Welcome back to the Healing Pain Podcast with Dr. Claire Thornton
We’re doing a little bit of a pivot. Historically, we have focused on the treatment of chronic pain mostly in populations of people that have conditions or diseases that contribute to the chronification but persistence of pain. We’re looking at athletes, how they respond, and cope to pain specifically how contact and non-contact athletes cope with pain. As you’re reading and our expert guests, take the time to consider, is there something that you learn that you can apply to all different types of people with pain, not just athletes, but those who are non-athletic and you’re helping them to promote some exercise or physical activity in their life to help them overcome chronic pain?
Joining me to discuss athletes and pain is sports psychologist, Claire Thornton. Claire is PhD examined athletes and pain with a focus on contact athletes specifically Rugby, American football players, and martial artists. Her main research interest centers around pain responses within this population in terms of pain tolerance, pain coping styles, challenge and threat perceptions and performance. Without further ado, let’s begin. Let’s meet Claire and discuss how different types of athletes cope with pain.
Watch the episode here:
Athletes & Pain: How Do Athletes Deal With Pain? With Dr. Claire Thornton
Pain Coping Styles Of Contact And Non-Contact Sport Athletes
Claire, thanks for joining me.
Joe, thanks. It’s nice to be invited. Thank you very much.
As a former athlete, I love this topic and lots of people going to be able to get their brain wrapped around some interesting things with regard to pain. I want to point everyone toward an interesting paper that Claire wrote. It’s in the June 2020 Journal of Pain. It’s called Exposure To Contact Sports Results and Maintain Performance During Experimental Pain. You are a psychologist. You’re studying pain in athletes which is so interesting. Tell us how you became interested in studying pain in athletics.
That was about several years ago, I did a Master’s degree in Sport and Exercise Psychology. One of the professors who was working with us had done a little experiment in the lab where he says, “Test the water and see if different athletes responded differently to different pain stimuli.” He found that athletes who participate in heavy contact sports like Rugby or American football responded differently to pain. It was a conversation we had. I decided to do a page off the back of it. Michael Fisher was in based on looking at differences between athletes and how they respond to pain, how they cope with pain, and how they perform in pain as well.
The followers of this show are familiar with the literature on chronic pain. Should we be as interested in the literature around athletes and pain? We hear less about it I would say.
Surprisingly, it has been very under researched. Even in the sports domain, if you are a sports psychologist or you work in sport, not a lot of research has been done on it. I do think there are things we can learn from athletes especially in chronic pain. Especially to deal with things like coping and how athletes adapt to pain and that pain response overtime. Athletes themselves are a unique group to look at because they voluntarily expose themselves to pain on regular basis whether that’s through injury. It could be through exudation of extreme fatigue. If you think about people who do ultra-long-distance events, for example or through contact with other people through collisions and a few tackling.
These are people who deliberately through choice voluntarily put themselves into these painful situations. Understanding how they cope with that, how they perhaps adapt to that over time, and could potentially be useful to chronic pain patients as well. To me, they’re a fascinating population to look at. We hear often about big great feats of endurance that athletes put up with the athletes who played through broken limbs or terrible muscle injuries. They’ve continued to do so. It’s that mindset and how they force themselves to do those things that is quite a fascinating thing.
When I think about athletics, I’m wondering, are there differences in responses to pain with regard to an athlete versus “a normal person” or a non-athlete. Within athletics themselves, because there are many different types of athletes, are there different pain responses within groups?
It’s the differences between athletes and non-athletes. Generally, what that research tells us is that athletes do tolerate pain than the non-athlete. If we give them experimental pain in the form of cold pressor or ischemic pain or whatever, they tolerate pain better than other athletes. With that type of population serving equally if we’ll look at pain perception in terms of intensity of unpleasantness or bothersomeness of pain, athletes tend to perform better than other groups on those measures. The poor pain is less intense and less bothersome than other groups. If we look then which is where my interest lies into athlete differences so differences between different groups of athletes. That might be a regular exerciser basis, a contact sport player or a non-contact sport player.
