Telehealth Chronic Pain Management for the Elite Athlete Population: A Multifactorial Approach

Introduction: Chronic Pain in the General Population Versus the Elite Athlete Population

Chronic musculoskeletal pain, a multifaceted experience, has substantial consequences on patients themselves, as well as on their families, relationships, social and professional lives, and ultimately causes a decline in quality of life (QOL) for both the patients and their families [1,2]. The IASP (2020) definition of pain is: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” [3]. The Global Burden of Disease Study in 2016 reiterated that the high prominence of pain and pain-related diseases and disorders is the foremost cause of disability and disease burden globally [4]. As a consequence, the 2016 National Pain Strategy called for greater precision in the estimation of chronic pain (CP) and high-impact CP in order to reliably establish the occurrence of CP and assist in the development and establishment of population-wide pain intervention strategies [5]. National estimates of high-impact CP can help distinguish individuals with restrictions in major life domains including work, social, recreational, and self-care activities from those people whom seem to preserve normal life activities despite their CP experiences [5]. This provides better insight into the population who seem to be in need of pain services [5]. Hunt and Day (2019) state that elite sportsman who experience CP have a different experience to the general population who experience CP [6]. This may be most likely due to the interconnection between their professional (physical and psychological training, pre-habilitation, playing their specific sport and post-game routine), recreational and social demands placed on them. In addition, it is suggested that acute pain (AP) perception as a result of sporting injuries differs greatly from those athletes suffering from the CP experience [6]. Acute injury and/or AP has been the focus in the past and still in the present on the elite sporting population. However, CP has been underrepresented in this group of individuals. Specific statistics around the incidence of CP in professional sports players is still not well known. The high training volume in elite athletes, potentially increases the prevalence rates of chronic low back pain, for example, as might less training or exercise ratios do so in the general active or inactive population [7]. Research has also revealed that the relatively uninvestigated factors surrounding psychosocial issues in elite athletes suffering from CP, need further assessment and treatment [8].

Interdisciplinary Chronic Pain Management for the Elite Athlete

Research has suggested that various aspects of an athlete`s identity, such as negative affect, can lead to a heightening of pain-related distress, that has negative consequences on a patient`s rehabilitation back to health and full fitness [9]. Due to the large amount of emphasis placed on sports in today`s world, being a high-performance athlete comes with additional stress and demands to return to their particular sport [9]. The above therefore places enormous amounts of pressure to perform within the parameters of their required high level [9]. In turn, this may lead to pain-related psychological anguish such as anxiety and depression [9]. Therefore, understanding the CP experience in the elite athlete population needs to be dissected through a comprehensive biopsychosocial framework, as with CP in the general population. Targeting assessment and treatment of AP and CP in this sub-group of the global population, should certainly account for all pain manifestations including physiological and/or anatomical mechanisms, psychological and social mechanisms. For example, encouraging athletes in pain to maintain social interactions with their teammates, as part of developing an interdisciplinary treatment plan, may be an extremely necessary task to accomplish social goals as part of the biopsychosocial model of rehabilitation. Understanding patient-driven goals instead of clinician-driven goals, and patient motivations as part of their recovery, should be a critical task in order to achieve potentially getting back to their highest level of performance [9]. Interdisciplinary pain management certainly proves to be a viable format in which all individuals experiencing CP, including professional athletes, may use to engage in full patient-centered management consultations to help manage their pain through a biopsychosocial lens. Interdisciplinary telehealth pain management, has been found not only efficacious in monitoring and adjusting analgesic medication but also for the delivery of non-pharmacological treatments. Non-pharmacologocal treatments may include pain self-management strategies such as Cognitive Behavioral Therapy (CBT), mindfulness based intervention, motivational instructions for exercise based treatment [10-14], goal setting, therapeutic pain neuroscience education, graded activity, graded exposure, pacing and other self-pain management techniques. CBT and new psychological techniques falling under its umbrella, has become the most widely used psychosocial treatments for CP, with evidence of improved pain intensity, pain-related disability and associated problems such as anxiety, depression and insomnia, for example [15-16]. Other psychological modalities born out of CBT used to manage CP, include Dialectical Behavioral Therapy (DBT) and now the widely used treatment of Acceptance Commitment Therapy (ACT). However, research for pure CBT, specifically for athletes, is limited. One previous study did find that CBT intervention reduced athletes` anxiety, pain and days to recovery following arthroscopic surgery for meniscus repair [17]. Therefore, further research still needs to be conducted around CBT techniques for elite sportsmen/sportswoman, in addition to studies investigating DBT, ACT and other psychological treatments. However, it is hypothesized that as with the general population whom suffer from CP conditions, improvement in pain outcomes based on all the above described pain management techniques [2,18-25], these treatment techniques and modalities would most likely be extremely viable for professional sports players also suffering from CP. These pain management techniques encompass a full biopsychosocial framework of management for all patients with CP, thus providing an all-encompassing treatment direction that understands pain through a patient-centered approach. Utilizing pain management techniques, as alluded to above, ultimately aids in patients with CP managing their pain rather than their pain managing them. In addition, these non-pharmacological and non-invasive techniques assists patients with CP in achieving short, medium, and long-term goals, which may incorporate getting back to full fitness to participate competitively in their specific sport.

