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Pain vs Tissue Damage

There is more to pain than tissue damage: eight principles to guide care of acute non-traumatic pain

"ARE YOU CAREFUL WITH HOW YOU LABEL AN ATHLETE’S PAIN? Musculoskeletal pain in athletes is common, but not always associated with injury (ie, tissue damage).1 Damage occurs when load exceeds tissue tolerance, such as ligament tear or a fracture. However, pain in athletes that occurs in the absence of trauma and tissue damage is still often labelled an ‘injury’ by clinicians, coaches and athletes themselves. This highlights a gap between knowledge (tissue damage is not necessary for pain) and practice (assuming that all pain arises from tissue damage) in our clinical community.1 2 This applies particularly in the area of acute non-traumatic pain (such as back and joint pain). To help bridge this gap, we outline eight principles to guide clinicians who manage musculoskeletal pain in sport (see infographic in figure 1).

1. In the absence of trauma, do not assume that pain indicates tissue damage

► Labels such as ‘sports injury’, ‘overuse injury’ or ‘microtrauma’ convey that pain is caused by tissue damage, resulting in over-protection of the athlete. While pain related to repetitive loading may be associated with a stress fracture, pain that presents with no identifiable pathoanatomical basis should not be labelled or treated as tissue damage.2

► In the absence of trauma and relevant pathology, the use of labels such as sports-related ‘knee pain’ rather than ‘knee injury’, enables clinicians to practice in line with guidelines, whilst exploring and targeting modifiable factors relevant to the athlete’s pain experience.

2. Do not refer for imaging unless it will directly influence care, or when there is suspicion of serious or specific pathology

► Many imaging findings are present in athletes who have no pain (ie, disc bulges, degeneration and labral tears, etc).2 3 Imaging an athlete with no red flags or indicators of specific pathology increases the risk of clinicians mislabelling them as having ‘pathology’, and attributing such findings as the cause of pain. Inaccurate and threatening health information can adversely impact the athlete and lead to invasive interventions.

► When imaging is not indicated, clinicians must reassure patients and provide an evidence-informed alternative explanation for their symptoms.

3. Explore biopsychosocial factors that may contribute to pain ► Musculoskeletal pain is modulated by the interplay of different biopsychosocial factors,4 such as training load, conditioning, levels of fatigue, sleep quality, mental health, and abdominal obesity.2 5 6

► Patient-centred communication and psychosocial screening tools form an integral part of the assessment of athletes with acute non-traumatic musculoskeletal pain.7 This enables clinicians to explore how different biopsychosocial factors interact to influence the athlete’s pain experience (see table 1 for examples).

4. Deliver positive messages about pain during examination and treatment

► Positive language validates the athlete’s pain experience while reducing the perception of threat. Pain during examination and treatment should be framed as tissue sensitivity rather than tissue damage.8

► Reinforce that the body is strong, trustworthy and adaptable. Behavioural experiments can be used to reinforce positive messages that the athlete is safe when engaging in feared, avoided or pain provocative movements and activities.

► Engage athletes in graded loading and time-contingent rather than pain-contingent participation. This promotes a message of body confidence and reinforces that movement and loading are protective.5

5. Improve tissue tolerance to load and sports exposure

► Ensure rehabilitation programmes involve graduated exposure to movement and loading, and also meet strength and conditioning needs for the athlete to remain active and/or return to sport.

► Build mental and physical resilience including helping individuals sleep better, be more resilient to stress and maintain a healthy body weight.

6. Use passive treatments only as an adjunct to active management ► While passive treatments may provide short-term pain relief, in isolation they may undermine the athlete’s self efficacy and create dependency.

7. Use shared decision-making to build self efficacy

► Build athletes’ self-efficacy by educating and engaging them in a process of informed and shared decision-making. This empowers athletes to take charge of their health, make evidence-informed treatment choices and effectively advocate for themselves when communicating with stakeholders including, clinicians, coaches, media, sponsors and family.

8. Use an interdisciplinary approach to deliver a unified message

► Adopt a uniform narrative about nontraumatic pain across medical and coaching staff to ensure the athlete has consistent health messages regarding treatment and sports participation.

► This is particularly important when athletes have comorbidities such as diabetes, Crohn’s disease and mental health disorders. Implementing these principles will require a cultural change within sport and sports medicine. Enormous barriers exist such as vested interests, clinician/coaching silos, pain beliefs reinforced by early access to imaging, treatment expectations and provision of quick ‘fixes’ and conflicting messages regarding training and return to sport for athletes in pain. Even with buy-in from clinicians, coaches and athletes this new paradigm will provide a major implementation challenge."


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