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: ß-endorphins 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 dorso- lateral 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 TENS, massage, analgesic balms Decrease pain fiber transmission velocity Cryotherapy, ultrasound Stimulate small-diameter afferent fibers and descending pain control mechanisms 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