Again, there are differences. What we find is that those who participate in painful contact sports tend to tolerate pain, but they respond better to pain in terms of intensity, the report is less they’ll find pain and haven’t been less bothersome. They’ve all inter-athlete differences as well. If you think of it as a higher or at the top, you’ve got the contact athletes, who do best in pain than the non-contact athletes, and then non-athletes tend to find that’s the pattern when we measure things in the lab. There are lots of reasons why there might be those differences, but that tends to be what’s found. The only where we are that we don’t find differences between groups is on pain threshold. That is the point at which something becomes painful. There isn’t as much evidence that athletes and non-athletes are different on pain threshold and equally into athlete differences don’t tend to manifest themselves for pain threshold. It tends to be tolerance perception of pain where the differences lie.
I like that visualization you gave with that pyramid. At the top of the pyramid are contact sport athletes, in the middle are non-contact sport athletes and the bottom is the general population. Can you define for us what a contact sport athlete might be and the non-contact? For some sports, I’m sure there’s a little bit of a gray area there.
There is and it’s never going to be perfect science. When I’ve done my research, I’ve always chosen athletes who are definitely where contact is allowed within the rules of the sport, it’s part of the sport, it wouldn’t be penalized. If we think about Rugby, American football, martial arts, they tend to be the three main populations that I would draw my participants from. In terms of non-contact athletes, this is the greatest of the areas because they’re all sports where contact isn’t allowed in the rules. For example, a sport like this which is netball, you get penalized for contact. However, that’s not to say the contact never happens in that sport.
You could choose a sport like Cricket which I don’t know if your American friends are familiar with Cricket. It is a great sport, but that is a non-contact sport like baseball in the sense that you’ve got to play in individual positions in the teams. There are horrific injuries happen in Cricket. People break their fingers quite regularly. People get stuck with the ball quite regularly. When I’m doing my research, I’ve tried to keep it to sports which are definitely non-contact so volleyball, badminton, racket sports rather than try like soccer, for example, is a classic one. It’s not meant to be a contact sport but contact thus happen.
There is a problem with having this dichotomy of contact and non-contact. I try my best to try and make those differentiations as clear as possible. You could argue as well that if you had individual athletes, athletes who did athletics or running, cycling, once they might experience contact in those sports, they regularly experience pain especially if you think about a triathlete or a distance swimmer, you’re going to get a lot of fatigue based pain that as well. They’ve all had difficulties in using these dichotomous groups. Even so, the differences are apparent when we do the research, which is a good thing.
Within that, as you’re talking, I’m running through all the different types of sports I’ve ever done in my life and sports I find interesting and unique. American football clearly is a contact sport, long-distance marathon, long-distance running, not a contact sport for the most part. What about performance sports? Things where you may not be coming in contact with another human, but you may be coming in contact with either a piece of equipment or the ground itself from gravitational forces. I’m thinking more like performance sports like gymnastics and figure skating falling on the ice, doesn’t feel so well?
There has been some quite nice research-driven gymnastics in particular more so around the culture of playing hurt and the show must go on. In those kinds of sports where collision with the ground or an object that a piece of equipment may occur and then you may become injured, but then you put yourself may feel compelled to go on. There was some quite nice sociological psychological research on there about how those athletes in those sports then cope with pain and deal with pain whether they’re willing to report pain or not. Those sports equally, you’ve got to think, do you have an element of pain to them? That’s why that research exists because they’re quite interesting population to look at.
Can you give us an insight into what some of the research around gymnastics might say?
Some of it is quite old, but it generally says that from a sociological point of view have this attitude that pain shouldn’t be reported because they might not be able to compete. This culture exists also in book that conducts sports where there’s machismo involved and people might feel embarrassed to admit that they’re in pain or they might not want to report an injury because they might look soft or whatever. In gymnastics, there was also some quite nice research done about how athletes understand what pain means. The look and the experience level of athletes.
