Ep 215: Assessing pain in athletes, with Ciarán Purcell

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. How do you approach assessing pain when you're working with athletes? What tools do you find most helpful? Today,

[00:00:28] sports physiotherapist and researcher Ciarán Purcell joins me to share a big project he's leading to gather consensus from athletes and sports medicine and rehabilitation clinicians about how best to assess athletes' pain. And there's an opportunity to contribute to this work so please listen to the end to find out how you can get involved. Ciarán is an assistant professor at the University of Limerick in Ireland where he combines his passions of teaching physiotherapy

[00:00:57] students, researching predominantly in the field of athlete pain and clinical practice in elite women's rugby and athletics. Okay, here's today's episode. Ciarán Purcell, welcome to JOSPT Insights. Ciarán Purcell Thank you so much, Clare, for having me. I really appreciate the invitation. Ciarán Purcell I really appreciate you taking the time, Ciarán. You're leading a program of work to improve how athletes' pain is assessed by sports

[00:01:23] medicine clinicians, including sports PTs. Today we're going to take a close look at the consensus process you led with international sports PTs and listeners can find the link to the article, the consensus article in the show notes of today's episode. Why don't we start with a bigger picture type of question, Ciarán. First, why was a consensus needed on how to assess athletes' pain? Ciarán Purcell Yeah, it's a really good question and I think for me it started as a clinical

[00:01:51] question, Clare. So I worked for a number of years as a clinical tutor in Dublin and I worked with students, physiotherapy students and a lot of athletes came into the clinic and over and over again athletes would come in with injuries, be that ankle, hamstring, knee from across a range of different sports. But inevitably they'd be walking out of the clinic and we might not have been able to provide an answer. So they might be back in the pitch, they might be playing, but ultimately there are still

[00:02:19] some level of pain, it might be influencing their performance, might be impacting their quality of life. And I just felt like there was something that we could do better in terms of understanding that experience because ultimately that you know asking how sore is it out of 10, you know with 10 being the worst and zero being none, it gives us a marker right and it can be helpful but it definitely doesn't tell the full picture. So that's how I kind of got into that area and wanted to

[00:02:45] explore it a little bit more. From there I embarked on a PhD in athlete pain assessment, particularly around upper and lower limb pain as there was some work being done in central pain or back pain. What I started off with was a scoping review to look at, okay let's have a look at all the times upper and lower limb pain has been assessed in the research over the past 50 years. What types of tools, questions, things that people have done to try and gain an understanding around that experiences,

[00:03:13] those experiences that athletes have. And we were able to kind of map some of those assessment tools to the gold standard which is the IOC, the International Olympic Committee. They have a consensus statement on pain which was published in 2017 actually and they have five key domains of pain assessment. The first one being neurophysiological then biomechanical which most clinicians are well aware of. There are things like

[00:03:38] you know localizing, finding where the pain is, severity, irritability, nature, you know those things that you typically see on your pro forma or your questionnaires as a student and even into early practice. And then biomechanical, you know how is someone moving, what's their load like, what's their you know strength, their range of motion, their motor control. They're kind of the local biomechanical and the wider biological and biomechanical include things like their training load, include things like their

[00:04:06] nutrition status, their sleep, their recovery, menstrual status for female athletes as well. That was the second category, there's three more. Cognitive, so how does the athlete understand their pain, how much attention do they pay to it or not, do they ignore it, what are their beliefs, their kind of ideas and concepts around pain. And then the effective category is also called psychological or emotional

[00:04:31] and this is one I think we're becoming more and more aware of particularly from the the pain science in the general population so things like maybe anxiety and depression levels, fear avoidance, their willingness to exercise through pain. All of these I suppose contribute to the overall emotional experience of pain and we know that there's there's a definition of pain that encompasses both the sensory aspects and the

[00:04:58] emotional aspects so we can't parse them apart and so that's why this effective category is quite important and that fifth and final category and that was identified by that IOC consensus statement 2017 by Ayn Lyon and colleagues is the socio-environmental domain. We might think working with athletes you know what has that got to do with us but actually quite a lot so that's the culture within sport so is there a play through pain culture do we try try and ignore pain what are our

[00:05:27] teammates and our support network like around us what are our access to facilities and medical resources and staff and so there's a huge amount of that socio-environmental aspect as well that can play into that pain experience. So to rewind back to that scope and review and where we looked at all of those occurrences where pain was assessed in upper and lower limb pain we found that predominantly the neurophysiological and biomechanical domains were ticked off so people use those pain assessment tools

