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Citing a lack of evidence-based guidelines for managing acute and chronic pain in elite athletes, the International Olympic Committee (IOC) issued a consensus statement (abstract only available for free) recommending a comprehensive, multidisciplinary team approach to address “biomechanics and the kinetic chain continuum, and psychosocial and contextual domains" among elite athletes. It's an approach that recognizes physical therapists (PTs) as "front-line clinicians who … address conceptualizations of pain and injury."

While experts suggest nonpharmacologic interventions as first-line treatment, IOC authors acknowledge that “when an athlete has severe acute pain, relief of pain is not only humane but may be necessary to facilitate early mobilization.” Drugs, they state, should be used only as “one component” of a broader plan that could include physical therapy, psychosocial interventions, and, if necessary, surgery.

PTs should provide interventions such as strength training and conditioning, as well as all types of exercise, to treat pain and fear of reinjury, according to authors. According to the statement, evidence has shown many passive PT interventions such as electrical stimulation to be ineffective for pain associated with musculoskeletal injury.

The statement also encourages clinicians to educate athletes about the role of the central nervous system in pain. “In addition to physical therapy targeted at increasing strength, stamina, and endurance, and at correcting biomechanical contributors to pain and injury, trained and informed [PTs] can act as front-line clinicians who identify and address inaccurate conceptualizations of pain and injury plus psychosocial and contextual influences on pain,” authors write. Working in concert with behavioral health providers, PTs can offer “psychologically informed physical therapy” such as cognitive behavioral therapy to address fear-avoidance.

The statement supports improved quality of sleep as playing an important role in decreasing pain, but it backs away from a full endorsement of nutritional interventions, with authors asserting that, so far, there isn't enough evidence of effectiveness.

Because of the complex nature of chronic pain, “an informed and well-documented discussion should occur between the clinician, the broader health care team, and the athlete when considering approaches to the management of chronic pain,” authors write.

If pharmacologic therapy is needed, paracetamol, NSAIDs, and topical analgesics are preferred for acute pain for lesser injuries, according to the statement. For injuries that do not allow for same-day return-to-play, the recommendations do allow for morphine, fentanyl, and nitrous oxide—but for no longer than 5 days and “at the lowest effective dose.” In addition to the risks for addiction, opioids can impair an athlete’s performance due to their effects on cognition.

Authors note that “pain management and injury management are not necessarily identical,” and, as such, “managing pain in elite athletes must account for the tension between ignoring or masking pain versus understanding the protective role of pain in the presence of injury.”

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