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Abstract
Background Upper and lower limb (peripheral) pain is prevalent in athletes. Contemporary research prioritises multidimensional pain assessment and classification. This study aims to review comprehensive athlete pain assessment practices against the reference standard (International Olympic Committee, IOC Athlete Pain framework), identifying trends and highlighting gaps.
Methods and analysis Six databases were searched using a comprehensive search strategy. This review followed the Joanna Briggs Institute standardised methodology for scoping reviews and is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Title and abstract, full-text screening and data charting were completed by two independent reviewers.
Inclusion criteria Original research, systematic reviews and clinical practice guidelines reporting assessment or classification of pain in athletes of any age with chronic or acute peripheral pain in English on human participants from database inception.
Results 470 studies with 175 different pain assessment tools were mapped against the IOC Athlete Pain Framework. Papers included tools from neurophysiological (470/100%), biomechanical (425/90%), affective (103/22%), cognitive (59/13%) and socioenvironmental (182/39%) domains. Pain classification was included in 108 studies (23%). 4 studies (0.85%) defined pain. Athletes with physical disability were included in 13 (3%) studies and no studies included athletes with intellectual disabilities. Socioeconomic factors were addressed in 29 (6%) studies.
Discussion Neurophysiological and biomechanical domains are frequently addressed. Affective, socioenvironmental and cognitive tools are under-represented. Potential tools for use by researchers and clinicians are highlighted. Defining and classifying pain and determining predominant pain mechanisms is needed in both research and clinical practice. More work on underrepresented populations is needed.
Conclusion This review informs researchers and clinicians working with athletes in pain how pain assessment and classification is currently conducted and highlights future priorities.
- athletes
- diagnosis
- upper extremity
- lower limb
- sporting injuries
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Pain neuroscience and knowledge is advancing and a holistic biopsychosocial model is the gold standard to assess pain.
Pain is part of the sports injury experience, however, focusing on sports injury alone may under-report athletic pain prevalence.
In the last decade, research on the assessment and classification of athletic pain within a biopsychosocial framework has focused primarily on back pain.
WHAT THIS STUDY ADDS
This scoping review explored the available literature to determine how peripheral pain is currently assessed and classified in athletes.
The areas of cognitive, affective and socioenvironmental pain assessments have been identified as less represented in the literature and context on the dominant pain assessment domains neurophysiological and biomechanical has been provided.
Determining the predominant pain mechanism and classifying and defining pain are priority areas for future research and practice.
More research on under-represented populations such as those with disabilities and reporting socioeconomic factors is needed.
Researchers and clinicians managing athletes can review the available pain assessments and consider the additional possibilities beyond commonly used tools.
Introduction
Sports-related injuries, frequently reported as time-loss injuries, refer to a physical complaint that results in an athlete being unable to train or compete in subsequent sessions.1 Pain is often experienced as part of a time-loss injury, however, some injuries can occur in the absence of pain. Likewise, pain can occur and persist in the absence of sports-related injury. Pain is a substantial issue impacting an athlete’s performance and quality of life2 3 and the decision to seek medical treatment or ‘play through pain’ poses a significant psychological and cognitive challenge for athletes.4 Despite a focus on time loss injury in the epidemiological research leading to an under-reporting of pain prevalence,5 significant upper and lower limb pain prevalence rates have been reported; 49% prevalence of hip and groin pain in football players,6 44.6% prevalence of knee pain in volleyball players7 and athletic shoulder pain prevalence of between 38% and 39.6% in swimmers.2 8 Over a 1-year period, 50.7% of athletes with disabilities across a variety of sports experienced muscle pain as part of their sport.9 Athletic pain is frequently recurrent, progressing gradually over time and persistent in nature, commonly lingering for periods of greater than 6 weeks.3 10 11
Modern pain neuroscience has identified a multidimensional understanding of pain with the established biopsychosocial model being further progressed to incorporate the body at multiple levels, from single cells to individuals and the environments they interact with.12–14 Advances in pain neuroscience in the general population have led to more comprehensive and nuanced assessments addressing both sensory and affective aspects of pain as well as incorporating thoughts, beliefs and context.15–17 People in pain are encouraged to discuss how the pain experience affects their feelings, emotions and mood and clinicians strive to understand the specific personal and environmental contexts of their clients and how this affects pain perception and behaviour.
