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www.elsevier.com/locate/pain
Department of General Internal Medicine and Psychosomatics, Medical Hospital, University of Heidelberg, Germany
Mannheimer Institute of Public Health, Medical Faculty Mannheim, University of Heidelberg, Germany
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
a r t i c l e
i n f o
Article history:
Received 6 September 2011
Received in revised form 5 March 2012
Accepted 5 March 2012
Keywords:
Athletes
Pain perception
Pain threshold
Pain tolerance
Systematic review
Meta-analysis
a b s t r a c t
This study systematically reviewed differences in pain perception between athletes and normally active
controls. We screened MEDLINE, Sport-Discus, EMBASE, Web of Science, PsycINFO, PSYNDEX, and the
citations of original studies and systematic reviews. All studies on experimentally induced pain that compared pain perception between athletes and normally active controls were eligible. The main outcome
measures were pain tolerance and pain threshold. Effects are described as standardized mean differences
and were pooled using random-effects models. Fifteen studies including 899 subjects met the inclusion
criteria. Twelve of these studies assessed pain tolerance, and 9 studies examined pain threshold. A metaanalysis of these studies revealed that athletes possessed higher pain tolerance compared to normally
active controls (effect size calculated as Hedges g = 0.87, 95% condence interval [CI95] 0.531.21;
P < 0.00001), whereas available data on pain threshold were less uniform (Hedges g = 0.69, CI95 0.16
1.21; P = 0.01). After exclusion of studies with high risk of bias, differences between groups in pain
threshold were not signicant any longer. Our data suggest that regular physical activity is associated
with specic alterations in pain perception. Psychological and biological factors that may be responsible
for these alterations are discussed.
2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
1. Introduction
Pain perception in athletes is commonly believed to differ from
pain perception in normally active persons. This belief is primarily
based on anecdotes of athletes who continue to exercise in the face
of severe injury. Researchers have also postulated that long-standing physical activity may alter pain perception and have often concluded that athletes possess higher pain thresholds and higher pain
tolerance [58,60]. However, the available scientic data on pain
perception in athletes are inconsistent and partially contradictory
[24,25,50,57,69].
Therapeutic exercise is included in most multidisciplinary
treatment programs, and it is recommended in numerous treatment guidelines for pain patients [7,29]. However, exercise therapy
is not a uniform method but often includes variations in content,
dose, and mode of delivery. Most studies of different exercise
modes and the long-term effects of exercise in patients have been
0304-3959/$36.00 2012 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.pain.2012.03.005
1254
3. Results
3.1. Characteristics of included studies
An initial database search identied 1333 studies. After adjusting for duplicates, 1152 studies remained. Of these studies, 1090
studies were discarded because after reviewing the abstracts, it appeared to both reviewers that these papers clearly did not meet the
inclusion criteria. The full text of the remaining 62 citations was
examined in more detail (see the web Appendix); 46 studies were
excluded due to the following reasons. Forty-one studies did not
fulll the predened inclusion criteria. In addition, there was one
double publication [72,73], and 6 studies initially provided insufcient information. Of these 6 potentially relevant studies, we contacted the corresponding authors for missing information. Three
authors provided additional data [25,59,60]. Two of these studies
met the inclusion criteria [25,59], but one study failed [60]. In the
remaining 3 studies, the authors were not available. These studies
were excluded because of insufcient information [49,56,79]. Two
measurements in one publication [34] that assessed pain perception in 2 different studies in 2 different populations were regarded
as independent units ([34] a,b). After this, 17 studies from 6 countries met the inclusion criteria. However, we excluded 2 studies
that assessed pain perception in athletes due to conceptual aws.
In these studies, the most tolerant subjects were excluded prior
to analysis, which constituted a strong oor effect [9,35]. Moreover, we excluded the values for heat pain thresholds in an older
study by Ryan and Kovacic [57] because of an irreproducible transformation of the original data by the authors. In addition to initial
database searching, 3 studies were identied based on abstracts
and reference lists and 2 by web search in the eld of sport sciences.
Responsible authors were contacted. One provided additional data,
thus the study could be included (see also the web Appendix).
Finally, 15 studies that allocated 568 athletes (202 women, 366
men) and 331 normally active controls (147 women, 184 men)
1255
provided sufcient data for our meta-analysis (Fig. 1). Eight of these
15 studies were conducted in the United States [19,20,34,57,
59,64,73], 2 of these studies were conducted in Canada [18,52], 1
study was performed in Australia [24], and 4 studies were performed in Europe [25,50,58,69]. Endurance athletes were included
in 9 studies [18,19,25,34,50,58,59,64]. Athletes that were active in
game sports were assessed in 8 studies [1820,52,57,64,69,73],
and strength sports were studied in 2 studies [24,25] (Table 1).
