Ask Mike Reinold

Pain Education in Athletes

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Pain science education has become a big part of orthopedic rehabilitation. But do we take the same strategies in the sports physical therapy setting?

Yes and no. Check out this week’s podcast to learn more!

To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 248: Pain Education in Athletes

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Show Notes



Transcript

Student:
So, we have Rachel from Philadelphia. Hey gang. How important is pain education with working with athletes? When an athlete is worried about an injury, what do you guys focus on when implementing patient education? As a former athlete I was always worried about not keeping up with my team due to an injury. How do you manage your athletes who have similar feelings?

Mike Reinold:
Awesome. Rachel, good question. And you went down a couple of paths right there, thinking about this and how to frame this for us to answer here. Because you talked about pain education and then I think you talked a lot about self-confidence and maybe some of the other psychosocial aspects of being injured as an athlete, which I don’t know if I would put that together with pain education, but I know these are popular topics on social media right now. So, I think it would be pretty good to take tackle a little bit. So, why don’t we start a little bit, why don’t we divide it into two halves, maybe team. We’ll talk about pain and science education in general and athletes and what that may mean in an athletic setting.

Mike Reinold:
And then maybe we talk about, obvious the psychosocial aspect of that a little bit, because I think that’s what Rachel wanted to talk about a little bit, because obviously everything’s related, right? That could obviously make your pain feel differently, right? If you’re completely depressed and feel left out of the team and stuff that, I think these are huge aspects of sports injuries that we’re not talking about as much as we should, but let’s talk a little bit about pain education. Because I think that’s how you started this off, Rachel. Dan, you want us to start off with, in an athletic environment what’s what is the role of pain science education?

Dan Pope:
Yeah. This is a challenging question just because there’s multiple elements there so, we’re talking about sports psychology and we’re talking about pain science education, and I think the thing about pain science is that it’s encompassed everything, right? So, people think about pain science. They think about therapeutic neuroscience education. They’re thinking about maybe the psychology of the patient and think about cognitive behavioral therapy, mindfulness pops up and they all are presented together in some of these research articles too. So, I think that makes things a little bit more confusing in terms of my education from a pain science perspective, it’s mostly from Adrian Lowe, therapeutic neuroscience education. And I think a big thing for athletes is they have to understand some little bits about pain if it’s altering their behavior in a negative way. Right?

Dan Pope:
I think you tease out a lot of this in the subjective and Jonathan and I were talking about this the other day. You have someone who comes in and you get to get an idea of their behaviors and their beliefs from the subjective. And I think at one point Jonathan asked something along the lines of what are your thoughts on movement? Are you fearful of movement, right? Because you know what, that’s a bad thing. A lot of athletes, when they have pain, they can do one of two things. They can blow through the pain or they can completely back off and be very fearful of movement. But, if you have an athlete that comes in and says, I might have hamstrings on me, but don’t still practice a 100%, they’re just blown through that pain.

Dan Pope:
Then they need to be educated that you have to build some trust with your body, right? But, if you have someone who’s not doing anything and they’re very fearful of movement, you have to do the opposite. You have to tell them it’s okay to move and show them how to do that. So, I think from the pain science education standpoint, you may give them some information about pain and how that process in the body. The main thing is to try to individualize that to the person, to make sure that they are on board with the plan of care you’re going to give them.

Mike Reinold:
That’s huge. And I how you put that together too, because I think a lot of times, part of what we do is to help them rebuild self-confidence in their limb or whatever their injury may be. Right? And we often do that, in the physical therapy world, we talk about this internally as the graded exposure to some activities. So, that way they can keep getting some self-confidence. Right? And we say that to our athletes all the time. The first time you do something, you’re probably going to be a little skiddish with it. And you may be a little nervous, but then, sometimes it’s subconsciously, you don’t even necessarily know that you’re thinking this, but in your head, you’re, you know what, I did okay with that exercise. It’s okay.

Mike Reinold:
And the next time you perform it, it goes much better. Right? We had that with a throwing program about a month ago, one of our athletes came in and started throwing, throwing it straight into the ground and hit the ceiling and broke somebody’s windshield out in the parking lot. So, we just had them, we say, hey, calm down. We’re going to be okay. We’re going to just throw into this little net until you get a little confidence in your limb. And then boom, two weeks later, the students can’t even catch them anymore. He’s he’s progressed so fast. So, a good example of that one. I that. What else do you guys think? Dave, what’s your experience?

