The International Olympic Committee released a statement on their stand on pain management for elite athletes two years ago. Today, we are going to share what you as an athlete should know about pain and injuries.
Different types of pain
We think understanding pain is important. You probably don’t think of muscle aches and soreness as pain but it, in fact, considered pain.
Without a good understanding of pain, it’s hard for you to move forward in your rehabilitation or back to sports program. We previously blogged about pain in Why Your Pain Hurts? From a Bayesian Brain Approach. While the IOC consensus statement doesn’t quite explain the why, their focus on the different types of pain will allow you to understand your current pain experience better.
The three types of pain highlighted by the IOC are nociceptive pain (and inflammatory) pain, neuropathic pain, and lastly nociplastic, algopathic and nocipathic pain.
To understand nociceptive pain, you have to first understand that there is no such thing as a “pain signal” (from a nervous system point of view anyway). Pain is a perception and it’s strictly an output of the brain based on its interpretation of the incoming information. To put things into context, the human brain can process over 11 million pieces of information per second. A noxious stimulus refers to any stimulus that leads to the perception of harm or threat. It can be a mechanical, chemical, or thermal stimulus. If the intensity of the stimulus is too high, the nociceptors are activated and a “this-may-be-harmful-or-threatening” signal is sent to your brain.
To put that into humanely readable words: The thermal receptors in your skin are activated during your warm shower to interpret the water as warm. If you were to dip your fingers into a boiling pot of water, both the thermal and nociceptive receptors in your skin will be activated at (almost) the same time. Nociceptors are only activated when the intensity of a stimulus crosses a particular threshold.
Once this (nociceptive) information reaches your brain, your brain will process it and – perhaps – give you a pain experience. As explained in our earlier Why Your Pain Hurts entry, it is possible to experience no pain in spite of an injury. I.e. It is possible to dip your hand in boiling water and not feel pain. No, please don’t try this at home!
Inflammatory pain are similar to nociceptive pain. It refers to a pain experience as a result of the nociceptive receptors triggered by inflammatory markers/mediators. We are going to leave this as is.
I know. Nociceptive pain is a difficult pathway to understand. This is largely because we are taught to wrongly think of pain as a type of sensation. If we can for a moment step away from that and accept that pain is a perception (i.e. brain output), the above explanation will be a lot easier to process.
Neuropathic pain refers to pain as a result of damage or disease to a nerve or nervous tissue. It is also complex to understand. Because it does not affect most day-to-day athletes, we are not going to focus on it.
Nociplastic, algopathic and nocipathic pain
This is the one that affects most chronic pain patients. If your pain is more than three months old, this is the most likely explanation for your pain. When we think of chronic neck or low back aches that don’t resolve with time, this is it.
To keep it simple and easy to understand, this type of the pain is due to hypersensitivity of the affected tissue rather than an underlying injury. Because most tissue damage would have healed by three to six months, any pain that persists beyond that is largely due to hypersensitivity to a given benign stimulus rather than pain from an actual injury (nociceptive pain).
The alarm system analogy is probably the best at explaining this type of pain:
Just as your home alarm system triggers when a burglar breaks the window, the pain alarm goes off if it perceives danger or threat. This is an attempt to alert and protect us in order to increase the chance for survival. However, occasionally the alarm may dysfunction. In fact that reminds me of a time when the smoke alarm in my apartment had a low battery and decided to go off full blast at 3 in the morning and wake me from a dead sleep. Even after I put my heart back in my chest, stood on a chair in the dim light and ripped it off the ceiling it kept screaming at me. It didn’t stop until I grabbed a hammer and smashed it into a million pieces….well maybe that last part didn’t happen and I simply pulled the battery out, but I wanted to smash it. But I digress, during persistent pain the trigger on the alarm system can become very easy to set off for reasons other than tissue damage or danger (low battery= poor sleep, stress, memories, emotions, etc). Instead of needing a burglar to break a window to set the alarm off, the wind only needs to blow on the grass in the front yard to set it off. Just the same, instead of tissue damage occurring or something physically being “wrong” to cause pain, the smallest movements can set off the alarm system and cause one to unnecessarily experience pain.
