1. Chapter 10: Tissue Response to Injury © 2011 McGraw-Hill Higher Education. All rights reserved.

2. The Healing Process Essential for athletic trainer to possess in depth knowledge of healing process Essential for athletic trainer to possess in depth knowledge of healing process Three Phases: Three Phases: 1. Inflammatory Response 2. Fibroblastic Repair Phase 3. Maturation- Remodeling Phase Healing is a continuum Healing is a continuum Can not speed up the process but one can impede it Can not speed up the process but one can impede it © 2011 McGraw-Hill Higher Education. All rights reserved.

3. Figure 10-1 © 2011 McGraw-Hill Higher Education. All rights reserved.

4. Inflammatory Response Phase Once tissue is injured- the process of healing begins immediately Once tissue is injured- the process of healing begins immediately Cardinal Signs of Inflammation (caused by damged tissue) Cardinal Signs of Inflammation (caused by damged tissue) Rubor (redness) Rubor (redness) Tumor (swelling) Tumor (swelling) Color (heat) Color (heat) Dolor (pain) Dolor (pain) Functio laesa (loss of function) Functio laesa (loss of function) © 2011 McGraw-Hill Higher Education. All rights reserved.

5. Phase I: Inflammatory Response Phase Injury results in altered metabolism and liberation of various materials Injury results in altered metabolism and liberation of various materials Initial reaction by leukocytes and phagocytic cells Initial reaction by leukocytes and phagocytic cells Goal Goal Protect Protect Localize Localize Decrease injurious agents Decrease injurious agents Prepare for healing and repair Prepare for healing and repair © 2011 McGraw-Hill Higher Education. All rights reserved.

6. Chemical Mediators Derived from invading organisms, damaged tissue, plasma enzyme systems and white blood cells (WBC’s) Derived from invading organisms, damaged tissue, plasma enzyme systems and white blood cells (WBC’s) Histamine (from mast cells) Histamine (from mast cells) Causes vasodilatation and changes cell permeability owing to swelling Causes vasodilatation and changes cell permeability owing to swelling Leukotrienes & prostaglandins: Impact margination (adherence along cell walls) Leukotrienes & prostaglandins: Impact margination (adherence along cell walls) Increase permeability locally for fluid and protein passage (diapedesis) Increase permeability locally for fluid and protein passage (diapedesis) © 2011 McGraw-Hill Higher Education. All rights reserved.

7. QUESTION What are the 5 cardinal signs of inflammation? What are the 5 cardinal signs of inflammation? What are the goals during the inflammatory phase? What are the goals during the inflammatory phase?

8. Vascular Response Vasoconstriction (decrease in diameter of blood vessel) and coagulation occur to seal blood vessels and chemical mediators are released Vasoconstriction (decrease in diameter of blood vessel) and coagulation occur to seal blood vessels and chemical mediators are released Followed by vasodilation (increase in diameter of blood vessel) 5-10 minutes later Followed by vasodilation (increase in diameter of blood vessel) 5-10 minutes later Initially increases blood flow (transitory) Initially increases blood flow (transitory) Swelling Swelling WBC’s able to adhere to walls WBC’s able to adhere to walls Initial effusion of blood and plasma lasts 24-36 hours Initial effusion of blood and plasma lasts 24-36 hours © 2011 McGraw-Hill Higher Education. All rights reserved.

9. Figure 10-3 © 2011 McGraw-Hill Higher Education. All rights reserved.

10. QUESTION What happens to the vascular system during the Inflammatory Phase? What happens to the vascular system during the Inflammatory Phase?

11. Clot Formation Platelets adhere to exposed collagen leading to formation of plug (clot) Platelets adhere to exposed collagen leading to formation of plug (clot) Clots obstruct lymphatic fluid drainage and aid in localizing injury Clots obstruct lymphatic fluid drainage and aid in localizing injury Requires conversion of fibrinogen to fibrin Requires conversion of fibrinogen to fibrin Initial stage: thromboplastin is formed Initial stage: thromboplastin is formed Second stage: Prothrombin is converted to thrombin due to interaction with thromboplastin Second stage: Prothrombin is converted to thrombin due to interaction with thromboplastin Third stage: thrombin changes from soluble fibrinogen to insoluble fibrin coagulating into a network localizing the injury Third stage: thrombin changes from soluble fibrinogen to insoluble fibrin coagulating into a network localizing the injury © 2011 McGraw-Hill Higher Education. All rights reserved.

