Talking pain at the Irish Institute of Sport 27th April 2017
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A talk for elite coaches, physiotherapists and strength & conditioning coaches about the problem of pain.
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Talking pain at the Irish Institute of Sport 27th April 2017
- 1. Pain in sport RICHMOND STACE SPECIALIST PAIN PHYSIOTHERAPIST & PAIN COACH
- 2. Declarations Specialist Pain Physio Clinics UP | understand pain Hon. Clinical Lecturer | QMUL Editorial Team | Physiotherapy Pain Association
- 4. Beginner’s mind ‘In the beginner’s mind there are many possibilities, but in the expert’s there are few” ~ Shunryu Suzuki
- 5. Outline The huge problem that is pain Current understanding of pain Influences & vulnerabilities The MDT and overcoming pain
- 6. The HUGE problem of pain
- 7. Costs & numbers $560-635 billion each year (2011) Healthcare costs Loss of productivity 100 million Americans 20% of the population 1:5 children ‘chronic pain is an urgent medical problem worldwide’ (Tsang et al., 2008) Is it a medical problem?
- 8. Chronic pain: it’s the biggest club Global health burden: 20% of people
- 9. No.1 Global health burden In the top 12 Back pain Neck pain OA Headache & migraine Global burden of disease studies (2010) DALYs ~ Daily adjusted life years; to quantify burden of disease, measuring gap between ideal and existing health
- 10. Why is pain such a HUGE issue? Pain is misunderstood Dualist thought predominates The search for a structure to explain pain In society In healthcare Wrong messages communicated Manage, cope, pain = injury Low expectations Even morphine effects impacted by belief Poor outcomes result
- 11. Pain is a societal issue Universal experience Society needs to understand pain and what to do We have sex education in schools Where is the pain education in schools? Pain is a public health issue
- 12. What is pain?
- 13. Acute pain Is it an injury? “I sincerely thought it was the last ball I would be touching for a long time because of the pain” ~ Messi (2012)
- 14. Damage? Is there damage? Does more damage = more pain?
- 15. Pain and injury Poorly related “The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.” ~ Wall (1979) Whole person state
- 16. Pain is felt in a space Phantom limb pain Pain is dynamic
- 17. IASP Definition An unpleasant sensory and emotional experience associated with actual and potential tissue damage, or described in terms of such damage (1994) Where’s the person?
- 18. The person The person who experiences pain The person suffers It is as much about the person as the condition We need to know the person It is he or she we treat
- 19. The person suffers ‘a state of severe distress associated with events that threaten the intactness of the person’ (Cassell, 1982) ‘suffering occurs when an impending destruction of the person is perceived’ (Cassell, 1982) Threat ~ perception of threat Perceived loss of the sense of self
- 20. Suffering Pain is part of suffering 1st and 2nd arrow “Clinicians commonly see the alleviation of their patients’ suffering as one of their principal aims…” (Sensky, 2010)
- 21. Oliver Sacks on our role “…a disease is never a mere loss or excess – there is always a reaction, on the part of the affected organism or individual, to restore, to replace, to compensate for and to preserve its identity, however strange the means may be: and to study or influence these means, no less than the primary insult to the nervous system, is an essential part of our role….” (1985; The Man Who Mistook His Wife For His Hat)
- 22. Pain is… Normal Part of protection Important for survival Unpleasant A motivator that compels action
- 23. Pain & threat Pain is part of a response to a perceived threat Circumstances suggest danger or possible danger to the person = threat => pain Pain is contextual Chronic pain: no. of threats widen
- 24. Threat vs safety Perception of threat => pain Perceived safety => no pain Perception of threat => protect systems Safety and healthy habits => care-giving system (parasympathetic)
- 25. What is threatening? Individual ‘rating’ Consciously: ‘this might hurt’, ‘this will hurt’ Based on knowledge, experience, belief etc Unique meaning to the person The inner dialogue ‘under my hat’ What is the script saying Unaware of most of our ‘biology in the dark’ Bubbles through to be conscious
- 26. There are no… Pain signals Pain messages Pain centres Nothing specific to pain There are states that we experience consciously Underpinned by interwoven biology and predicted meaning of that biology
- 27. Pain models Gate theory Mature Organism Model Neuromatrix Salience Biopsychosocial Predictive processing
- 29. The salient network ~ Ianetti A cortical network A system for: Detecting salient events Orientating attention towards salient events Reacting to salient events Regardless of sensory channel Detecting threat
- 30. Biopsychosocial model Is it truly used? Do you use BSP model? How do you use it? Chronic pain: sociopsychobio?
- 32. Best guess A hypothesis About the possible causes of the sensory information Based on what we know & prior experience What is the weighting of the evidence? That’s our experience….the best guess Just in case….
- 33. Chronic pain A different biology Adaptations in emotional, reward and emotional centres (Loggia et al. 2014; Baliki et al. 2012; Hasmi et al. 2013) Envelops the person and their life The impact The despair The suffering Pain itself is the problem in its own right
- 34. Is there chronic pain in sport?
- 35. Pain in sport Expected An occupational hazard – unwanted! Aches and pains of training and playing ‘no pain, no gain’ Normalised Culture and beliefs
- 36. Persisting (chronic) pain in sport When is pain classified as chronic? When does it start? When is pain a problem?
- 37. When does chronic pain start? A pain moment Injury Insidious Often a persistent problem has a back story What is the person’s story? Know the person Nothing happens in isolation Priming Circumstances How was the person at this time?
