The IOC’s consensus statement on pain management

In September 2017, the International Olympic Committee (IOC) published the first consensus statement on pain management in elite athletes in the British Journal of Sports Medicine.¹

Prior to this, there were no guidelines on effective pain management for the elite athlete population.

The authors suggest an approach to pain management, however, that can be used not just for athletes but for every patient. The process is to identify the “cause(s) and type of pain and development of a treatment strategy that addresses the contributing factors across physiological, biomechanical, and psychosocial domains.”²

Painful sensations are an individually unique experience. Are pain sensations beneficial? Yes, because pain serves to protect individuals from potentially dangerous or damaging tissue injury. If you have enough pain, it will limit the use of the injured body structures. In this regard, it should promote healing by rest or modified use. Athletes are good at adaptation and will often ignore pain until something really bad happens.

Types of pain

As the IOC paper relates to chiropractic practices, patients can present with more than one type of pain. The current thinking on the different types of pain include:

Nociceptive pain: Nociceptors innervate nearly all tissues of the body. They respond to extreme temperatures, mechanical stresses, chemicals, bacteria and viral proteins, and UV radiation stimuli to drive the sensation of pain. Nociceptive pain includes inflammatory pain (resulting from active inflammation). Pain may develop from overuse injury, and it may be influenced by factors such as training load and sleep.

Neuropathic pain: This pain is recognized as a disease process that may involve multiple pathophysiological mechanisms producing burning or lancinating pain that occurs with an increased response or duration and is provoked by minimal or even absent stimuli, suggesting a sensitized and hyperactive nociceptive system.³ 

You may see a patient with neuropathic pain that develops following surgery for a sports injury or from repetitive mechanical and inflammatory irritation of peripheral nerves in endurance sports athletes. The key takeaway here is that neuropathic pain is a common disorder that affects neurological function and the treatment for neuropathic pain is a nervous system lesion rather than tissue injury.

Nociplastic, algopathic, and nocipathic pain: This refers to pain that is not a consequence of nerve or tissue damage. These types of pain are observed in fibromyalgia, irritable bowel syndrome, and complex regional pain syndrome. Nociplastic pain refers to a change in function of nociceptive pathways, algopathic pain is pathologic pain not generated by injury, and nocipathic pain refers to a pathologic state of nociception.⁴

Pain assessment in elite athletes is no different than that for other patients—you set goals and expectations of treatment. Your intake should include numerical pain intensity, location, duration, and impact on performance, as well as precipitating and aggravating factors. Whether the patient is an athlete or not, it’s recommended to explore:

• Childhood—exposures, illnesses, nutrition, nurturing
• Past few years —dietary choices and adequate nutrition questions
• Lifestyle—exercise, daily activities, work, etc.
• Adequate hydration
• Stressors
• Emotional expression and changeability
• Sleep patterns and cycles
• Environment—location and exposure
• Triggers for pain—GI distress, fatigue, mood imbalances, headaches

The IOC authors stress that the longer the duration of pain persists, the less likely it will reflect tissue damage and the more benefit there is likely to be in taking a multidisciplinary approach to the problem.

Patient management

Chiropractors are good at the physical examination of athletes because they include a biomechanical assessment. Practitioners who consider the fascial distortion model (kinetic chains) know that it is an effective exam approach and treatment to relieve patients of pain and restore exercise tolerance.

What are other potential treatments for athletes? Use whatever works. The authors suggest discussing training load, periodization, physical conditioning and lifestyle factors. These can be optimized by a sports- or rehab-oriented chiropractor.

Understanding psychological and behavioral interventions, social and environmental modifications may be managed by a pain psychologist. It’s vital to ask about sleep. “Pain can disrupt sleep, and sleep problems can worsen pain. A sleep-deprived athlete is not in an optimal state of recovery, and sleep deprivation can alter tissue sensitivity and load capacity, thereby increasing risk of injury and pain,” the authors explain.

A 2014 study found that the risk for injury was nearly doubled in adolescent athletes who slept an average of fewer than eight hours per night versus eight hours or more.5 Sleep deprivation affects overall recovery and has been linked to anxiety and depression, which can lead to worsened pain and performance.^6,7

If you can discuss and manage diet, that can be helpful too. But if you are not qualified, then use the interdisciplinary management approach and refer to a nutritionist. Is the athlete’s diet regulated for energy balance? Is there sufficient caloric intake relative to caloric needs? An imbalance could result in osteopenia, diminished performance, illness, and injury.^8,9 Consider performing a body composition analysis that includes hydration levels, and you might check blood sugars, too.

