chapter 3: managing pain with therapeutic modalities jennifer doherty-restrepo, ms, lat, atc...

Chapter 3: Chapter 3: Managing Pain Managing Pain

With With Therapeutic Therapeutic ModalitiesModalities

Jennifer Doherty-Restrepo, MS, Jennifer Doherty-Restrepo, MS, LAT, ATCLAT, ATC

FIU Entry-Level ATEPFIU Entry-Level ATEP

Therapeutic ModalitiesTherapeutic Modalities

Understanding PainUnderstanding Pain

Pain is a Pain is a ________________ sensation sensation Pain is composed of a variety of Pain is composed of a variety of

discomforts discomforts Perception of pain can be Perception of pain can be

subjectively modified by subjectively modified by _____________ _____________ and and ________________________________

Much of what we do to treat pain is Much of what we do to treat pain is to change to change ______________________ of pain of pain

Understanding PainUnderstanding Pain

Pain control is an essential aspect of Pain control is an essential aspect of caring for the injured patient caring for the injured patient

Several therapeutic modalities elicit Several therapeutic modalities elicit analgesic effectsanalgesic effects

Selection of a therapeutic agent Selection of a therapeutic agent should be based on a sound should be based on a sound understanding of its physical understanding of its physical properties and physiologic effects properties and physiologic effects

Types of PainTypes of Pain

___________ ___________ == pain of sudden onset pain of sudden onset ___________ ___________ == pain lasting for more pain lasting for more

than 6 monthsthan 6 months _____________ _____________ = pain that is perceived = pain that is perceived

to be in an area that seems to have to be in an area that seems to have little relation to the existing little relation to the existing pathologypathology May be either acute or chronicMay be either acute or chronic Examples: Kehr’s Sign, Myofascial Examples: Kehr’s Sign, Myofascial

trigger pointstrigger points

Types of PainTypes of Pain

________________ ________________ = pain caused by = pain caused by irritating nerve roots and extending irritating nerve roots and extending distallydistally

_______________ _______________ = pain associated = pain associated with a segment of bone innervated with a segment of bone innervated by a spinal segment that is a deep by a spinal segment that is a deep somatic pain somatic pain

Pain AssessmentPain Assessment

Pain is a complex phenomenon which Pain is a complex phenomenon which is difficult to evaluate and quantify is difficult to evaluate and quantify because it is because it is ________________

Thus obtaining an accurate and Thus obtaining an accurate and standardized assessment of pain is standardized assessment of pain is problematicproblematic

Pain AssessmentPain Assessment

Pain profiles Pain profiles Identify type of pain Identify type of pain Quantify intensity of pain Quantify intensity of pain Evaluate the effect of the pain Evaluate the effect of the pain

experience on patients’ level of function experience on patients’ level of function Assess the psychosocial impact of painAssess the psychosocial impact of pain

Visual Analogue ScalesVisual Analogue Scales

Scales are quick and simple tests Scales are quick and simple tests Consist of a line, usually Consist of a line, usually ________ ________ in length, in length,

the extremes of which are taken to represent the extremes of which are taken to represent the limits of the pain experiencethe limits of the pain experience

Scales can be completed Scales can be completed __________ or or ________________

Pain ChartsPain Charts

Used to establish Used to establish ________ ________________ ________ of pain of pain Two-dimensional graphic portrayals assess Two-dimensional graphic portrayals assess ________________ and and

____________________ of pain of pain Patient colors areas that correspond to pain Patient colors areas that correspond to pain

Blue = aching pain, Yellow = numbness or tingling, Red = burning Blue = aching pain, Yellow = numbness or tingling, Red = burning pain, Green = cramping painpain, Green = cramping pain

McGill Pain QuestionaireMcGill Pain Questionaire

78 words that describe 78 words that describe pain are grouped into pain are grouped into 20 sets and divided 20 sets and divided into 4 categories into 4 categories Represent dimensions Represent dimensions

of the pain experience of the pain experience Completion may take Completion may take