Caneiro et al 18 and Hoegh et al 19 propose a set of guiding principles around comprehensive athlete pain assessment and management. Clinicians are encouraged to differentiate between sports injuries with pathoanatomical diagnoses, predictable healing trajectories and prognoses, and sports-related pain where there may be an absence of specific trauma. In sports-related pain, imaging and reliance on passive treatments are discouraged, while exploring biopsychosocial pain contributors alongside positive pain education within a shared decision making and interdisciplinary framework are promoted. While load management principles have classically been used to manage overuse injuries,20 a shift in focus to improve tissue tolerance, build mental and physical resilience and address wider biological contributions such as sleep and nutrition is proposed for sports-related pain.
To reflect this shift, a consensus statement from the International Olympic Committee (IOC) on athlete pain21 and associated works22 23 address comprehensive pain assessment in athletes and outline the need to establish the predominant pain mechanism based on the International Association for the Study of Pain (IASP) model of nociceptive, neuropathic or nociplastic/algopathic/nocipathic pain and to determine contribution of specific pathology.15 Nociceptive pain refers to typical pain as a result of actual or threatened damage to non-neural tissue, neuropathic pain refers to pain caused by a lesion or disease of the somatosensory nervous system, nociplastic/algopathic/nocipathic pain refers to pain in individuals that is neither nociceptive nor neuropathic and is often associated with altered nociceptive functioning and hypersensitivity. Athletes with chronic or persistent pain presentations presenting with symptoms of central sensitisation and increased contribution from psychosocial aspects are likely to fall into the latter category.15 The IOC Athlete Pain Framework and related works outline that injury management and pain management may differ and consequently propose a comprehensive assessment of pain in athletes spanning five key domains: (figure 1) the two traditional areas of neurophysiological (eg, location and intensity of pain, quantitative sensory testing and pain characteristics) and biomechanical (eg, fatigue, training load, motor control and strength) alongside three more contemporary domains of cognitive (eg, attention, distraction, appraisal of pain and situation), affective (eg, mood, stress, fear and beliefs) and socioenvironmental (eg, social functioning, coach/parent relationships, personal/coach conflicts, pain culture and lifestyle). While some of the wider aspects of assessment are not solely tools for assessing pain, they are viewed as pain assessment tools as part of a comprehensive pain assessment in athletes and this scoping review acknowledges this.
IOC Athlete Pain Framework—Pain Domains; visual representation of the five athlete pain assessment domains outlined in the 2017 IOC Athlete Pain Consensus statement and related works. IOC, International Olympic Committee.
Sports injury classification systems24 and detailed injury coding practices25 have supported the development of comprehensive assessment models for specific pathologies of the upper and lower limb including ankle sprains26 and femoral acetabular impingement of the hip.27 Conversely, comprehensive athletic pain assessment protocols have not been developed. Although research in athletic back pain assessment is emerging,28–30 to date, little is understood regarding how upper and lower limb (peripheral) pain assessment in athletes is conducted in research and clinical practice.
A scoping review of the literature was conducted to outline current peripheral pain assessment practice, map assessment and classification to the IOC Athlete Pain Framework and highlight gaps for researchers, clinicians and athletes. Outlining current assessment practice involves highlighting how pain is currently assessed and in what context. Mapping involves comparing current assessment with that outlined by the IOC Athlete pain Framework.
Review question
How is peripheral (upper and lower limb) pain assessed and classified in athletes?
Aims
To establish the sport (team/individual), anatomical site (upper/lower limb) and context (clinical/research) of comprehensive peripheral pain assessment and classification tools used in athlete cohorts.
