introduction and overview of pain it is important to remember that pain is both a sensory and emotional experience pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage pain does not occur in the body without the Mind reacting to and contributing to the experience your reaction to pain is dependent upon a variety of factors including your current emotional state as a result we need to be able to discern between pain sensation and pain perception pain sensation is a stimulus that is received by the nervous system via nosioceptors whereas pain perception is the conscious interpretation of the nocioceptive stimulus as pain pain Sensations our athletes seem to be educated about the difference between pain and discomfort as well as the difference between benign pain which is often related to sports performance and injury pain which is often related to actual harm as a review let's talk for a minute about the psychology of pain when we experience pain nozioceptors which are sensory neurons that respond to potentially damaging stimuli are activated which transmits sensory information to the brain through the spinal cord this process is known as nocioception the stimulation of nocioceptors by chemical stimuli explains why pain is felt even after removing the interest agent that has been contributing to the pain as long as these chemicals are still present we may still feel residual pain from the original injury since nocioceptors become more sensitive to the presence of ongoing stimulation the injured athlete may actually experience increased sensitivity to noxious stimuli this is known as hyperalgia as you can see on this slide once gnocioceptors have been stimulated through mechanical thermal or chemical stimuli they carry information to the dorsal Horn of the spinal cord from here pain information continues up to the brain specific brain structures involved in processing of pain information include the thalamus and the hypothalamus the brain stem the limbic system and the cerebral cortex this also includes the anterior cingulate complex and the somatosensory cortex transmission of pain through the hypothalamus explains many of the physical responses to paint such as sweating dilated pupils and increased heart rate pulse and blood pressure however the limbic system in the anterior cingulate cortex are the areas responsible for the emotional responses to pain such as fear anxiety and even sadness pain perception is influenced by a variety of factors very stressful situations such as sport participation the fight-or-flight response may cause a decrease in the physiological sensations of pain in addition the physiological perception of pain may be decreased because of The Athlete's focus on factors other than the pain such as training or on the competition emotions behaviors and culture as well as gender factors can all influence pain perception for example many Studies have found that males will tolerate higher levels of pain than females and the extroverts May express pain more freely compared to introverts remember the difference between pain sensation and pain perception that we discussed earlier the perception of pain can be broken down into two factors known as the pain threshold and the pain tolerance pain threshold can be defined as the level of noxious stimuli required for pain to be felt whereas pain threshold is a measure of the maximal amount of pain a person can or will tolerate pain tolerance is often associated with the limbic system and cerebral cortex however both pain threshold and pain tolerance are completely subjective and individualized they can both be influenced by the individual's history of pain as well paid inventory surveys being aware of an athlete's pain level and pain coping strategies can place the athletic trainer in a position to help the athlete with pain management there are several different pain inventories that can be used to measure and monitor pain levels in coping two of those are listed here on this Slide the first is the brief pain inventory or BPI the BPI has two skills that ask the respondent to rate severity of pain at its worst or at least on an average and current levels it also requires the individual to rate how much pain is interfering with their daily activities the sport inventory for pain or sip is a 25 item questionnaire there is also a shorter version called the Sip or sip15 that is available that contains only 15 questions the Sip 15 is specific to the athletic training setting and it can help to identify athletes who are not coping effectively with paint this tool can also help to identify athletes who have had a change in pain management and as a result May benefit from the implementation of Psychosocial strategies the duration of pain another factor in this full processing of pain is the duration that the pain is experienced acute pain is pain that is of recent onset and sudden onset and is typically high intensity pain that is localized at or near the site of injury acute pain is generally easy to diagnose and easy to manage in contrast chronic pain is pain that persists beyond the normal time expected for healing typically a minimum of three to six months chronic pain is often no longer located in the area of the original tissue damage and is non-responsive to treatment attempts the term persistent pain has been used to differentiate pain that meets the time frame defined as chronic but is actually a symptom of a treatable condition so for example a soccer player who is diagnosed with patellar tendonitis at the start of the season but who continued to play Through The Fall season might have persistent pain and not necessarily chronic pain persistent pain is a calm persistent pain is common in athletics because many athletes are unwilling or unable to rest for the amount of time needed for symptoms to resolve athletic trainers need to be able to differentiate true chronic pain from persistent pain chronic pain is much more difficult to treat because it often involves more social emotional and psychological input compared with acute pain and as a result it can be perpetuated with much less tissue damage complex regional pain syndrome also known as CRPS has two types type 1 and type 2. complex regional pain syndrome type 1 is also known as reflex is also known as reflex sympathetic dystrophy syndrome this may occur following a minor nerve injury such as a sprain strain or even firm surgery complex regional pain syndrome type 2 is known as causalgia this can follow a more major nerve injury CRPS involves a sympathetic nerve system and assumes an abnormal function after an injury athletic trainers who work with athletes to report ongoing pain should be aware of the signs symptoms and potential treatments for CRPS it is commonly accepted that athletes with CRPS should not be treated with ice because it can cause additional nerve damage and it may lead to the condition worsening and spreading to other areas of the body there are a variety of signs and symptoms that are associated with CRPS and you can see some of these listed on the screen this is not an all-inclusive list of signs and symptoms but these are the major ones that we should be able to look out for and identify there are some red flags to consider when dealing with a patient who is experiencing chronic pain athletes experiencing chronic pain may be at an increased risk for suicide as a result athletic trainers should be aware of the psychological impact of pain we should also make sure that we refer athletes to a mental health professional if we have any concerns for The Athlete's well-being or health care we need to remember the referral considerations that we have discussed when we're considering making such a referral as injured athletes progress through the rehabilitation process they're likely to experience different pain Sensations in various phases of Rehabilitation an understanding of the role of pain during each Rehabilitation phase can help athletes to cope with these pains and discomforts and it can also help them to use pain as information about the physiological processes that are happening within their body athletes need to understand how the injury will progress and what levels of Pain and Disability are to be expected following surgery if necessary and at each phase of the recovery process along the way this can help our athletes to manage expectations and to understand what is Normal and abnormal sensations of pain non-pharmacological treatment strategies for pain management include a variety of things such as psychosocial strategies which we'll discuss in a few slides in addition we can use visual distraction such as providing something interesting for the athlete to focus on during Rehabilitation protocols or even treatments we can also use auditory distraction which can be something as simple as talking to the athlete or even listening to music there are also things like massage and transcutaneous electrical nerve stimulation also known as tens that are as well as other pain control therapeutic modalities that can be effective non-pharmacological pain management techniques the placebo effect is suspected to have occurred when pain reduction is obtained through mechanisms other than the physiological effects of treatment the placebo effect is linked to a psychological mechanism whereby if the athlete believes the treatment is beneficial then the pain can be reduced research on pain control theories support the existence of the placebo effect all modalities and other therapeutic strategies also utilize some degree of the placebo effect psychosocial strategies and Pain Management are to diminish both the autonomic changes associated with pain such as muscle spasms and psychological distress athlete education is a key part in the implementation of Psychosocial strategies specifically with pain management the athlete should be educated on the pain spasm cycle and how stress May influence the cycle stress management techniques such as deep breathing and progressive muscle relaxation can also be helpful for athletes dealing with pain imagery can be used as a relaxation strategy to distract the athlete from focusing on injury-related pain athletic trainers can also work with athletes who have pain during Rehabilitation or those with chronic or persistent pain to create a pain management plan this plan may include both associate and dissociative strategies for pain management dissociated strategies or techniques that distract the athlete from the pain and focus their attention in a different direction such as imagery Scripts associative strategies are techniques that help the athlete interpret the pain that they are experiencing