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Conditioned pain modulation in elite athletes: a systematic review and meta-

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Article  in  Scandinavian Journal of Pain · March 2020

DOI: 10.1515/sjpain-2019-0153

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Systematic review
Jessica McDougall*, Catherine R. Jutzeler, Alex Scott, Peter R.E. Crocker and John L.K. Kramer
Conditioned pain modulation in elite athletes:
a systematic review and meta-analysis
https://doi.org/10.1515/sjpain-2019-0153
Received November 3, 2019; revised January 8, 2020; accepted
January 15, 2020
Abstract
Background and aims: Elite athletes reportedly have supe-
rior pain tolerances, but it is unclear if results extend to
conditioned pain modulation (CPM). The aim of our study
was to synthesize existing literature in order to determine
whether CPM is increased in elite athletes compared to
healthy controls.
Methods: A systematic review and random-effects meta-
analysis was conducted. Cochrane Central Register of
Controlled Trials, SPORTDiscus, PsycINFO, CINAHL,
Web of Science, and PubMed were searched for English-
language studies that examined CPM in adult elite athlete
populations.
Results: Seven studies were identified; all were of poor to
fair methodological quality. There was no overall differ-
ence in CPM between elite athletes and controls (Hedges
g = 0.37, CI95 −0.03−0.76; p = 0.07). There was heterogene-
ity between studies, including one that reported signifi-
cantly less CPM in elite athletes compared to controls.
An exploratory meta-regression indicated that a greater
*Corresponding author: Jessica McDougall, MA, International
Collaboration on Repair Discoveries (ICORD), University of British
Columbia, Vancouver, British Columbia, Canada; and Department
of Rehabilitation Sciences, Faculty of Medicine, University of British
Columbia, Vancouver, British Columbia, Canada,
Phone: +604-831-7706, E-mail: jessie.mcdougall@ubc.ca
Catherine R. Jutzeler: International Collaboration on Repair
Discoveries (ICORD), University of British Columbia, Vancouver,
British Columbia, Canada
Alex Scott: Centre for Hip Health and Mobility, Vancouver Coastal
Health Research Institute, Vancouver, British Columbia, Canada; and
Department of Physical Therapy, Faculty of Medicine, University of
British Columbia, Vancouver, British Columbia, Canada
Peter R.E. Crocker: School of Kinesiology, University of British
Columbia, Vancouver, British Columbia, Canada
John L.K. Kramer: International Collaboration on Repair Discoveries
(ICORD), University of British Columbia, Vancouver, British
Columbia, Canada; and School of Kinesiology, University of British
Columbia, Vancouver, British Columbia, Canada
© 2020 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
Scand J Pain 2020; aop
number of hours trained per week was associated with
higher CPM.
Conclusions: The overall number and quality of studies
was low. Despite nominally favoring higher CPM in elite
athletes, aggregate results indicate no significant dif-
ference compared to healthy controls. A possible factor
explaining the high degree of variability between studies
is the number of hours elite athletes spent training.
Implications: Based on available evidence, athletes do not
have remarkable endogenous pain modulation compared
to controls. High quality experimental studies are needed
to address the effect of hours trained per week on CPM in
athletes.
Keywords: athletes; sports; pain perception; pain modula-
tion; diffuse noxious inhibitory control.
1 Introduction
In terms of sensitivity to pain, athletes represent a dis-
tinct population, with studies consistently reporting
greater pain tolerance compared to non-athletes [1]. Pre-
vious studies also suggest differences in athlete’s ability
to modulate pain. This has been examined based on
the m­ easurement of changes in sensitivity to a noxious
stimulus tested in the presence of an additional noxious
conditioning stimulus [2–6] – so-called conditioned
pain modulation (CPM). Seminally reported in 2013,
elite endurance athletes were initially observed to have
reduced CPM (i.e. lesser capacity to turn down pain in the
face of another source of pain) compared to healthy, non-
elite athletes [7]. More recently, studies demonstrated the
opposite effect – higher CPM in elite athletes (from mainly
endurance-based sports) compared to non-elite athletes
and non-athletic controls [2–4, 6].
In light of studies demonstrating decreased ­sensitivity
to pain [1], reduced CPM in athletes seems somewhat
paradoxical. After all, reduced CPM has been extensively
reported as a characteristic of patients with chronic pain
[8] – a population commonly associated with increased
sensitivity to painful test stimuli [9–12]. More intuitively,
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2      McDougall et al.: Conditioned pain modulation in elite athletes