To map the peripheral pain assessment tools highlighted in the review against the IOC Athlete Pain Framework.
To report the pain definitions and classifications used in peripheral athletic pain cohorts.
Methods
The Joanna Briggs Institute Evidence Synthesis and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SCr) guidelines were chosen as they reflect best practice,31 32 see online supplemental appendix I for the PRISMA-SCr checklist. Methods were in keeping with the scoping review protocol, which has been previously registered (10.17605/OSF.IO/9DGQ5) and published (http://dx.doi.org/10.1136/bmjsem-2021-001215). A scoping review was deemed most appropriate as the objectives of this study included examining a broad area of knowledge and identifying gaps, clarifying and mapping key concept and definitions and to examine the conduct of research in comprehensive peripheral pain assessment and classification in athletes.33
Supplemental material
Sources
Published, peer-reviewed primary research with qualitative and/or quantitative data published in the English language on humans since database inception were included. Epidemiological, questionnaire based, interview based, randomised and non-randomised controlled trials, prospective cohort, retrospective case–controls, cross-sectional design and other primary study designs were considered. Systematic reviews and clinical practice guidelines were included to identify potential additional original research studies. Given that primary data on pain assessment and classification tools used in research and practice were sought, review articles, editorial letters, book chapters, conference proceedings and websites along with other secondary research designs were excluded.
Search strategy
A preplanning phase identified a research team where the population (athletes, defined as anyone engaged in a sport, training regularly on a weekly basis, with the intent to improve performance and compete against others as an individual or as part of a team), concept (pain assessment and classification) and context (peripheral or upper and lower limb, pain) were agreed. For full details on the development of the search strategy, please see the published scoping review protocol.34 The population, concept and context was then brought to a medical librarian for consultation where a comprehensive search strategy was developed, trialled and refined (see online supplemental appendix II).
An initial search of MEDLINE (PubMed) and CINAHL (EBSCO) was undertaken on 1 August 2021, to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE (PubMed) (online supplemental appendix II). The search strategy, including all identified keywords and index terms, were subsequently adapted, and updated for each database from inception; CINAHL (EBSCOhost), MEDLINE (PubMed) PsychINFO (ProQuest), EMBASE (Elsevier), SCOPUS (Elsevier) and the Cochrane Database of Systematic Reviews. A full search with the updated search strategy was conducted on 15 August 2021.
Study selection
Relevant papers identified were imported into the Covidence reference management system (Covidence; Covidence Melbourne, Australia) where duplicates were removed. Following a pilot test, titles and abstracts were screened against the inclusion and exclusion criteria (see protocol) by two independent reviewers (CP and CD/SD). Reference lists of systematic review and clinical practice guidelines included in the review were screened for additional papers which were in turn reviewed against the inclusion and exclusion criteria. Authors were contacted where necessary to secure full texts. Full texts were screened by two independent reviewers (CP and CD/SR). Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with a third reviewer (BC).
Data charting
In line with methodological guidance,31 a pilot data charting tool was drafted, and a charting exercise was conducted independently by three members of the review team. The team developed a charting tool throughout the pilot through an iterative process to capture the diversity of comprehensive pain assessment and classification tools encountered (online supplemental appendix III). Study characteristics (citation details, country/region, research setting, study design, pain-related aims and limitations), athlete demographics and context (sport, competition level, time frame, physical/intellectual disability and region of pain) were charted. All pain assessment tools identified were charted against the five domains of the IOC Athlete Pain Framework; neurophysiological, biomechanical, affective, cognitive, and socioenvironmental and further classified in terms of pain categories. Frequencies of pain assessment tools, pain definitions and classification systems used were recorded.
Results
Initial searching identified 3292 articles for screening (figure 2). Following title and abstract review, 866 full texts were assessed against the inclusion and exclusion criteria. The initial title and abstract and follow-up full text screening pilots of 50 articles had an agreement of >85% between reviewers. A total of 470 articles met the inclusion criteria following full-text review and were included in the scoping review. The initial charting pilot of 30 articles had an agreement of >80% between reviewers. Demographic data and information relating to the context of comprehensive assessment tools were charted by three reviewers.