12. Figure 10-2

13. Chronic Inflammation Occurs when acute inflammatory response does not eliminate injuring agent Occurs when acute inflammatory response does not eliminate injuring agent Tissue not restored to normal physiologic state Tissue not restored to normal physiologic state Involves replacement of leukocytes with macrophages, lymphocytes and plasma cells Involves replacement of leukocytes with macrophages, lymphocytes and plasma cells As inflammation persists necrosis and fibrosis prolong healing process As inflammation persists necrosis and fibrosis prolong healing process Granulation and fibrotic tissue continue to develop within highly vascular and loose connective tissue. Granulation and fibrotic tissue continue to develop within highly vascular and loose connective tissue. Cause for shift from acute to chronic is unknown Cause for shift from acute to chronic is unknown Typically associated with overuse, overload, cumulative microtrauma Typically associated with overuse, overload, cumulative microtrauma © 2011 McGraw-Hill Higher Education. All rights reserved.

14. SCENARIO- INFLAMMATORY

15. Phase II: Fibroblastic Repair Phase Scar formation (begins within the first few days and last as long as 4- 6 weeks) Patient has complaints of pain and tenderness gradually subside during this period Patient has complaints of pain and tenderness gradually subside during this period Persistent inflammation = extended fibroplasia Persistent inflammation = extended fibroplasia © 2011 McGraw-Hill Higher Education. All rights reserved.

16. Figure 10-2

17. Phase III: Maturation & Remodeling Long-term process, may require several years to complete Long-term process, may require several years to complete Realignment of collagen relative to applied tensile forces Realignment of collagen relative to applied tensile forces Continued breakdown and synthesis of collagen = increased strength Continued breakdown and synthesis of collagen = increased strength Tissue will gradually assume normal appearance Tissue will gradually assume normal appearance © 2011 McGraw-Hill Higher Education. All rights reserved.

18. Figure 10-2

19. Role of Progressive Mobilization Initially must maintain some immobilization in order to allow for initial healing during Inflammation Phase Initially must maintain some immobilization in order to allow for initial healing during Inflammation Phase As healing moves into repair phase controlled activity should be added As healing moves into repair phase controlled activity should be added Work towards regaining normal flexibility and strength Work towards regaining normal flexibility and strength Protective bracing should also be incorporated Protective bracing should also be incorporated During remodeling aggressive ROM and strength exercises should be incorporated During remodeling aggressive ROM and strength exercises should be incorporated Facilitates remodeling and realignment Facilitates remodeling and realignment Must be aware of pain and other clinical signs – may be too much too soon Must be aware of pain and other clinical signs – may be too much too soon © 2011 McGraw-Hill Higher Education. All rights reserved.

20. Factors That Impede Healing Extent of injury: macrotears (acute) vs microtears (chronic) Extent of injury: macrotears (acute) vs microtears (chronic) Edema (swelling) Edema (swelling) Hemorrhage (bleeding) Hemorrhage (bleeding) Poor Vascular Supply Poor Vascular Supply Separation of Tissue (smooth vs jagged edge) Separation of Tissue (smooth vs jagged edge) Muscle Spasm Muscle Spasm Atrophy Atrophy Corticosteroids Corticosteroids Keloids and Hypertrophic Scars Keloids and Hypertrophic Scars Infection Infection Humidity, Climate, Oxygen Tension Humidity, Climate, Oxygen Tension Health, Age, and Nutrition Health, Age, and Nutrition © 2011 McGraw-Hill Higher Education. All rights reserved.

21. SCENARIO- MATURATION- REMODELING PHASE

22. Tissues of the Body Bone - not classified as soft tissue Bone - not classified as soft tissue 4 types of soft tissue 4 types of soft tissue 1. Epithelial tissue Skin, vessel & organ linings Skin, vessel & organ linings 2. Connective tissue Tendons, ligaments, cartilage, fat, blood, and bone Tendons, ligaments, cartilage, fat, blood, and bone 3. Muscle tissue Skeletal, smooth, cardiac muscle Skeletal, smooth, cardiac muscle 4. Nerve tissue Brain, spinal cord & nerves Brain, spinal cord & nerves © 2011 McGraw-Hill Higher Education. All rights reserved.

