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14 Articles in Volume 18, Issue #7
A 2018 Update: The Federal Pain Research Strategy
A Commentary on Medical Cannabis
Are Abuse-Deterrent Opioids Appropriate for Your Pain Patient?
Behind the AHRQ Report
Challenges Facing Abuse-Deterrent Formulations
Demystifying Opioid Abuse-Deterrent Technologies
Editorial: Our Clinical Pain Neighborhood
Independent Pain Practice: A Case Example
Inside Performing Arts Medicine
Letters to the Editor: ACT Therapy; Compounded Topicals
Nerve Growth Factor and Targeting Chronic Pain
Pain Control for Athletes: What Works?
Quality Training: One Center’s Experience with Pain Assessment
The Importance of Developing Professional Relationships in Pain Practice

Pain Control for Athletes: What Works?

Athletes often fight through their pain to reach their ultimate goals. Specific pain therapies may get them back to performing at their best.

With Karen D. Davis, PhD, Craig Spurdle, MD, and Elmer Pinzon, MD, MPH, DABIPP

When athletes in pain seek medical help, they tend to have one thing in common. Whether they are professionals or amateurs, they want to get back to their workouts and events as soon as possible. Ankle sprains, shin splints, shoulder injuries, tennis elbow, plantar fasciitis, spine-related pain conditions and ACL tears are just some of the common pain-specific musculoskeletal conditions a practitioner may come across in athlete patients.1

Ongoing research from Canada reveals that pain does not affect the performance of all athletes equally. Some, in fact, perform better when in pain, according to Karen D. Davis, PhD, professor of surgery at the University of Toronto, and head of brain imaging and behavior-systems neuroscience at the Krembil Brain Institute at Toronto Western Hospital. These findings, replicated in her previous studies over the years, has led Dr. Davis to classify athletes in pain as either A-type or P-type. The A-types can focus their attention on making their sports goal: running the race, beating the competition, etc. Their intent is so strong that they do well in their sport despite the pain—and sometimes even perform better than when not in pain. P-types, however, focus intently on the pain and do not usually perform well, as their attention is diverted.

Athletes often fight through their pain to reach their ultimate goals in sports(Source: 123RF)

Consider the Type of Athlete Being Treated

In a recent study, Dr. Davis first classified 51 healthy people as either A-types or P-types, based on how they performed a complex mental task when exposed to a painful stimulus, compared to when they were not exposed to it. Next, she administered a functional MRI (fMRI) scan, focusing on neural activity in the executive control (EC) network and the salience network. EC is known to optimize a person's behavior in response to what is occurring in their environment, while the salience network helps to determine which stimuli deserve attention.2

A-types demonstrated more flexibility in both networks, which may explain how they are able to prioritize performance over pain, Dr. Davis explained. “About half the people in our initial sample actually did the task faster and better when we were administering a painful stimuli,” she told Practical Pain Management (PPM). With her research ongoing, Dr. Davis could not conclude if it is possible to change a P-type into an A-type.

As a physician trying to help athletes in pain, simply knowing that pain affects an athlete’s performance differently may guide approaches for pain control. Below are a few tried-and-true therapies that may be used, according to clinicians who work regularly with athletes.

Elevation & Ice—In the Correct Form

Asking a patient to “elevate and ice” is a common first-line technique, but this approach is often not explained correctly or misinterpreted, said Craig Spurdle, MD, an orthopedic surgeon and sports medicine specialist at Nicklaus Children's Hospital in Miami. A physician for the United States Ski Team, Dr. Spurdle works with pediatric and young adult athletes at all levels.

According to Dr. Spurdle, most people think about elevating only the injured area. “Instead, the whole extremity needs to be elevated.” It is also important that the heart be lowest, he said. For instance, if the foot is the painful, injured site, it should be highest, while the heart should be lowest. “It keeps a lot of the swelling down, and inflammation [from swelling] is a big component of pain,” he said.