one could anticipate that elite athletes develop or are
predisposed to greater CPM, a factor that facilitates with-
standing high demands of training and competition. On
the other hand, athletes regularly experience acute, as
well as chronic pain in the course of competition (e.g.
injuries persisting for more than 3  months) [13], which
may then drive reduced CPM over time. Additionally, other
factors previously found to influence CPM in other popu-
lations, such as age and sex [8], pain modality [14], or use
of differing CPM protocols [15] could be contributing to
this paradox.
To provide clarity and inform future studies on the
impact of elite athletics on CPM, we performed a system-
atic review and meta-analysis/regression. Our goal was to
provide an overall estimate of CPM from published studies
involving elite athletes and to address study level factors
(e.g. type of athlete, sample characteristics) associated
with outcome (i.e. the degree to which CPM in elite athletes
was different compared to controls). A secondary outcome
was to evaluate the quality of the studies investigating
CPM in elite athletes to date, given that there has not been
a thorough investigation of variability in CPM protocols in
this population. To this end, we developed novel evalua-
tion criteria based on available CPM guidelines [16].
databases until December 12, 2019  were searched using
the following databases: Cochrane Central Register of
Controlled Trials, SPORTDiscus, PsycINFO, CINAHL, Web
of Science, and PubMed. Librarians at the University of
British Columbia assisted in the development of search
strategies. The complete search strategy was modified
to fit the appropriate mesh terms and keywords for each
database, with an example search shown in Table 1 for
PsychINFO. All titles and abstracts were assessed against
inclusion criteria, and in cases when the abstract did not
give full information as to the application of criteria, full-
text versions of the articles were retrieved. Reference lists
of relevant articles were also scanned for further studies to
expand the data set. The review was registered with PROS-
PERO (#CRD42018112925).
2.3 Study selection and data extraction
JM reviewed the studies to determine eligibility for inclu-
sion, with JK confirming inclusion. Data were extracted
into a Microsoft Excel© spreadsheet, with the template
adapted from the Cochrane Collaboration [17] to match
this review’s goals. For all studies the study design,
number and characteristics of participants, population,
intervention and/or purpose, study procedure/time-

2 Methods line, CPM protocol and pain modalities, CPM outcomes

(primary outcomes), and secondary outcomes including
other variables measured and other non-CPM outcomes of
2.1 I nclusion and exclusion criteria note were extracted.

The inclusion criteria for this review were as follows:

(1) human participants, (2) published in the English lan- Table 1: Electronic database search strategy for PsycINFO (until
guage, and (3) focused on participants identified as elite December 12, 2019). The search was performed in sequential
athletes. As there is no conclusive definition of “elite numerical order.

athletes”, we opted to include studies that explicitly

No. Search terms Results
described participants as athletes participating at a high
level of their sport (e.g. competing at a national/interna- 1 Conditioned pain modulation 199
tional level). This was done in order to exclude studies that 2 Diffuse noxious inhibitory control 174
3 Diffuse noxious inhibitory controls 174
were examining the general effects of exercise (but not
4 Endogenous pain modulation 81
in a defined athletic population) on CPM. No conditions 5 Heterotopic noxious conditioning 17
were placed on control groups. In studies with multiple 6 CPM 743
measurements of CPM, we aimed to extract a measure- 7 DNIC 124
ment made at baseline (i.e. at rest). Review articles, case 8 EPM 1,445
9 HNC 200
reports, and pediatrics studies were excluded.
10 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 2,602
11 Athlete 20,081
12 Sport* 59,898
2.2 Systematic review 13 Exercise 83,448
14 Physical activity 41,045
Relevant studies were identified using a systematic search 15 11 or 12 or 13 or 14 146,608
16 10 and 15 151
of the literature. Articles published from inception date of