23. Cartilage Healing Limited capacity to heal Limited capacity to heal Little or no direct blood supply Little or no direct blood supply If area involves subchondral bone (enhanced blood supply) granulation tissue is present and healing proceeds normally If area involves subchondral bone (enhanced blood supply) granulation tissue is present and healing proceeds normally © 2011 McGraw-Hill Higher Education. All rights reserved.

24. Ligament Healing Follows similar healing course as other vascular tissues Follows similar healing course as other vascular tissues Proper care will result in acute, repair, and remodeling phases in same time required by other vascular tissues Proper care will result in acute, repair, and remodeling phases in same time required by other vascular tissues Repair phase will involve random laying down of collagen which, as scar forms, will mature and realign in reaction to joint stresses and strain Repair phase will involve random laying down of collagen which, as scar forms, will mature and realign in reaction to joint stresses and strain Full healing may require 12 months Full healing may require 12 months © 2011 McGraw-Hill Higher Education. All rights reserved.

25. Factors affecting ligament healing Surgically repaired ligaments tend to be stronger due to decreased scar formation Surgically repaired ligaments tend to be stronger due to decreased scar formation With intra-articular tears (inside the joint capsule) synovial fluid prevents clotting and spontaneous healing With intra-articular tears (inside the joint capsule) synovial fluid prevents clotting and spontaneous healing Exercised ligaments are stronger Exercised ligaments are stronger Exercise vs. Immobilization Exercise vs. Immobilization Muscles must be strengthened to reinforce the joint Muscles must be strengthened to reinforce the joint Increased tension will increase joint stability since ligament is more lax Increased tension will increase joint stability since ligament is more lax © 2011 McGraw-Hill Higher Education. All rights reserved.

26. Skeletal Muscle Healing Collagen will mature and orient along lines of tension Collagen will mature and orient along lines of tension Healing could last 6-8 weeks depending on muscle injured Healing could last 6-8 weeks depending on muscle injured © 2011 McGraw-Hill Higher Education. All rights reserved.

27. Tendon Healing Requires dense fibrous union of separated ends Requires dense fibrous union of separated ends Abundance of collagen is required for good tensile strength Abundance of collagen is required for good tensile strength Too much = fibrosis – may interfere with gliding Too much = fibrosis – may interfere with gliding Initially injured tendon will adhere to surrounding tissues (week 2) Initially injured tendon will adhere to surrounding tissues (week 2) Week 3 – tendon will gradually separate Week 3 – tendon will gradually separate Tissue not strong enough until weeks 4-5 Tissue not strong enough until weeks 4-5 © 2011 McGraw-Hill Higher Education. All rights reserved.

28. Nerve Healing Nerve cell cannot regenerate after injury Nerve cell cannot regenerate after injury Regeneration can take place within a nerve fiber Regeneration can take place within a nerve fiber Proximity of injury to nerve cell makes regeneration more difficult Proximity of injury to nerve cell makes regeneration more difficult For regeneration, optimal environment is required For regeneration, optimal environment is required Rate of healing occurs at 3-4 mm per day Rate of healing occurs at 3-4 mm per day Injured central nervous system nerves do not heal as well as peripheral nerves Injured central nervous system nerves do not heal as well as peripheral nerves © 2011 McGraw-Hill Higher Education. All rights reserved.

30. Modifying Soft-Tissue Healing Blood supply and nutrients is necessary for all healing Blood supply and nutrients is necessary for all healing Healing in older patients or those with poor diets may take longer Healing in older patients or those with poor diets may take longer Certain organic disorders (blood conditions) may slow or inhibit the healing process Certain organic disorders (blood conditions) may slow or inhibit the healing process © 2011 McGraw-Hill Higher Education. All rights reserved.

