1. Chapter 3: Managing Pain With Therapeutic Modalities
Jennifer Doherty-Restrepo, MS, LAT, ATC
FIU Entry-Level ATEP
Therapeutic Modalities

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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 ________

9. 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

10. 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

11. 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

12. 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

13. 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

14. Pain Perception: Sensory Receptors

15. 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

16. 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

17. 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

18. 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

19. Afferent First Order Neurons
First order, or primary, afferents transmit impulses from the sensory receptor to the _____ _____ of the spinal cord

20. 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

21. Afferent First Order Neurons

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. Nociception
____ and __ fibers transmit sensations of pain and temperature
____ fibers are larger and faster
A neurons = “____ ____”
C fibers = “____ ____”

30. 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

31. 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

32. Gate Control Theory
These impulses stimulate the _________ _________ at dorsal horn of the spinal cord
Results in ________ of synaptic transmission from the ____ and ___ afferent fibers

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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 _____________

40. -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

41. -Endorphin and Dynorphin
-Endorphin and Dynorphin are _________ _________ with potent analgesic affects
The pain control mechanisms elicited from -Endorphin and Dynorphin are not well understood

42. 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

43. 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

44. 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