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 McDougall et al.: Conditioned pain modulation in elite athletes      3

2.4 R
 isk of bias assessment
Risk of bias was assessed using multiple measures. First,
the Downs and Black tool [18] was used to assess quality.
The Downs and Black tool, which was designed to assess
non-randomized controlled trials, consists of 27 one-point
questions. To simplify interpretation, scores ≥24  were
considered methodologically to be of excellent quality;
20–23 were considered to be good quality; 15–19 were con-
sidered to be fair quality; and scores of ≤14 were consid-
ered to be of poor quality [19]. In addition, a CPM Quality
Assessment Tool was created based on recommendations
from the current guidelines for CPM studies (Table 2) [16].
The guidelines were examined, and each recommendation
was turned into a question used in risk of bias and quality
assessment. Three additional questions were added fol-
lowing discussion with experts in CPM testing. When
reviewing the articles in the meta-analysis, each question
was answered with either “yes” or “no”, with “yes” equal-
ing one point, and “no” equaling zero points. This assess-
ment scored each article from 0 to 12, with 12 indicating
that all recommendations were followed. Finally, a risk of
bias assessment criteria of CPM-specific studies was used
[8]. This risk of bias assessment results in a score from 0 to
8, with 0 indicating low risk of bias and 8 indicating high
risk of bias.
2.5 Statistical analysis
All statistical analyses were performed in R version 3.5.1
[20]. Effect sizes for each study were calculated using
means and standard deviations of the elite athlete and
control groups baseline pain scores and conditioning step
pain scores (during or following the conditioning pain
stimulus). If a study reported CPM values for different
sport type elite athlete groups (e.g. a study that looked at
triathletes and weightlifters separately) the groups were
entered into the meta-analysis separately. This was done
to investigate potential differences in CPM scores based
on sport type. Hedge’s G and 95% CI were the measures
chosen to examine effect sizes (R function: esc_mean_sd).
When means and standard deviations were only pre-
sented in graphical formats, values were extracted using
an online graph digitizer (WebPlotDigitizer; https://apps.
automeris.io/wpd/). When a confidence interval, stand-
ard error, or interquartile range was presented it was
transformed into standard deviation. To calculate an
overall effect size, a random effects model was used as we
expected heterogeneous study populations (R function:
rma). Effect sizes from studies that compared elite athletes
to a control sample were entered into the overall measure.
We produced Forest plots to visualize the results from the
random-effect models (R function: forest). Heterogeneity
was assessed using Q, τ2 and I2. Funnel plots were used
to assess publication bias (R function: funnel). We used
the Egger test to examine asymmetry of the funnel plot for
publication bias (R function: regtest) [21].
A subgroup analysis was planned to examine the
effects of sport type on CPM. Effect size estimates were
determined with the studies divided into sport subtypes,
namely endurance sports and “other” sports. When a
study included multiple sport types the data from each
subgroup was entered separately into the data analysis.
This does violate assumptions of data independence;
however, given that we expected a low number of studies

Table 2: Conditioned pain modulation quality assessment checklist, based on recommendations by Yarnitsky et al. [16].

1. Did the study use either (a) 2 different test stimuli with the same conditioned stimuli, or (b) 2 full CPM protocols?a Yes/no
2. Did the study use the recommended pain stimuli?a Yes/no
a. Either mechanical or heat pain as test stimuli
b. 1-min cold water bath as conditioned stimuli
3. Was the test stimulus delivered at a pain rating of 40/100 or higher?a Yes/no
4. Was the conditioned stimulus delivered at a pain rating of 20/100 or higher?a Yes/no
5. Was the test stimulus given at an ascending or fixed protocol?a Yes/no
6. Was test stimulus delivered twice?a Yes/no
7. Was a sequential (as opposed to concurrent/parallel) protocol used?a Yes/no
8. Was one upper and one lower limb used as the testing sites?a Yes/no
9. Results presentation: was pain inhibition presented as a negative value, and pain facilitation presented as a positive value?a Yes/no
10. Did study include a control condition to ensure CPM validity? Yes/no
11. Did the study include a familiarization process? Yes/no
12. Was an adequate sample size used/was the sample size justified through a power analysis? Yes/no
Total/12