31. Management Concepts Drug utilization Drug utilization Non-steroidal anti-inflammatory agents (NSAID’s) Non-steroidal anti-inflammatory agents (NSAID’s) Medications will work to decrease vasodilatation and capillary permeability Medications will work to decrease vasodilatation and capillary permeability Concerns may interfere with Inflammatory Phase Concerns may interfere with Inflammatory Phase © 2011 McGraw-Hill Higher Education. All rights reserved.

32. Therapeutic Modalities Therapeutic Modalities Thermal agents are utilized Thermal agents are utilized Heat facilitates acute inflammation Heat facilitates acute inflammation Cold is utilized to slow inflammatory process Cold is utilized to slow inflammatory process Electrical modalities Electrical modalities Treatment of inflammation Treatment of inflammation Ultrasound, microwave, electrical stimulation (includes transcutaneous electrical muscle stimulation and electrical muscle stimulation) Ultrasound, microwave, electrical stimulation (includes transcutaneous electrical muscle stimulation and electrical muscle stimulation) © 2011 McGraw-Hill Higher Education. All rights reserved.

33. Therapeutic Exercise Therapeutic Exercise Major aim involves pain free movement, full strength, power, and full extensibility of associated muscles Major aim involves pain free movement, full strength, power, and full extensibility of associated muscles Immobilization, while sometimes necessary, can have a negative impact on an injury Immobilization, while sometimes necessary, can have a negative impact on an injury Adverse biochemical changes can occur in collagen Adverse biochemical changes can occur in collagen Early mobilization (that is controlled) may enhance healing Early mobilization (that is controlled) may enhance healing © 2011 McGraw-Hill Higher Education. All rights reserved.

34. PART II

35. Bone Healing Follows same three phases of soft tissue healing Follows same three phases of soft tissue healing Less complex process Less complex process Acute fractures have 5 stages Acute fractures have 5 stages Hematoma formation Hematoma formation Cellular proliferation Cellular proliferation Callus formation Callus formation Ossification Ossification Remodeling Remodeling © 2011 McGraw-Hill Higher Education. All rights reserved.

36. Figure 10-6 A: Blood vessels broken, forms a hematoma B: Blood vessels grow into the fracture, soft callus C: Fibrocartilage becomes ossified forms a bony cartilage D: Osteoclasts remove excess tissue

37. Hematoma Formation Trauma to the periosteum and surrounding soft tissue occurs due to the initial bone trauma Trauma to the periosteum and surrounding soft tissue occurs due to the initial bone trauma During the first 48 hours a hematoma within the medullary cavity and the surrounding tissue develops During the first 48 hours a hematoma within the medullary cavity and the surrounding tissue develops Blood supply is disrupted by clotting vessels and cellular debris Blood supply is disrupted by clotting vessels and cellular debris © 2011 McGraw-Hill Higher Education. All rights reserved.

38. Hard callus becomes more well-formed as osteoblasts lay down cancellous bone, replacing cartilage Hard callus becomes more well-formed as osteoblasts lay down cancellous bone, replacing cartilage With crystallization of callus remodeling begins With crystallization of callus remodeling begins Less than ideal immobilization produces a cartilaginous union instead of a bony union Less than ideal immobilization produces a cartilaginous union instead of a bony union © 2011 McGraw-Hill Higher Education. All rights reserved.

39. Ossification is complete when bone has been laid down and the excess callus has been resorbed by osteoclasts Ossification is complete when bone has been laid down and the excess callus has been resorbed by osteoclasts Bone continually adapts to applied stresses Bone continually adapts to applied stresses Balance between osteoblast and osteoclast activity Balance between osteoblast and osteoclast activity Time required is dependent on various factors Time required is dependent on various factors Severity and site of fracture Severity and site of fracture Age and extent of trauma Age and extent of trauma Time will range from 3-8 weeks Time will range from 3-8 weeks © 2011 McGraw-Hill Higher Education. All rights reserved.

40. Acute Fracture Management Must be appropriately immobilized, until X- rays reveal the presence of a hard callus Must be appropriately immobilized, until X- rays reveal the presence of a hard callus Fractures can limit participation for weeks or months Fractures can limit participation for weeks or months A clinician must be certain that the following areas do not interfere with healing A clinician must be certain that the following areas do not interfere with healing Poor blood supply Poor blood supply Poor immobilization Poor immobilization Infection Infection © 2011 McGraw-Hill Higher Education. All rights reserved.