Dave Tilley:
Yeah, actually, I have a really good example. We’re working on together right now and it comes into the other side of the question, which was about athletes feeling they’re not part of the team. In my opinion, a lot of times athletes feel as though they’re at this super high level of training, they’re really fit. They’re pursuing their goals. They have this awesome path. They get injured and it really knocks them down the ladder in terms of what they feel their work capacity is and they miss that feeling of being an athlete. And so we have an athlete now that we’re working with that, as a super high level gymnast, she has a really big scholarship coming next year.

Dave Tilley:
And she had a big surgery, a really big surgery. She feels out of shape. She feels she’s missing out. She’s worried about what she’s going to look when she goes to school as a freshman next year. And I think this is an opportunity for us to educate, obviously, on why we have to go slow. She had a huge surgery, so it’s three months out and she still has precautions. Right? So it’s, listen, they literally broke your limb and reattached it. And it’s a reason why you have to go slow. But at the same time, I think this is why some of the things we have to our tools of advantage are, you can still get a really good workout if you know how to program around some of these precautions.

Dave Tilley:
And so she riding this boring rehab process until we could introduce BFR. I talked to her surgeon and I was, hey, could we do it in a modified setting around the protocol? And he was, it sounds great, and that first day she got crushed in a good way. She was, Oh man, my quads feel sore. My hip feels so I feel great. She sweat. And she’s in there for three hours. She’s working her butt off between Dewey and I, and I think that was a really big hurdle to get over where she felt as though she was really behind the curve. But, then also as she started training with Dewey and I, just yesterday, he’s given her these massive upper body sets where she can, obviously, be safe for her lower body.

Dave Tilley:
But she’s killing herself in a good way. And she really got a lot of positive feedback back because she’s not with her team. She’s not working. She’s just girls training five hours a day to get where she wants to go. And so she doesn’t have that anymore. And I think there’s finding creative way to make them feel an athlete still and make them work out, especially around there. You can train three limbs very, very well. I think that’s massive for people to, to really hang on to.

Mike Reinold:
Yeah. And that’s going to put her in such a different frame of mind that, who knows maybe her ability to cope with some of the discomfort is lessened a little bit because she’s in a better frame of mind and able to handle a bit, of course her injury is going to be painful. Right? But sometimes it’s about how your brain accepts that pain and then determines what you’re going to do. Are you going to lay down and just try to rest? Or are you going to try to gradually try to improve yourself? Great stuff. What else, Dan?

Dan Pope:
All right. I got so much to say about this. I think it’s a very nuanced thing. One of the big problems athletes faced is all this pressure from the team, from their staff, from their coach in terms of their performance. And sometimes that’s really legit. I can think of a rugby player we’re with the other day and basically strained his hamstring. And if he doesn’t go to practice and perform, the coach doesn’t care, he’s just going to cut him and he’s not going to play. So, then he’s in this tough predicament where it’s, well, what’s the best thing for you to back off, right? You need to back off for, the best chance of this thing to heal. He doesn’t necessarily have that ability to do that. So, for a lot of athletes, I think they feel that tremendous pressure.

Dan Pope:
And what Dave was talking about is that, for most athletes, especially high-level athletes, a huge sense of their self-worth is all wrapped up in their ability to be an athlete, and when they get hurt, they feel their entire world has gone away and their teammates don’t care about them. Their friends don’t care about them. Coaches doesn’t care about them. Sometimes that’s accurate, right? There’s a lot of coaches out there that when there’s an injured athlete in front of them, doesn’t mean anything to them. Get this athlete out of my face.

Dan Pope:
So, I do think, and this is a very challenging thing to create and Dave can probably talk on this a lot better, is you need that a culture of acceptance. You need to have a coach, an athletic trainer, physical therapist, and the athletes to understand injury, and injury happens the best course of action to get someone back is not to keep push, push, push, right? Sometimes maybe you need to push, push, push. But if there’s not that culture of acceptance and the athletes always going to feel all this pressure when they have an injury to try to continue pushing, right? Or feel that stress from their team or whatever may be.

Mike Reinold:
Yeah. It’s thanks that people feel that way. But I think that’s common, right? And I think that’s probably more common than we think, because a lot of people just stuff those feelings down sometimes, right? I’ll give an example. I had a few athletes just in the last month and honestly, a few, I think that the biggest thing I did for them in my treatment session was, evaluate them and tell them that, look, I ruled out all the things that we should be worried about. Oh. You have knee pain. Okay. And you’re worried. Here’s a good example. Let’s use an actual example. It was a catcher, a baseball player. He’s a pro ball catcher. Right? He tore his meniscus years ago, I don’t even remember six, seven years ago. He tore his meniscus in one of his knees.