Indicates questions were based on recommendations by Yarnitsky et al. [16].

a

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4      McDougall et al.: Conditioned pain modulation in elite athletes
to have multiple elite athlete groups, impact on the
outcome is expected to be minimal. Analyses were per-
formed using the rma function in R-Studio.
Exploratory meta-regression was also planned to
examine potential confounders of CPM. Factors were
drawn from previous CPM reviews in non-athletic popula-
tions and included age of study participants, proportion
of males in study samples [8], type of pain modalities used
for both test and conditioning stimulus [14], and sample
sizes. Additionally, the impact of a quantitative measure of
“elite” athleticism on CPM was examined using the most
commonly reported quantitative measure of athleticism.
Assessing quantitative measures of performance has been
recommended to measure and compare elite athletes of
different sport types [22]. This analysis is termed “explora-
tory” as we expect a small number of studies to report on
all these characteristics. Analyses were performed using
the rma function in R-Studio.
3 Results
3.1 Search strategy
A total of 1,816  studies were originally identified. Six
hundred and forty-eight duplicates were removed, resulting
in 1,168 articles screened (i.e. review of titles and abstracts).
One thousand and one hundred and twenty-nine studies
were excluded due to ineligibility, with the reasons for
exclusion shown in Fig. 1. The most common reason for
exclusion was that the study did not examine CPM. Seven
articles were identified for inclusion in our review.
3.2 D
 escription of studies and participants
Table 3 provides a summary of information for each study.
Eligible studies ranged from 25 to 56 participants. Study
types included six non-randomized controlled trials [2,
4–7, 23] and one case-control study [3].
Elite athlete types included triathletes, long dis-
tance runners, endurance athletes, and groups of mixed-
sport athletes. Average ages ranged from 20.8 ± 1.2 [23] to
42.1 ± 6.9 [4]. Four studies included male and female par-
ticipants [2, 4, 5, 23], and three studies included only male
participants [3, 6, 7]; no studies included only female par-
ticipants. Six of the seven studies included a control group
[2, 4–7, 23], five of which were amateur or recreational ath-
letes [2, 5–7, 23] and one of which was a non-active control
group [4].
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Quantitative descriptors of athletic performance varied
widely. Variables included hours trained per week [2, 3,
5–7], training sessions per week [2, 5–7], years or months
spent training [3, 5, 7], VO2max [7, 23], BMI and other anthro-
pometric measures [7, 23], number of competitions per year
[3], distance ran in a race [4], and other cardiorespiratory
and energy expenditure measures [7, 23]. The test stimuli
used was either heat [2, 3, 5, 7] or pressure [4, 6, 23]. Three
studies used pain threshold as their test stimuli intensity [4,
6, 23], two used a pain intensity of 7/10 on a visual analog
scale (VAS) [2, 5], one used 5/10 on a VAS [3], and one used
50/100 on a numerical rating scale (NRS) [7]. Conditioning
stimuli included cold water baths [2, 4–7, 23] and heat [3].
Three studies applied a sequential protocol [6, 7, 23].
Three studies scored “fair” and four scored “poor” on
the Downs & Black scale. On the CPM Quality Assessment
Tool, scores ranged from 2 to 7 out of 12, and on the CPM Risk
of Bias Scale scores ranged from 3 to 5 out of 8. On the CPM
Quality Assessment Tool, only one study reported using
a second full CPM protocol [23], and no studies reported
using more than one type of test stimulus. One study [23]
used an upper and lower limb for test sites and five studies
reported that the pain rating of the conditioning stimulus
exceeded the recommended 2/10  NRS rating [16]. On the
CPM Risk of Bias Scale, most studies showed poor partici-
pant and researcher blinding, only one study reporting that
the experimenter was blinded to results of the test [4].
3.3 Study outcomes
Three studies showed that elite athletes had significantly
higher CPM than controls [2, 4, 6], and one study found
control groups had higher CPM than elite athletes [7]. One
study found no difference in CPM between elite athletes
and controls [23]. One study examined elite strength and
endurance athletes separately and found endurance ath-
letes had greater CPM than controls, but strength athletes
CPM did not differ from controls [5]. One study did not
have a control group [3]. No study reported on the propor-
tion of participants who demonstrated pain modulation in
response to the CPM protocol.
3.4 Meta-analysis
Data from six of the seven studies were pooled for the
meta-analysis. The Geva et al. [3] study was excluded as
it did not include a control group. The overall effect size
favored higher CPM in elite athletes but was not signifi-
cant (Hedges g = 0.37 [CI95 −0.03−0.76]; p = 0.07, Fig. 2).
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 McDougall et al.: Conditioned pain modulation in elite athletes      5