41. Poor blood supply Poor blood supply Bone may die and union/healing will not occur (avascular necrosis) Bone may die and union/healing will not occur (avascular necrosis) Common sites include: Common sites include: Head of femur, navicular of the wrist, talus, and isolated bone fragments Head of femur, navicular of the wrist, talus, and isolated bone fragments Relatively rare in healthy, young athletes except in navicular of the wrist Relatively rare in healthy, young athletes except in navicular of the wrist Poor immobilization Poor immobilization Result of poor casting allowing for motion between bone parts Result of poor casting allowing for motion between bone parts May prevent proper union or result in bony deformity May prevent proper union or result in bony deformity © 2011 McGraw-Hill Higher Education. All rights reserved.

42. Infection Infection May interfere with normal healing, particularly with compound fractures May interfere with normal healing, particularly with compound fractures Severe streptococcal and staphylococcal infections Severe streptococcal and staphylococcal infections Modern antibiotics has reduced the risk of infections Modern antibiotics has reduced the risk of infections Closed fractures are not immune to infections within the body or blood Closed fractures are not immune to infections within the body or blood If soft tissue alters bone positioning, surgery may be required to ensure proper union If soft tissue alters bone positioning, surgery may be required to ensure proper union © 2011 McGraw-Hill Higher Education. All rights reserved.

43. Healing of Stress Fractures Result of cyclic forces, axial compression or tension from muscle pulling Result of cyclic forces, axial compression or tension from muscle pulling Electrical potential of bone changes relative to stress (compression, tension, or torsional) Electrical potential of bone changes relative to stress (compression, tension, or torsional) Constant stress axially or through muscle activity can impact bone resorption, leading to microfracture Constant stress axially or through muscle activity can impact bone resorption, leading to microfracture © 2011 McGraw-Hill Higher Education. All rights reserved.

44. If osteoclastic activity is not in balance with osteoblastic activity bone becomes more susceptible to fractures If osteoclastic activity is not in balance with osteoblastic activity bone becomes more susceptible to fractures Management: Decreased activity and elimination of factors causing excess stress will be necessary to allow for appropriate bone remodeling Management: Decreased activity and elimination of factors causing excess stress will be necessary to allow for appropriate bone remodeling To treat stress fractures a balance between osteoblast and osteoclast activity must be restored To treat stress fractures a balance between osteoblast and osteoclast activity must be restored Early recognition is necessary to prevent complete cortical fractures Early recognition is necessary to prevent complete cortical fractures © 2011 McGraw-Hill Higher Education. All rights reserved.

45. What are the 4 Conditions that may interfere with fracture healing? Poor Blood Supply Poor Blood Supply Poor Immobilization Poor Immobilization Infection Infection Soft Tissues between severed ends of bone Soft Tissues between severed ends of bone

46. Pain Major indicator of injury Major indicator of injury Pain is individual and subjective Pain is individual and subjective ATC needs to have balance between pain and progression ATC needs to have balance between pain and progression Factors involved in pain Factors involved in pain Anatomical structures Anatomical structures Physiological reactions Physiological reactions Psychological, social, cultural and cognitive factors Psychological, social, cultural and cognitive factors © 2011 McGraw-Hill Higher Education. All rights reserved.

47. Scenario- Fracture Healing

48. Pain Categories Pain sources Pain sources Fast versus slow pain Fast versus slow pain Acute versus chronic Acute versus chronic Projected or referred pain Projected or referred pain © 2011 McGraw-Hill Higher Education. All rights reserved.

49. Pain sources Pain sources Cutaneous pain: is sharp, bright and burning with fast and slow onset (lacerations, burns, bumps) Cutaneous pain: is sharp, bright and burning with fast and slow onset (lacerations, burns, bumps) Deep somatic pain: originates in tendons, muscles, joints, periosteum and blood vessels Deep somatic pain: originates in tendons, muscles, joints, periosteum and blood vessels Visceral pain: begins in organs and is diffused at first and may become localized (appendix) Visceral pain: begins in organs and is diffused at first and may become localized (appendix) Psychogenic pain: is felt by the individual but is emotional rather than physical Psychogenic pain: is felt by the individual but is emotional rather than physical © 2011 McGraw-Hill Higher Education. All rights reserved.

