Psychosocial stress and symptoms in athletes

Brain-generated pain, weakness or joint stiffness is common in many people who seek chiropractic care. These issues are particularly common in athletes whose competitive drive is not coming from a healthy place, but instead is linked to early family adversity, stress, abuse or trauma.

These symptoms can resemble problems that respond to chiropractic care, but because their cause is different, they typically do not improve as expected. Fortunately, evidence shows that assessment for and treatment of psychosocial stress can beneficially be added to care provided by DCs. 

If you see patient athletes with the following pain characteristics, you are not alone: 

• Does not appear to have a structural cause 

• Persists after an injury has healed, sometimes for years or decades 

• Does not respond to treatment as expected 

• Improves with treatment, only to be replaced by pain in a new location 

• Fluctuates in severity, but not as expected with pain that has a structural cause 

• Is exacerbated by a particular activity, but not by a similar activity 

• Migrates from its original location 

• Is widespread or present in multiple locations 

• Is associated with numerous non-pain symptoms or illnesses 

• Is linked to or triggered by psychosocial stress 

• Occurs in people with past or present mental health issues, such as anxiety, depression, post-traumatic stress, substance abuse, eating disorders or cutting behavior 

Brain-generated pain and stress

Patients with symptoms like those above comprise 40% of those seen in primary medical care. This pain or illness is not caused by disease or injury but rather is generated by the brain. Numerous fMRI studies of the brain in these patients show altered neuroanatomic pathways that change the processing of interoceptive signals. This is often referred to as central sensitization and is associated with past or present psychosocial stress. The nature and degree of stress is usually not recognized by the patient, and this can be a barrier to achieving the best outcomes. 

Stress evaluation

Use the following three-step process to uncover underlying stress(es):  

Step 1

Understand the chronology of the pain or illness in relation to stressful life events. A good example is a man who developed pain only while driving to his highly stressful job. Another patient had daily back pain except when he was on vacation. He was just as active on vacation as he was during the rest of the year, but his stress level was much lower. 

Step 2

It is essential to assess for depression, anxiety or post-traumatic stress. Often these are hidden unless specific questions are asked. An older woman with numerous unexplained symptoms told me she didn’t feel depressed, but she slept poorly, cried regularly including during our interview, had no appetite and had been contemplating suicide. Treatment for depression relieved all her symptoms. 

Another patient developed several unexplained symptoms and had an extensive diagnostic evaluation. Eventually she was seen by one of my colleagues, who learned that just before her illness began, she had been a hostage during the robbery of a store. A pistol had been held to her neck for a half-hour. Not surprisingly, she also had several symptoms consistent with post-traumatic stress disorder. 

A third example is a high school soccer player who developed severe bowel problems on days she was in competition but not on days limited to practice. She was highly anxious about how she would perform in games. 

Step 3

Identify adverse childhood experiences (ACEs). I look for any events that could harm a child’s self-esteem. These can include abuse of the child, loss of a parent, substance abuse or mental illness in the home, excessive criticism, lack of material or emotional support and many more things. Be aware that patients who recall ACEs tend to underestimate or repress their severity.  

Athletes (and others) who endure ACEs often acquire personality traits that can be pushed to stressful levels by competition. These include, but are not limited to the following: 

• Low self-esteem 

• Perfectionism 

• Limitations in self-care skills 

• Excessive self-criticism 

• Detrimental devotion to the needs of teammates or loved ones 

• Poor assertiveness 

Insight into stressful personality traits

The personality traits listed above can drive an athlete to dedication and focus on their sport. But when taken too far, they can cause athletes to overtrain or to train and compete despite injury that needs rest to heal. The stress from these traits also can contribute to brain-generated pain or illness.  

Two exercises can help clarify for the athlete whether these traits have crossed a line into being more harmful than helpful. First, ask the athlete to write (privately) what they say to themselves when they make a mistake in competition. Then ask if they would feel comfortable directing the same criticism to a teammate who had made the same mistake. This exercise can provide insight into whether the athlete’s self-criticism is at a healthy level. 

The second exercise is for the athlete to imagine they are a butterfly on the wall of their childhood home, watching a child they care about living the same life the athlete once did. Do they feel sad or angry as they watch? This can open the door to seeking psychotherapy to expand upon this insight. Psychotherapy also can help identify repressed emotions or the existence of present-day triggers that are common in ACE survivors. 

When any of the three categories of stress are identified in a patient whose pain or illness has the characteristics listed at the beginning of this article, there is a high probability treatment of the stresses will relieve the pain or illness. A good example is a 37-year-old woman with a severe symptom unexplained after tests at two universities. Uncovering her history of eight years of sexual abuse as a girl led to psychotherapy that completely relieved her medical condition after several months. 

Although most patients need weeks or months to recover from stress-related symptoms, some will need years of psychotherapy. But even these patients recognize they are on a path to healing and their utilization of healthcare usually decreases significantly.  

Final thoughts

Several recent research studies of patients with non-structural pain confirm that evaluation and treatment for psychosocial stresses provides much better relief than older methods. Adding these concepts to traditional chiropractic care will improve outcomes in the large number of patients who have brain-generated symptoms. Courses and books for clinicians, professional conferences and self-help resources for patients are available. The techniques work best when medical and mental health clinicians collaborate. Not only are patients enormously grateful for this care, but clinicians also gain great professional satisfaction from facilitating it. 

DAVID D. CLARKE, MD, is president of the Psychophysiologic Disorders Association (PPDA), a 501(c)(3) nonprofit dedicated to ending the chronic pain epidemic. Clarke holds a medical degree from the University of Connecticut School of Medicine and is board-certified in internal medicine and gastroenterology. His organization’s mission is to advance the awareness, diagnosis and treatment of stress-related, brain-generated medical conditions. Learn more at EndChronicPain.org.