PRISMA-SCR flow diagram. Reasons for excluding articles at identification, screening and eligibility stages are provided. PRISMA-SCR, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.
The 470 articles included were drawn from research settings where the data captured was done so to explicitly answer a research question (n=265, 56%) and case studies/service deliveries from clinical or sports settings where the data was part of routine data captured for normal practice (n=205, 44%). The total number of athletes included was 23770; male (n=12 884), female (n=6828) and not specified (n=4058). Thirteen studies (3%) included athletes with a physical disability, no studies included athletes with an intellectual disability. Most studies included were from the previous 10 years, 2011–2021 (n=323, 69%). Acute pain (n=153, 32%), chronic pain (n=116, 25%) and subacute pain (n=5, 1%) were all represented with some studies (n=103, 22%) including a mixture of presentations. Ninety-three studies (20%) did not include a time classification. Lower limb pain (n=291, 62%) was included more often than upper limb pain (n=151, 32%) with a few studies including both upper and lower limb pain presentations (n=28, 6%). A variety of individual, team, strength and endurance sports labels were included (n=55). The most common sports were soccer/football (n=108), running/track (n=106), basketball/netball (n=75), volleyball(n=64) and baseball (n=57). For a more detailed breakdown of setting, context and demographics, see figure 3.
Article context and athlete demographics. Figure is based on the entire scoping review sample of 470 studies. Some articles included multiple age groups, competition levels, time classification, pain site and sports. Pain classifications displayed are taken from studies where a pain classification system was included. See online supplemental appendix V for the full data set.
Comprehensive pain assessment and classification
The comprehensive pain assessment tools included in the studies were charted against the five pain domains identified by the IOC Athlete Pain Framework.21 The five categories are neurophysiological, (eg, impact on performance, pain location and pain during sport task) biomechanical, (eg, training load, height/weight/body mass index (BMI) and range of motion) affective, (eg, confidence to return to play, feelings and emotions and concern/worry about pain) cognitive, (eg, attention/distraction, Pain Beliefs Questionnaire and the Pain Catastrophising Scale) and socioenvironmental (eg, time of season and quality of life). Pain tools were used a total of 5295 times with an average of 11 tools used in each study (figure 4). Each pain assessment tool included in the review is classified under one of the five pain assessment domains detailed above. Similar tools were grouped into categories of pain assessment within each domain and the frequency of specific pain assessment tools per category were documented (see online supplemental appendix V).
Number of pain assessment tools used per domain. Displays the total number of pain assessment tools (y-axis) identified in this review in each of the five pain assessment domains; neurophysiological, biomechanical, affective, cognitive and socioenvironmental (x-axis).
All articles (n=470) included pain assessments from the neurophysiological domain with 90% (n=425) of papers also including a biomechanical assessment tool. Affective assessment tools were included in 22% of papers (n=103), a socioenvironmental assessment tool was included in 39% of articles (n=182) and 13% (n=59) of articles included an assessment tool from the cognitive domain.
The pain assessment tools identified from each domain are summarised in figure 4. A total of 175 different pain assessment tools were identified with the 77 most frequently encountered tools presented in table 1. Overall, the 32 neurophysiological pain assessment tools identified were used a total of 3083 times which accounts for some papers including multiple neurophysiological pain assessment tools. The 96 biomechanical tools were used 1620 times, the 21 affective tools were used 227 times, the 18 socioenvironmental tools were used 264 times and the 8 cognitive tools were used 101 times.
Comprehensive pain assessment tools used per domain
Although 40% (n=189) of all articles were published in the last 5 years, following the release of the IOC Athlete Pain Framework in 2017, these accounted for 45% (n=118) of all socioenvironmental tools, 55% (n=124) of all affective pain tools and 65% (n=66) of all cognitive pain tools used. While there appears to be an emerging trend in the quantity of cognitive, affective and socioenvironmental pain assessment tools used in research and practice, their use remains substantially lower than neurophysiological and biomechanical tools as shown in figure 5.
