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

'Another world of pain'-athlete and sport physiotherapist perspectives on the unique experience of pain in sport

Our objective was to explore athlete's and sports physiotherapists' experiences of sports-related pain in the upper and lower limb. Using a constructivist and pragmatic perspective, we carried out focus groups comprising a deliberate criterion sample of athletes and sports physiotherapists. We used a topic guide that moved from open exploratory questions to questions focusing on the phenomena of sports-related pain in athletes. We coded, developed candidate themes and refined finalised themes using reflexive thematic analysis. A member of our research team acted as a critical friend adding additional perspectives. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ). We completed five focus groups comprising 12 athletes (n=5 female, n=7 male) and four sports physiotherapists (n=4 male) including one initial pilot (two athletes). We developed four final themes (1-4) and nine subthemes (1.1-4.3): (1) Athlete Pain Lens (1.1-pain is part of being an athlete and 1.2-pain shapes the life of an athlete), (2) Exploring And Navigating Pain (2.1-the sports-related pain spectrum and 2.2-making sense of pain), (3) The Emotional Toll of Pain (3.1-challenging emotions and 3.2-the impact of time) and (4) Coping, Community and Communication (4.1-coping with pain, 4.2-influence of community and support network and 4.3-communication, the broken key). We highlighted the distinct and challenging phenomenon of sports-related pain experienced by athletes and physiotherapists. Through effective communication, members of the athlete's community may recognise, and adjust to these challenges.

The Locus Coeruleus in Chronic Pain

Pain perception is the consequence of a complex interplay between activation and inhibition. Noradrenergic pain modulation inhibits nociceptive transmission and pain perception. The main source of norepinephrine (NE) in the central nervous system is the Locus Coeruleus (LC), a small but complex cluster of cells in the pons. The aim of this study is to review the literature on the LC-NE inhibitory system, its influence on chronic pain pathways and its frequent comorbidities. The literature research showed that pain perception is the consequence of nociceptive and environmental processing and is modulated by the LC-NE system. If perpetuated in time, nociceptive inputs can generate neuroplastic changes in the central nervous system that reduce the inhibitory effects of the LC-NE complex and facilitate the development of chronic pain and frequent comorbidities, such as anxiety, depression or sleeping disturbances. The exact mechanisms involved in the LC functional shift remain unknown, but there is some evidence that they occur through plastic changes in the medial and lateral pathways and their brain projections. Additionally, there are other influencing factors, like developmental issues, neuroinflammatory glial changes, NE receptor affinity and changes in LC neuronal firing rates.

What contextual factors influence pain management decision making concerning player availability in professional men's football? A qualitative analysis of practitioner perceptions

PURPOSE

Football practitioners must regularly assess the risk of participation when determining player availability. At present, there is a lack of information detailing the factors that influence risk assessments. Accordingly, the following research question was explored: what contextual factors influence pain management decision-making when determining player availability in professional men's football?

METHODS

20 semi-structured interviews were conducted with club doctors (8), physiotherapists (6), and heads of medicine and performance (8) working in professional men's football in the United Kingdom. The methodology is reported using COREQ criteria and data were analysed using thematic analysis.

RESULTS

Three themes were created that explain how decision-making concerning analgesia was influenced by: (1) access to medical resources, (2) trust between staff and players, and (3) prioritising short-term success. First, the time, resources, and medical information available to staff impacted the ability to assess players and their risk tolerance in relation to analgesia. Second, decision-making was perceived as a multi-stakeholder process and the nature of relationships with players and performance staff could increase or decrease risk tolerance. Third, player decisions are made against a performance and working environment that privileges short term success over long term wellbeing.

CONCLUSION

The data support that pain management decision-making in professional men's football is influenced by the player and staff's working context. Further, practitioners viewed potential harm to a player from a socio-economic and physical perspective. These findings support the adoption of a patient-centred care approach and can inform clear recommendations from international and national governing bodies.

Musculoskeletal Injury Prevalence, Pain Perception, and Physical Activity Level Among Brazilian Strength and Cross-Training Practitioners

In this study, we sought to determine the prevalence of musculoskeletal injuries, perceived pain, and physical activity level among Brazilian practitioners of strength training (ST) and functional fitness (FF). Participants were 311 men and women who trained in 10 FF training centers and seven ST gyms. Each participant completed surveys of the prevalence of musculoskeletal injuries, their pain perception, and their physical activity level. A chi square test was used to analyze associations between groups and distributions of injuries. When any significant difference was observed, the difference score was analyzed through the adjusted residual values. Fisher's exact test was used to determined the associations between musculoskeletal injury prevalence and training modality (FF and ST) and between musculoskeletal injury prevalence and practice frequency (times/wk). To measure the magnitude of association between variables, the Phi coefficient was calculated for 2x2 associations and Cramer's V was used whenever the distributions were outside this standard. When the dependent variable presented a dichotomous characteristic, an Odds Ratio (OR) was calculated with a confidence interval of 95%. We found a higher musculoskeletal injury prevalence in the axial skeleton (n = 52; 83.88%) in FF practitioners and in the lower limbs of ST practitioners (n = 9; 52.96%). When the physical activity level cutoff point was set at 300 minutes per week, there was a significant relationship between physical activity and training modality (p = 0.005). There was also a significant association between pain perception and musculoskeletal injury (p < 0.001). Clinical follow-up was a protective factor to being injured (OR = 0.18; CI = 0.06-0.49), and, even after multivariate analysis this significant association was maintained (OR = 0.03; CI = 0.01 - 0.08). Thus, FF practitioners reported more musculoskeletal injuries than STs, and follow-up medical or physical therapy was a protective factor to these injuries. FF practitioners also had a higher level of weekly physical activity weekly than ST practitioners. Functional fitness practitioners may be at a higher risk of injuries than those who participate in traditional strength training.