[00:05:55] quite a lot but that the pain assessment tools have been cognitive, the psychological are effective and the socio-environmental were used far far less even within each of those five domains there are tools that are used quite a lot and tools that could be used more considered more so our scope and review kind of identified 176 different pain assessment tools overall and it's kind of nice for clinicians to be able to

[00:06:18] consider those and think about other ways that they could assess pain. 176 different tools Kiron that's a lot of tools to navigate and I guess it reflects the diversity and complexity of assessing and managing pain how would one go about choosing a particular tool to use in their context with the athlete they're working with? Yeah and it's it's a question that I contemplated a lot as well Claire so I was really delighted to see so many

[00:06:45] and then also a bit inundated and a little bit overwhelmed with the the amount of different tools as I'm sure lots of clinicians are on a on a weekly basis too. First of all I said okay this is what's been done can I go and ask athletes and physiotherapists what's actually important to them add the athlete and physio voice into this equation and see you know maybe a certain tools are being used why and if certain tools are not being used why not and could we improve that so I conducted a set of focus groups

[00:07:14] which combined both athletes and physios in in the one room so we had five focus groups 12 athletes four physios in total across a range of of different backgrounds and sports and what came out inevitably was that there's this unique experience of pain and sport actually that athletes go through that's quite different to pain in other circumstances and that there definitely is value in the current tools

[00:07:38] that we have in terms of having a tangible outcome measure being able to tell someone yeah your strength is lower on one side than the other being able to quantify give some numbers around that pain experience as well but also that there's a huge gap around in particular those contextual factors so psychological cognitive and socio-environmental both athletes and physios reckoned that we could do better there and

[00:08:04] in particular the emotional side of pain we spoke about it earlier that there's two aspects in terms of pain perception that was rarely I suppose investigated or assessed when it came to athlete pain assessment so fast forwarding a little bit to the end of those focus groups we conducted what was called a nominal group technique which is a method within research which essentially gets all of the ideas of the participants puts them up on a whiteboard and then all of the participants vote on what they feel

[00:08:32] are important or should be included and we asked everybody to give us their ideas and we came up with a set of 13 different pain assessment ideas and and contributions so before we narrow down the process a little bit we actually ended up asking or adding a little a little bit more so we now have this six domain of aspects of the

[00:08:55] assessment approach which actually talks to things like the timing of the pain assessment the communication pathways how you give that information across how you speak with coaches with the athlete support network the selection of pain assessment tools which actually helps us a little bit in this filtering things down a little bit so that we pick the right assessment tools at the right time we don't use too many and we might change the assessment

[00:09:19] tools we use throughout the process too so we arrived at this stage at the end of our focus groups knowing that we're onto something with the lack of use of you know contextual assessment tools and that might be an area we need to pursue and that we have some additional tools that we need to consider it was at this stage that i said okay we do really need to start narrowing these down and being a clinician

[00:09:43] myself i know the the value of you know being able to pick up something being able to read through it in 20 minutes and to actually be able to implement some strategies with the athlete that's coming in the door in five minutes time or maybe afterwards to reflect on and see what could i do better next time so we then went at this process of consensus generation so i recruited 41 sports physiotherapists from around the world if

[00:10:07] you're a member of ifs pt you might have gotten a email from me so it was clinicians who were working in sports had an interest in sports and had a minimum experience of three years that the mean amount of experience that clinicians had was 15 years so it was quite an experienced cohort but we wanted to capture the experiences and ideas of kind of early career physical therapists right the way through to people who are qualified for a long period of time and we went through a process whereby all of the the members

[00:10:36] of the panel or the experts voted on which items that we generated from the scoping review and the focus groups and through consultation with our ppi panel and some expert pain physiotherapists we asked those physiotherapists about on which items they felt would be required in a pain assessment framework and also we asked them how often they felt each of those pain assessment items should or could

[00:11:03] be used in practice and so what we were left with was a set of 64 pain assessment items that met our criteria for inclusion which was that 70 percent of those who participated either agreed or strongly agreed with those items being included which actually narrows things down quite a bit so we've gone from 176 down to 64 which is quite good and it also includes items from that six domain of aspects of pain