Pain assessment tools 1971–2021. Displays the number of pain assessment tools (y-axis) in each of the five pain assessment domains; neurophysiological, biomechanical, affective, cognitive and socioenvironmental each year (x-axis) from 1971–2021.
A pain classification system was included in 23% of papers (n=108). The predominant pain classification system was the biomedical model (n=72, 67%) based around structural pathology. Of the 72 papers using the biomedical model, 50 were in a clinical/service delivery context. The biopsychosocial pain classification was used in 16% (n=17) of the papers. The remaining 17% of pain categories included the IASP pain classification (6%), somatosensory pain classification (5%) and other classification systems (6%). Just four studies (0.85%) included a pain definition.
Of the 190 case studies included, 185 (97%) included a diagnosis and 164 (86%) indicated screening for sinister pathologies or onward referral for diagnostic imaging or expert opinion. Just 11 studies (6%) assessed or documented a dominant pain mechanism.
Discussion
This paper presents the wide range of pain assessment tools for peripheral pain in athletes over the past 50 years mapped to the five domains of the IOC Pain Framework. Affective, cognitive and socioenvironmental pain assessment tools are considerably underrepresented in the literature. Although there is merit in including pain assessment tools from the traditional neurophysiological and biomechanical domains, an overhaul of the assessment of upper and lower limb pain assessment in athletes is needed to bring research and practice in line with contemporary multidimensional and biopsychosocial pain research priorities.35 36 Furthermore, research on upper and lower limb pain focuses almost exclusively on pain assessment in athletes without physical or intellectual disabilities, with comprehensive demographic information rarely included in assessment. More work is needed to reflect the diversity of athletes that operate in a modern global society.37–39
Although the neurophysiological and biomechanical domains are well represented, it was beneficial to drill down into some of the specific pain tools used and highlight some of the lesser used pain tools such as assessing the dominant pain mechanism, and identifying wider biomechanical contributions such as fatigue and sleep. Recent research in the field of injury prevention which incorporates the voice and values of athletes points towards exploring the context of athlete pain as being pivotal to understanding the pain experience.40 Context can be provided from two perspectives, an individual’s lived experience, appraisals, understanding and beliefs about pain and second the socioenvironmental ecosystem they inhabit. Socioenvironmental, affective and cognitive tools can provide a wealth of pain assessment information and exploring the use of specific tools can aid in enhanced understanding of the pain experience.
Fewer than one in four papers included a pain classification system, with the predominant system, the biomedical model, widely regarded as obsolete.41 42 Furthermore, the majority of clinical and service delivery-based studies did not address the underlying mechanism of pain, an element the IOC Athlete Pain framework includes as an important component in keeping with gold-standard IASP pain definitions.21 Researchers and clinicians recording clinical case studies or service delivery should consider the classification of pain and clearly articulate the pain definition. When striving towards better pain assessment and understanding, reporting pain mechanisms and including clear pain definitions would facilitate a common language and understanding for researchers, clinicians and athletes alike.
Neurophysiological pain assessment tools
When considering the assessment of pain, neurophysiological tools may be the first that spring to mind and are often prioritised in both research and clinical practice settings. They are the most common pain assessment tools and are represented in every study in this review with tools such as pain location, ratings of pain intensity and pain during or impacting sporting or daily activities dominating. These typically encountered pain assessments tend to reflect more simple, unidimensional, easy to administer tools that are useful to give basic summary information and may satisfy some researchers and clinicians. Tools focusing on the neurological contribution of pain and assessing the predominant pain mechanism and nature of the pain are less represented, which is somewhat concerning given the importance of understanding the nature of each pain presentation. The IOC Athlete Pain Framework recommends those working with athletes to follow contemporary pain assessment standards as outlined by the IASP15 and label the dominant pain mechanism (nociceptive, neuropathic or nociplastic), thus considering potential neurological pain contributions. The scoping review highlighted 32 different neurophysiological pain assessment tools including pain diaries, which offer a more contextual outlook beyond a once off measure, a pain map, which may elicit additional information through visual representation, and pain sensitisation and pain fields which when measured over time may help determine relative contribution of inflammatory or neuropathic processes.43 44 The lesser used tools highlighted above have utility in aiding researchers and clinicians to meet recommended standards of practice and add valuable insights into assessing and classifying pain.