Icing is also often done insufficiently. “Patients need more specific instructions,” and while icepacks are often coldest, “they can give you frostbite,” Dr. Spurdle said. He suggests putting ice in a bag with a towel over the skin for protection. He tells patients to ice for 10 to 15 minutes every hour, and individualizes the length of time to continue the remedy on a case-by-case basis. Despite differences in the literature about the effectiveness of this method, Dr. Spurdle said, in his clinical experience, it has made a substantial difference, both short-term for acute pain and long-term for chronic pain.

TENS Makes a Comeback

Transcutaneous electrical nerve stimulation (TENS) units are making a comeback, said Elmer Pinzon, MD, MPH, medical director of the University Spine and Sports Specialists in Knoxville, TN, and an editorial advisor for PPM. While the devices do not work for everyone, they may be worth a try, he said. The small, battery-operated devices deliver low-voltage electrical pulses to the painful area. Prices vary from about $30 to around $100, he said, noting that some are available over-the-counter, but not all are covered by insurance. Dr. Pinzon suggests having patients try a TENS unit as part of a physical therapy setting first before purchasing one.

While published research has produced mixed findings on the efficacy of TENS, in a recent study, researchers concluded that TENS does indeed lead to pain reduction, possibly due to the activation of the descending pain-inhibitory pathway. In the study, patients given a painful stimuli without the TENS unit during the exposure had significantly higher pain and unpleasantness ratings than those given the TENS unit during exposure to the painful stimuli. The researchers administered functional MRI (fMRI) scans to detect brain activity in both those who had and did not have the TENS unit, suggesting that this activation of the pain-inhibitory pathway was key to pain reduction.3

Electrotherapy such as TENS is typically used along with other treatments, and it may help alleviate pain enough for a patient to participate more actively in targeted physical therapy exercises, Dr. Pinzon said. He clarified that TENS units often prove more effective in treating chronic pain than acute pain.

Self-Help, Yoga, and Meditation

Also better for chronic pain than acute pain, yoga may help athletes suffering from neck and back conditions, Dr. Pinzon said. They may experience gains in strength, flexibility, and endurance fairly quickly, he added. In one recent study, experts compared physical therapy with yoga in 320 people who had moderate to severe chronic low back pain and found that yoga was as effective as going to physical therapy.4

Dr. Pinzon suggested that combining meditation with yoga may also help. As both techniques are calming, Dr. Spurdle also recommended this method. “The more anxious a person is, the more it hurts,” Dr. Spurdle said. British researchers evaluated a common meditation practice called mindfulness-based stress reduction (MBSR) in 20 athletes, ranging from 21 to 36 years old, all with severe injuries that prevented their participation in their sport for more than three months. Injuries ran the gamut, from proximal phalanx to shoulder issues and knee ACL problems.5

They assigned all 20 to their usual physical therapy, but also assigned half of the group to a weekly 90-minute MBSR session for 8 weeks. At baseline and at Week 9, researchers gave all the athletes a cold pressor test to evaluate pain tolerance. Those who added on the MBSR had an increase in pain tolerance, the researchers reported. At baseline, no significant differences were found between groups in terms of pain tolerance (P = 0.9) but a significant difference occurred at Week 9 (P = 0.016).

Massage & Manipulation

Both massage and manipulation are worth trying for both acute and chronic pain conditions, Dr. Pinzon said. He recommends deep-tissue massage from a certified massage therapist or physical therapist. Manipulation with soft-tissue mobilization may include various techniques from physical therapists, he said, such as the McKenzie and Maitland methods.6,7 Developed by New Zealand physiotherapist Robin McKenzie, this method of assessment and treatment of the spine and extremity pain emphasizes active patient involvement. The Maitland concept employs mobilizations of the spine to treat pain.

Use the Athletic Advantage

Whichever pain control technique a clinician may use to manage pain in athletes, tapping into their innate determination to set goals and meet them is recommended by Dr. Spurdle. “They are used to doing that physical training,” he explained. If athletes look at the rehabilitation process in the same way that they look at training to win a marathon, a swim meet, or a century ride, they are more likely to meet the necessary goals and reap the rewards, he noted. They aim to come back stronger, pain-free, and perform better for their sport.

Last updated on: October 4, 2018
Continue Reading:
Managing Musculoskeletal Pain in Endurance Athletes
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