[00:11:31] assessment or the pain assessment approach and so we now have quite a comprehensive list of tools that are still divided amongst those five different domains that any sports physical therapist can look read through and have an idea of how to maybe better quantify that pain that that athlete presents to the clinic with amazing and such a detailed body of work and i think that also adds to our sense of this is

[00:11:59] trustworthy and and and this is something that i can really hang on to as a clinician to help guide my practice without being a recipe and telling me exactly what i have to do exactly which tool to use and i guess that's the balance isn't it between giving the recipe and saying use this one in this circumstance and giving people a suite of options and allowing different people to choose totally clear it's a really good point so in terms of rigor and trustworthiness that was something that was really

[00:12:26] important to me actually because if someone's going to take time to read through this paper i want to make sure that i've done the best job i can and so there's been some recent guidelines in this area that have been released that we followed up with throughout the process we kind of worked closely with some experts in the area around how to develop consensus guidelines and statements and how to you know just apply a decent level of rigor in terms of how we conducted the trial and also or conducted the study and

[00:12:54] also how we reported so that people you know can be really confident in what they're reading and that that it's quite transparent and easy to read yeah so there's a couple of steps throughout the process really one was having a steering committee to ensure that we followed all of the different steps completely then we had our athlete ppi panel so we made sure that the survey that the sports physios voted on had been reviewed by athletes beforehand as well so there's that it was something that was

[00:13:21] relevant that we're asking them about equally we had some pain experts who contributed to that initial survey too and they were able to look at kind of the contemporary pain science and see if there's anything that we could add into sport there then we had our a priori consensus threshold which basically means that we decided that if an item reached 70 agreement of agree or strongly agree then

[00:13:47] that will get included we decided on that before we started our study sometimes these consensus thresholds can be agreed after the study and it just takes away a little bit from the overall rigor and the trustworthiness of the research so totally that was really important to me and then as you said balancing that with something something that's clinically applicable so i didn't want to make any decisions myself and add my bias into the into the research so all of the tools and items that are now

[00:14:17] incorporated and included have been generated through expert consensus and you can trust in the fact that other sports officials from around the world with lots of experience feel that they're worthy and important to include also before we talk a little bit about the key results and and give people a bit of guidance around those tools i want to come back to the population and the the idea of athlete because sometimes when when people talk about athlete populations they're talking about the very elite the

[00:14:47] very top professional level sometimes we're talking about a much broader cohort of active people can you give us a sense your on of who is this consensus applicable to if you look across the literature there's lots of different definitions about what the athlete is so when we were conducting our scoping review and starting out this project we considered all of the available research out there and the

[00:15:12] definition we used was an athlete is anyone who is engaged in their sport on a weekly basis so they must be training or competing on a weekly basis there must be some level of competition so there has to be competition either against others so it could be you know a team or an individual competition where they're you know looking to to compete there or it could be a competition against themselves as well that competitive element is really important for identifying an athlete a recreational exercise there

[00:15:41] might be someone who is involved in their sport on a weekly basis but that competition or that competitive aspect just isn't there so five-side football for example although they might be you know playing a game against their friends the competition focus is not quite there so that intent on performance is uh i suppose one of the key aspects of our definition and then apart from that it could be an amateur athlete so someone who is you know training a couple times a week competing at

[00:16:07] the weekend right the way up to a professional athlete elite athletes at different levels and we had sports pts who are involved in working with all of those different athlete cohorts and equally our focus groups uh consisted of athletes and and physios who are working with those different groups too so we do feel like it's important to recognize that there's lots of different contributions to a pain experience based on the level that someone is competing at as well i think that's a really good point

[00:16:36] particularly when you talk about the psychological and the socio-cultural aspects of pain and those domains being areas where we don't tend to assess quite so much in sports pt or in sports medicine and i guess that leads nicely into what do you see as the main messages of this consensus work what should our listeners today consider when they're working with athletes in terms of something practical one nice

[00:17:01] take-home part of that paper is if you look in the supplementary information we've provided a framework protocol so i've given an example or a question that you can use for each one of those pain assessment tools to implement in your clinical practice so if there's an item there that you like in any of those six domains so you feel you know what i think this could be really relevant with this athlete i'm about to see then there's an example of how you can implement that tomorrow or today even so that's one

[00:17:28] key take-home point i guess the other is just raising the profile of these contextual assessment items i think that's really important to do understanding that you know the psychological bit isn't just for someone else it's for us as pts too and it's for the athlete in front of you because ultimately it will impact their performance it will impact their quality of life and also their ability to interact to communicate and to be effective so oh we need to