Articles identified from electronic databases 0 Articles identified from other sources
– PubMed – 695
– SportDiscus – 143 – Reference lists of articles identified
– CINAHL – 222 through electronic databases were
reviewed
– Web of Science – 618
– PsycINFO – 138

1816 Total articles retrieved for analysis

648 Duplicate articles

1168 Total articles after duplicates removed

1168 Total articles screened based on title and abstract

1120 Articles excluded based on abstracts

– Did not include athletes – 62
– Did not use CPM – 1022
– Was not original study
(eg. commentary, review) – 36

48 Articles assessed for eligibility

41 full text articles excluded

– Did not include athletes – 37
– Did not use CPM – 1
– Was not original study (eg.
Commentary, review) – 3

7 articles included in review

Fig. 1: Flow diagram of the study selection process. CPM = conditioned pain modulation.

Heterogeneity was high, with I2 = 95.27%, Q = 182.78
(p < 0.0001), τ2 = 0.52. The funnel plot is shown in Fig. 3,
and demonstrated symmetry (p = 0.55).
3.5 Subgroup analysis
The data was separated into endurance [2, 4, 5, 7, 23]
and other [5, 6] elite athletes. One study examined both
an elite endurance athlete group and a strength athlete
group [5]; this study was entered into the meta-analysis
as two separate entries sharing the same control group.
Flood et al. [6] examined a mixed group of elite endurance
and non-endurance athletes; this study was placed into
the “other” category as it was not possible to separate the
data according to sport type.
The pooled effect sizes favored both groups of elite
athletes (Fig. 2), but in neither case was significant

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 Table 3: Summary of included studies.

Study   Sport type   Athlete criteria   Control   Hours   Hours   Age   N   Sex   Protocol   TS   CS   CPM score (SD)a   Hedges G   Outcome   D&B   CPM   Bias
group trained trained (% male) type (95% CI) measure rating quality score (/8)
per week per week score (/12)
(athletes) (controls)

Tesarz   Endurance   Competed in regional   Amateur   9.6 (3.5)   <0.5   A: 27.8 (4.1)   A: 25   A: 100%   Seq   Heat   CW bath  A: 3.1 0 (8.7)   −0.60 [− 0.76, −0.44]   PR   Fair   6   4
et al. [7] mixed (triathlon, sport clubs. Trained athletes C: 28.0 (4.5) C: 26 C: 100% C: 9.60 (12.2)
cycling, 3 h/week for ≥3 years
running)
Geva and   Triathlon   Competed in ≥2   Amateur   13.18 (4.2)   2.4 (1.9)   A: 39.6 (12.0)   A: 19   A: 62.5%   Con   Heat   CW bath  A: 3.04 (2.28)   0.66 [0.42, 0.90]   PR   Poor   4   3
Defrin [2] national triathlon or athletes C: 36.5 (11.0) C: 17 C: 41.2% C: 1.50 (2.28)
Ironman triathlons
per year, trained
≥3 years
Flood   Mixed   Competed in top tier   Amateur   14.8 (5.0)   2.1 (1.1)   A: 24.4 (5.3)   A: 15   A: 100%   Seq   Pressure  CW bath  A: 1.19 (1.12)   0.80 [0.53, 1.07]   PTh   Poor   5   4
et al. [6] (endurance, of local competition. athletes C: 23.4 (3.8) C: 15 C: 100% C: 0.30 (1.04)
football, Trained ≥10 h/week
weightlifting,
martial arts)
6      McDougall et al.: Conditioned pain modulation in elite athletes

