REHABILITATION PSYCHOLOGY

MASTERING PAIN IN SPORT AND REHABILITATION

By Dr Edmund O’Connor, PhD, sports psychologist

Pain is common in sport. An athlete’s success is often determined by his pain tolerance. The quality and intensity of their training depends on the ability to push beyond discomfort. In competition, maximal effort must be given for optimal performance. Among athletes of similar skill, pain tolerance can be the difference between winning and losing. Endurance athletes must sustain a high level of performance over long periods of time despite extreme fatigue. Athletes in contact sports may play while hurt or through injury. Other athletes tolerate pain associated with overuse and repetition as the season progresses. A similar scenario exists in rehabilitation where perseverance despite pain in therapeutic exer- cise is required to maximise healing and return to sport.

What does the pain mean? The International Association for the Study of Pain (2002) defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It is not either physical or mental, but both with each pain experience. As a result, an ath- lete’s perception of what the pain means directly affects the level of pain she feels, her emotional reactions, and coping behaviours.

Addison, Kremer, and Bell (1) define the spectrum of pain experi- enced by athletes. The experience of fatigue, discomfort and pos- itive training pain should be expected during rehabilitation and practice, and interpreted as an encouraging sign of progress. In this context, pain is ideally perceived as evidence that the ath- lete is pushing to higher levels of training intensity. But when the meaning of pain is not readily understood by the athlete, or is falsely believed to be negative acute pain (a sudden result of injury perceived as intense and specific, and evaluated as cata- strophic), it may lead to distress. This can decrease compliance with rehabilitation, even if benign (2). Among healthy athletes, pain can be a major distraction, interfere with skill development and increase the risk of injury.

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Hurt versus harm An athlete must appropriately decide if the pain he is experiencing is a signal that more damage is being done (‘harm’) or if the sensation is very uncomfortable but safe (‘hurt’). Only then can appropriate decisions be made about what to do next. Stopping the activity, rest, appropriate therapeutic exercises and other analgesic remedies (eg. medication) may be appropriate when the pain is truly signaling harm. Tolerating the pain and using the skills described later are appropriate when the athlete ‘hurts’ and is not putting himself at further risk.

Catastrophizing In a previous sportEX medicine article (3), pain catastrophizing was described as one of the most problematic approaches towards the pain experience. Catastrophizing intensifies pain and as a result performance suffers. If the endurance athlete believes that he won’t be able to tolerate the pain of running a marathon (helplessness), he won’t because of this belief. If the rehabilitating athlete sees her pain as the worst she has ever experienced (magnification), she won’t persist in physiotherapy. If the athlete focuses on pain rather than skill execution (rumination), performance declines. On the other hand, those who believe they can tolerate the pain, do so to a greater extent (4). A variety of mental and physical skills can be practiced to foster this belief.

Working through pain Education Education is the first and most important step towards improving pain tolerance. An athlete must fully understand the meaning of pain, and be aware of the risks if he pushes through it. Understanding that he is not causing more harm increases the focus on skill execution and reduces anxiety. Also be aware of how long the pain will last and set a specific goal for tolerance (5). Knowing that there is only 30 minutes left in the race establishes a specific, challenging and realistic goal to manage the pain and