The brain is involved -- as are other systems

Salient network

✤ A cortical network that detects, processes and reacts to salient events regardless of the sensory channel through which the event is conveyed

✤ Network within the brain that detects sensory information that stands out

✤ In contrast to surrounding areas

✤ Attention grabbing & novel stimuli

✤ Stimulus intensity

✤ Orientates attention due to potential threat

Practical knowledge

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

✤ Pain is allocated a ‘space’

✤ Pain: response to a perceived threat

✤ Depends on how much danger your brain THINKS you are in

✤ Pain is dynamic

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

✤ Neurobiology... multidimensional

✤ The influences upon the neurobiology

Influences to consider

✤ Context/Situation

✤ Emotional state

✤ Anxiety

✤ Stress

✤ Fatigue

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

✤ Environment

✤ Attentional bias

✤ Beliefs

✤ Vision

✤ Strategy

Pain in sport

✤ Normal

✤ Expected

✤ Part of training and playing

✤ Accepted risk of injuries that hurt

An illustration of painMessi

Acute vs Chronic pain

✤ Acute

✤ Initial pain

✤ Protective device - amazing

✤ Normal response

✤ Part of a protective response

✤ Promotes healing

✤ Chronic

✤ Timeline? 3/12

✤ When do processes start?

✤ Persisting beyond useful time

✤ Maladaptive behaviours

Injury moment

✤ Context

✤ Mechanism

✤ Immediate thoughts

✤ Meaning

✤ Body responses

✤ Pain intensity

✤ Stress/anxiety/traumatic

✤ Early care

✤ Treatment

✤ Messages given

✤ Investigations

✤ Others’ responses

Injury -- not in isolation

✤ Circumstance

✤ Priming factors

✤ Immune system -- microglia

✤ Genetics -- epigenetics

✤ Fitness

✤ Body sense

✤ Pre-existing sensitivity

✤ Fatigue

✤ Inflammation

✤ General health

✤ Prior experience of injury

✤ CLIMB OUT OF THE TISSUES

Responses to tissue damage

✤ Pain

✤ Change in motor control

✤ Healing

✤ Autonomic responses

✤ Inflammation -- immune priming?

✤ Behaviours based upon beliefs

✤ Normal

Inflammation

✤ Brain wants to know

✤ Balance of pro- and anti-inflammatory cytokines

✤ Tip the balance

✤ Diet

✤ Stress

✤ Lack of recovery

✤ Normal fluctuations

✤ Morning stiffness

✤ Over-responsive?

✤ CRPS

Pain persists

✤ Tissues are healing but pain persists

✤ Pain is not an accurate indicator of tissue damage

✤ Mechanisms?

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

✤ On-going protection

✤ e.g./ pain -- altered motor control -- guarding -- ANS

Persisting problems

✤ Tendinopathy

✤ Anterior knee pain

✤ Back pain

✤ Repeated muscle ‘strains’

✤ Hamstring

✤ Groin

Hamstring

✤ Recurring pain

✤ Is there an injury? Is there tissue damage?

✤ Does it hurt like a repeated injury?

✤ Evidence?

✤ What happens?

Hypermobility

✤ Common in sports people

✤ Commonly seen in persisting pain

✤ Joint Hypermobility Syndrome (JHS): hypermobility + pain

✤ Beighton score 0-9/9

✤ Brighton criteria

Functional pain syndromes

✤ IBS

✤ Pelvic pain

✤ Migraine

✤ TMJ dysfunction

✤ Anxiety/Depression

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

✤ Seeing these?