[00:17:57] consider that so there's nice in assessment tools on that effective domain that we can consider questions that we can ask and so i would encourage readers maybe to have a look at that and then one of my own favorites is the cognitive pain assessment tools as well so there's a really simple way of just asking someone what do you think is going on with your pain here what do you understand i think sometimes we skip that part and we go into you know i am the expert mode and i'm definitely guilty doing this

[00:18:23] myself and trying to explain what's going on and what's driving the pain and you know the injury versus the pain where it's actually allowing the athlete to to take a little bit of time tell you their story and then guide that process can be really effective in terms of the cognitive and the understanding and for that light bulb moment that we all look for sometimes so they just get it and when they get it then that means they can have confidence in the process they can understand why you're giving them that rehab and they can have hope for the future in terms of getting back to

[00:18:51] their play and level of performance the way they want it as well love that the light bulb moment for sure we're all looking for that turon how do how else do these measurement tools show up in your practice or how do you think about using them across the number of consultations you would see an athlete are they are these one-off you know i'm getting you to rate your pain on a zero to ten visual

[00:19:16] analog scale or how whether you how do you incorporate these tools into your practice working with different athletes on that framework prototype supplementary material we've we've developed a three-stage prototype there really and the first part kind of explains when you can use this pain assessment tool so something that you can use anytime you're working with an athlete in pain it doesn't mean you have to use all tools each time and equally it might mean that you might select different

[00:19:44] tools over five six seven consultations and that's totally fine so it's meant to be a scaffolding to help enrich your practice to build on what you're already doing to offer you some additional tools and ideas which i think is actually quite reassuring as a pt that we don't have to get everything right that first time it's not that you have to get in you have 10 minutes especially in sport oftentimes it could be pitch side you could be in a change room with a plint that you've just taken out of your you know off your back and you're trying to scramble and get it up and you know there's someone else

[00:20:13] coming in after this athlete so yeah i think to give yourself permission to select some of the most important tools at the start but then to use it as a reflection mechanism to be able to plan your future sessions that's how i would see those tools being used quite a lot and like you mentioned the zero to ten pain scale you know it's not that we're looking to throw out any of our current tools but that we might use them you know in different ways similar to you know some of ebony rio's research

[00:20:39] is focused on tendon pain and creating that traffic light system you know we can start to pick some of these pain assessment measures marry them with others to give a full overall technical picture of what's going on to really help that athlete in front of us and guide our kind of messaging our education and also our rehab strategies as well let's finish up by talking about what's next because i know from talking with you about this project that the nominal group technique the the consensus

[00:21:08] work you've been doing that we've been talking about today was just the start so let's give the listeners a bit of a taster of what's coming up and and what's in the future of this big program of research you're leading karon thank you claire yeah so i'm really excited to share that we're an international consensus statement development panel 2025 and thankfully we just had a really interesting and insightful sports congress in the last couple of weeks and building on from that

[00:21:36] sports congress we have a really strong team of experts in pain pain assessment including physicians or medical professionals sports pts of different backgrounds dietitians sports scientists and we're looking at taking this framework and this consensus that we've already developed and making it a little more implementable allowing that additional step forward so that clinicians can have a tool in

[00:22:02] their hands to be able to use with the athletes in front of them too so there's lots of excitement lots of good things to look forward to i think for for your listeners if anyone would like to be a part of that process you're more than welcome to get in touch with me as well we would love to hear from sports pts from around the world who have an interest in this area it's very much my passion that i'm starting at the ground up the grassroots where i was working and trying to figure out a clinical problem and that's where i want to get back to as well so yeah lots of excitement and fun things to look forward to

[00:22:30] there and also excitement in my own clinical practice working with athletes and and making mistakes and figuring them out hopefully as i as i go forward absolutely and i think if we can do that together we're stronger together and learning from each other will only help us to do a better job for the athletes with whom we work so if people want to get in touch about the the work they can do so check out the show notes and and find contact details for curan it's been wonderful chatting

[00:22:58] and learning more about this work looking forward to seeing the future and really grateful for you taking the time to share the work with us today on jspt insights you're on purcell thanks for joining me thank you so much claire i really appreciate it thanks for listening to this episode of jspt insights for more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice subscribe to jspt insights on apple

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