________________ Administered every Administered every ____

weeksweeks

Activity Pattern Indicators Activity Pattern Indicators

Pain ProfilePain Profile A 64 question, A 64 question, ________________ tool used to tool used to

assess functional impairment assess functional impairment associated with pain associated with pain

Measures the frequency of certain Measures the frequency of certain ________________ such as housework, such as housework, recreation, and social activities that recreation, and social activities that produce painproduce pain

Numeric Pain ScaleNumeric Pain Scale

Most common acute pain profile used in Most common acute pain profile used in sports medicine clinics sports medicine clinics

Patient is asked to rate pain on a scale Patient is asked to rate pain on a scale from from ________________ ______ represents the worst pain experienced or represents the worst pain experienced or

imaginable imaginable Questions asked Questions asked __________ and and __________ Tx Tx

When Tx provides pain relief, patients are When Tx provides pain relief, patients are asked about the extent and duration of the asked about the extent and duration of the relief relief

Goals In Managing PainGoals In Managing Pain

To control acute pain and protect To control acute pain and protect patient from further injury while patient from further injury while encouraging progressive exercise in encouraging progressive exercise in a supervised environmenta supervised environment

Encourage body to heal through Encourage body to heal through exercise designed to progressively exercise designed to progressively increase functional capacity and to increase functional capacity and to return the patient to work, return the patient to work, recreational and other activities as recreational and other activities as swiftly and safely as possibleswiftly and safely as possible

Pain Perception: Sensory Pain Perception: Sensory ReceptorsReceptors

Sensory ReceptorsSensory Receptors

____________________________________:: activated by light activated by light touchtouch

________________________________:: activated by deep activated by deep pressurepressure

________________________________:: activated by deep activated by deep pressure and hair follicle deflectionpressure and hair follicle deflection Respond slower than Pacinian CorpusclesRespond slower than Pacinian Corpuscles

________________________________:: located in the skin and located in the skin and are activated by touch, tension, heat, and are activated by touch, tension, heat, and proprioceptionproprioception


______________________________________:: activated by decreased activated by decreased temperature and touchtemperature and touch

______________________________________________________:: activated by activated by extreme mechanical, thermal, or chemical extreme mechanical, thermal, or chemical energyenergy Respond to impending or actual tissue damageRespond to impending or actual tissue damage

______________________________:: located in joints capsules, located in joints capsules, ligaments, and tendons and provide ligaments, and tendons and provide information regarding joint position and information regarding joint position and muscle tonemuscle tone


__________________________:: activated by changes activated by changes in length and tension when a muscle in length and tension when a muscle is stretched or contractedis stretched or contracted

__________________________________:: activated by activated by changes in length and tension within changes in length and tension within a musclea muscle

Neural TransmissionNeural Transmission

________________ nerve fibers transmit nerve fibers transmit impulses from the sensory receptors impulses from the sensory receptors toward the braintoward the brain

________________ fibers, such as motor fibers, such as motor neurons, transmit impulses from the neurons, transmit impulses from the brain toward the peripherybrain toward the periphery

Afferent First Order Afferent First Order NeuronsNeurons

First order, or First order, or primary, afferents primary, afferents transmit impulses transmit impulses from the sensory from the sensory receptor to the receptor to the _____ _____ of the _____ _____ of the spinal cordspinal cord


Four different types of afferent first order Four different types of afferent first order neuronsneurons A-alpha (A-alpha (αα)) A-beta (A-beta () ) A-delta (A-delta ()) C fibersC fibers

____ and ____ fibers are characterized as ____ and ____ fibers are characterized as being being large large diameter afferents with diameter afferents with _____(fast) conduction velocity_____(fast) conduction velocity

__ and __ fibers as __ and __ fibers as small small diameter diameter afferents with _____ (slow) conduction afferents with _____ (slow) conduction velocityvelocity

Afferent Second Order Afferent Second Order NeuronsNeurons

Second order Second order afferents carry afferents carry sensory messages sensory messages from the _____ _____ from the _____ _____ to the _____to the _____