What they found was that the more experience athlete has in gymnastics, the more conservative they become about how they respond to injury. An athlete, if it’s new with the sport may twist an ankle and not understand what that means and what that injury feels like, they might never experience it before. Therefore, it may continue whereas a more experienced gymnast would know what that pain meant. Was it benign? Is it at home full, can I continue on it? They would then make decisions accordingly. I did a qualitative study which hasn’t been published which I found very similar results with contact athletes, the older, the way or the more experience they had, the more conservative and realistic the way about dealing with pain and injury and deciding whether to continue or stop their participation.
Bring us up-date on your research. We want to hear about your study in the Journal of Pain. Tell us about that study and tell us what some of your findings were.
There’s a couple of similar studies, which I’ve done using a similar protocol. It was using a novel motor task of as novel as possible motor task with pain and without pain and examined athletes according to whether they are contact athletes or non-contact athletes and also according to experience. People that had over three years of experience at playing contact sports was one group. They were experience contact athletes. People who had less than six months experience being in contact sport with that group. We had a group of regular athletes who don’t pick contact sport. They did a more of a task in the lab in pain and not in pain. Even they already know that in painful conditions, contact athletes tend to perform better than other athletes do in pain.
Down to attentional capacity pain is lesser and then perhaps less bothersome. Therefore, they can use more of the attentional focus on the task at hand. We wanted to look at challenge and threat manipulation. In sports psychology, if I’m a coach and I’m telling an athlete don’t prepared enough before you go out and compete. if I give them challenge-based instructions, I tell them things which is going to help their self-efficacy. That make them feel a little bit more confident about themselves. They can achieve what it is that they want to achieve, generally challenge instructions result in better performance. That’s been proven across the board as sports psychology. That can be indexed through physiological measures as well as self-report measures. We can take heart rate variability.
There were other that more complex cardiovascular measures we can take. I took the weight variability mainly because of the equipment they had and self-report measures of challenge and threat. If you give people threaten instructions, people tend to perform poorly as you would imagine. I was interested to see how performance differed between the three groups that are hard but also whether those challenge of threat manipulations would make any difference to how the athletes performed. If somebody is nervous about pain, for example, or hasn’t experienced it a lot, if I give them challenge-based instructions, can that help them to perform better? What we found was that athletes, didn’t matter what level of experience they had, performed better in pain than when not in pain and the non-contact athletes performed with in pain, which was what I expected was going to happen.
What I found was that the non-contact athletes were more threatened by pain regardless of any instructions given. In particular, what that tells us is that even if they were given challenge-based instructions, these athletes, their pain is overriding those instructions and they wouldn’t feel threatened anyway whereas the contact athletes were the opposite. If I gave them threaten instructions, they still felt challenged by the pain. Again, that goes down the experience and the fact that these athletes perform, train in pain quite a lot. Therefore, given them pain stimulus in the lab, potentially wasn’t threatening to those to the contact athletes.
It’s quite a complex design in the sense of how it ends up but it did give back the results that were expected. We took secondary measures like pain tolerance would measure pain intensity, pain bothersomeness. We also measure the coping style called direct coping which is it’s taken from a sports-based questionnaire, the sport before pain and dive a coping base at years that I see pain as challenge as wanting to face it head-on. I see this something to be overcome. Lo and behold, the contact athletes had a high level of direct coping and comparison to the non-contact athletes.
They tell us that our exposure to, even brief exposure, because there wasn’t much difference between the experienced contact athletes and the non-experience contact athletes even very brief exposure to conduct pain in the form of playing sport is enough to help to maintain performance in due with painful stimulus in the labs. Even that very brief amount of training and all of the novice athletes as I called them, contact athletes, they had less than six months experience of playing a contact sport.