Telehealth Chronic Pain Management

The question arises around how and when can the elite athlete access interdisciplinary pain management strategies when they are travelling for competitions or events? Telehealth, based on the recent COVID-19 pandemic, has become an important medical and psychological consultation tool to use for the general population, due to the previous COVID-19 social distancing protocols. The growing field of telehealth, defined for the purposes of this paper as “technology that allows for distance interaction between providers and/or patients” (McGeary et al, 2012 p.570), offers a new opportunity to expand upon pain assessment, consultatory work and treatment services beyond the healthcare provider`s consultation rooms [26]. It has continued to be an essential and integral component of healthcare delivery. In addition, telehealth has continued to be an extremely resourceful modality for those individuals who may not have geographical access to medical and psychological care, including pain management appointments. Besides often not having the convenience of an entire healthcare team travelling with elite athletes such as a doctor, trainer, physiotherapist (Physical Therapist), sports psychologist and others, as briefly mentioned above, telehealth may be used as an important add-on to rehabilitation for elite athletes suffering from CP. A systematic review and meta-analysis completed in 2008 that looked at research conducted using telehealth with patients presenting with a broad array of diseases, found that some of the main benefits derived from telehealth services (remote patient monitoring- RPM) were reduced hospital utilization, improved compliance to treatment plans, improved patient satisfaction with health-care provided, and improved QOL [27,28]. Therefore, a consultation through “TelePain”, as referred to by Eaton (2014) et al, with the patients` primary care provider or pain specialist has been shown to be a feasible manner in which to improve patients` QOL and general functioning [29]. Ultimately TelePain bridges physical distances through the use of video, web and telephone conferencing technologies to increase access to chronic pain management” (Eaton, 2014, p.22) [29]. This in turn, would aid in bridging the gap for professional sportsman suffering from CP, who are on the road travelling, and would therefore contribute to the ability to consult with a pain management specialist and/or other healthcare providers if necessary. Herbert et al (2017), found that treatment for patients with CP, suggest that in-person ACT, a key psychological treatment mentioned earlier in this review, which is now used to treat patients with CP and aids with self-management of their symptoms, was as efficacious when delivered via video teleconferencing (VTC) [30]. This result should be no different to when treating elite athletes with CP. Overall, research has found high patient satisfaction when using telehealth, independent of technical difficulties. However, further investigation needs to be be completed to pin-point the best methods of telehealth delivery to make use of covert efficacious treatment variables such as the therapeutic alliance (TA) to maximize the clinical benefit and intervention outcomes [31].

The Therapeutic Alliance: A Key Variable in Telehealth Pain Outcomes

A relatively recent PhD study and an extremely newly published article investigating the predictive nature of the TA on pain outcomes through telehealth pain management programs, found an extremely strong relationship between a robust TA and improved pain outcomes using telehealth methods [32,33]. Strong evidence suggests that a strong patient-clinician relationship and positive therapeutic encounter between the patient and clinician leads to further clinical benefits [33,34]. Research has revealed that the most vital therapeutic contextual expectancies related to placebo analgesia are most likely correlated to the therapeutic alliance; the patienthealthcare relationship that should be established and that aims to provide the patient with the most beneficial outcomes [35-38]. Losin et al (2017), continue to suggest based on their research findings, that teaching clinicians ways in which to establish common ground with their patients may be an effective way in which to create greater trust and rapport with the patient, and in turn positively influence the patient`s pain experience [39]. Research has also broadly shown that clinical empathic engagement with the patient, which is core in rapport development with patients, is beneficial to the patient in terms of compliance, positive clinical outcomes and less complications [40-43]. This seems to be of utmost importance within an elite athlete population, where compliance in terms of CP exercise principles would be crucial to recovery and return to hopefully maximum performance. In addition, the healthcare provider`s attitudes and behaviors towards the patient and the passion for the suggested mode of treatment, are also viewed as the most important therapeutic contextual expectancy factors related to placebo analgesia [44,45]. A meta-analysis by Birkhauer et al (2017) assessing trust in the healthcare professional and health outcomes, found that patients appeared to report more beneficial health behaviors, minimized symptoms, enhanced QOL and greater satisfaction with clinical intervention when they had higher trust in their health-care professional [46]. Therefore, specifically utilizing the TA clinically within telehealth sessions for athletes with CP should certainly be implemented further within telehealth pain management consultations. Clinicians involved in pain healthcare, who are considering the medium of telehealth as a pain treatment option for elite sports players, are encouraged to critically evaluate how to translate in-person TA and care, equally, into a telehealth format [47].

