Transcript Managing Pain With Therapeutic Modalities

Chapter 3:
Managing Pain With
Therapeutic Modalities
Jennifer Doherty-Restrepo, MS, LAT, ATC
FIU Entry-Level ATEP
Therapeutic Modalities
Understanding Pain




Pain is a ________ sensation
Pain is composed of a variety of
discomforts
Perception of pain can be subjectively
modified by _____________ and
________________
Much of what we do to treat pain is to
change ___________ of pain
Understanding Pain



Pain control is an essential aspect of
caring for the injured patient
Several therapeutic modalities elicit
analgesic effects
Selection of a therapeutic agent should be
based on a sound understanding of its
physical properties and physiologic effects
Types of Pain



___________ = pain of sudden onset
___________ = pain lasting for more than 6
months
_____________ = pain that is perceived to
be in an area that seems to have little
relation to the existing pathology
May be either acute or chronic
 Examples: Kehr’s Sign, Myofascial trigger
points

Types of Pain


________________ = pain caused by
irritating nerve roots and extending distally
_______________ = pain associated with a
segment of bone innervated by a spinal
segment that is a deep somatic pain
Pain Assessment


Pain is a complex phenomenon which is
difficult to evaluate and quantify because it
is ________
Thus obtaining an accurate and
standardized assessment of pain is
problematic
Pain Assessment

Pain profiles
Identify type of pain
 Quantify intensity of pain
 Evaluate the effect of the pain experience on
patients’ level of function
 Assess the psychosocial impact of pain

Visual Analogue Scales



Scales are quick and simple tests
Consist of a line, usually ________ in length, the
extremes of which are taken to represent the
limits of the pain experience
Scales can be completed _____ or ________
Pain Charts



Used to establish ________ ________ of pain
Two-dimensional graphic portrayals assess
________ and __________ of pain
Patient colors areas that correspond to pain

Blue = aching pain, Yellow = numbness or tingling,
Red = burning pain, Green = cramping pain
McGill Pain Questionaire

78 words that describe
pain are grouped into
20 sets and divided
into 4 categories



Represent dimensions
of the pain experience
Completion may take
________
Administered every __
weeks
Activity Pattern Indicators
Pain Profile


A 64 question, ________ tool used to
assess functional impairment associated
with pain
Measures the frequency of certain
________ such as housework, recreation,
and social activities that produce pain
Numeric Pain Scale


Most common acute pain profile used in
sports medicine clinics
Patient is asked to rate pain on a scale
from ________


___ represents the worst pain experienced
or imaginable
Questions asked _____ and _____ Tx

When Tx provides pain relief, patients are
asked about the extent and duration of the
relief
Goals In Managing Pain


To control acute pain and protect patient
from further injury while encouraging
progressive exercise in a supervised
environment
Encourage body to heal through exercise
designed to progressively increase
functional capacity and to return the
patient to work, recreational and other
activities as swiftly and safely as possible
Pain Perception: Sensory Receptors
Sensory Receptors



__________________: activated by light touch
________________: activated by deep pressure
________________: activated by deep pressure
and hair follicle deflection


Respond slower than Pacinian Corpuscles
________________: located in the skin and are
activated by touch, tension, heat, and
proprioception
Sensory Receptors


___________________: activated by decreased
temperature and touch
___________________________: activated by
extreme mechanical, thermal, or chemical energy


Respond to impending or actual tissue damage
_______________: located in joints capsules,
ligaments, and tendons and provide information
regarding joint position and muscle tone
Sensory Receptors


_____________: activated by changes in length
and tension when a muscle is stretched or
contracted
_________________: activated by changes in
length and tension within a muscle
Neural Transmission


________ nerve fibers transmit impulses
from the sensory receptors toward the
brain
________ fibers, such as motor neurons,
transmit impulses from the brain toward
the periphery
Afferent First Order Neurons

First order, or primary,
afferents transmit
impulses from the
sensory receptor to
the _____ _____ of
the spinal cord
Afferent First Order Neurons

Four different types of afferent first order
neurons






A-alpha (α)
A-beta ()
A-delta ()
C fibers
____ and ____ fibers are characterized as being
large diameter afferents with _____(fast)
conduction velocity
__ and __ fibers as small diameter afferents with
_____ (slow) conduction velocity
Afferent First Order Neurons
Afferent Second Order Neurons


Second order
afferents carry
sensory messages
from the _____ _____
to the _____
Second order
afferents are
categorized as wide
dynamic range or
nociceptive specific
Afferent Second Order Neurons

Wide dynamic range
second order afferents
serve relatively large,
overlapping receptor
fields


Receive input from A, A
and C fibers
Nociceptive specific
second order afferents
respond exclusively to
_____ stimulation

Receive input only from A
and C fibers
Afferent Third Order Neurons
 All
afferent neurons
synapse with third
order afferents,
which carry
information to
various ________
________ where the
input is integrated,
interpreted and
acted upon
Facilitators and Inhibitors of
Synaptic Transmission



