Pain Management in the Elite Athlete: Prof Wayne Derman MBChB,BSc (Med)(Hons) PhD, FFIMS

Transcription

1 Pain Management in the Elite Athlete: Prof Wayne Derman MBChB,BSc (Med)(Hons) PhD, FFIMS

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3 Hainline et al., BJSM 51; ,

4 Outdated concepts regarding pain Pain=injury Pain is mediated by tissue damage or activity in primary nociceptors Pain reduction depends on repairing, removing or anaesthetizing the parts of the body or peripheral nervous system believed to be generating the pain (incorrect use and increasing chance of falling foul of WADA) Physical therapy strategies are limited to those that improve strength of the tissues or provide peripheral input to close the pain gate Psychological strategies are limited to those that help the athlete cope with their pain and function well despite their pain

5 New concepts in pain and pain management Pain is a subjective experience that depends on complex interactions of neuroimmune, cognitive, affective, contextual and environmental factors Pain reduction also depends on identifying factors from other biological processes, psychosocial and contextual domains, that might be contributing to pain and removing or modifying those factors via a range of techniques. Physical therapy strategies also target pain reduction via modifiable CNS processes involved in pain, inaccurate conceptualization of pain and injury and minor to moderate psychosocial and contextual influences on pain. Psychological strategies also target pain reduction via modifiable major psychosocial and contextual influences on pain.

6 The bio-psychosocial model 6

7 Different management strategies for different athletes 7

8 Types of pain Nociceptive pain tissue damage or inflammation (threat) Neuropathic pain lesion or disease in the somatosensory nervous system Nociplastic, algopathic or nocipathic chronic pain hypersensisitivity that suggests altered nociceptive functioning eg fibromyalgia

9 Non-pharmacological pain management strategies in elite athletes Education regarding the current understanding of pain Modalities and massage Movement, strength and conditioning Psychosocial interventions Sleep and nutrition Surgery 9

10 Clinical guidelines for pharmacological management Only one component of managing pain. The lowest effective dose for the shortest period of time. prescribed in a manner consistent with established, recognised pharmacological principles. Physicians prescribing should possess a complete understanding of the prevailing rules and regulations regarding prohibited substances and Therapeutic Use Exemptions. Recording athlete-reported severity of pain. Licenced healthcare providers who understand potential side effects or misuse of medications, and whose licensure includes this scope of practice. Written documentation of each assessment and prescription is a basic standard of care. Informed consent is fundamental in medical care, including those situations in which medication is prescribed. (Difficult with same day RTP) Medications should not be prescribed to athletes for pain or injury prevention. 10

11 IOC Consensus Meeting on Pain Management Management strategies for acute pain Athletes with severe acute on-field injuries need effective analgesia Analgesia must be provided immediately Analgesia provision must be pre-planned Depending on the Field of Play skill base Select an appropriate drug and dose Select an appropriate route Formal training in effective Field of Play analgesia is mandatory Differentiation between same day return to play or non-same day return to play Lausanne, November

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13 IOC Consensus Meeting on Pain Management Management strategies for acute pain Intranasal Administration Painless Ease of use No IV access required Avoids first pass metabolism Nose-brain pathway Compliance - easy and fast to deliver Widely used in paediatric emergency medicine Lausanne, November

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17 17 Pain Project

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19 IN CONCLUSION: Differentiate from injury management. Move away from uni-dimensional paradigm of analgesic, rest and rehabilitation. Pain is its own entity and the clinician must define the cause of pain: May or may not be causally related to the injury. May or may not be nociceptive. May or may not require multi-disciplinary management A number of useful toolboxes of agents and circumstances are provided. Special edition on Pain Management in CJSM in June 2018

20 Prof Wayne Derman MBChB,BSc (Med)(Hons) PhD, FFIMS Thank you for your attention!