They were still able to maintain performance in pain relative to when they were in pain. There was no decrement in performance. Even that very short exposure was enough to keep their performance like on a platform or feeling whereas the non-contact athletes performed significantly worse in pain. This explain if we are exposed, that can be something which might buffer the effects of pain on attentional capacity perhaps, and help people to be able to maintain performance.
I want to break some of those things down a little bit because there are lots of interesting pieces in there for us to chew on here. You have three groups. You have the contact athletes, the non-contact and then the third group is non-athletes, is that correct?
They were non-contact athletes. I had experienced contact, not contact athletes, novice contact athletes, and then normal athletes.
From a research perspective, and this is getting into the nitty-gritty for those who don’t know research although we have a lot of practitioners follow the show, someone who volunteers for a study like this may outcome slightly. You’re saying on some level, a human being is okay to come into a lab and subject themselves to some pain, which naturally humans don’t like to subject themselves to pain.
One of the things for these studies is recruitment. However, what I’ve found in the many studies I’ve done especially the contact athletes wanted to know about the pain tolerance and their pain threshold although they know what it feels like, they’re quite curious. That’s something you’ve got to watch out for because you don’t want them, especially some of the male counterparts, want to compare themselves to their friends. They want to know did they tolerate more pain than him, for example. You’ve got to be very careful about not letting them share results with one another. Not giving them their results so they can’t compare to each other. Yet surprisingly, a lot of these athletes couldn’t see how much they can tolerate. It’s bizarre. You would think it would be hard to recruit but it’s not particularly.
On some level, they’re competitive individuals. Either they’re competing with themselves or teams or against other teams. The cognitive part of your study, I’d like to threes off people a little bit also, because if we look at chronic pain, in the back of my mind, there’s constantly chronic pain running from what I do for a living. When we look at a traditional cognitive model for chronic pain, we can look at pain as a threat, a challenge, or a loss are typically the three categories that they fall into. In your study, you’re challenging the threat aspect and not the loss part, but the threat and the challenge aspect. Explain to us what that means from a psychological perspective and why that’s important.
As I said, the challenge was chosen mainly because of the sports psychology literature about performance and about how challenge instructions tend to result in better performance. If we do a simple basketball free-throw shooting task, for example, under challenge conditions, we tend to perform better than if it’s in the threatening conditions. That was where that came from. I made the instructions. We try to build self-efficacy. A lot of the challenge conditioning instructions were many people have been successful at this task before, you should be successful at this task. Those kinds of phrases whereas in the threat condition, it was more getting to people thinking they weren’t able to complete the tasks. When we have done this task before, many people have failed at it. Try and get into the self-efficacy side of things.
That was the thought process. I also wanted to see how that interacted with the pain stimulus because I would call the support. I’ll say to you if you find the painful situation threatening, those results may be negated. Those instructions might be negated. That was what we found especially with the non-contact athletes. It didn’t matter what the instructions were. Those athletes felt threatened when they were in the pain condition would go, whereas the contact athletes were exactly the opposite. They felt challenged by it. Again, as I said, that goes down to experience. The fact that the contact athletes potentially may have experienced pain a lot equally. I mentioned sport and culture earlier in a lot of contact sports, there is this culture of you’ve got to be the tough guy.
You’ve got to take one for the team, that kind of thing. I alluded to it in the paper that potentially that mindset might still be there in those athletes. Not to say that it’s not present in other sports, but particularly in contact sports and Rugby in particular, which is where a lot of my participants came from. There was that culture of you’ve got to keep going, you’ve got to take one for the lines, you can’t let the team down. It potentially is that the challenge and perceptions came from that culture thing as well.
If I’m an athlete and the narrative I have running in my head and/or the narrative that exists in my sport, so to speak is one where I see pain as a challenge where it’s challenging. It’s a challenge for me to overcome. I may be more effectively able to cope with that but if I have a personal narrative in my head, there’s a narrative that has developed in my life, or within the context of my sport, that pain is a threat to me, body, sports and happiness, then it may have an impact on how pain is modulated in my central nervous system.