3.2. Meta-analysis
3.2.1. Pain tolerance
Twelve studies reported pain tolerance outcomes (Fig. 2). The
average pain tolerance was signicantly elevated in athletes with
a pooled standardized mean difference of 0.87 (CI95 0.531.21;
I2 = 76%). Five studies revealed statistically signicant elevations
in pain tolerance in athletes [50,57,58,69,73], and 7 studies demonstrated no signicant differences [1820,34,52,64]. A sensitivity
analysis to exclude studies with a high risk of bias did support
the assumption of an overall signicant difference in pain tolerance
(Hedges g = 0.93, CI95 0.521.34; I2 = 73%; n = 7). The funnel plot
was symmetrical, with no evidence of relevant small study bias
(see the web Appendix). The exclusion of any single study did not
alter the magnitude or statistical results of the summary estimate.
Subgroup analyses (Table 2): Exploratory subgroup analyses
demonstrated that the effects on pain tolerance varied with different types of physical activities, but not with different types of noxious stimuli.
In endurance athletes (Hedges g = 0.65, CI95 0.420.88; I2 = 6%;
n = 8), pain tolerance was consistently characterized by a moderate
effect size and low heterogeneity, but in game sport athletes, the
effect was high and was characterized by high heterogeneity
(Hedges g = 0.98, CI95 0.401.57; I2 = 86%; n = 8). In strength
sports, only one study [20] was available and reported no differences between athletes and normally active controls (Hedges
g = 0.07, CI95 0.73-0.87).
Signicant differences between athletes and normally active
controls were observed for both ischemic stimulation (Hedges
g = 0.72, CI95 0.331.10; I2 = 42%; n = 4) and cold pain stimulation
(Hedges g = 0.73, CI95 0.161.30; I2 = 81%; n = 5). However, the
heterogeneity was high. With one study per type of stimulus, data
for electrical, heat, and pressure pain tolerance were not further
analyzed.
Separate analyses of male (Hedges g = 0.87, CI95 0.401.35;
I2 = 77%; n = 8) and female athletes (Hedges g = 1.18, CI95 0.34
1.68; I2 = 84%; n = 3) showed signicant sex differences.
3.2.2. Pain threshold
Nine studies reported data on differences in pain threshold between athletes and normally active controls (Fig. 3). The pooled
standardized mean difference was 0.69 with a CI95 0.161.21. Five
studies showed a statistically signicant elevation of pain threshold in athletes [24,25,34,69], and 4 studies showed no signicant
differences [50,58,59,73]. One of the studies [50] showed an effect
size in the opposite direction (Hedges g = 0.57) and another
study was characterised by an extraordinary high effect size of
2.22 [24]. The exclusion of any single study did not alter the magnitude or the statistical result of the summary estimate. A sensitivity analysis that excluded studies with a high risk of bias did not
support the assumption of an overall signicant difference in pain
threshold (Hedges g = 0.75, CI95 0.02-1.53; I2 = 90%; n = 6). Due
to the limited number of studies (<10), we did not perform a funnel
plot for pain threshold [65].
3.2.2.1. Subgroup analyses (Table 3). Assessment methods and
the nature of physical activity varied across studies. Therefore,
1256
Fig. 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) ow diagram. Study selection process.
exploratory subgroup analyses were performed. Cold pain threshold was assessed in 3 studies [34,69], and ischemic pain threshold
was measured in 4 studies [34,50,58]. Electrical pain threshold was
measured in 2 studies [25,73]. Subgroup analyses for different
stimuli resulted in a reduction in heterogeneity (0.0% to 56%). No
signicant differences between athletes and normally active controls were observed for ischemic (Hedges g = 0.24, CI95 0.790.32; I2 = 52%; n = 2) or electrical stimulation (Hedges g = 0.80,
CI95 0.19-1.78; I2 = 56%; n = 2). Signicant differences were observed in cold-pressor pain thresholds (Hedges g = 1.00, CI95
0.701.29; I2 = 0%; n = 3).
Endurance sports were assessed in 6 studies [24,34,50,58,59].