Mike Reinold:
All of a sudden his other knees started getting a little sore and his brain went, boom, this feels just my last injury. And that was the last one was traumatic. It was a pivot and shift in the sand, pop, bucket handle, meniscus tear. It was a big deal. Right? This one was just one day. He was a little sore and a little puffy, he’s a catcher, he’s a pro ball catcher. He’s been doing this a long time. And he totally was nervous that, I did it again. I tore my other meniscus. So, my exam and my treatment was ruling out all the bad things. Hey, your ligaments look good. I don’t think your meniscus looked that bad. And then that is going to lead to the best chance of recovery than actually anything I physically did with them. Right? What else, Lisa?

Lisa Russell:
Yeah. I completely agree. I feel having someone understand how they’re feeling and why they’re feeling that way is super powerful and teaching them how to even discern that for themselves of, is this pain that I need to worry about? Or is this pain that is just a part of training and I’ll be cool. I have a rower right now who was super fearful of getting back on the water after a back injury and everything. And I think the biggest thing we did was talk through expected return to sport, soreness versus bad pain versus all those things.

Lisa Russell:
And it was great. She came in the other day and even told me a few of her teammates were complaining about this thing hurting this way, or that thing hurting that way. And she felt she was able to tell them, Oh no, that’s normal. Just got back on the water versus you probably should go see someone. It was a neat moment because she got it. She’s getting it anyway, that difference of training versus bad pain. And you were at risk of doing something, that’s going to pull you out for x number of months. If you ignore it versus yes you’re back sore because you just started back on one.

Mike Reinold:
Yeah. We deal with that all the time with our return to sport athletes do, is they start running and they start jumping. They start throwing whatever it may be, and they’re, it’s a little achy. Is that normal? Some of them completely panicked. Some of them know how to put the blindfold on and just proceed. To be honest with you, both ends of that spectrum are probably equally as potentially bad. So, we got to be careful with that. So, I’ll end it with this, and I think this is a good way to end it here, a lot of times when we talk about pain education and pain science, we talk a lot about nocebo effects and some of the negative that we can do with some of our terminology and dialogue with our patients and our clients.

Mike Reinold:
I think what we just talked about, there was a completely different way to reframe it. We just talked about a positive way, not a negative way of being sure that we’re talking about pain with our athletes. And I think that’s an important concept in a different slant await the way you do it. Because think about everything we just said, we just talked about how we’re trying to educate people to realize that, yes, they have some pain, but we will help you get through this a little bit. So, a lot of things, they get shunned right now on social media. Things modalities, manual therapy, stuff that. So, heat ultrasound, Easton, soft tissue massage, vibration, all these things. Some people just say, Oh no, you’re doing a disservice to your client. Well, if my person’s nervous about getting out there and doing an exercise or a sport activity, I’m going to educate them on why we’re going to slowly get to that.

Mike Reinold:
And I may do things modalities and manual therapy to get them to feel better. So, that way then when they go out there, they have less fear in their limb. I think that is a crazy way of… sometimes people take it too far and say, all we should do is just graded exercise with people because that’s all they need. That might be all they need. But that doesn’t mean the other things aren’t helpful for getting them to accomplish those tasks. So, I’m not sure if I articulated that completely. Well. I know we’ve got to wrap up this episode a little bit here, but I think, man, as I listened to everybody talk, it made me think we’re dealing with people with fear, anxiety, I don’t know if depression is always the case as is, as it’s probably more common than people ever tell us.

Mike Reinold:
People say I’m in pain or I’m fearful sometimes when people don’t say, well I’m down about it. I feel that. We talk about that all the time. But, some of these things, we do touch modalities, our manual therapy can really help lift those people up. So, just keep that in mind, there is some positivity to some of those things and how that may impact somebody’s pain and their psychosocial outlook. So, that way we can get more out of them and get them back on the field. Makes sense. So, awesome question. Great tackling. And I think everybody had some good thoughts on this one. If you have more questions, head to mikereinold.com, click on that podcast link, fill out the form to ask away and be sure to keep catching us on iTunes and Spotify. See you on the next episode. Thanks.

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