This document discusses pain in the context of sport. It notes that pain is a complex experience influenced by biological and psychological factors. It is not always indicative of actual tissue damage. When an injury occurs, many individual factors like a person's health history, mindset, and early treatment can influence whether the pain persists long-term. Managing persisting pain involves seeing the whole person, understanding pain scientifically, and using rehabilitation to restore normal function and a positive self-identity, rather than just focusing on pain alone.

1. Pain in sport
Richmond M. Stace MCSP MSc (Pain) BSc (Hons)
Specialist Pain Physiotherapist

2. Behind every pain…
…is a story
…a person
Know the person to know the pain
It’s as much about the person as the condition – Oliver Sacks
When a person is better, the pain is better
People with persisting pain often fall in the cracks

3. Picture this..
16 year old sporty girl with shin pain
2 years and worsening
Continues to play sport most days at school
Very tender to touch
Sometimes very painful to walk
First thoughts?

4. Then….
8 year h/o migraines
Digestive disturbances
Disturbed sleep
Widespread tenderness
Perfectionist & demanding school
This a case for……

5. A lack of signs? Puzzling?
Is there an actual injury?
Is there sensitivity?
e.g./ hamstring ‘re-injury’
What’s the story?
 is there damage or does it just feel like damage?

6. 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)

7. Acute injury
 Is there actual damage?
 Does more damage = more
pain?

8. Pain is…
Normal
Part of protection
Important for survival
Unpleasant
A motivator compelling action

9. Pain definition
IASP
An unpleasant sensory and emotional experience associated
with actual or potential tissue damage, or described in
terms of such damage

10. Pain is the No.1 global health burden
 Back pain, neck pain,
headache, migraine, OA
 All in top 12
 depression
 Persisting pain
 What do you think about?
 Is persisting pain in sport?

11. The problem
Pain misunderstood
Society
Healthcare
Wrong messages communicated
Low expectations
Even morphine affected by expectation
Poor outcomes

12. Persisting pain in sport
Yes
How common?
Impact – this is the ‘lived experience’
Person
Professional vs amateur
Participation
Performance
Playing with pain

13. What can we do?
 Develop understanding of
pain
 Answer the question: what is
pain really?
 This answer leads to a route
onwards
 Different thinking
 Neurobiology
 Neuroimmunobiology
 neuroimmunoendobiology

14. What is pain?

15. What is any experience?
 The brain’s best guess!
 Making sense of the world now
 Generates & constructs
explanations for its sensory
input
 Generates predictions of
sensations
 Generates hypotheses to try to
explain what is happening in
the outside world

16. Mature organism model (Gifford)

17. Important principles

18. Change
 We change
 ‘Neuroplasticity’
 Which direction?
 There’s more than one
direction
 If you think there is…
 Your choice

19. Whole person
 ‘I’ think
 ‘I’ feel (pain, thirst, hunger)
 My ______ does not feel pain,
I do
 What do we treat?
 Or who do we treat?

20. Embodied cognition
The body an extension of the mind
We are more than a brain
Our bodies in the world do much of the work needed to
achieve goals (not just the brain)
e.g mechanics of walking
Gestures reduce load on brain
I think with my whole person
Where do you feel anxious? Hungry?

21. Embodied athletes
Identify with body & performance
Their sense of self encompasses body & performance
‘gestures’ part of their cognition
Automatic
Predictions not responses – otherwise miss the ball!
Injury => loss of sense of self

22. Pain
 Consider…
 Pain is a lived experience
 Pain is not an accurate
indicator of tissue damage
 Pain is about perceived threat
 Pain is allocated a space
 Pain is dynamic

23. What influences pain?
 The meaning – what do you
tell yourself?
 The context
 Where you are
 What you are doing
 What you are planning to do
 What you have just done
 Emotional state – anxiety,
stress
 Tiredness
 Prior experience
 Beliefs about pain/health
 Attention bias
 Who we are with

24. Pain in sport
 Expected
 Part of training & playing
 Accepted risk
 ‘no pain, no gain’
 What if the pain persists……
or injuries recur?

25. New injury
 What do you want to know?

26. The injury moment
 Context
 Mechanism
 Meaning
 Body responses
 Pain intensity
 Current health
 Early care
 Initial management
 Messages given
 Investigations
 Other’s responses
 Facial
 Verbal

27. Injury – not in isolation
 Why?
 Pain vulnerabilities
 Pre-existing sensitivity
 Functional pain syndromes
 Injury patterns
 Fatigue
 Health
 Prior injuries & pain
 Circumstances
 The person
 Priming factors
 Pain vulnerability
 Genetics
 Body sense
 e.g. hypermobility

28. Persisting pain
Begins at the moment of injury
Vulnerable
Uncontrolled pain
Wrong treatment
Pain beyond a useful time?
Or are there health issues?
Habits of thought and action

29. What have you seen?
Features?

30. What do we see?
 Loss of sense of self
 Change in body sense
 Altered movement patterns
 Altered thinking
 Outlook?
 Altered planning
 Change in perception of the
environment
 Sickness responses
 Other aches and pains
 Poor sleep
 Varied emotions

31. What are we trying to do?
 Restore a sense of self as
defined by the person
 Resume a meaningful life
 Matching what is expected
with what is happening
 What does that look like?
 Ask the person?
 Their vision

32. How do we do it?
 Working knowledge of pain
 Reduce threat
 Take healthy action
 Develop body sense
 Sensorimotor training
 Motor imagery
 visualisation
 Focus on health (not pain)
 What we focus on, we get
more of…
 Deal with distractions from the
vision
 Programme must be lived
 Moment to moment
 Build tolerance for activities
 Graded exposure
 General fitness
 Sleep habit
 Meet basic needs!
 Pain Coach
 Strengths based coaching
 Become their own coach

33. Key points
Pain is whole person: when the person gets better, the
pain gets better
Early messages are key!
Understanding pain is vital – working knowledge
Pain is a lived experience, which the programme must
reflect
Pain is temporary, each moment unique
Change is certain; direction can be a choice

34. Thanks!
@painphysio
www.specialistpainphysio.com
painphysiolondon@gmail.com
07932 689081
UP | understand pain – www.understandpain.com
@upandsing