Game sports were measured in 2 studies [69,73], and strength
sports were measured in one study [24]. Subgroup analyses of
endurance athletes showed no signicant differences (Hedges
g = 0.35, CI95 0.14-0.84; I2 = 73%), but the 2 studies that assessed
game sports (Hedges g = 0.82, CI95 0.101.55; I2 = 76%) and the
single study that assessed strength sports (Hedges g = 2.22, CI95
1.562.87) demonstrated signicant differences between athletes
and normally active controls.
A separate analysis of males and females yielded no signicant effects in the male subgroup (Hedges g = 0.51, CI95
0.16-1.19; I2 = 82%; n = 5), but female athletes were characterized by signicantly heightened pain thresholds compared to
normally active controls (Hedges g = 0.56, CI95 0.041.08;
I2 = 50%; n = 3).
4. Discussion
The present study analyzed whether differences in pain perception exist between athletes and normally active persons. We conducted a meta-analysis of pain tolerance and pain threshold as
essential characteristics of pain perception.
The most important nding was that pain perception differed in
athletes compared to normally active controls. Athletes possessed
consistently higher pain tolerance than normally active controls.
However, the available data on pain thresholds were rather sparse
and less uniform.
The generally heightened pain tolerance in athletes was consistently characterized by moderate to large effect sizes (Fig. 2). These
effects remained signicant when only high-quality studies were
included in the analysis. These results support the hypothesis that
athletes generally possess elevated pain tolerance. Compared to effect size estimates in other experimental pain studies showing only
low-to-moderate effects by gender or genetic variants [16], the effects reported in our analysis were strong and exceeded effect sizes
of most classical pain interventions [17,36,61]. The data emphasize
a possible impact as well as clinical relevance of athletic status on
pain tolerance.
It is postulated that pain threshold is relatively constant in an
individual, but pain tolerance is strongly modulated by psychological and psychosocial factors [11,27,42,54,55,62]. Coping skills can
increase pain control [6,22,23,68,76]. For example, self-efcacy and
Table 1
Characteristics of the studies.
Study
Assessed
outcomes
Assessment tools
No of
athletes
(f/m)
No of
controls
(f/m)
Risk of bias
Tolerance
50 (male)
10 (male)
75.0%
(92.0/62.5/
62.5)
Moderate
Tolerance
Pressure in mm Hg
(gross pressure device
according to Ryan)
Ischemia
(number of st
contractions)
29 (male)
16 (male)
Ellison and
Freischlag
1975 [20]
Tolerance
72 (male)
12 (male)
Granges and
Littlejohn
1993 [24]
Threshold
30 (26/4)
30 (27/3)
Threshold
Electrical stimulation
in mAmp for leg exion
nociceptive reex
threshold
6 (2/4)
8 (1/7)
Threshold
tolerance
Ischemia(time in s to
rst painful sensation/
withdrawal) CPT (time
in s to rst painful
sensation/withdrawal)
12 (male)
18 (male)
Threshold
tolerance
Ischemia (time in s to
rst painful sensation/
withdrawal) CPT (time
in s to rst painful
sensation/withdrawal)
36 (male)
24 (male)
Threshold
tolerance
20 (male)
20 (male)
Athletes were randomly chosen from inter-university athletes (M = 22 y; football, boxing, fencing, karate and crosscountry skiing). A control group of nonathletes (M = 22 y) was also included in the experiment. All the subjects in the
experimental group trained for at least 3 90 min/wk and competed on a regular basis during their competitive
season. Excluded from the study were subjects who had frostbite, cardiac disorders, poor circulation, hypertensive
disease, or who were frequent recipients of cryotherapy. The cultural background and pain status at rest or during
activity of the subjects were not controlled
Athletes tolerated signicant more pain than normally active persons. In particular, football players and the crosscountry skiers tolerated more pain than karate and fencers. These ndings do not support the hypothesis that contact
sports tolerate more pain than noncontact sports
Subjects were male university students. They were classied into 3 groups: 1) contact sports athletes (varsity football
players); 2) endurance sports athletes (cross-country runners), and 3) nonathletes. These 2 groups of athletes
participated in the study while they were not in their competitive season. The nonathletes were drawn from a physical
activity class in personal tness. Only students who had not participated in any form of regular physical exercise or
varsity athletics were used in this sample. No information is given about age, current or past pain experiences
There were signicant differences in gross pressure pain tolerance among these 3 groups: contact athletes tolerated
more pain, whereas endurance athletes tolerated less pain than controls. No differences in ischemic pain tolerance
were found among the 3 groups
Undergraduate male students were selected randomly from intercollegiate athletic teams (baseball, basketball,
football, track distance/sprint) and from the nonathlete male population at the university. Subjects were tested
individually, told only that pain tolerance was the factor being investigated, and had no knowledge that comparisons
were to be made among athletes and nonathletes. No information is given about age, or current or past pain
experiences
No differences in pain tolerance were found among groups
Healthy controls (M = 32 y) exercising less than 2 h/wk were selected from 2 different hospital physiotherapy staffs.
Exercising subjects (M = 36 y) were selected from different tness centers. To enter the study, the mean exercise time
(regular aerobic/strength exercises) was set at more than 6 h/wk. While these patients were not formally assessed for
aerobic tness, it was considered that they represented the upper echelon of the exercising public. No subject had
reported any signicant musculoskeletal pain in the 6 months before assessment
The t subjects signicantly differed from the unt for pain threshold
Controls consisted of subjects (M = 24 y), who had undergone no intensive sports training in the past; athletes
(M = 22 y; runner, bodybuilder, weightlifter) regularly participated in national or international sporting events and
underwent 1 or 2 intensive training sessions every day. No information is given about current or past pain experiences
The only study using objective measurement tools (leg exion reex threshold).The nociceptive exion reex threshold
at rest was found to be signicantly higher in athletes than in the controls
Post hoc analysis of old data (the runners data were from the prerun condition of an exercise-induced analgesia study;
control subjects data were from the placebo condition of a drug study): controls consisted of subjects (M = 27 y) who
did not participate in a regular aerobic training program. Athletes consisted of male runners (M = 39 y) training an
average of 69.2 km/wk. For the CPT, 4 additional runners (M = 44 y: mean training: 33.0 km/wk) were recruited. All
subjects were paid for their participation. No information is given about current or past pain experiences
These data indicate that runners are less sensitive than controls only to noxious cold, but more sensitive to heat
stimulation. Signal detection theory measurements demonstrated that runners discriminated noxious thermal stimuli
better than controls. Thus, runners do not appear to be generally stoical
Athletes consisted of male runners (M = 30 y) who had been training at least 30 km/wk for at least 3 mo. Controls
consisted of subjects (M = 28 y) who were not engaged in any regular aerobic training program. All subjects were paid
for their participation. No information is given about current or past pain experiences
Regular athletic training seems to produce effects similar to cold acclimatization, blunting the sensory response to
noxious cold. In general, however, runners do not appear to be any less sensitive to noxious stimulation than normally
active controls
The group of athletes (M = 20 y) engaged in training for competitive rowing; controls (M = 22 y) were not training for any
specic sport at the time of testing. No information is given about current or past pain experiences Pain tolerance, but not
threshold, was signicantly higher for athletes. Pain tolerance was correlated with the number and quality of coping
strategies used during testing. Pain threshold of the control group was characterized by high variability
50.0%
(66.7/50.0/
25.0)
High
71.4%
(75.0/62.5/
75.0)
Moderate
82.1%
(100/75.0/
62.5)
Moderate
61.0%
(75.0/50.0/
63.0)
Moderate
54.0%
(75.0/50.0/
25.0)
High
57.0%
(75.0/25.0/
62.5)
High
71.4%
(66.7/75.0/
75.0)
Moderate
1257
Study
Assessed
outcomes
Assessment tools
No of
athletes
(f/m)
No of
controls
(f/m)
Risk of bias
Paparizos et al.
2005 [52]
Tolerance
CPT (time in s to
withdrawal)
47
(female)
26
(female)
71.4%
(83.3/75.0/
50.0)
Moderate
Tolerance
Pressure (mm Hg at
withdrawal) Ischemia
(number of
contractions = time in
s)
37 (male)
18 (male)
Scott and
Gijsbers 1981
[58]
Threshold
tolerance
Ischemia (numbers of
st contraction to rst
pain sensation/
withdrawal)
60 (31/29)
26 (16/10)
Threshold
Heat (temperature of
rst painful sensation)
26 (13/13)
26 (13/13)
Sternberg et al.
1998 [64]
Tolerance
Heat (time in s to
withdrawal)
67 (33/34)
20 (14/6)
Tajet-Foxell and
Rose 1995
[69]
Threshold
tolerance
52 (26/26)
53 (26/27)
Threshold
tolerance
Electrical stimulation
(mAmp)
24
(female)
24
(female)
The group of athletes consisted of conveniently sampled women dancers from the Queens Dance Club (mean trainings
history of 10 y; M = 20 y), controls were conveniently sampled from the Queens University Undergraduate Psychology
Subject Pool (M = 19 y). No restriction in age or dance ability was enforced within the dance sample, while the control
group consisted of women who had never experienced professional training. Anyone with history of cardiac disease or
extreme hypertension, or anyone who had experienced frostbite to their nondominant hand was excluded from the
study. No information is given about current or past pain experiences
Dancers had signicantly higher pain tolerance than controls. High-skill dancers had signicantly higher pain tolerance
than low-skill dancers. No difference in pain sensitivity was found. Despite an ability to withstand higher amounts of
pain, dancers still found it as painful as controls but were able to manage longer exposure
Subjects were male university students and based on a questionnaire classied into 3 groups: 1) contact sports athletes
(boxing, football, or wrestling); 2) endurance sports athletes (golf, tennis, track), and 3) nonathletes (physical
inactive).The subjects assumed they had been randomly selected, and were unaware that athletic participation was a
factor or that the experiment was in any way related to the questionnaire administered earlier. No information is given
about age, current or past pain experiences
There were no signicant differences between groups (contact/noncontact/control) in pain threshold, but a highly
signicant difference between groups in pain tolerance, wherein the contact athletes tolerated more pain than the
noncontact athletes, who in turn tolerated more pain than the normally active persons
The group of athletes consisted of swimmers (highly conditioned swimmers of the Scottish national squad and
competitive club swimmers). Controls were made up of undergraduate students of whom none had experience of sport
at a competitive level. No information is given about age, current or past pain experiences
While pain threshold showed little difference between the groups, pain tolerance was signicantly different. Pain
tolerance of the competitive swimmers varied according to the stage of the training season (so the author suggested
that the enhanced pain tolerance of the competitive swimmers would seem to lie in their systematic exposure to brief
periods of intense pain)
The subject population was composed of Haverford College students, including an equal number of male and females in
each category. Athletes were recruited from the Haverford track team and nonathletes were recruited from the general
campus population via signs posted around campus and in athletic buildings. Subjects who answered yes to any
questions of diseases or pain were excluded. No information is given about age. Eligible subjects were monetarily
compensated at the conclusion of their participation
There were no differences between athletes and normally active persons (or sexes) in heat pain threshold, but an
interaction between sex and athletic status on cold-pressor ratings (sensitivity) could be observed: female athletes
pain ratings were signicantly lower than ratings in normally active females, but male athletes did not differ from
normally active male subjects
The group of athletes consisted of active members of college teams (NCAA Division III; basketball, fencers, track
athletes). Controls were recruited from an introductory psychology class. All subjects (athletes and nonathletes) were
given the option of participating in the study for course credit (if applicable) or for potential monetary compensation.
No information is given about age, current or past pain experiences
There were no signicant differences between athletes pain values. But the results of this and normally active persons
baseline suggest that athletic competition modulates responses to noxious stimuli. The degree and direction of this
modulation (inhibition or potentiation) depended on the pain test, the body region tested, and the sport in question
Athletes consisted of professional ballet dancers from a national ballet company (M = 25 y), controls were selected from
students at a university institution (M = 24 y). No information is given about current or past pain experiences
Dancers were found to have signicantly higher pain threshold and pain tolerance than age-matched controls in the
CPT. They also reported a more acute experience of the sensory aspects of pain
Female college students (1824 y) enrolled in 2 colleges served as subjects. Athletes consisted of active members of the
varsity basketball teams; controls (selected from required physical education classes), who had never participated in
any type of athletic competition on an inter-school basis, served as a nonathletic group. Each had an A health rating
from her college medical service. No information is given about current or past pain experiences
Athletes showed signicantly higher pain tolerance than normally active persons. Threshold did not vary by group
classication
1258
Table 1 (continued)
50.0%
(58.3/37.5/
50.0)
High
50.0%
(62.0/25.0/
87.5)
High
71.4%
(66.7/75.0/
75.0)
Moderate
78.6%
(91.7/75.0/
62.5)
Moderate
CPT, cold pressor test; m, male; f, female; N, number; y, years (range of age), M, mean age; Risk of bias, The quality scoring was divided into 3 sections (patient sampling/pain assessments used/analysis). Each article was than
graded as a low risk of bias (80% or above for all 3 sections), moderate risk of bias (50% or above for all 3 sections), or high risk of bias (scored <50% for any one section) study (for further information, see text).
39.3%
(50.0/37.5/
25.0)
High
78.6%
(67.0/75.0/
100)
Moderate
1259
Fig. 2. Overall effect on pain tolerance. Standard mean differences (SMDs) were calculated as Hedges g. A DerSimonian-Laird random-effects model was used to calculate
pooled estimates with 95% condence intervals (95% CI). Heterogeneity among the studies was described using the I2 statistic.
Table 2
Exploratory subgroup analyses for pain tolerance.
Outcome title
Number of
studies
Number of subjects
(athletes/controls)
Heterogeneity
I2 (%); s2
Induction stimulus
Cold
Ischemia
Electrical
Heat
Pressure
5
4
1
1
1
201/131
181/74
24/24
67/20
27/18
0.73
0.72
1.36
0.50
2.45
0.01
0.003
<0.001
0.05
<0.001
81; 0.33
42; 0.06
8
8
1
240/179
198/146
12/12
0.98 (0.401.57)
0.65 (0.420.88)
0.07 ( 0.73-0.87)
0.001
<0.001
0.86
86; 0.60
6; 0.01
Sex
Female
Male
3
8
97/76
276/145
1.18 (0.341.68)
0.87 (0.401.35)
0.006
<0.001
84; 0.46
77; 0.36
Risk of bias
Moderate/low
High
7
5
325/171
175/96
0.93 (0.521.34)
0.80 (0.171.43)
<0.001
0.01
73; 0.22
81; 0.42
(0.161.30)
(0.331.10)
(0.731.99)
(0.001.01)
(1.653.25)
Exploratory subgroup analyses were performed for pain induction methods, types of athletic participation, sex and risk of bias to identify possible
moderators of heterogeneity. Effect sizes were calculated as Hedges g. A DerSimonian-Laird random-effects model was used to calculate pooled estimates
with 95% condence intervals (95% CI). Heterogeneity among the studies was described using the I2 statistic.
1260
Fig. 3. Overall effect on pain threshold. Standard mean differences (SMDs) were calculated as Hedges g. A DerSimonian-Laird random-effects model was used to calculate
pooled estimates with 95% condence intervals (95% CI). Heterogeneity among the studies was described using the I2 statistic.
Table 3
Exploratory subgroup analyses for pain threshold.
Outcome title
Heterogeneity I2 (%); s2
(0.701.29)
( 0.79-0.32)
( 0.19-1.78)
( 0.46-0.63)
(1.562.87)
<0.001
0.40
0.11
0.76
<0.001
0; 0.00
52; 0.09
56; 0.31
76/77
138/96
30/30
0.82 (0.101.55)
0.35 ( 0.14-0.84)
2.22 (1.562.87)
0.03
0.16
<0.001
76; 0.21
73; 0.26
3
5
63/63
111/102
0.56 (0.041.08)
0.51 ( 0.16-1.19)
0.04
0.13
50; 0.11
82; 0.48
6
3
192/161
78/68
0.75 ( 0.02-1.53)
0.56 (0.051.07)
0.06
0.003
90; 0.82
55; 0.40
Number of
studies
Number of subjects
(athletes/controls)
3
2
2
1
1
104/95
80/46
30/32
26/26
30/30
1.00
0.24
0.80
0.06
2.22
Induction stimulus
Cold
Ischemia
Electrical
Heat
Pressure
Exploratory subgroup analyses were performed for pain induction methods, types of athletic participation, sex and risk of bias to identify possible
moderators of heterogeneity. Effect sizes were calculated as Hedges g. A DerSimonian-Laird random-effects model was used to calculate pooled estimates
with 95% condence intervals (95% CI). Heterogeneity among the studies was described using the I2 statistic.
1261
4.1. Limitations
4.2. Conclusions
In conclusion, our data indicate that regular physical activity is
associated with specic alterations in pain perception. The effects
are generalized over different types of physical activities and pain
assessment methods, which suggest a common trend in pain perception in athletes. Nevertheless, there is also evidence for differential effects in pain tolerance and pain threshold, with pain
threshold showing more ambiguous results. This observation is
consistent with the concept that pain perception is modiable by
physical activity, which provides promise for patients with chronic
pain conditions for the use of noninvasive methods with few side
effects. However, further research is required to clarify the exact
relationship between physical activity and modications in pain
perception and to identify underlying mechanisms. These ndings
emphasize the potential role of physical exercise in the management of pain.
Acknowledgments
The authors thank Dr. rer. nat. Gerta Rcker from the Institute
of Medical Biometry and Medical Informatics of University Medical
Center Freiburg for her helpful comments.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at http://dx.doi.org/10.1016/j.pain.2012.03.005.
References
[1] Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett Jr DR, Tudor-Locke
C, Greer JL, Vezina J, Whitt-Glover MC, Leon AS. 2011 Compendium of physical
activities: a second update of codes and MET values. Med Sci Sports Exerc
2011;43:157581.
[2] alAbsi M, Petersen KL. Blood pressure but not cortisol mediates stress effects
on subsequent pain perception in healthy men and women. Pain
2003;106:28595.
[3] Anshel MH, Russell KG. Effect of aerobic and strength training on pain
tolerance, pain appraisal and mood of unt males as a function of pain
location. J Sports Sci 1994;12:53547.
[4] Association of the IOC Recognized International Sports Federations (ARISF),
<http://www.arisf.org> [accessed 31.12.11].
[5] Baker SL, Kirsch I. Cognitive mediators of pain perception and tolerance. J Pers
Soc Psychol 1991;61:50410.
[6] Birrer D, Morgan G. Psychological skills training as a way to enhance an
athletes performance in high-intensity sports. Scand J Med Sci Sports
2010;20:7887.
[7] Bouwmeester W, van Enst A, van Tulder M. Quality of low back pain guidelines
improved. Spine 2009;34:25627.
[8] Bria S, Bianco M, Galvani C, Palmieri V, Zeppilli P, Faina M. Physiological
characteristics of elite sport-dancers. J Sports Med Phys Fitness
2011;51:194203.
[9] Broucek MW, Bartholomew JB, Landers DM, Linder DE. The effects of relaxation
with a warning cue on pain tolerance. J Sport Behav 1993;16:23950.
[10] Bruehl S, Chung OY. Interactions between the cardiovascular and pain
regulatory systems: an updated review of mechanisms and possible
alterations in chronic pain. Neurosci Biobehav Rev 2004;28:395414.
[11] Chen AC, Dworkin SF, Haug J, Gehrig J. Human pain responsivity in a tonic pain
model: psychological determinants. Pain 1989;37:14360.
[12] Chung OY, Bruehl S, Diedrich L, Diedrich A, Chont M, Robertson D. Baroreex
sensitivity associated hypoalgesia in healthy states is altered by chronic pain.
Pain 2008;138:8797.
[13] Cohen J. Statistical power analysis for the behavioral sciences. 2nd
ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.
[14] Defrin R, Shramm L, Eli I. Gender role expectations of pain is associated with
pain tolerance limit but not with pain threshold. Pain 2009;145:2306.
[15] DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials
1986;7:17788.
[16] Doehring A, Kusener N, Fluhr K, Neddermeyer TJ, Schneider G, Lotsch J. Effect
sizes in experimental pain produced by gender, genetic variants and
sensitization procedures. PLoS One 2011;6:e17724.
[17] Eccleston C, Palermo TM, Williams AC, Lewandowski A, Morley S.
Psychological therapies for the management of chronic and recurrent pain in
children and adolescents. Cochrane Database Syst Rev 2009;2:CD003968.
[18] Egan S. Acute-pain tolerance among athletes. Can J Sport Sci 1987;12:1758.
[19] Eitter TJ. Pain tolerance training applied to the athletic environment. Diss
Abstr Int 1980;41:20056.
[20] Ellison K, Freischlag J. Pain tolerance, arousal, and personality relationships of
athletes and nonathletes. Res Q 1975;46:2505.
[21] Ewalt KL. Athletic training in dance medicine and science. J Dance Med Sci
2010;14:7981.
[22] Fernandez E, Turk DC. The utility of cognitive coping strategies for altering
pain perception: a meta-analysis. Pain 1989;38:12335.
[23] Geisser ME, Robinson ME, Pickren WE. Differences in cognitive coping
strategies among pain-sensitive and pain-tolerant individuals on the coldpressor test. Behav Ther 1992;23:3141.
1262
[54]
[55]
[56]
[57]
[58]
[59]
[60]
[61]
[62]
[63]
[64]
[65]
[66]
[67]
[68]
[69]
[70]
[71]
[72]
[73]
[74]
[75]
[76]
[77]
[78]
[79]
Pfaffenbarger RS, Patrick K, Pollock ML, Rippe JM, Sallis J, Willmore JH. Physical
activity and public health. A recommendation from the centers for disease
control and prevention and the American college of sports medicine. JAMA
1995;273:4027.
Price DD, Harkins SW. Psychophysical approaches to pain measurement and
assessment. In: Turk DC, Melzack R, editors. Handbook of pain
assessment. New York: Guilford Press; 2001. p. 11221.