Geva   Triathlon   Competed in ≥5   N/A   16.4 (9.8)   2.4 (1.9)   A: 35.9 (10.0)a   A: 25  A: 100%   Con   Heat   Heat   A: 3.15 (1.7)     PR   Fair   6   5
et al. [3] triathlons or Ironman
triathlons per year.
Trained ≥7 h/week
Agnew   Runners (long   Participants in 25, 50,   Unknown   N/A   N/A   A: 40.4 (8.3)   A: 45   A: 51%   Con   Pressure  CW bath  A: 535.76 (149.15)   0.87 [0.65, 1.09]   PTh   Poor   2   5
et al. [4] distance) and 100 mile races C: 23.4 (4.7) C: 11 C: 54.5% C: 405.75 (143.15)
Assa   Mixed (triathlon,  Competed in   Amateur   E: 15.2 (7.7)   2.5 (1.9)   E: 32.8 (9)   E: 19   A: 61%   Con   Heat   CW bath  E: 2.70 (2.00)   E: 0.62 [0.38, 0.86]   PR   Fair   5   3
et al. [5] weightlifting, ≥5 national or athletes S: 10.4 (3.1) S: 36.5 (11) S: 17 C: 41% S: 1.10 (2.50) S: 0.18 [−0.06, 0.42]
powerlifting, international C: 36.5 (11.0) C: 17 C: 1.49 (1.90)
hammer, competitions per year
shotput throw)
Peterson   Runners   Collegiate track team   Amateur   N/A   N/A   A: 20.8 (1.2)   A: 13   A: 84%   Seq   Pressure  CW bath  A: 87.4 (229.09)   0.07 [−0.22, 0.36]   PTh   Poor   7   5
et al. [23] (≤1,500 m runners, ≥1,500 m athletes C: 22.8 (2.0) C: 13 C: 84% C: 106.8 (331.85)
distance) distances

a
Positive values represent pain inhibition. This goes against the recommendations of Yarnitsky et al. [16], however this was chosen in order to have positive effect sizes indicate greater CPM in
athletes.
A = athlete group; C = control group; TS = test stimulus; CS = conditioned stimulus; CPM = conditioned pain modulation; seq = sequential; con = concurrent; CW = cold water; PR = pain rating;
PTh = pain threshold; D&B = Downs & Black; E = endurance athletes; S = strength athletes; CI = confidence interval.

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 McDougall et al.: Conditioned pain modulation in elite athletes      7

Mean Athlete Mean Control

Authors and year N Age N Age Effect size [95% CI]

Endurance athletes

Tesarz et al. [7] 25 27.8 (4.1) 26 28.0 (4.5) −0.60 [−0.76, −0.44]

Peterson et al. [23] 13 20.8 (1.2) 13 22.8 (2.0) 0.07 [−0.22, 0.36]

Geva & Defrin [2] 19 39.6 (12.1) 17 36.5 (11.1) 0.66 [0.42, 0.90]

Assa et al. [5] 19 32.8 (9.0) 17 36.5 (11.0) 0.62 [0.38, 0.86]

Agnew et al. [4] 45 40.4 (8.3) 11 23.4 (4.7) 0.87 [0.65, 1.09]

RE model for subgroup (Q = 15.28, df = 4, p = 0.00; I2 = 71.3%) 0.31 [−0.24, 0.86]

Other athletes

Assa et al. [5] 17 28.3 (8.0) 17 36.5 (11.0) 0.18 [−0.06, 0.42]

Flood et al. [6] 15 24.4 (5.3) 15 23.4 (3.8) 0.80 [0.53, 1.07]

RE model for subgroup (Q = 1.48, df = 1, p = 0.22; I2 = 32.4%) 0.47 [−0.13, 1.08]

Random effects model 0.37 [−0.03, 0.76]

RE model for all studies (Q = 182.78, df = 6, p = 0.00; I2 = 95.3%)

−1 0 0.5 1 1.5
Mean difference

Fig. 2: Forest plot of Hedge’s G for comparisons of elite athlete and control group conditioned pain modulation (CPM) scores, divided into
elite endurance athlete studies and studies that examined other types of elite athletes.