50. What are the 4 Pain Sources? Cutaneous Cutaneous Deep somatic Deep somatic Visceral Visceral Pyschogenic Pyschogenic

51. Acute versus Chronic Pain Acute versus Chronic Pain Acute pain is less than six months in duration Acute pain is less than six months in duration Chronic pain last longer than six months Chronic pain last longer than six months Chronic pain classified by International Association for the Study of Pain (IASP) as pain continuing beyond normal healing time Chronic pain classified by International Association for the Study of Pain (IASP) as pain continuing beyond normal healing time © 2011 McGraw-Hill Higher Education. All rights reserved.

52. Referred Pain Referred Pain Pain which occurs away from actual site of injury/irritation Pain which occurs away from actual site of injury/irritation Unique to each individual and case Unique to each individual and case May elicit motor and/or sensory response May elicit motor and/or sensory response Three types of referred pain include: myofascial, sclerotomic, and dermatomic Three types of referred pain include: myofascial, sclerotomic, and dermatomic © 2011 McGraw-Hill Higher Education. All rights reserved.

53. Myofascial Pain Myofascial Pain Trigger points or small hyperirritable areas within muscle resulting in bombardment of CNS Trigger points or small hyperirritable areas within muscle resulting in bombardment of CNS Acute and chronic pain can be associated with myofascial points Acute and chronic pain can be associated with myofascial points Active points cause obvious complaint Active points cause obvious complaint Trigger points do not follow patterns Trigger points do not follow patterns © 2011 McGraw-Hill Higher Education. All rights reserved.

54. Nociception: Pain receptors Pain receptors -free nerve endings sensitive to extreme mechanical, thermal and chemical energy Pain receptors -free nerve endings sensitive to extreme mechanical, thermal and chemical energy Located in meninges, periosteum, skin, teeth, and some organs Located in meninges, periosteum, skin, teeth, and some organs Afferent nerve fibers: transmit nerve fibers towards the spinal cord Afferent nerve fibers: transmit nerve fibers towards the spinal cord Efferent nerve fibers: transmit nerve fibers from the spinal cord to the periphery Efferent nerve fibers: transmit nerve fibers from the spinal cord to the periphery © 2011 McGraw-Hill Higher Education. All rights reserved.

55. Facilitators and Inhibitors of Synaptic Transmission Nervous system is electrochemical in nature Nervous system is electrochemical in nature Chemicals called neurotransmitters are released by pre-synaptic cell to transmit message Chemicals called neurotransmitters are released by pre-synaptic cell to transmit message Two types mediate pain Two types mediate pain Endorphins Endorphins Serotonin Serotonin Neurotransmitters release stimulated by noxious stimuli- resulting in activation of pain inhibition transmission Neurotransmitters release stimulated by noxious stimuli- resulting in activation of pain inhibition transmission © 2011 McGraw-Hill Higher Education. All rights reserved.

56. Mechanisms of Pain Control: Three Models or Theories © 2011 McGraw-Hill Higher Education. All rights reserved.

57. 1. Gate Theory Sensory information from cutaneous receptors enters the spinal cord Sensory information from cutaneous receptors enters the spinal cord Pain simultaneously travels along A-delta and c-fibers Pain simultaneously travels along A-delta and c-fibers Sensory information overrides pain information, closing gate, Pain message never received Sensory information overrides pain information, closing gate, Pain message never received Gate control occurs at the level of the spinal cord Gate control occurs at the level of the spinal cord Example: When you bump your head you rub it. Why? Example: When you bump your head you rub it. Why? © 2011 McGraw-Hill Higher Education. All rights reserved.