Second order Second order afferents are afferents are categorized as categorized as wide wide dynamic rangedynamic range or or nociceptive nociceptive specificspecific

Afferent Second Order Afferent Second Order NeuronsNeurons

Wide dynamic range Wide dynamic range second order afferents second order afferents serve relatively large, serve relatively large, overlapping receptor overlapping receptor fields fields

Receive input from AReceive input from A, A, A and C fibers and C fibers

Nociceptive specific Nociceptive specific second order afferents second order afferents respond exclusively to respond exclusively to _____ stimulation _____ stimulation

Receive input only from AReceive input only from A and C fibersand C fibers

Afferent Third Order Afferent Third Order NeuronsNeurons

All afferent All afferent neurons synapse neurons synapse with third order with third order afferents, which afferents, which carry information carry information to various to various ________________ ________________ where the where the input is integrated, input is integrated, interpreted and interpreted and acted upon acted upon

Facilitators and Facilitators and Inhibitors of Synaptic Inhibitors of Synaptic

TransmissionTransmission ____________________________________ = = substance that substance that

passes information between two passes information between two neuronsneurons

It is released from one neuron terminal It is released from one neuron terminal (__________ __________), enters the (__________ __________), enters the synaptic cleft, and attaches to a synaptic cleft, and attaches to a receptor site on the next neuron receptor site on the next neuron (____________ ___________)(____________ ___________)

Causes ___________ of the post-Causes ___________ of the post-synaptic membranesynaptic membrane

Facilitators and Facilitators and Inhibitors of Synaptic Inhibitors of Synaptic

TransmissionTransmission Several compounds, which are not true Several compounds, which are not true

neurotransmitters, can facilitate or neurotransmitters, can facilitate or inhibit synaptic activityinhibit synaptic activity _________ ________ _____________________ ________ ____________

Active in descending (efferent) pathwaysActive in descending (efferent) pathways __________ ___________ __________ ___________

Neurotransmitter-like substancesNeurotransmitter-like substances

Facilitators and Inhibitors Facilitators and Inhibitors of Synaptic Transmissionof Synaptic Transmission

Biogenic amine transmittersBiogenic amine transmitters __________ - block pain neurotransmitters__________ - block pain neurotransmitters _____________ – inhibits pain transmission _____________ – inhibits pain transmission

between efferent 1between efferent 1stst and 2 and 2ndnd order neurons order neurons Neuroactive peptidesNeuroactive peptides

___________ – a peptide functioning as a ___________ – a peptide functioning as a neurotransmitter in small-diameter primary neurotransmitter in small-diameter primary afferent neuronsafferent neurons

______________ – endogenous opiod that inhibits ______________ – endogenous opiod that inhibits depolarization of efferent 2depolarization of efferent 2ndnd order nociceptive order nociceptive neuronsneurons

___________ – neurohormone opiod that blocks ___________ – neurohormone opiod that blocks pain neurotransmitterspain neurotransmitters

NociceptionNociception

A _________ neuron is one that A _________ neuron is one that transmits pain signalstransmits pain signals

Once released, substance P initiates Once released, substance P initiates electrical impulses along _______ electrical impulses along _______ fibers toward spinal cord fibers toward spinal cord

Substance P is also a transmitter Substance P is also a transmitter substance between afferent ____ & substance between afferent ____ & ____ order neurons____ order neurons

NociceptionNociception

____ and __ fibers transmit ____ and __ fibers transmit sensations of pain and temperature sensations of pain and temperature ____ fibers are larger and faster____ fibers are larger and faster

AA neurons = “____ ____” neurons = “____ ____” C fibers = “____ ____”C fibers = “____ ____”

Mechanisms of Pain Mechanisms of Pain ControlControl

Gate Control TheoryGate Control Theory Descending mechanisms: Central Descending mechanisms: Central