I did try and get to the bottom of this in a longitudinal study I did back in 2017 because I was interested in, does anything change over time in people who come particularly to contact sport? We collected data on some new Rugby players overseas and never played contact sport before. We took measures over the season, various psychological measures. We looked at a pain bothersomeness. We took pain tolerance measures, also the coping strategies. What we found was that at the outset of playing a contact sport, most of the athletes who stuck at the sport had this direct coping and challenged style about them, that they saw pain as something to be overcome or was a challenge. Those are the athletes who stuck at the sport by the end of the season, the athletes who had lower levels of challenge and direct coping at the start the season what the athletes who dropped out of the sport.
A lot of it is to do with mindset and to do with, I use the word resilience whilst I’ve not directly measured that, it is a linked to challenge stage and that we round about where. If we can build the resilience or this divert coping style or challenge states in people regardless of whether they’re athletes or chronic pain patients, they can see pain as something to be overcome, it’s something to be met head-on, it’s something which is potentially not necessary, but it’s something which has to be gone through to get to an outcome. We might be able to get positive results.
We see that in the clinic. We’ve seen athletes who you rehabilitate and they walk into the clinic with what seems like a devastating injury. They look at it as a challenge and their rehab almost becomes part of their training protocol. They’re going to challenge it and get through this. They’re going to regain back their strength, range of motion, flexibility, endurance, all the things that a part of their physical capacity and they’re back on the field. There are other athletes who come in and you can tell there’s this sense of deep loss and threat that this injury is impacting who I am as a person. At times, that rehab may not go as smoothly. The people were more aware of the psychosocial variables and things. As I’m listening to you speak about this, it makes it sound like the challenge is the way out of all this. There’s a double-edged sword there because if you are injured, you have to attend to that injury?
If it’s true chronic pain then that challenge aspect could be a nice coping mechanism but if it’s an acute injury, it’s different.
Yeah. There’s some great research out there about athletes taking risks doing rehab especially with acute injury not report an injury, under-report an injury, lying about it especially in the sociological field research out there about how athletes don’t want to report pain, unwilling to and do dangerous things. If it was a chronic pain situation and you wanted that person to attend to a rehab program, having that challenge mindset, this direct coping style that I keep mentioning seems to be important. There seem to be important factors in not only adherence to the sport but also to adaptive responses to pain or being able to perform well in pain, being able to tolerate pain, report pain as less bothersome. This direct coping does seem to be quite an important thing.
Do we have enough data or have you seen data or is this part of your research to look at sports and say, “Athletics and sport from a young age may be a positive way to help people learn skills that may help later on down the line with regard to catastrophizing or coping about pain and other ways.”
I don’t personally think gamut of day about the minute, that longitudinal study I mentioned is the start of where we could go. To my knowledge, it was the first-ever study that looked longitudinally at pain responses in athletes over a season and looked at what outcomes resulted in that. Did the athletes stick at the sport or did they drop-out? More longitudinal studies like that are needed. In that study, we did find that surprise the people who dropped out of sport where the catastrophizers at the outset. I do think that there was a case to be made that having a high pain tolerance isn’t necessarily a massively important thing to stick at a sport. It’s useful but it doesn’t seem to be the most important thing.
It seems to be how you psychologically and cognitively deal with that pain. In terms of your coping styles like I’ve mentioned before, challenge perceptions. That seems to be more important than pain tolerance at the outset. If I’ve got high pain tolerance, it doesn’t mean I’m going to stick it and played American football. How I cope with that pain, how I deal with it, and how I perceive it might influence that. If you flip that on its side to say chronic pain patients, if you’ve got somebody who has certain coping styles in terms of as said challenge of threat at coping, that’s more of a predictive whether they’ll get positive outcomes.
We have the juvenile pain rehabilitation that doing and then being able to tolerate a lot of pain and be able to put up with a lot of pain. The psychological side seems to be a lot more important. That’s certainly what I’ve found in my studies. Pain tolerance can differentiate different athlete groups. That’s great. It’s interesting but I don’t think pain tolerance is to be all and end all of whether you be successful athlete and you’ll stick at the sport or not.