(Hedges g = 0.31 [CI95 −0.24−0.86] p = 0.27 for endur-
ance athlete group and Hedges g = 0.47 [CI95 −0.13−1.08]
p = 0.13 for the “other” athlete group). Heterogeneity in
the elite endurance athlete studies was considerable, with
I2 = 71.30%, Q = 15.28 (p < 0.01), τ2 = 0.36. The “other” elite
athlete group studies were more homogenous (I2 = 32.36%,
Q = 1.48, p = 0.22, τ2 = 0.06).
3.6 Meta-regression
To reduce potential collinearity, we opted to only assess
the most frequently reported quantitative performance
measure in our meta-regression – hours trained per week
– alongside the planned factors (age of study participants,
proportion of males, pain modalities of test and condi-
tioning stimulus, and sample sizes). Two studies did not
report hours trained per week [4, 23] and were therefore
not included in the meta-regression.
According to our meta-regression, only hours spent
training on a weekly basis was positively related to CPM,
such that longer number of training hours per week
was associated with greater CPM (F1 = 10.58, p < 0.001,
R2 = 98.60%, Fig. 4). None of the other variables con-
sidered in our planned meta-regression analysis were
significant.

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8      McDougall et al.: Conditioned pain modulation in elite athletes

Funnel plot asymmetry: p = 0.12

4 Discussion
0

Sport type
Endurance
Other 4.1 Summary

Our aim was to determine the extent CPM differed in elite

0.097
athletes compared to controls, review the quality of availa-
ble data, and, where possible, examine study level factors
associated with outcome. While there was a trend for elite
athletes to demonstrate higher CPM compared to controls,
Standard error

0.194
our meta-analysis revealed no overall significant differ-
ences. The quality of reporting in the majority of studies
was “poor” according to established reporting guidelines.
Meta-regression analysis revealed one study level factor
associated with CPM outcome – hours of training. Well-
0.29 designed studies with greater quantitative descriptions
of elite athlete inclusion criteria are warranted to better
understand the impact of elite athleticism on CPM.

0.387

–0.5 0 0.5 1 4.2 Reporting and risk of bias

Mean difference
An important outcome of our review was that the quality
Fig. 3: Funnel plot for all elite athlete studies. Note that the Assa
of the studies examining CPM in athletic populations has,
et al. [5] study was separated into strength and endurance elite
athletes, and is therefore represented twice.
according to established guidelines, been relatively poor.
Among potential sources of bias, studies did not blind
examiners to testing group (i.e. elite athletes or healthy
controls). Moreover, no study entirely conformed to pub-
lished recommendations for testing CPM [16]. For example,
1.0
no study used more than one test stimulus and only one
Flood et al. [6] study used an additional full CPM protocol [23]. The study
Geva & Defrin [2] Assa et al. [5],
Endurance
that included the additional protocol scored the highest
0.5 on the CPM Quality Assessment Tool and within the top
3 on both the Lewis Bias Scale and Downs & Black Scale
Assa et al. [5],
(Table 3), and, coincidentally, was also one of two studies
Effect size

Strength
0.0
Sport type
that found no significant difference between controls and
Endurance elite athletes [5, 23]. Also, there were studies that did not
Other report the pain intensity of the conditioning stimulus [2,
−0.5 Sample size 4, 5, 23], did not use upper and lower limb test sites [2–7],
Tesarz et al. [7] 10
20
and applied a test stimulus intensity that was less painful
40 than the recommended 4/10 on an NRS [4, 6, 23]. Painful
−1.0 stimuli are needed in order to generate CPM [16, 24], and
10 12 14 reporting these components is necessary to determine if
Hours trained per week CPM was, in fact, the phenomenon being investigated.
There was also very little consideration of potential con-
Fig. 4: Relationship between elite athlete’s training hours per week
and effect size. Size of bubble reflects sample size. Two studies founding factors. For example, only four studies clarified
did not report training hours per week and were excluded from the as to whether elite athletes were excluded based on signs/
analysis. symptoms of chronic pain. In light of high prevalence of