58. Gate Control Theory Figure 10-7 © 2011 McGraw-Hill Higher Education. All rights reserved.

59. Descending Pathway Pain Control © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 10-8

60. 2. Central Biasing (Descending pathway) Stimulation of descending pathways used to inhibit pain transmission Stimulation of descending pathways used to inhibit pain transmission Involves release of enkephalin and norepinephrine release in dorsal horn blocking and inhibiting synaptic transmission Involves release of enkephalin and norepinephrine release in dorsal horn blocking and inhibiting synaptic transmission The pain from the cut on your hand eventually subsides or reduces to a lower intensity. The pain from the cut on your hand eventually subsides or reduces to a lower intensity. If you consciously distract yourself, you don't think about the pain and it bothers you less. If you consciously distract yourself, you don't think about the pain and it bothers you less. People given placebos for pain control often report that the pain ceases or diminishes. People given placebos for pain control often report that the pain ceases or diminishes. © 2011 McGraw-Hill Higher Education. All rights reserved.

61. Release of β  -Endorphins © 2011 McGraw-Hill Higher Education. All rights reserved. Figure 10-9

62. 3.Release of B-endorphins Noxious stimuli can trigger endorphin releaseNoxious stimuli can trigger endorphin release Stimulation of pain sensory fibers requiredStimulation of pain sensory fibers required Causes release from hypothalamusCauses release from hypothalamus Strong analgesic effectsStrong analgesic effects IE: acupuncture, acupressure, runner’s highIE: acupuncture, acupressure, runner’s high

63. Pain assessment: subjective Self report is the best reflection of pain and discomfort Self report is the best reflection of pain and discomfort Utilize multi- and uni-dimensional questionnaires Utilize multi- and uni-dimensional questionnaires Assessment techniques include: Assessment techniques include: Visual analog scales (0-10, marked no pain to severe pain) Visual analog scales (0-10, marked no pain to severe pain) Pain charts: Location and scale Pain charts: Location and scale McGill Pain questionnaire: 78 words may take 20 minutes McGill Pain questionnaire: 78 words may take 20 minutes Activity pain indicator profiles: housework, running Activity pain indicator profiles: housework, running Numeric rating scale: Verbal Numeric rating scale: Verbal © 2011 McGraw-Hill Higher Education. All rights reserved.

64. Visual Analog Scale

65. Pain chart. Use the following instructions: “Please use all of the figures to show me exactly where all your pains are, and where they radiate to. Shade or draw with blue marker. Only the athlete is to fill out this sheet. Please be as precise and detailed as possible. Use yellow marker for numbness and tingling. Use red marker for burning or hot areas, and green marker for cramping. Please remember: blue = pain, yellow = numbness and tingling, red = burning or hot areas, green = cramping.” Used with permission from Melzack R: Pain measurement and assessment, New York, 1983, Raven Press.

67. Modalities Modalities Must have clear rationale for use Must have clear rationale for use Used to relieve pain and control other signs and symptoms of injury/surgery Used to relieve pain and control other signs and symptoms of injury/surgery Must use in conjunction with exercise Must use in conjunction with exercise Induced analgesia Induced analgesia Introduce thermal agents for pain control Introduce thermal agents for pain control Utilize electrical modalities to reduce pain Utilize electrical modalities to reduce pain TENS, superficial heat/cold, massage used to target Gate Theory TENS, superficial heat/cold, massage used to target Gate Theory Acupuncture, electrical stimulation, deep massage used to stimulate endorphin release Acupuncture, electrical stimulation, deep massage used to stimulate endorphin release Treating Pain © 2011 McGraw-Hill Higher Education. All rights reserved.

68. Pharmacological Agents Pharmacological Agents Oral, injectable medications Oral, injectable medications Commonly analgesics and anti- inflammatory agents Commonly analgesics and anti- inflammatory agents Important to work with referring physician or pharmacist to ensure patient is taking appropriate medications Important to work with referring physician or pharmacist to ensure patient is taking appropriate medications © 2011 McGraw-Hill Higher Education. All rights reserved.

69. Psychological Aspects of Pain Pain can be subjective and psychological Pain can be subjective and psychological Pain thresholds vary per individual Pain thresholds vary per individual Pain is often worse at night due to solitude and absence of external distractions Pain is often worse at night due to solitude and absence of external distractions Personality differences can also have an impact Personality differences can also have an impact Patients, through conditioning, are often able to endure pain and block sensations of minor injuries Patients, through conditioning, are often able to endure pain and block sensations of minor injuries © 2011 McGraw-Hill Higher Education. All rights reserved.