Biomechanical pain assessment tools
Biomechanical tools are also represented in the majority (n=420, 90%) of studies, with anthropometric (height/weight/BMI and swelling), training load (daily/weekly load), mobility (range of motion) and strength (manual muscle resistance) being most common across all study contexts. Biomechanical tools were further dichotomised into local biomechanical (eg, posture, motor control, strength and power measures) and wider biomechanical/biological (eg, sleep tools, fatigue assessment, blood tests, fitness tests). Local biomechanical tools accounted for 70% (1143) of all biomechanical tools used. Local tools such as specific sport and exercise technique assessment and agility measures were less represented, while in the wider biological and biomechanical category female health measures, maturation/development and nutritional considerations were less common. Considering the emerging evidence base around the integration of body systems and the influence sleep, fatigue, nutrition and biological considerations have on inflammation and pain perception it is incumbent on researchers and clinicians to consider the wider biological and biomechanical pain assessment tools available.12 45–47
Affective pain assessment tools
The inclusion of affective pain assessment tools alongside sensory tools is necessary to understand the full pain experience.15 Just over one-fifth (22%) of studies in this review included an affective component with confidence/readiness to return to play, feelings scales/assessment and concern and fear around pain and injury being the most commonly reported. Lesser used pain assessment tools in this domain include both general and sports-related stress and anxiety, which are elevated during painful periods and have been shown to be predictive of sustaining future sports-related injuries.48 49 Assessing willingness to exercise with pain is useful, as incorporating painful exercise through graded exposure has been noted to improve functional outcomes and resilience compared with pain free exercise and rehab. Improved general conditioning, affective components such as reduced fear of movement and improved self-efficacy, improved immune functioning, and engaging central pain inhibition are proposed mechanisms of exercising with pain. Therefore, assessing willingness to exercise with pain fits within a biopsychosocial and neuromatrix framework and warrants consideration.50 Furthermore, avoiding pain may perpetuate the pain and anxiety cycle, particularly when it comes to more chronic pain presentations.51 Clinicians and researchers are strongly encouraged to consider these elements given the impact stress, mood and psychological status play on pain perception.52
Socioenvironmental pain assessment tools
Recently the role of context in athletic injury and pain literature has been highlighted to understand the impact of pain experience on an athlete’s performance and quality of life.53 Time of season, quality of life and general well-being were the predominant tools identified in this study. Assessing or asking about relationships with family members and coaches, pain culture within the sport and additional sociodemographic considerations such as access to key facilities and resources may open a window into the individual’s specific context and, therefore, pain experience and facilitate the choice of tailored, individual and environmentally appropriate treatments and interventions.54–56 With regard to socioeconomic factors, very few studies documented race/ethnicity, addressed employment/education or highlighted income, access to facilities or medical support, which have all been previously linked with higher pain prevalence rates.57 Sociocultural factors such as access to facilities, team culture, sport pressures and occurrence of significant life events have been linked with increased injury risk and play an important role in determining an athletes appraisals and coping strategies in the rehabilitation process.56 A substantial gap has been highlighted around understanding pain in athletes with respect to diversity and context. Clinicians and researchers must strive to improve the assessment of pain from a socioenvironmental perspective when working with athletes to deliver appropriate and effective pain management strategies.