For example, if someone is reading this, you can add to this and tell me if I’m on the right path here, training your child to be physically tough in a sport may not make them better cope with pain when it happens later on because their psychological responses meaning what they think about pain, how they can cope with pain, and how their thoughts develop around pain are more likely to have an impact.
That would be my conclusion from the little amount of day I’ve collected. That’s far more important because as I said, you could be a child who is able to withstand heavy tackling in Rugby or American football, it doesn’t mean that you’re going to like it, you’re going to want to carry on doing it, and you’re going to cope well with it. The study I’m referring to, I wasn’t interested on differences to sport. If we’re trying to encourage young people to take up sport and to participate in such sports like American football, Rugby, etc., it’s more to do with how we perceive that pain, how we processed that pain, and cope with the pain than how much pain can you take. It’s not as important.
How could you make this portable to a sports physical therapist, a sports physiotherapist comes to mind, but also like an athletic instructor or a coach who may be coaching different types of sports, let’s say their coaching style is the same.
The take-home message from a lot of the research I’ve done is that it isn’t a one-size-fits-all approach. When it comes to how we coach and deal with athletes, we all know that anyway. If we can foster things like this direct coping style, some of the worked out how to do that properly yet, and that’s fit the research down the line. We can look how to manipulate challenge states in terms of each of the verbal instructions that we give to people.
The way that will verbalize what we want them to do, whether that be a physiotherapist, somebody how to do exercise rehab program or whatever, it’s a coach telling them a bunch of kids how they go out there and when it would be game the way we verbalize the words that we use, and the phrases that we use are going to be important in getting people to be able to get into a challenge state. Words and behaviors isn’t the way forward. It’s a bespoke thing. I don’t think that you can blanket say this will work for everybody. I do think if we focus on challenge states, positive and direct coping, and building self-efficacy around how people feel able to cope with pain or injury especially during rehab if we’re talking about injury is important.
Once again, I enjoyed reading the article. Claire, what’s next for you? What are you interested in researching that we’d like to hear about in the future?
I’ve got a few ideas about examining attentional focus a little bit more due in pain. In that study, you’ve mentioned we measured performance and the high contact athletes were able to maintain performance due in pain. I’m interested to try and get to the bottom of what’s the attentional things going on there. I got an idea for an eye-tracking study to look at where visually athletes are focusing due in painful stimulation when they’re doing a physical task. To try and see if there’s any trade-off in the contact athletes, perhaps they’re using visual cues better than the non-contact athletes. I’ve got some of the studies on-the-go looking more at injury occurrence and how sports like a British American football are using in return to play protocols and things like that. There is a little bit of sports injuries to the name as well.
We’ll be sure to follow your work, Claire. It’s been a pleasure chatting with you. Please let our readers know how they can learn more about you.
If you visit the Northumbria University website on our research pages, my profile is on there. I am on Twitter and Northumbria University Exercise and Rehabilitation Research Group is also on Twitter, which shares all of the researches going on in my institution. Feel free to check us out on social media.
Make sure to follow Claire Thornton on her Twitter handle. I want to thank Claire for being here and discussing pain in professional and amateur athletes and how they respond to it. Make sure to stay tuned. Share this episode with your friends, family and athletes who are interested in learning more about pain. We’ll see you next time.
- Claire Thornton
- Journal of Pain
- Twitter – Claire Thornton
- @NUSportEx – Twitter
About Dr. Claire Thornton
I have worked in higher education for almost 20 years, teaching sport psychology. My PhD examined athletes and pain, with a focus on contact athletes (i.e. rugby, American football players, martial artists). My main interests are around pain responses within this population in terms of pain tolerance and bothersomeness, pain coping styles, challenge or threat perceptions and performance. I am particularly interested in the mechanisms behind differences in pain responses in athletic populations.
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