__________________ = substance that
passes information between two neurons
It is released from one neuron terminal
(__________ __________), enters the
synaptic cleft, and attaches to a receptor
site on the next neuron (____________
___________)
Causes ___________ of the post-synaptic
membrane
Facilitators and Inhibitors of
Synaptic Transmission

Several compounds, which are not true
neurotransmitters, can facilitate or inhibit
synaptic activity

_________ ________ ____________


Active in descending (efferent) pathways
__________ ___________

Neurotransmitter-like substances
Facilitators and Inhibitors of
Synaptic Transmission

Biogenic amine transmitters



__________ - block pain neurotransmitters
_____________ – inhibits pain transmission between
efferent 1st and 2nd order neurons
Neuroactive peptides



___________ – a peptide functioning as a
neurotransmitter in small-diameter primary afferent
neurons
______________ – endogenous opiod that inhibits
depolarization of efferent 2nd order nociceptive
neurons
___________ – neurohormone opiod that blocks pain
neurotransmitters
Nociception



A _________ neuron is one that transmits
pain signals
Once released, substance P initiates
electrical impulses along _______ fibers
toward spinal cord
Substance P is also a transmitter
substance between afferent ____ & ____
order neurons
Nociception

____ and __ fibers transmit sensations of
pain and temperature



____ fibers are larger and faster
A neurons = “____ ____”
C fibers = “____ ____”
Mechanisms of Pain Control




Gate Control Theory
Descending mechanisms: Central Biasing
Release of endogenous opioids: ßendorphins
Pain relief may result from a combination
of these 3 mechanisms
Gate Control Theory

Pain modulation due to
sensory stimulation in the
large diameter ____
afferent fibers


Blocking the pain impulses
with ascending ____ input
Pain impulses from
ascending ____ afferent
fibers are carried along
__ and __ afferent fibers
to enter the dorsal horn of
the spinal cord
Gate Control Theory


These impulses
stimulate the
_________ _________
at dorsal horn of the
spinal cord
Results in ________ of
synaptic transmission
from the ____ and ___
afferent fibers
Gate Control Theory


Due to this inhibition of
synaptic transmission, the
“pain message" carried
along A and C afferent
fibers is ___ transmitted to
2nd order neurons and
never reaches sensory
centers in the brain
Therefore, the “pain
message” must be carried
along the large diameter
___ afferent fibers to reach
sensory centers in the
brain
Gate Control Theory


The balance between
input from the large
diameter ____ afferent
fibers and the small
diameter ____ and ____
afferent fibers determines
how much of the pain
message is blocked or
gated
Increased stimulation of
large diameter ____
afferent fibers =
________ pain sensation
Descending Pain Control
Mechanisms: Central Biasing


Input from the A and C
afferent fibers stimulate
descending pathways in
the ________ ____ of the
spinal cord
Impulses from the thalamus
and brain stem are carried
along the dorsolateral tract
and act to “close the gate”
and block transmission of
impulses carried along the
___ and __ afferent fibers
Descending Pain Control
Mechanisms: Central Biasing

It is theorized that
previous _________,
________ ________,
________ ________,
and other factors
could influence the
transmission of pain
messages and
perception of pain
Descending Pain Control
Mechanisms: Central Biasing


Endogenous Opiod Model
for the activation of
descending pain control
mechanisms
Input from A and C afferent
fibers along with _________
____________ stimulates the
Periaquductal Grey Region
in the midbrain, which then
stimulates the ________
____________ in the pons
and medulla
Descending Pain Control
Mechanisms: Central Biasing


The Raphe Nucleus
sends impusles along
________ fibers in dorsolateral tract, which
synapse with enkephalin
interneurons (serotonin)
Release _________ into
the dorsal horn, inhibiting
the synaptic transmission
of impulses to ______ 2nd
order neurons
Descending Pain Control
Mechanisms


A second descending
pain control pathway
projecting from the
pons to the dorsal horn
has been identified
Thought to inhibit
transmission due to
release of
_____________
-Endorphin and Dynorphin



Stimulation of A and
C afferent fibers can
stimulate the release
of endogenous
opioids
______________
released from the
hypothalamus
_________ released
from periaqueductal
grey region
Dynorphin
released
-Endorphin and Dynorphin


-Endorphin and Dynorphin are _________
_________ with potent analgesic affects
The pain control mechanisms elicited from Endorphin and Dynorphin are not well
understood
Mechanisms of Pain Control



The theories presented are only models
Pain control is the result of overlapping
mechanisms
Useful in conceptualizing the perception of
pain and pain relief
Pain Management

Therapeutic modalities can be used to…

Stimulate large-diameter afferent fibers


Decrease pain fiber transmission velocity


Cryotherapy, ultrasound
Stimulate small-diameter afferent fibers and
descending pain control mechanisms


TENS, massage, analgesic balms
Accupressure, deep massage, TENS
Stimulate release of endogenous opioids
through prolonged small diameter fiber
stimulation

TENS
Summary


The goal of rehabilitation programs is to
encourage early, pain-free exercise while
promoting optimal healing processes
Therapeutic modalities used to control pain
DO NOT necessarily promote tissue healing