I recall a time when a consultant told me that chronic pain does not exist in private medicine. I was somewhat dumbfounded that an intelligent person could have such a thought. As a far as I was (and am) concerned, pain is classless. This was some years ago, however I am reminded of this when I think about the lack of recognition of chronic pain in sport.
Injury and pain are part of sport and we all know this well. Healthy people engaging in regular physical activity gain the physical and psychological benefits of exercising, but there is a risk of injury. And whilst many people who are injured will heal and recover, resuming their sport, there are a cohort who do not return to full participation and suffer on-going pain. Persisting pain affects one’s ability to perform, self-confidence, self-efficacy and in the professional case, a career. This is no different to the situation with a non-athlete with chronic pain.
There are a number of reasons why an athlete fails to recover including the context of the injury, early management, the development of fear, the understanding of the pain and injury, and the intensity of the pain at the outset. When lecturing on this subject, I tell the story of Messi who believed that his career was over because of the pain he experienced in his knee having collided with a goalkeeper. He was immediately taken for an MRI scan that revealed no injury. Recovery was swift when Messi knew he had not damaged his body. The pain he experienced on the field when he thought his footballing days were over was intense with a meaning that drove into the heart of his emotions, and that of the silenced crowd.
The reasons that pain persist are no different in the non-sporting person: the context of the injury, the state of health at the time, prior pain and injury and how they were dealt with, initial management etc. This being the case, we can bring the modern thinking about chronic pain into the sports arena for two reasons. One is to look at how injuries are dealt with in the early stages, and the other to take a broad perspective in tacking the on-going or recurring injury.
The early management of sports injuries is well known. The aspect to which I refer is the communication about injury and pain. In fact, even before an injury, providing education for players and athletes would impact upon those first vital moments that can prime and set up the recovery. At the point of injury, a whole body, all-system response kicks in, and recognising these processes in their entirety will maximise the recovery potential from the outset. All the necessary processes for recovery are in the human body. The main proponents of disruption are over-zealous treaters, fearful potential recoverers and those who ignore what the body is orchestrating. A careful explanation of the injury, pain and what will happen to aid recovery goes a long way to calming excited protective body systems.
Changing a pain state is entirely possible. Understanding that pain emerges in the body but involves the whole body is vital when considering all the factors necessary to set up recovery. When pain persists there are many habits and behaviours that become part of the problem. These need identification and re-training as much as the altered body sense, altered movement patterns, altered thinking, altered emotional state, altered immune responses, altered endocrine responses, altered autonomic responses, altered self-awareness, altered perception of the environment — we are altered in this state and it involves a host of responses, not set in stone but instead, adapting and surviving. On spraining a knee ligament, it’s not the ligament as much as how the body is responding to the detection of chemicals released by the injured tissue, the perception of threat and how the individual responds to the conscious feelings created by the whole body that drive thoughts and behaviours.
In the light of this knowledge (that has existed for many years), far more comprehensive treatment and training measures have been devised in small quarters. This approach delivers vastly improved outcomes because the problem is being addressed in a way that recognises that pain emerges from the whole. This notion was crafted from the merging of neuroscience and philosophy and is now taking our thinking forward (thanks to Mick Thacker and Lorimer Moseley for bringing this mode of thinking to physical therapy and beyond). I no longer refer to ‘pain management’ as this implies we are not trying to change pain, and I believe that we can and do change pain.
Pain is changing all the time as is every conscious experience. What patients believe is what they will achieve: “Whether you think you can, or think you can’t, you’re right”, Henry Ford. Let us draw upon the psychology of success, create a clear vision and go for it. Every action and thought can be challenged with the question, “Will this take me towards my vision?”. This is the same in sport as it is in the general population and we can use exactly the same principles, just with different end points — everyone has a different end point, hence my push for recognition that chronic pain exists in sport and remains a huge and costly problem for individuals and clubs.
How can we go about this? Initially we must create awareness of the extent of the problem, recognising that a wider approach is needed and subsequently implementing contemporary treatment and training methods that work with the whole person. Understanding the pain mechanisms, the pain influences and the context of the pain for the individual orientates thinking that creates a route forward toward the identified vision. Blending specific training (e.g./ body awareness, sensorimotor control) with techniques that boost self-efficacy and maintain motivation for the necessary steps towards recovery. The recovery is part of the vision and is determined by prioritising the programme and working consistently.
Using comprehensive measures and thinking, we can create the conditions that allow for pain to change in the whole person by allowing body systems to do their work. Our role is to facilitate this biology by what we say, do and advise. Drawing upon the contemporary way persisting pain is approached in the general population, sportsmen and women can access the same benefits, optimise their potential to return to exercise and reduce the risks of recurrence.
Richmond specialises in creating the conditions for people with chronic pain and injury to recover and move forward. When he is not seeing patients, Richmond spends his time writing and talking about pain with the aim of bringing the modern understanding of pain into the public domain for better treatment