- 38. Vulnerability to chronic pain Gender Age Personality Psychosocial environment Previous pain Stress Depression (Tracey, 2016)
- 39. Influences on pain ~ the narrative Emotional state Stress Beliefs Context Culture Previous experience (priors) Tiredness Environment Isolation Inner dialogue (now)
- 40. Stress Individual’s perception of a situation Is there a threat perceived? Chronic stress => pro-inflammatory Miller et al. (2014) Carers showed greater inflammatory activity vs controls (free of major stress) Blunted glucocorticoid signaling Chronic pain is chronically stressful
- 41. Emotional state Governs our quality of life in this moment How am I feeling right now? How am I choosing to feel right now? Could I choose to relate to this moment in a different way?
- 42. Beliefs about pain and injury General What have I been told all my life? Prior experiences Existing strategies Beliefs guide actions Believe that pain = injury? Sporting Influence of sporting culture Concern about performance Resuming play Funding Career
- 43. Inner dialogue What am I telling myself about my pain? Based on beliefs What is the script? Can I choose a different script? Choose a positive script Inner dialogue determines self-confidence
- 44. Isolation Pain is isolating ~ only I feel my pain Cole et al (2007) Altered activity at a gene level in respect of perceived isolation ~ pro-inflammatory Loneliness is a health issue
- 45. Pain and inflammation Summary of reasons for on-going cycle of inflammation: Chronic stress Perceived loneliness Neurogenic inflammation
- 46. Chronic pain is different Different biology Different behaviours Different thinking Needs different consideration
- 47. Treatment and management What is your existing model and philosophy?
- 48. Consider… An approach to pain that does not focus exclusively on pain Instead focuses on living well Pain Coach approach Addresses pain mechanisms and influences Much of which are ‘non-pain’ Significant focus on skills of well being Proven skills for a happy and healthy existence
- 49. Treatment and management ~ delivering the best General principles A person at the centre An athlete A human Thinks Emotes Acts Perceives Early messages Team strive for best care “Every pain problem, acute or chronic, has a thinking, reasoning and emotional brain attached to it” (Gifford)
- 50. Acute pain and the team Best outcome envisioned and subscribed to by all All thinking and actions in line with best outcome MDT creates a supportive and compassionate environment MDT: open communication to capture entire narrative Key co-ordinator of care Athlete ALWAYS feels nurtured and supported through to return to sport
- 51. Chronic pain & recurring injury Complexity, vulnerabilities, influences require optimum MDT functioning Many chronic pain patients ‘fall through cracks’ That could be career ending for an athlete NO CRACKS MDT is a ‘super team’ ~ created
- 52. MDT: The super team ~ the people People who want to: Be positive Do positive work Be professional To be peak performers The people know WHY they do what they do They have a purpose
- 53. Man’s Search for Meaning
- 54. Super-team ~ the story The team clarifies their picture of success Strengths are identified and co-ordinated To do best work The team knows the challenges The team knows who will deliver what What are we doing? Why are we doing it? How are we doing it? Who is doing it? When are we doing it?
- 55. Super team vision & how ~ example All members are clear on the vision and how it will be achieved Athletes return to full participation What does that look like? Clear communication between all members Positively encourage at every opportunity The athletes and team members To clarify what went well and how we can do more
- 56. (2) My role in the team is……….. We will always create the best environment for positive work to take place We will praise best efforts Athletes and each other We will celebrate success We will identify areas to improve and take action We will foster the skills of wellbeing including compassion, empathy, acts of generosity and gratitude
- 57. Principles of performing To deliver best performance Attention to detail in preparation Focus Re-focus Always seek to do one’s best Rehearse Practice a positive script Work to strengths Same principles for overcoming pain/injury
- 58. John Wooden ‘Make each day your masterpiece’
- 59. To overcome chronic pain ~ the athlete Understand pain ~ a working knowledge Reduce & minimise fear Clarifies picture of success & strengths What brings me success? What went well? How can I do more? Focus on What he/she can control Own thoughts & actions Doing best and dealing with distractions Feels supported
- 60. To overcome chronic pain ~ a strengths based programme Based upon foundation of understanding pain Develop a belief that ‘I can overcome pain’ Focused on desired outcome and the ways to get there Person creates conditions for recovery Skills of well-being: positive outlook, attention, resilience, generosity, Promotes and cultivates a care-giving state Aware of protect state and learns to change gears Sensorimotor training
- 61. ~ strengths based programme (2) Basic exercises and movements => conditioning Simple movements => sport specific Living socially => building tolerance Normal activities => building tolerance Use living to get back to living Making the choice to take positive action
- 62. Overarching focus ~ complex pain Living well Meaningful life is the goal What does that mean to the individual? Define those terms Think about what you want, not what you don’t want Frame positively
- 63. Who’s in the team? ~ complex pain The ‘co-ordinator’ must understand pain Currently no single profession has ownership of pain Physiotherapists Doctors S&C Psychology An open forum for discussion Include the athlete at times
- 64. Summary Pain is complex To fully address the interlocking and overlapping dimensions we need a tight team The team needs to be created and led Team needs clarity Vision How it will be achieved Who will play which role Strengths based approach: what works to deliver results
- 65. Thank you @painphysio @Upandlivewell www.specialistpainphysio.com www.understandpain.com UP | understand pain ~ a social enterprise to change the way society addresses pain