✤ Think central sensitisation

Central sensitisation

✤ Pain reflects the excitability of the central circuits involved with nociception

✤ Adaptation in the CNS

✤ Activity-dependent changes in synaptic function induced by input -- ? multisensory

✤ Underpinning seemingly different conditions

✤ Features

✤ Dynamic tactile allodynia

✤ Amplification of normal inputs

✤ Varied pattern

✤ Normal tissue sensitive

✤ Reduced inhibition

Immune system: the players

✤ Injury to nerves --> neuropathic pain

✤ Nerves: soft tissue

✤ Glial activation

✤ Astrocytes: PICs released/glutamate transport effect

✤ Microglia: primed by injury and environmental stresses

✤ Toll like receptors

✤ Infection

✤ ? explanation for females with chronic pain

✤ TLR4 upregulated in CP

✤ Interaction between TLR4 & oestrogen receptors

Autonomic Nervous System

✤ Sympathetic & Parasympathetic

✤ Responds to perceive threat

✤ Thoughts -- rumination

✤ Outputs in response to:

✤ Thinking about a situation

✤ Being in a situation

Injury & neuropathic pain

✤ Hidden in the presentation

✤ Stimulates central sensitisation

✤ Pain description -- quality

✤ Altered sensation

✤ Increased sensitivity

✤ Allodynia (also inflammation)

Persisting pain features

✤ Pain pattern: varied, disconnected

✤ Altered body sense

✤ Incongruence

✤ Altered motor control

✤ Beliefs - Behaviours

✤ Thoughts

✤ Stress responses

✤ Vigilance -- conscious/unconscious

✤ ANS activity

✤ Ready to fight or run

Altered body sense

✤ Brain constructs sense of self

✤ Normally well defined sensory & motor maps

✤ Multisensory input

✤ Altered body sense -- injury, illusions, PTSD, functional pain syndromes

✤ Illusion?

Moving?Illusions

✤ The problems

✤ Participation

✤ Frustration

✤ False starts

✤ Career

✤ Finance

✤ Self-esteem

✤ Adherence

✤ Motivation

Athletes with persisting pain

Approach -- assessment

✤ Assessment

✤ Narrative/listen

✤ How do they feel?

✤ What is the impact?

✤ What is their experience?

✤ 1st & 3rd person perspectives -- drawn together

✤ Which factors imply threat and non-threat?

Approach -- treatment & training (1)

✤ Develop understanding to give meaning -- individualised

✤ Metaphors -- consider language

✤ Our body language/verbal

✤ Top down -- prime, expectations

✤ Explain & demonstrate

✤ Tracey study

✤ Bottom up

Approach -- (2)

✤ Start point - actual/imagery?

✤ Principles of learning

✤ Meaning

✤ Chunking

✤ Focus/attention

✤ Little and often

✤ Practice

✤ Feedback

✤ Functional

✤ Imagery

✤ Movements

✤ Dimensions of pain

✤ Interface of experience with thought --> what happens next?

Contemporary techniques

✤ Graded motor imagery

✤ Multisensory training

✤ Tactile discrimination training

✤ Target the processing -- eg/ manual therapy

✤ Nourishing movements

✤ Mindfulness

Manual therapy

✤ Putting things back in?

✤ Back in place?

✤ Altered body sense -- emergent from a process

✤ Sensory processing targeted with manual therapy

Graded motor imagery (GMI)

✤ GMI is a rehabilitation process used to treat pain and movement problems related to altered nervous systems by exercising the brain in measured and monitored steps which increase in difficulty as progress is made.

✤ The three different treatment techniques include left/right discrimination training, motor imagery exercises and mirror therapy. (NOIGroup)

Sensory training

✤ Normalise sense of self

✤ Targeting higher centres -- not in isolation

✤ How?

✤ Multisensory feedback: mirrors, touch

✤ Tactile discrimination

✤ 2 point discrimination

Summary

✤ What is pain?

✤ Reconceptualisation of pain

✤ Persisting pain -- why?

✤ Persisting pain in sport

✤ Approach -- neurobiology of pain + individual influences upon the pain

Evolve

✤ An urge to evolve our practice to incorporate modern pain science into our thinking and treatment of persisting pain

✤ Designed to learn and change -- pain can change if we create the right conditions

Questions

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