By Balraj Ougra (@backspace.chiro)

On August 3^rd Sports Medicine Australia (SMA) hosted its New South Wales (NSW) State Symposium in the world-renowned 2000 Olympic Games Precinct at Genea Netball Centre, Sydney Olympic Park. Titled“The Pain of Sports & Exercise Management of Acute & Chronic Pain in Sport”, the symposium was aimed at clinicians from all health disciplines who consider best practice to manage athletes who experience pain.

The management of pain in exercise and sport needs to be addressed using a multimodal approach. Science is needed for a health professional to identify the type of pain while the art of the practice involves clearly communicating to athletes to enhance their performance, improve their welfare and reduce injury incidence rates.

So how should we be managing athletes with pain? What interventions can we use? And, what is considered best practice?

The core principles to do so were discussed at the SMA symposium and are summarised below:

Featured Topic’s & Speakers

• Pain Messaging from a Sports Physicians Perspective. Dr David Samra, Specialist Sport and Exercise Medicine Physician. Club Doctor with the AFL Sydney Swans.
• Management of Chronic Pain in the Sports Clinic. Dr Seamus Dalton, Rehabilitation Physician and a Sport and Exercise Physician. Team Doctor Sydney Kings NBL Team.
• Medical Management of Intractable Chronic Pain. Dr Bruce Mitchell, Sports and Interventional Pain Physician and a Director of Metro Pain Group.
• The Neurobiology of Pain and it’s Clinical Implications. Associate Professor Tasha Stanton, Associate Professor of Clinical Pain Neuroscience at the University of South Australia, Adelaide and Neuroscience Research Australia, Sydney.
• Initial On-Field Management of Pain. Dr John Orchard, Sport and Exercise Physician. Chief Medical Officer for Cricket Australia.
• Training Athletes and Pain – How Much is Too Much? John Quinn, Clinical Exercise Physiologist & High Performance & Sprint Coach.
• Practical Session: Non-Medical Acute Management of Sporting Injuries on Field. Dr Tim McGrath, Physiotherapist for NRL St George-Illawarra Dragons, Clinical Director at Elite Rehab & Pitch Ready.

Highlights

• Dr David Samra @dave_samra discussed pain messaging from a sports physician’s perspective. Explaining sound communication through simple but effective messaging will form a part of good management of the athlete’s pain and influences their belief systems in both the short and long term. He highlighted a common thought in athletes is that all pain = tissue damage, which isn’t true and as clinicians we need to do a better job in communicating this when pain arises for the athlete’s wellbeing and athletic performance.
• Dr Seasmus Dalton followed with the management of chronic pain in the sports clinic, stating normal anatomy can be painful. Athletes in chronic pain will be experiencing a state of Central Sensitization or Peripheral Sensitization, and understanding the differences of Neuropathic, Nociceptive and Nociplastic pain is essential in the management of their chronic pain.
• Dr Bruce Mitchell @drbrucemitchell, made a distinction between somatic pain and radicular pain in intractable chronic pain.  Understanding pain is perceived in the brain, with the Amygdala influencing our threat and fear response to pain, and it is the role of the prefrontal cortex to work in suppressing the Amygdala. When this pathway is highly aroused by hormones and chemicals, we lose some our ability to respond to the pain and fall into the cycle of central sensitization. Dr Mitchell, introduced the concept of links between microbiome and central sensitization and how a healthier gut could influence our perception of pain.
• Assoc Prof Tasha Stanton@tash_stanton discussed the current research into clinical pain neuroscience with a key emphasis on communication and delivery of pain messaging to patients. She highlighted that our bodies experience pain to protect us from perceived or real threats, with tissue damage and pain relating poorly, whilst the environment around you can also be an influencer of our pain. Suggested rehabilitation exercise approach included the concept of unpairing movements that hurt with that exact movement to reprogram the threat response to our brain; e.g. Full elbow extension with a tennis backhand is painful, you could consider rehabilitating the elbow using a yoga position that utilises elbow extension e.g. a downwards dog position.
• Dr John Orchard@DrJohnOrchard, as the world leading expert in local anaesthetic injections in sport, discussed the initial on field management of pain through these injections. Local Anaesthetic can provide athletes a window to perform whilst minimising pain during a match. Dr Orchard highlighted challenges during match days included informed consent and education around the false protective mechanism these injections can create, leading athletes potentially going harder than their bodies would with their normal pain threat mechanisms. A well planned adoption of this pain management approach typically would include lengthen conversations, education and signed informed consent in the week leading up to the athletes match or competition.
• High Performance Coach John Quinn@JQuinn_01 discussed the fine balance of training athletes and managing their pain. Aims to consider in training elite athletes should be a combination of Preparing for the event, Achieving Peak Performance & Maintenance and Preventing Injuries. This can be achieved by individualising the plan and specifically targeting the athletes Posture, Movement, Training Zones and Recovery periods. He highlighted a combination of tracking an athletes load spikes and Rate of Perceived Exertion (RPE) are best practice in training athletes and keeping them on track in their pursuit for peak performance.
• Dr Tim McGrath@_timmcgrath ran a practical session, sharing his experience as a physiotherapist in non-medical Acute Management of sporting injuries on field. He provided a simple framework that each therapist engaging on field care should consider, including communication, diagnosis and return to play protocols.

To summarise: the management of acute and chronic pain needs to be monitored and coupled with a multimodal approach and sound communication to influence the athlete’s belief system positively. Thank you to SMA for hosting an outstanding event and BJSM for allowing me to share my highlights.

For more information on SMA visit https://sma.org.au/

Thank you also to Nash Anderson @sportmednews for his assistance on this blog.

Recommended follow-up reads:

1. International Olympic Committee consensus statement on pain management in elite athletes (URL- https://bjsm.bmj.com/content/51/17/1245.long)
2. Infographic. International Olympic Committee consensus statement on pain management in athletes: non-pharmacological strategies (URL- https://bjsm.bmj.com/content/53/12/785.full)
3. Gut microbiota: implications for sports and exercise medicine (URL- https://bjsm.bmj.com/content/51/9/700)
4. ‘Microbes in sport’ – The potential role of the gut microbiota in athlete health and performance (URL- https://bjsm.bmj.com/content/51/9/698)
5. IOC consensus statement: dietary supplements and the high-performance athlete (URL: https://bjsm.bmj.com/content/52/7/439)
6. Use of ratings of perceived exertion for predicting maximal work rate and prescribing exercise intensity in patients taking atenolol. (URL: https://bjsm.bmj.com/content/31/2/114)
7. Reliability of ratings of perceived effort regulation of exercise intensity. (URL: https://bjsm.bmj.com/content/22/4/153)
8. Communication quality between the medical team and the head coach/manager is associated with injury burden and player availability in elite football clubs (URL: https://bjsm.bmj.com/content/53/5/304)

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Balraj Ougra is a Sports Chiropractor in Sydney, Australia. He has been working with the Australian Volleyball League, toured with the Australian U20’s Mens Volleyball Team and worked on the Beach Volleyball World Tour medical team in Sydney in November for the past two years. Balraj has started a sports based clinic, Back Space Chiropracticin Sydney. He has a special interest in sports injuries and sports performance. You can follow him on Instagram @backspace.chiro.