– Best and Worst Analogies in Physical Therapy by Jarod Hall
We think athletes should be familiar with at least two (out of three) different types of pain – 1) nociceptive pain where the pain experienced is either due to the injury itself or the inflammatory markers post-injury, 2) nociplastic, algopathic and nocipathic pain where the pain is due to tissue sensitivity or an over-sensitive alarm system (brain) rather than an underlying damage or injury. The nature of their pain will determine what is best appropriate care and if professional help is indeed.
Different mechanisms (or types) of injuries
We think this is more straightforward.
Sports injuries (according to the IOC) refer to any musculoskeletal complaints as a result competition or training that require medical attention. There are three main types: 1) acute traumatic injuries, 2) overuse injuries, and 3) subacute recurrent injuries or chronic “degenerative” conditions.
Acute traumatic injuries result from a single event that lead to damage (trauma) on previously healthy tissue.
Overuse injuries are a bit more technical. They refer injuries from repetitive (submaximal) loading of the body when there is insufficient time allowed for adequate structural adaption to occur. In the case of an Achilles tendon injury from running, the cumulative effects of the repetitive steps in running cause damage to the tissue because there is not enough rest time between runs for adaption to occur. Overuse injuries – as the name suggest – is largely due to poor load management. Check out: Nine High Value Tips for Your Tendon Pain.
We are going to skip discussing chronic “degeneration” conditions because I am not convinced of their relevance. Subacute recurrent injuries are injuries that had occurred before in the past and they have to be the same type of injury and at the same site of a previous injury to be considered recurrent.
At this stage we want to reiterate that pain =/= injury and vice versa. It is crucial for athletes to get that because it will change your perception on your recovery. Knowing the differences between the different types of pain and injury will help you decide if need professional help or if rest is the appropriate intervention.
Pain management vs. injury management
Unfortunately, the IOC statement is fairly brief on its conservative pain management. I found that that the statement doesn’t really provide any insights to how an athlete should approach their pain management. Before we move on to the options available, it should be well noted that pain management and injury management are not the same thing. We will largely focus on non-pharmacologic interventions or conservative care because these are within our scope of practice.
Ice, massage, and electrotherapy
We think the following statement speaks for itself:
“Recent studies, however, show that many physical therapy techniques have no clear benefit beyond non-specific effects and natural history, with some exceptions.”
In short, most manual therapy and electro-modalities do not work. Sure, you can opt-in to receive such treatment but be mindful that they are unlikely to give you any meaningful result. One of the paper cited by the IOC acknowledged that while the RICE and PRICE protocols are established practices in acute sports injuries, cryotherapy (i.e. icing) is not a validated intervention. There are simply no high quality randomised controlled trials supporting their efficacy. Furthermore, studies such as the one published by Hassan et al. in 2011 found heat to be a favourable intervention. In that study, warm water significantly decreased markers of muscle stress reaction (skeletal troponin I, creatine kinase, myoglobal levels) while cold-water immersion elevated levels of muscle stress reaction markers.
Movement and Exercise: A Sports Chiropractor Toolbox
Not surprisingly, movement and exercises are recommended interventions. Beyond the rehabilitation and back to sport roles, strength and conditioning programs are helpful with pain management. Beyond the pain relieving effects of isotonic and eccentric exercises in the management of tendon pain, isometric exercises are also useful to help improve pain by suppressing certain nervous pathways in the brain.
Unfortunately for us, very little was covered in the statement. While it is a good read, I don’t think there are many good takeaway messages beside for the education aspect on the types of pain and injuries. We think if you are looking to examine pain management options for yourself as an athlete or elite athlete, you would probably need to research each modality or intervention on its own. To be fair, there are a lot of pain management options available today and it might not have been practical for them to cover every aspect of it.
You can check out the full IOC consensus statement.
For more reads: