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Consensus on the Use of Therapeutic Interventions in Pain Management, Recovery, and Athletic Performance: A Delphi Study

Authors:
Bailey McLagan at University of Southern California
Bailey McLagan
Kyle Silvey
Kyle Silvey
Kyle Silvey
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Timothy Roberts
Timothy Roberts
Timothy Roberts
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David Erceg
David Erceg
David Erceg
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Abstract and Figures

Background Therapeutic interventions are widely used in clinical practice to prepare individuals for movement, recover from exercise, and mediate pain and inflammation associated with injury. However, there has yet to be cited consensus regarding when to use such interventions. Purpose Using the Delphi method, this study aimed to develop consensus among physical therapists (PTs) and athletic trainers (ATs) regarding the use of percussive, vibration, infrared, heat, and cryotherapy in a variety of treatment circumstances. These included preparation and recovery from physical activity, treatment of acute and chronic joint pain, and treatment of acute and chronic soft tissue/muscle pain. Methods Four rounds of surveys were delivered to individuals who were licensed or certified PTs/ATs, with more than 1,000 hours of experience working with athletic populations and experience using at least one of the interventions of interest in the prior five years. Consensus was defined as a greater than 70% agreement, and consideration for use was defined as selecting “In Some Instances’’ and”In Most Instances.” Results Ninety-four individuals responded to the screening survey (n 1 = 74, n 2 = 68, n 3 = 44, n 4 = 32). The individuals who participated agreed that they would consider using the following therapeutic interventions in treatment: 1) percussive therapy, local vibration, and local heat therapy in the preparation for physical activity; 2) local cryotherapy in recovery from physical activity; 3) local cryotherapy for the treatment of acute joint pain and acute soft tissue/muscle pain; 4) local heat and local cryotherapy for the treatment of chronic joint pain; and 5) percussive, local vibration, local heat, and local cryotherapy in the treatment of chronic soft tissue/muscle pain. Conclusion Clinical intervention often relies on patient presentation and preference. This study provides a consensus on the use of common therapeutic interventions for the management of athletic recovery, pain, and inflammation among ATs and PTs. Level of Evidence 3
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Consensus on the Use of Therapeutic Interventions in Pain
Management, Recovery, and Athletic Performance: A Delphi Study
Bailey McLagan1a, Kyle Silvey2, Timothy Roberts3, David Erceg1, Jonathan C. Sum1, E. Todd Schroeder1
1 Division of Biokinesiology and Physical Therapy, University of Southern California, 2 Therabody Inc. , 3 Therabody Inc.
Keywords: Delphi, Technology, Treatment, Consensus
https://doi.org/10.26603/001c.129968
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Corresponding Author:
Bailey McLagan
Division of Biokinesiology and Physical Therapy
Clinical Exercise Research Center
1540 Alcazar St
Los Angeles, CA 90033
Email: mclagan@usc.edu
Tel: 720-202-9839
a
McLagan B, Silvey K, Roberts T, Erceg D, Sum JC, Schroeder ET. Consensus on the Use
of Therapeutic Interventions in Pain Management, Recovery, and Athletic Performance:
A Delphi Study. IJSPT. 2025;20(3):420-428. doi:10.26603/001c.129968
Level of Evidence
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International
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Therapy
Figure 2. Characteristics of the analyzed study population.
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Table 1. Summary of responses for Round 4. All data displayed relate to the consideration of using the
therapeutic intervention. “Consideration” is de0ned as a selection of “In Some Instances” or “In Most Instances.”
Local
Cryotherapy
Local IR
Therapy
Local Vibration
Therapy
Percussive
Therapy
Local Heat
Therapy
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International
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Sports
Physical
Therapy
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Appendix A
9A869+.2>>:=34=:>=-296+=>3-+2;-97+<>3-6/-98=/8=?=98>2/?=/90>2/<+:/?>3-38>/<@/8>398=38
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Appendix B
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Appendix C
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Appendix D
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A Clinically-Reasoned Approach to Manual Therapy in Sports Physical Therapy
Article
Full-text available
  • Feb 2023
  • Int J Sports Phys Ther
Symptom modification techniques have been recently dichotomously labeled as either passive or active therapies. Active therapy such as exercise has been rightfully advocated for while “passive” therapies, mainly manual therapy have been regarded as low value within the physical therapy treatment spectrum. In sporting environments where physical activity and exercise are inherent to the athletic experience, the utilization of exercise-only strategies to manage pain and injury can be challenging when considering the demands and qualities of a sporting career which include chronically high internal and external workloads. Participation may be impacted by pain and its influence on related factors such as training and competition performance, career length, financial earning potential, educational opportunity, social pressures, influence of family, friends, and other key stakeholders of their athletic activity. Though highly polarizing viewpoints regarding different therapies create black and white “sides,” a pragmatic gray area regarding manual therapy exists in which proper clinical reasoning can serve to improve athlete pain and injury management. This gray area includes both historic positive reported short-term outcomes and negative historical biomechanical underpinnings that have created unfounded dogma and inappropriate overutilization. Applying symptom modification strategies to safely allow the continuation of sport and exercise requires critical thinking utilizing not only the evidence-base, but also the multi-factorial nature of sports participation and pain management. Given the risks associated with pharmacological pain management, the cost of passive modalities like biophysical agents (electrical stimulation, photobiomodulation, ultrasound, etc), and the indications from the evidence-base when combined with active therapies, manual therapy can be a safe and effective treatment strategy to keep athletes active. Level of Evidence 5
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Photobiomodulation and Sports: Results of a Narrative Review
Article
Full-text available
  • Dec 2021
Benefits of photobiomodulation (PBM) have been known for several decades. More recently, PBM applied in sports offers a special chance to support the modeling of the performance and recovery. Increasingly complex physical activities and fierce competition in the world of sports generate a state of psycho-emotional and physical stress that can induce chronic fatigue syndrome, failure in physical training, predisposition to muscle damage, physical and emotional exhaustion etc., for which PBM could be an excellent solution. To evaluate and identify all risk factors and the influence of PBM on health and performance in sport and for a better understanding of its effects, we did a search for “Photobiomodulation and Sports” on PubMed, to update the PBM science applied in sports, and we retained for analysis the articles published from 2014 to date. The term “PBM” is recent, and we did not include previous studies with “low level laser therapy” or “LLLT” before 2014. In the present research, PBM has been shown to have valuable protective and ergogenic effects in 25 human studies, being the key to success for high performance and recovery, facts supported also by 22 animal studies. PBM applied creatively and targeted depending on sport and size of the level of physical effort could perfectly modulate the mitochondrial activity and thus lead to remarkable improvements in performance. PBM with no conclusive results or without effects from this review (14 studies from a total of 39 on humans) was analyzed and we found the motivations of the authors from the perspective of multiple causes related to technological limitations, participants, the protocols for physical activity, the devices, techniques and PBM parameters. In the near future, dose–response experiments on physical activity should be designed and correlated with PBM dose–response studies, so that quantification of PBM parameters to allow the energy, metabolic, immune, and neuro-endocrine modulation, perfectly coupled with the level of training. There is an urgent need to continuously improve PBM devices, delivery methods, and protocols in new ingenious future sports trials. Latest innovations and nanotechnologies applied to perform intracellular signaling analysis, while examining extracellular targets, coupled with 3D and 4D sports motion analysis and other high-tech devices, can be a challenge to learn how to maximize PBM efficiency while achieving unprecedented sports performance and thus fulfilling the dream of millions of elite athletes.
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Acute Effects of a Percussive Massage Treatment on Movement Velocity during Resistance Training
Article
Full-text available
Abstract: The aim of this research was to verify whether the application of percussion therapy during inter-set rest periods increases the number of repetitions performed before reaching a 30% velocity loss threshold during a bench press exercise. Methods: Twenty-four male university students participated in this study (24.3 ± 1.3 years; 77.5 ± 8.3 kg; 177.0 ± 5.6 cm; 24.7 ± 2.6 kg·m−2). Participants were randomized into two groups: a percussion therapy group (PTG) and a control group (CG). They performed 4 sets at 70% of a one-repetition maximum before reaching a 30% velocity loss threshold with an inter-set recovery of 3 min. Results: The PTG performed a greater total number of repetitions compared to the CG (44.6 ± 4.8 vs. 39.5 ± 6.8; p = 0.047; ES = 0.867). No differences were observed for the different movement velocity variables and fatigue control (p > 0.05). Conclusions: Percussion therapy is an effective method to delay the loss of movement velocity in the bench press exercise.
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Delphi methodology in healthcare research: How to decide its appropriateness
Article
Full-text available
  • Jul 2021
The Delphi technique is a systematic process of forecasting using the collective opinion of panel members. The structured method of developing consensus among panel members using Delphi methodology has gained acceptance in diverse fields of medicine. The Delphi methods assumed a pivotal role in the last few decades to develop best practice guidance using collective intelligence where research is limited, ethically/logistically difficult or evidence is conflicting. However, the attempts to assess the quality standard of Delphi studies have reported significant variance, and details of the process followed are usually unclear. We recommend systematic quality tools for evaluation of Delphi methodology; identification of problem area of research, selection of panel, anonymity of panelists, controlled feedback, iterative Delphi rounds, consensus criteria, analysis of consensus, closing criteria, and stability of the results. Based on these nine qualitative evaluation points, we assessed the quality of Delphi studies in the medical field related to coronavirus disease 2019. There was inconsistency in reporting vital elements of Delphi methods such as identification of panel members, defining consensus, closing criteria for rounds, and presenting the results. We propose our evaluation points for researchers, medical journal editorial boards, and reviewers to evaluate the quality of the Delphi methods in healthcare research.
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The cold truth: the role of cryotherapy in the treatment of injury and recovery from exercise
Article
Full-text available
  • Apr 2021
  • EUR J APPL PHYSIOL
Cryotherapy is utilized as a physical intervention in the treatment of injury and exercise recovery. Traditionally, ice is used in the treatment of musculoskeletal injury while cold water immersion or whole-body cryotherapy is used for recovery from exercise. In humans, the primary benefit of traditional cryotherapy is reduced pain following injury or soreness following exercise. Cryotherapy-induced reductions in metabolism, inflammation, and tissue damage have been demonstrated in animal models of muscle injury; however, comparable evidence in humans is lacking. This absence is likely due to the inadequate duration of application of traditional cryotherapy modalities. Traditional cryotherapy application must be repeated to overcome this limitation. Recently, the novel application of cooling with 15 °C phase change material (PCM), has been administered for 3-6 h with success following exercise. Although evidence suggests that chronic use of cryotherapy during resistance training blunts the anabolic training effect, recovery using PCM does not compromise acute adaptation. Therefore, following exercise, cryotherapy is indicated when rapid recovery is required between exercise bouts, as opposed to after routine training. Ultimately, the effectiveness of cryotherapy as a recovery modality is dependent upon its ability to maintain a reduction in muscle temperature and on the timing of treatment with respect to when the injury occurred, or the exercise ceased. Therefore, to limit the proliferation of secondary tissue damage that occurs in the hours after an injury or a strenuous exercise bout, it is imperative that cryotherapy be applied in abundance within the first few hours of structural damage.
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A critical evaluation of percussion massage gun devices as a rehabilitation tool focusing on lower limb mobility: A literature review
Preprint
Full-text available
  • Jan 2021
Aims In recent years there has been a significant rise in the popularity of muscle gun devices. However, the current research regarding handheld muscle gun devices is unclear. Therefore, this literature review will explore the current literature regarding the effect of muscle gun device on lower limb range of motion, muscle activation, force output and the possibility of reducing delayed onset muscle soreness. Methods Four databases were used along with two academic search engines to search for studies that satisfied the inclusion criteria. To fulfil the inclusion criteria studies had to be of a pre-post design with a focus on the use of percussion massage devices on lower limbs. Studies exploring range of motion and muscle force output were of particular interest. Results Thirty-nine included studies were used in this literature review. It was found that handheld percussive massage devices are the most effective method of increasing lower limb range of motion compared to foam rolling and other self-myofascial protocols. The use of handheld percussive massage devices directly after exercise reduces delayed onset muscle soreness. However, there was no reported significant increase in muscle activation or force output following the usage of a handheld percussive massage device. Conclusion The use of muscle gun devices is recommended as part of a structured warm-up pre-exercise due to an increase in range of motion, reduction in perceived muscle soreness whilst having no negative impact on muscle activation and force output. Muscle guns may also be implemented as part of a rehabilitation programme post injury due to their ability to increase range of motion and reduce perceived pain and muscle soreness.
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Comparison of Interventional Strategies to Improve Recovery after Eccentric Exercise-Induced Muscle Fatigue
Article
Full-text available
The aim of this study was to compare the effects of various recovery techniques on muscle tissue after eccentric exercise-induced muscle fatigue (EIMF). Forty subjects (24.3 ± 2.6 years; 77.45 ± 8.3 kg; 177.0 ± 6.4 cm; 24.66 ± 1.6 kg∙m−2) were randomly assigned to one of the following groups: manual therapy (n =10, MT), mechanical vibration (n = 10, MV), percussion therapy (n = 10, PT) or foam roller (n = 10, FR). The contraction time (Tc) and the radial displacement (Dm) of the gastrocnemius was evaluated through tensiomyography (TMG). The application of the different techniques had positive effects for Tc and Dm in the treated leg compared to the untreated leg (F = 50.01, p < 0.01, η2p = 0.58 and F = 27.58, p < 0.01, η2p = 0.43, respectively) and for the interaction of the factors (Time x Leg x Therapy: F = 5.76, p < 0.01, η2p = 0.32 and F = 5.93, p < 0.01, η2p = 0.33, respectively). The results of the various methods used were similar: Tc (F = 0.17, p = 0.917; η2p = 0.01) and Dm (F = 3.30, p = 0.031, η2p = 0.22). PT interventions show potential for restoring muscle compliance and reducing stiffness, similar to MT and possibly more effective (cost-time relationship) compared to MV or FR.
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Acute Pain Management
Article
  • Nov 2021
  • Oral Maxillofac Surg Clin
Control of acute pain in oral and maxillofacial surgery is important for patient care and comfort. Oral surgical procedures are associated with tissue injury and inflammation. Acute pain can arise directly from a surgical procedure or from problems such as dental caries, infection, perforation of maxillary sinus, pericoronitis, and jaw fractures. The major factor in acute pain management is deciding on an appropriate intervention and/or analgesics that will provide the best pain relief. Multimodal pain control has taken a leading role in effectively managing acute pain. This article covers the different options available to dental clinicians.
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Passive Recovery Strategies after Exercise: A Narrative Literature Review of the Current Evidence
Article
  • Jul 2021
  • Curr Sports Med Rep
Passive recovery techniques are popular and offer a diverse spectrum of options for athletes and the clinicians providing care for them. These techniques are intended to minimize the negative effects of training or competition, thus enabling the athlete a quicker return to peak performance. Current evidence demonstrates improved athlete recovery with compression garments, cold water immersion, partial body cryotherapy, hyperbaric oxygen, and vibratory therapies. Other popular modalities, such as compression devices, whole body cryotherapy, percussive gun-assisted therapy, neuromuscular electrical stimulation, and pulsed electromagnetic therapy lack convincing evidence concerning athlete recovery. This article seeks to review the current literature and offer the reader an updated understanding of the mechanisms for each modality and the evidence regarding each modality's potential benefit in an athlete's recovery strategy.
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Heat and cold therapy reduce pain in patients with delayed onset muscle soreness: A systematic review and meta-analysis of 32 randomized controlled trials
Article
  • Jan 2021
  • PHYS THER SPORT
Objective The aim of this review and meta-analysis was to evaluate the effect of heat and cold therapy on the treatment of delayed onset muscle soreness (DOMS). Methods We followed our protocol that was registered in PROSPERO with ID CRD42020170632. A systematic review and meta-analysis of randomized controlled trials (RCT) was conducted. Nine databases were searched up to December 2020. Data was extracted from the retained studies and underwent methodological quality assessment and meta-analysis. Results A total of 32 RCTs involving 1,098 patients were included. Meta-analysis showed that, the application of cold therapy within one hours after exercise could reduce the pain of DOMS patients within 24 hours (≤24 hours) after exercise (SMD -0.57,95%CI -0.89 to -0.25, P = 0.0005) and had no obvious effect within more than 24 hours (>24 hours) (P=0.05). In cold therapies, cold water immersion (SMD -0.48, 95%CI -0.84 to -0.13, P=0.008) and other cold therapies (SMD -0.68, 95%CI -1.28 to -0.08, P=0.03) had the significant effects within 24 hours. Heat treatment could reduce the pain of patients. It had obvious effects on the pain within 24 hours (SMD -1.17, 95%CI -2.62 to -0.09, P=0.03) and over 24 hours (SMD -0.82, 95%CI -1.38 to -0.26, P=0.004). Hot pack effect was the most obvious, which reduced the pain within 24 hours (SMD -2.31, 95%CI -4.33 to -0.29, P=0.03) and over 24 hours (SMD -1.78, 95%CI -2.97 to -0.59, P=0.003). Other thermal therapies were not statistically significant (P>0.05). Both cold and heat showed effect in reducing pain of patients, however there was no significant difference between cold and heat group (P = 0.16). Conclusions The current evidence indicated that the application of cold and heat therapy within one hour after exercise could effectively reduce the pain degree of DOMS patients for 24 hours cold water immersion and hot pack therapy, which had the best effect, could promote the recovery of DOMS patients. But more high-quality studies are needed to confirm whether cold or heat therapy work better.
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