A focused plan

In summary, the goals of athlete pain management include identifying and addressing the cause of pain; is it pain consistent with an injury, or is it pain that is more consistent with some other biomechanical, psychological, social, or addiction factors?

You want to treat acute pain aggressively to prevent chronic pain from developing. Focus on returning the athlete to play or competition. In the event you’re part of a multidisciplinary team, promote excellent communication between other practitioners and the patient.

In addition to eliminating subjective discomfort with manual therapy, laser, shockwave therapy, or similar as indicated, assess the biomechanical forces that may have led to the injury (the kinetic chain approach). And finally, use outcome assessment tools (OATs) to improve outcomes.

Chiropractors are non-pharmacologic practitioners, but some athletes and patients will require medication. The types of medications MDs tend to prescribe to athletes have an extremely limited role in managing musculoskeletal injuries and should rarely be used for more than three to five days.

The IOC study suggests cannabinoids have no role in managing musculoskeletal injury (but my personal experience with athletes and other patients suggests otherwise). The medical cannabis debate in athletics will continue.

It’s helpful to boost feelings of patient inclusion in the treatment decision-making process. Look for opportunities to get to know each other and collaborate to work on new treatment innovations. Athletes are willing to do the work and if regular patients are willing to do the work too, present it to them.

After 35-plus years in private practice treating all kinds of athletes, the evidence is pretty clear to me: Every patient will behave more like their best selves, more of the time, if doctors take a few modest steps to foster an environment where the patient’s brain isn’t overloaded; focus more on rewards (healthy aging lifestyle) than threats (fear of degeneration).

My pain management list includes:

• Give patients a timeline and expectations.
• Be conservative when setting the baseline.
• Exercise protocols should fit the needs and requests of the patient.
• Use aerobic exercise as well as motor control training.
• Include exercise of non-painful parts of the body.
• Allow increased pain during and shortly following exercise but avoid continuously increasing pain intensity over time (i.e., modify exercise).
• Use multiple and long recovery breaks in between exercises.
• Minor symptom flares are natural during initial stages of exercise therapy, but should cease once an exercise routine is established.
• Do not grade the exercise protocol in case of major symptom flares.

With some behavioral science in your toolkit, you can build a more productive athlete (patient), a better teammate—and a happier one at that.

Jeffrey Tucker, DC, practices in Los Angeles, Calif. He is the current secretary/ treasurer of the ACA Rehab Council. He can be contacted through DrJeffreyTucker.com.

 

References

1  Hainline B, Derman W, Vernec A, et al. International Olympic Committee consensus statement on pain management in elite athletes. Br J Sports Med. 2017;51(17):1245-1258.

2  Hainline B, Turner JA, Caneiro JP, Stewart M, Lorimer Moseley G. Pain in elite athletes-neurophysiological, biomechanical and psychosocial considerations: a narrative review. Br J Sports Md. 2017;51(17):1259-1264.

3  Clark MR, Chodynicki PM. Pain management. In Levenson JL, ed. Textbook of Psychosomatic Medicine. Arlington, VA: American Psychiatric Publishing; 2005:827-867.

4  Kosek E, Cohen M, Baron R, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain. 2016;157(7):1382-1386.

5  Milewski MD, Skaggs DL, Bishop GA, et al. Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop. 2014;34(2):129-133.

6  Neckelmann D, Mykletun A, Dahl AA. Chronic Insomnia as a risk factor for developing anxiety and depression. Sleep. 2007;30(7):873-880.

7  Bonvanie IJ, Oldehinkel AJ, Rosmalen JG, Janssens KAM. Sleep problems and pain: a longitudinal cohort study in emerging adults. Pain. 2016;157(4):957-963.

8  Martinsen M, Bratland-Sanda S, Eriksson AK, Sundgot-Borgen J. Dieting to win or to be thin? A study of dieting and disordered eating among adolescent elite athletes and nonathlete controls. Br J Sports Med. 2010;44(1):70-76.

9  Sundgot-Borgen J, Torstveit MK. The female football player, disordered eating, menstrual function and bone health. Br J Sports Med. 2007;41(Suppl 1):i68-i72.