Access to the PPM Journal and newsletters is FREE for clinicians.

The Athlete’s Approach to Pain Management

A national swim champion offers solutions on training the mind to perceive pain differently.
A Young Athlete's Perspective, part of a larger primer on Chronic Overuse Injuries and Sports Medicine
Since the dawn of time, people have been searching for better ways to treat pain. Examination of Neanderthal skeleton remains, ancient Egyptian drawings, and accounts from thousands of years of using opium to treat war wounds and various ailments leads us to believe that suffering from pain has been a ubiquitous component of life.
However, there are two distinct groups of people—athletes and non-athletes—who often respond differently to pain. What makes athletes different? We are the most compliant with therapy and will not accept defeat. We want to push our boundaries and discover our actual limitations.
And when it comes to limitations, I often ask, do they exist in the body, or is it the mind that is holding us back from our true potential?

Mind over Pain: Is It Possible?

Using the mind-body connection to relieve chronic pain is not a new concept. According to Jeff Gudin, MD, who is board-certified in pain medicine, anesthesiology, and palliative care and serves as an editor-at-large of PPM, “When a patient complains of a pain flare, I often wonder what current stressors/events might be in their life. Most often, you can find a recent stressor that ignited their flare.”
The late John Sarno, MD, touted as the back-pain doctor “to the stars,” held a philosophy that all back pain was stress-related and could be overcome with mental training. He believed that many patients could overcome their back or neck pain by merely acknowledging its psychosomatic origins. Although many doubted his theories, we have come to learn that there are emotional and behavioral components to chronic pain – thus, the emergence of the biopsychosocial approach to long-term pain care. 1
The International Association for the Study of Pain (IASP), describes pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”2
What does this mean in the mind of an athlete? For some, it may be an unbearable sense of burning in our muscles that inhibits our ability to continue at maximum effort. We try to not only defeat our opponents but also ourselves on the battlefield known as competition. However, all athletes reach a point where they feel an overwhelming sense of agony, cramps, muscle atrophy, and, most importantly, the doubt in our ability to continue.
At that moment, comes the decision on how to respond. Do we persevere and push through the unbearable feeling that overtakes our body, or do we crumble at its presence? Each person will respond differently. In those who prevail over pain, some may question whether they used something “extra” such as supplements, caffeine, or even steroids. And while these cases do occur, so many athletes press on naturally. They prevail because they believe that pain can be defeated.
Various coaches of mine have said that sports are 90% mental and 10% physical. As long as the athlete is willing to push themselves, reach out of their comfort zone, and embrace the “superpower” that is their brain, they have the ability to prevail. Let’s look at the science.
A 2015 study conducted at the University of Colorado explained how people have found a way to use “thoughts to modulate perceptions of pain as it utilizes a completely separate brain pathway, than the pathway used to send the physical pain signal to your brain.” 3 The authors referred to “hyper-endurance athletes,” the top 1% within the 1% of athletes who have discovered how to complete ultramarathons (135 miles of running) and the Triple Ironman (7.2-mile swim, 336-mile bike ride, and 78.6-mile run; non-stop). Their secret could be a technique called cognitive self-regulation, which grants the ability to subject onself to the highest degree of pain and still be able to push through at the maximum level of performance. This technique has been tied to the complex anatomy tangled within the brain.
Pathway signals controlling the severity of painful stimuli exist within nerves that are associated with the anterior cingulate cortex, which modulates pain perception. However, in the Colorado study, scientists associated the regulation of pain with an increase in medial prefrontal cortex activity, which is associated with emotional and motivational aspects of the mind. The bridge that hyper-endurance athletes walk guides their appreciation on how emotions affect motivation. These factors may outweigh the burden that physical pain places on an athlete.

Mood, Arousal, and Performance

Satisfaction, grit, and analytical thinking are just a few emotional mindsets that athletes embody. However, a question remains regarding how the chemistry of the brain alters these mindsets in various environments (eg, a practice setting versus a championship game). Does level of performance depend on the environment? Yes. There are some athletes, even the best in the world, who have mastered their craft in practice but still manage to crack under pressure in the heat of the moment.
In 1908, psychologists Robert Yerkes and John Dodson developed the “Inverted U Theory” (see figure below). 
Figure 1. Inverted U Theory. Reference 4.Figure 1. Inverted U Theory. Reference 4.
This bell curve demonstrates the relationship between arousal (X axis) and performance (Y axis). On the Y-axis, performance increases as one moves up. But, athletes need a certain amount of arousal to reach that maximum Y-axis performance. In general, too low of arousal means there is not enough of a stimulus, leading to boredom, and ultimately a mediocre performance. However, too much arousal can lead to anxiety and poor performance. For each athlete, within the Inverted U theory, there is a “Goldilocks zone” − the perfect amount of arousal leading to maximum performance.
When an athlete says they cramped up on a play or “died” in a distance race, did they expel all of their energy to the point where their body could not function, or did their mind simply tell them that they couldn’t continue? Did they fail before they even had begun? For that question to be answered, one must consider a few factors. What was their mood going into the competition? What were their goals? One could argue that an athlete who feels pessimistic about an event may perform worse than an optimistic athlete. Positive self-talk and positive thinking have the potential to alter the outcome of a performance.
In another section of the study carried out at the University of Colorado, participants were given painful heat stimuli on their arms, while their brains were scanned using MRI.3 In the first scan, participants were asked to clear their minds and not think of anything in particular while being subjected to the extreme heat on their arms. In the second scan, the participants were asked to imagine that the burning heat was damaging their skin. This second-scan mindset was found to increase perceptions of pain. In the final scan, participants were asked to imagine that the heat was a welcome sensation on an extremely cold day. This explanatory style was found to decrease the perceived experience of the pain.
Investigators discovered that when looking back at the scans, participants’ pain stimuli levels were consistent across the three tests. However, the influence of their brains had caused them to believe that the pain was sharper or weaker based on the prompts given.
It is likely that belief is relevant, possibly even more so than the physical component of a premier athlete.
The author, a national swim champion, contends that athletes can control and manage pain differently.

The Athletic Brain and Pain Mangagement

When people think of medicine, they may think of doctors offices, pharmacies, and pills—all things that work to make them feel better physically and mentally. When it comes to pain management, people primarly search for something that will alleviate their pain, especially if it is chronic, relentless pain.
As biopsychosocial approaches to managing chronic pain continue to grow—tackling not just the physical body but also looking at socioeconomic factors, lifestyle, and mental health—one researcher is considering how mind training may help.
Branch Chief and Program Director of Basic and Mechanistic Research in Complementary and Integrative Health, Wen Chen, PhD, discusses a study by Dr. Fadel Zeidan et al that dissects pain management through meditation.5 Specifcally, she explains how the study found that mindfulness meditation actually reduces pain indepependently of opioid neurotransmitter mechanism. Not everyone can be an athlete: but everyone in one way or another can try to think like an athlete. But what does this mean?
Consider the specific differences between psychologists and sports psychologists. Athletic patients tend to have different priorities and make decisions about their health differently than non-athletes.
When I was in the eighth grade, I experienced a shift in my coaching a few years into my training. I had been with the same coach for years, but I was getting older and I was getting faster which prompted the coaches to move me up into the more difficult group, run by a different coach. The pressure and expectations of a new coach with a crowd of new training partners started to affect me both in and out of the pool. Although it seems extreme, thoughts in school became hazy. I felt like I wasn’t completey focused on my assignments and wasn’t fully engaged in my classes. It had gotten to a point where it had led to me opening up to my parents.
My mom had heard through a friend about an accredited sports psychologist and proposed that I seek treatment. My initial response was taking offense that she would consider something like a sports psychologist. In my mind, I thought that she was implying that I was going crazy and needed help. Although I wasn’t going crazy, I did need help; and there is no shame in that.
I had never been to a psychologist of any kind so I was nervous about how it was going to go. Productive? Awkward? Waste of time? All these things were flowing through my mind as I was headed to my appointment. I honestly had no expectations. Once I sat down and I talked about what was going on, I felt all the haziness fade. My attention for the first time in a while felt like it was completely on the conversation with no distractions. The conversation was jam-packed for the entire hour. Topics ranged from sport/school prioritization, relationships on the team, goals, and who I wanted to be.
But the thing that I took away from the session was that I felt like he could understand my true thoughts about the sport and how it had impacted me. In the past, when I have tried to talk about a swimming issue to non-athletes, I didn’t feel like they could completely understand my frustration. Speaking with someone who specializes in the athletic mind provides the most critical element − listening.
Beth Darnall, PhD, a well-known pain psychologist at Stanford University, wrote: “Barriers exist to appropriate and sufficient psychological treatment for pain in those who require a higher level of care than is provided in weekly or bi-weekly treatment sessions.” 6 She has suggested that, “Many complex individuals require coordinated, interdisciplinary care with more intensive psych-behavioral treatment…” With our growing obsession in sports and increase in becoming healthy, it is clear that athletes appreciate the pressures of their sport as it affects them physically and mentally.
In fact, there appears to be physical difference in the brain between athletes and non-athletes. Kielan Yarrow, PhD, described how athletes, “allow more rigorous psychophysical characterization, computational modeling and brain-based hypothesis testing with single-unit recording and brain imaging.” 7
Essentially, there have been breakthroughs in how the mind of an athlete differs from that of a non-athlete, including increased mental dexterity, hand-eye coordination, motor control, and other physical attributes. Athletes tend to adapt to different situations more productively due to the disciplined lifestyle in their sport.

Going for the Win, One at a Time

One of the biggest challenges I have faced is managing chronic asthma. My lowest low was having an attack in the middle of a race, having to be saved by a lifeguard and removed from the pool. For a period of time, I had to stay out of the water, and this was crushing.
But athletes adapt to different situations because of the demand for the sport. Even though swimming literally took my breath away, I knew couldn’t live without it. I had to do whatever it took to get back to training. I went through appointment after appointment with my doctor and my coach to discuss whether “it was worth it.” Could I tolerate fragmented and altered training for the betterment of my career, or should I just give up?
Although these questions were specific to my situation, and I recognize that those living with chronic pain face far dire situations and questions, asking yourself “is it worth it” is something every person − athletes and non-athletes − have to decide when faced with adversity. Breaking this question down into steps, making each decision count, and striving for one goal at a time may make all the difference.
For me, swimming has molded my outlook on life and allowed me to face times of pain and frustration, but also moments of triumph. We all have this potential, we just have to be willing to attain it.
Last updated on: July 8, 2020
close X