Quiton RL, Greenspan JD. Across- and within-session variability of ratings of
painful contact heat stimuli. Pain 2008;137:24556.
Robinson ME. The effect of exercise on the perception of pain in athletes and
non-athletes: a signal detection theory analysis. Dissertation 1988.
Ryan ED, Kovacic CR. Pain tolerance and athletic participation. Percept Mot
Skills 1966;22:38390.
Scott V, Gijsbers K. Pain perception in competitive swimmers. Br Med J
1981;283:913.
Smith LD. The effects of competition and exercise on pain perception.
Dissertation 2004.
Spector TD, Harris PA, Hart DJ, Cicuttini FM, Nandra D, Etherington J, Wolman
RL, Doyle DV. Risk of osteoarthritis associated with long-term weight-bearing
sports. Arthritis Rheum 1996;39:98895.
Stein C, Reinecke H, Sorgatz H. Opioid use in chronic noncancer pain:
guidelines revisited. Curr Opin Anaesthesiol 2010;23:598601.
Sternbach RA. Psychophysiology of pain. Int J Psychiatry Med 1975;6:6373.
Sternberg WF. Athletes: pain and pain inhibition. APS Bull 1999;9:189.
Sternberg WF, Bailin D, Grant M, Gracely RH. Competition alters the perception
of noxious stimuli in male and female athletes. Pain 1998;76:2318.
Sterne JA, Sutton AJ, Ioannidis JP, Terrin N, Jones DR, Lau J, Carpenter J, Rucker
G, Harbord RM, Schmid CH, Tetzlaff J, Deeks JJ, Peters J, Macaskill P, Schwarzer
G, Duval S, Altman DG, Moher D, Higgins JP. Recommendations for examining
and interpreting funnel plot asymmetry in meta-analyses of randomised
controlled trials. BMJ 2011;343:d4002.
Streff A, Kuehl LK, Michaux G, Anton F. Differential physiological effects during
tonic painful hand immersion tests using hot and ice water. Eur J Pain
2010;14:26672.
Suzuki K, Maekawa K, Minakuchi H, Yatani H, Clark GT, Matsuka Y, Kuboki T.
Responses of the hypothalamic-pituitary-adrenal axis and pain threshold
changes in the orofacial region upon cold pressor stimulation in normal
volunteers. Arch Oral Biol 2007;52:797802.
Syrjala KL, Donaldson GW, Davis MW, Kippes ME, Carr JE. Relaxation and
imagery and cognitive-behavioral training reduce pain during cancer
treatment: a controlled clinical trial. Pain 1995;63:18998.
Tajet-Foxell B, Rose FD. Pain and pain tolerance in professional ballet dancers.
Br J Sports Med 1995;29:314.
van Middelkoop M, Rubinstein SM, Kuijpers T, Verhagen AP, Ostelo R, Koes BW,
van Tulder MW. A systematic review on the effectiveness of physical and
rehabilitation interventions for chronic non-specic low back pain. Eur Spine J
2011;20:1939.
Varrassi G, Bazzano C, Edwards WT. Effects of physical activity on maternal
plasma beta-endorphin levels and perception of labor pain. Am J Obstet
Gynecol 1989;160:70712.
Walker J. Pain parameters of athletes and non-athletes. Diss Abstr Int
1970;31:16078.
Walker J. Pain and distraction in athletes and non-athletes. Percept Mot Skills
1971;33:118790.
Wetterslev J, Thorlund K, Brok J, Gluud C. Trial sequential analysis may
establish when rm evidence is reached in cumulative meta-analysis. J Clin
Epidemiol 2008;61:6475.
Whiting PF, Rutjes AW, Westwood ME, Mallett S, Deeks JJ, Reitsma JB, Leeang
MM, Sterne JA, Bossuyt PM. QUADAS-2: a revised tool for the quality
assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:52936.
Whitmarsh BG, Alderman RB. Role of psychological skills training in increasing
athletic pain tolerance. Sport Psychol 1993;7:38899.
Williamson E, Williams M, Gates S, Lamb SE. A systematic literature review of
psychological factors and the development of late whiplash syndrome. Pain
2008;135:2030.
World Health Organisation. Global strategy on diet, physical activity and health.
World Health Organization, Geneva, <http://www.who.int/dietphysicalactivity/
strategy/eb11344/strategy_english_web.pdf>; 2004 [accessed 31.12.11].
Yamaguchi AY, Bucton BP. Differences in response and anxietyy between
athletes and non-athletes. J Athl Train 1997;32:45.