Cognitive pain assessment tools
The contemporary pain literature suggests a patient’s understanding and appraisal of their pain experience is integral to coping with and managing pain.58 In an athlete pain scenario where pain presentations are frequent, persistent and unpredictable, addressing the cognitive component of pain assessment is perhaps even more important. Just over 1 in 10 of all articles included in this review addressed the cognitive domain. Validated tools such as the Pain Catastrophising Scale and Pain Beliefs Questionnaire or simple interview techniques such as asking athletes why they think they have pain are low cost and efficient pain assessment tools that are easily implementable and consistent with contemporary pain research and clinical practice priorities.59 Cognitive appraisals link to affective aspects of decision making and have wide ranging influences from adherence to rehabilitation, tissue healing times and return to sport timelines.56 Knowing an athlete’s perception and understanding of pain, the level of attention/distraction it demands and the coping strategies used by athletes can help establish the need for treatments such as pain neuroscience education, which has proven successful in patients with MSK pain.60 Conversely, assessing these factors will also identify athletes who have a good understanding of their pain, positive appraisal and strong coping strategies and may indicate increased capacity for rehab progression.
Athletes with disabilities
Athletes with disabilities are not well represented when it comes to assessment of upper and lower limb pain with just 13 studies including athletes with physical disabilities and no studies addressing athletes with intellectual disabilities. Assessing pain in athletes with disabilities comes with unique considerations such as addressing shoulder pain in athletes who are wheelchair users. The Wheelchair User’s Shoulder Pain Index was identified in several studies, it addresses activities of daily living and functional assessment aspects that are helpful in understanding the pain experience from a neurophysiological perspective. There is a gap for future pain research to investigate athletes with disabilities and explore current and novel pain assessment tools across all five athlete pain assessment domains, particularly given the complexity and unique challenges faced in this cohort.61
Strengths and limitations
This study includes a large number of papers with a rigorous process where debate and agreement for areas of discrepancy was used at all stages of screening and data charting.
Not all studies included had pain-related aims, objectives or hypotheses and so assessing pain may not have been the primary goal of researchers and clinicians. While the research team looked at trends in papers where pain was and was not explicitly mentioned no clear differences were observable. Documenting the inclusion of a pain classification system was completed using a qualitative review by researchers. Very few studies explicitly stated specific classification systems used and so researchers included pain classification systems where their use was implicit and common terminology and labels associated with a specific pain classification system were used as indicators.
Further research
Future investigation into why certain comprehensive pain assessment tools, such as cognitive, affective and socioenvironmental tools, are under-represented is needed. For example, exploring the pain culture and attitudes of athletes, coaches, and support staff, and understanding priorities in the return to play, and playing with pain decision making processes can inform future requirements for adopting more comprehensive pain assessment tools. Piloting implementation of a comprehensive pain assessment protocol in a clinical setting to gauge feasibility and utility may also identify barriers and facilitators to change.
Conclusion
This scoping review presents the historical and contemporary landscape of upper and lower limb pain assessment tools in athletes, highlighting significant gaps in the use of affective, cognitive and socioenvironmental pain assessment tools as well as appropriate pain classifications. Increased diversity to include athletes with disability and demographic descriptions is also needed. This review informs researchers, clinicians and athletes about the available options for upper and lower limb pain assessment and the areas to focus on to improve understanding and future outcomes.
Ethics statements
Patient consent for publication
Acknowledgments
Diarmuid Stokes, librarian in University College Dublin for his assistance with the search strategy.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @Ciaran_Physio
Correction notice This article has been corrected since it published Online First. Data has been corrected in the abstract and results, due to rounding errors.
Contributors CP and BC conceived the original idea. CP, BC, CD, TW and BMF developed the original idea. CP, CD and SR completed title/abstract and full text review and data charting. CP completed analysis and composed the initial manuscript draft. BC, CD, SR, TW and BMF provided comments on and contributed towards the writing and editing of the final draft.
Funding This work was supported by the Chartered Physiotherapists in Sports and Exercise Medicine (CPSEM) branch of the Irish Society of Chartered Physiotherapists through the yearly spring research bursary. This work was supported by funding from Science Foundation Ireland under the grant for the Insight SFI Research Centre for Data Analytics (SFI/12/RC/2289_P2).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.