Group-Based Telehealth Pain Management: Another Key Variable in Telehealth Pain Outcomes for Elite Athletes

Another important covert therapeutic variable that has been proven to be useful in pain management is the idea of `the group` in group-based pain management programs (GPMPs) [33,48-52]. Recent meta-analyses proved the efficacy of GPMPs on various pain outcome measures [47,53]. The significant results around structural group-based factors, entities such as group dynamics (GDs), the group process, the group climate and therapeutic factors in group work may be key influential elements that work towards improvements in pain outcome measurements [33,54], including improvements in health related quality of life (HrQOL) measures. GPMPs may be extremely useful for athletes that specifically partake in sports that include teamwork, however, should not be exclusively limited to these athletes and should also include athletes that are involved in one-on-one competition. Telehealth pain management should include both one-on-one management and telehealth groupbased management programs (TGPMP) [52]. TGPMPs should include a number of athletes at the same time being involved in a single telehealth session or a full TGPMP. A full TGMP may be defined as a number of telehealth sessions with the same group of individuals in each session being taught different self-management techniques from session to session. Again, research has found that the GDs within TGPMPs are also significant predictors of improved pain outcomes following these programs [32,33]. To note, of interest to the notion of therapeutic contextual factors within a group-based program, is the idea of group cohesiveness [54]. Group cohesiveness is described by Frank-Saracini et al (1998, p.9) cited in Phan (2004, p.237) as “emotional closeness among members; members` caring and empathy toward each other; members` positive regard for what others feel, think and do” [54]. Group-cohesiveness is a relevant theme within group-based intervention that may reflect positively upon the outcomes of treatment.

Elite athletes who play in team-sports or those who play one-on-one sports, often require the energy, dynamics and direct conscious and subconscious observations of their fellow team members or opponents, to perform optimally. So to, this psychological process and mentality may be required or set in action if elite sports players with CP were to be incorporated into an interdisciplinary GPMP, for example. Modern learning theories understand learning as a result of changes in behavior that take place as a consequence of regularities in an individual`s environment [55,56]. Therefore, the therapeutic environment including the GDs within a GPMP should be taken into account when examining subjects` potential changes in behavior based on the therapeutic contextual environment. Behavior, in the above description, refers to both observable deliberate and automatic responses or neuronal activity (brain activity) [55,56]. This notion is in keeping with the pivotal work of Albert Bandura, the foremost theorizer and writer around the theory [56]. Bandura defined observational learning as “changes in patterns of behavior that are a consequence of observing the behavior of others” (Goubert, 2011, p.167- 168) [56]. Research has demonstrated that the social models of the pain experience have an impact on autonomic and psychophysical measures of sensory processing of painful events [56,57]. Therefore, based on the above, it is clear that observational learning of pain influences both visible expressions of pain as well as the subjective experience of pain [56]. According to Bandura`s model, it is necessary to clinically and through research, comprehend social observational learning according to covert or subconscious experiences that may explain behavioral, perceptual as well as psychosocial changes in pain perception, and therefore alterations in outcome measures following GPMPs. According to the social observational learning theory model, placebo analgesic effects can be learned through observations of other patients having an analgesic response to a particular treatment [58-61]. Treatment may include medication, invasive treatment, manual treatment, exercise, cognitive behavioral treatment, and other psychoeducational treatments for CP as described earlier. Hence, utilizing the group-process in TGPMPs, may certainly be to the advantage of athletes sharing common pain conditions and therefore may be a necessary and useful intervention to start practicing, and in turn facilitate further improvements in pain manifestations in this sub-group of the general population with CP.

Conclusion: Clinical Relevance

Therefore, in conclusion, elite athletes suffering from CP (or acute pain) may be ideal candidates for telehealth care. A large number of pain treatment modalities can be instituted, modified, monitored, and motivated via a telehealth format [62]. It is important to note however, that not all treatment modalities can be provided to elite athletes with CP via telehealth, such as the need for more invasive treatment techniques that are often required in the short-term to get patients through an event, game or match. Nevertheless, utilizing clinically, either one-on-one telehealth pain management sessions or TGPMPs appear to be an important steppingstone moving forward in the management of this population group. Not only has telehealth pain management proven to be efficacious for individuals suffering from CP, but it also breaks down the physical and practical barriers that may face athletes in accessing the much-needed interdisciplinary pain management healthcare model whilst travelling to undertake sporting competition. Furthermore, using TGPMPs for elite athletes, as a preventative modality to reduce the risk of an acute injury or chronicity following an acute injury, would be a specifically useful task in the future. Telehealth pain management may also reduce the financial burden on service providers and the touring athlete/s by mitigating all the costs that come with setting up a physical practice. Finally, it is recommended that future research starts to analyze in greater detail the possible efficacy underlying telehealth pain management for professional athletes so that thorough evidence-based practice is implemented moving forward.

Competing interests

The author declares that he have no competing interests.

Acknowledgements

There are no conflicts of interest for any of the authors of this manuscript. No sources of external support or funding. There are no additional acknowledgements to be made.

Publication history

Editor: Catherine Ortega, University of Texas Health Science Center, USA.
Received: 05-Feb-2023 Final Revised: 24-Apr-2023
Accepted: 20-May-2023 Published: 15-Jun-2023