Thursday, October 5, 2023

Basketball: Managing Pain

The opinions expressed in this piece are generic. The process starts with getting a diagnosis. Always consult your physician for individual recommendations. I am not discussing opioid use, side effects, or abuse in this piece. Additionally, although cannabinoid receptors play a role in pain, I am not discussing use of CBD in pain management. Regulatory impediments in the US have limited the amount of study of cannabinoids in human health and disease. 

Practically speaking, everyone gets hurt or ill. Athletes can't play with an acute migraine and play at reduced capacity with back or neck pain, sore muscles, and other soft tissue injuries to ankles, knees, and other parts. Here's an overview. 

Pain is one of our defense mechanisms. It tells us not to use or limit use of body parts. Pain permits survival. Touching a hot surface reflexly signals withdrawal to prevent injury.

You've heard the expression, "you can play hurt but you can't play injured." In 2016, Patriots quarterback Jimmy Garoppolo injured his shoulder. Writers criticized him widely for refusing to play injured. Most readers here know the controversy surrounding Ben Simmons and injury. Such is the nature of sports observers.

Pharmacologic management (non-opioid). We have access to over-the-counter acetaminophen (e.g. Tylenol) and common non-steroidals like ibuprofen (e.g. Motrin) and naproxen (e.g. Aleve). 

Acetaminophen helps relieve pain but not inflammation. Doses approaching 4,000 mg daily can be toxic to the liver so most practitioners avoid escalating toward that level. Alcohol can lower the toxic threshold. 

Non-steroidals decrease pain and inflammation. They may elevate blood pressure have potential toxicity to the stomach, GI system in general, and  kidneys. Alcohol increases the risks. It is estimated that 14 million Americans over 45 use NSAIDs daily. Charles Barkley said that the one thing NBA players feared was kidney disease from long term NSAID use. Barkley said having to take high doses over long periods was part of NBA life. 

Higher doses of famotidine reduce GI side effects. "Results from a 24-week double-blind, randomized comparison of placebo versus low-dose famotidine (20 mg twice daily) or high-dose famotidine (40 mg twice daily) prophylaxis against NSAID-associated gastroduodenal ulcers found that the incidence of gastric ulcers was 20% in the placebo group, 13% in the low-dose famotidine group and 8% in the high-dose famotidine group. Many of the patients enrolled in the study did not have abdominal pain or dyspepsia, but among those who did there was a trend toward reduction in dyspepsia in patients taking famotidine."

Non-pharmacologic therapy. Time is often the ultimate healer. Players want to be back on the field or court ASAP. Sometimes that can't happen. 

Physical therapy. Physical therapy is specific to the area of injury and trainees undergo seven years of undergraduate and postgraduate training to earn a Doctorate in PT. A paragraph won't summarize their knowledge and expertise. 

Mindfulness. Mindfulness/meditation can lessen pain. "We have recently witnessed a significant increase in studies demonstrating that mindfulness meditation reduces pain reports across a spectrum of chronic pain conditions." Experimentally, after only four twenty minute training sessions, "Meditation, after the four-session intervention, during noxious heat produced a mean 40% reduction in pain intensity and 57% reduction in pain unpleasantness ratings." Other studies have disentangled placebo responses and show mindfulness superior and distinct in reducing pain. 

Acupuncture. "Does acupuncture really work to quell pain? The evidence is mixed, with some studies showing that acupuncture relieves pain and others showing that it works no better than "sham" acupuncture (procedures designed to mimic acupuncture but to have no real effect, much like a placebo, or "sugar pill," used in medication studies). One of the problems with deciphering these results is that most acupuncture studies have been small. The design of "sham" acupuncture techniques has also varied widely, which complicates any comparison. It's also possible that acupuncture works for some people and not others."

When many treatments exist for a problem, none are superior for everyone or everything. Problems can also arise when conflicts-of-interest arise such that physicians and management pressure players to get athletes playing who are not ready. 

Lagniappe. 

Lagniappe 2.  

Lagniappe 3. 

 

 

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