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 McDougall et al.: Conditioned pain modulation in elite athletes      9
chronic pain in elite athletes [13] and effects of chronic
pain on CPM [8], this may have contributed to consider-
able heterogeneity.
4.3 M
 eta-analysis and meta-regression
results
Overall, we observed no effect of elite athleticism on CPM.
While this was primarily driven by the inclusion of one
study reporting significantly less CPM in elite athletes
compared to controls [7], two others reported no differ-
ence between the two groups [5, 23]. In the study reporting
lower CPM in elite athletes, the findings were proposed
as a function of continuously activating pain modulation
networks (e.g. diffuse noxious inhibitory control), which
rendered elite athletes less capable of responding to
noxious conditioning [7]. In essence, CPM is already fully
engaged as a function of their participation in athletics
and attempts to active the network using laboratory tests
was insufficient. A similar mechanism has been proposed
to explain decreased CPM in patients with chronic pain, in
whom pain modulation networks are purportedly already
fully engaged in the response to signs and symptoms
of chronic pain [8]. In contrast, studies have suggested
greater CPM is fundamental to manage repeated bouts of
acute pain experienced in the course of athletic competi-
tion [3].
Our meta-regression analysis indicated one factor
that may explain, in part, the divergence in study results
and lack of overall effect: the number of hours trained per
week. Average time spent training varied from less than 10
[7] to more than 16 h per week [3], and was strongly related
to effect size at the study level. This is consistent with
individual subject level observations from three studies,
which generally supported the notion that CPM is train-
ing duration dependent [2, 5, 6]. In principle, this suggests
that the effect of training on CPM are dose-dependent,
or conversely, that having greater CPM allows athletes
to train longer. Contrasting these observations, a recent
study in swimmers did not detect a relationship between
CPM and training duration [25]. One possible explanation
for the discrepancy between this study and our findings
(and the reason for the study’s exclusion from our sys-
tematic review) is that the average age of the swimmers
was ~15 years – younger than any study we reviewed and
potentially before CPM is modulated in relation to train-
ing, assuming CPM is plastic and changes over time.
Longitudinal exercise intervention studies suggest that
pain tolerance and thresholds can be increased through
exercise [26–28], however, it is not yet clear if the same
applies to CPM.
4.4 Limitations
An obvious limitation of our systematic review is that only
7 studies were identified applying CPM in athletic popu-
lations, examining 195 athletes. Our meta-analysis was
performed on an even smaller sample of studies (N = 6),
after one article was excluded because it lacked a control
group. In comparison, pain tolerance and threshold have
been examined in 15 published studies including 560
athletes [1]. Our aim to examine the effects of sport type
on CPM were hampered by the sparse number of studies
examining non-endurance sport athletes. Additionally,
it was a major challenge to objectively quantify elite ath-
letic participation. Across studies, only hours spent train-
ing per week was consistently reported, which ultimately
limited the scope of our meta-regression.
5 Conclusions
The results of our meta-analysis indicate that the availa-
ble evidence does not yet support the notion that athletes
have a greater CPM capacity compared to healthy controls.
However, training duration may explain variability in
study findings. To improve our understanding of CPM in
athletes, future studies should consider, or control for, the
amount of training their athlete groups undertake each
week, as well as follow published CPM testing recommen-
dations [16], and consider more rigorous methodological
design (e.g. blinding examiner to participant’s athletic
status, report quantitative measures of performance).
Authors’ statement
Research funding: This research did not receive any spe-
cific grant from funding agencies in the public, commer-
cial, or not-for-profit sectors. Dr. Kramer is supported by a
NSERC Discovery Grant.
Conflict of interest: We declare that we have no conflicting
interests for this review.
Informed consent: Not applicable.
Ethical approval: Not applicable.
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 10      McDougall et al.: Conditioned pain modulation in elite athletes
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