Comprehensive assessment and classification of upper and lower limb pain in athletes: a scoping review

BACKGROUND

Upper and lower limb (peripheral) pain is prevalent in athletes. Contemporary research prioritises multidimensional pain assessment and classification. This study aims to review comprehensive athlete pain assessment practices against the reference standard (International Olympic Committee, IOC Athlete Pain framework), identifying trends and highlighting gaps.

METHODS AND ANALYSIS

Six databases were searched using a comprehensive search strategy. This review followed the Joanna Briggs Institute standardised methodology for scoping reviews and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Title and abstract, full-text screening and data charting were completed by two independent reviewers.

INCLUSION CRITERIA

Original research, systematic reviews and clinical practice guidelines reporting assessment or classification of pain in athletes of any age with chronic or acute peripheral pain in English on human participants from database inception.

RESULTS

470 studies with 175 different pain assessment tools were mapped against the IOC Athlete Pain Framework. Papers included tools from neurophysiological (470/100%), biomechanical (425/90%), affective (103/22%), cognitive (59/13%) and socioenvironmental (182/39%) domains. Pain classification was included in 108 studies (23%). 4 studies (0.85%) defined pain. Athletes with physical disability were included in 13 (3%) studies and no studies included athletes with intellectual disabilities. Socioeconomic factors were addressed in 29 (6%) studies.

DISCUSSION

Neurophysiological and biomechanical domains are frequently addressed. Affective, socioenvironmental and cognitive tools are under-represented. Potential tools for use by researchers and clinicians are highlighted. Defining and classifying pain and determining predominant pain mechanisms is needed in both research and clinical practice. More work on underrepresented populations is needed.

CONCLUSION

This review informs researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and highlights future priorities.

The influence of a manipulation of threat on experimentally-induced secondary hyperalgesia

Pain is thought to be influenced by the threat value of the particular context in which it occurs. However, the mechanisms by which a threat achieves this influence on pain are unclear. Here, we explore how threat influences experimentally-induced secondary hyperalgesia, which is thought to be a manifestation of central sensitization. We developed an experimental study to investigate the effect of a manipulation of threat on experimentally-induced secondary hyperalgesia in 26 healthy human adults (16 identifying as female; 10 as male). We induced secondary hyperalgesia at both forearms using high-frequency electrical stimulation. Prior to the induction, we used a previously successful method to manipulate threat of tissue damage at one forearm (threat site). The effect of the threat manipulation was determined by comparing participant-rated anxiety, perceived threat, and pain during the experimental induction of secondary hyperalgesia, between the threat and control sites. We hypothesized that the threat site would show greater secondary hyperalgesia (primary outcome) and greater surface area (secondary outcome) of induced secondary hyperalgesia than the control site. Despite a thorough piloting procedure to test the threat manipulation, our data showed no main effect of site on pain, anxiety, or threat ratings during high-frequency electrical stimulation. In the light of no difference in threat between sites, the primary and secondary hypotheses cannot be tested. We discuss reasons why we were unable to replicate the efficacy of this established threat manipulation in our sample, including: (1) competition between threats, (2) generalization of learned threat value, (3) safety cues, (4) trust, and requirements for participant safety, (5) sampling bias, (6) sample-specific habituation to threat, and (7) implausibility of (sham) skin examination and report. Better strategies to manipulate threat are required for further research on the mechanisms by which threat influences pain.

Mobilisation or immobilisation-based treatments for first carpometacarpal joint osteoarthritis: A systematic review and meta-analysis with subgroup analyses

Introduction

Both joint mobilisation and immobilisation are thought to be effective in the treatment of first carpometacarpal joint (CMCJ) osteoarthritis (OA). The objective of this review was to establish whether either intervention reduced pain and improved pinch strength in people with first CMCJ OA in the short term and assess whether one intervention is superior to the other.

Method

This was a systematic review and meta-analysis. Seven databases were searched until May 2021. Only RCTs were included. The Cochrane Risk of Bias Tool and the Grade of Recommendations Assessment, Development and Evaluation system were utilised to rate the evidence. Random-effects meta-analysis with subgroup analyses were used.

Results

Eight studies were included with a total of 417 participants. Mobilisation treatments included manual therapy with or without exercise while immobilisation interventions utilised thumb splinting with several different designs. Very low-quality and low-quality evidence showed that mobilisation led to statistically but not clinically significant improvements in pain (standardised mean difference (SMD) = 0.53; 95% confidence interval (CI) = 0.03 to 1; I2 = 60%; p = 0.06) and pinch strength (SMD = 0.35; 95% CI = 0.03 to 0.7; I2 = 12%; p = 0.3) compared to placebo. Very low-quality and low-quality evidence showed no effect on pain and pinch strength compared to a control or no intervention. Subgroup analyses revealed no difference between interventions.

Discussion

Neither mobilisation nor immobilisation alone led to clinically important improvements in pain or pinch strength in the short term in people with symptomatic first CMCJ OA. Neither therapeutic strategy appeared to be superior.