BiasingBiasing Release of endogenous opioids: ß-Release of endogenous opioids: ß-

endorphinsendorphins

Pain relief may result from a Pain relief may result from a combination of these 3 mechanismscombination of these 3 mechanisms

Gate Control TheoryGate Control Theory

Pain modulation due to Pain modulation due to sensory stimulation in sensory stimulation in the large diameter ____ the large diameter ____ afferent fibersafferent fibers Blocking the pain Blocking the pain

impulses with ascending impulses with ascending ____ input____ input

Pain impulses from Pain impulses from ascending ____ afferent ascending ____ afferent fibers are carried along fibers are carried along __ and __ afferent fibers __ and __ afferent fibers to enter the dorsal horn to enter the dorsal horn of the spinal cordof the spinal cord


These impulses These impulses stimulate the stimulate the _________ _________ _________ _________ at dorsal horn of the at dorsal horn of the spinal cord spinal cord

Results in ________ of Results in ________ of synaptic synaptic transmission from transmission from the ____ and ___ the ____ and ___ afferent fibersafferent fibers


Due to this inhibition of Due to this inhibition of synaptic transmission, synaptic transmission, the “pain message" the “pain message" carried along Acarried along A and C and C afferent fibers is ___ afferent fibers is ___ transmitted to 2transmitted to 2ndnd order order neurons and never neurons and never reaches sensory centers reaches sensory centers in the brainin the brain

Therefore, the “pain Therefore, the “pain message” must be message” must be carried along the large carried along the large diameter ___ afferent diameter ___ afferent fibers to reach sensory fibers to reach sensory centers in the braincenters in the brain

Gate Control TheoryGate Control Theory The balance between The balance between

input from the large input from the large diameter ____ afferent diameter ____ afferent fibers and the small fibers and the small diameter ____ and ____ diameter ____ and ____ afferent fibers afferent fibers determines how much determines how much of the pain message is of the pain message is blocked or gatedblocked or gated

Increased stimulation Increased stimulation of large diameter ____ of large diameter ____ afferent fibers = afferent fibers = ________ pain ________ pain sensationsensation

Descending Pain Control Descending Pain Control Mechanisms: Central Mechanisms: Central

BiasingBiasing Input from the AInput from the A and C and C

afferent fibers stimulate afferent fibers stimulate descendingdescending pathways pathways in the ________ ____ of the in the ________ ____ of the spinal cord spinal cord

Impulses from the Impulses from the thalamus and brain stem thalamus and brain stem are carried along the are carried along the dorsolateral tract and act dorsolateral tract and act to “close the gate” and to “close the gate” and block transmission of block transmission of impulses carried along impulses carried along the ___ and __ afferent the ___ and __ afferent fibersfibers


BiasingBiasing It is theorized that It is theorized that

previous _________, previous _________, ________ ________, ________ ________, ________ ________, ________ ________, and other factors and other factors could influence the could influence the transmission of transmission of pain messages and pain messages and perception of painperception of pain


BiasingBiasing Endogenous Opiod Model Endogenous Opiod Model

for the activation of for the activation of descending pain control descending pain control mechanisms mechanisms

Input from AInput from A and C and C afferent fibers along with afferent fibers along with __________________ ________________________ stimulates the stimulates the Periaquductal Grey Periaquductal Grey RegionRegion in the midbrain, in the midbrain, which then stimulates the which then stimulates the ________________ ________________________ in the in the pons and medulla pons and medulla


BiasingBiasing The Raphe Nucleus sends The Raphe Nucleus sends

impusles along ________ impusles along ________ fibers in dorsolateral tract, fibers in dorsolateral tract, which synapse with which synapse with enkephalin interneurons enkephalin interneurons (serotonin) (serotonin)

Release _________ into the Release _________ into the dorsal horn, inhibiting the dorsal horn, inhibiting the synaptic transmission of synaptic transmission of impulses to ______ 2impulses to ______ 2ndnd order order neuronsneurons

Descending Pain Control Descending Pain Control Mechanisms Mechanisms

A second descending A second descending pain control pathway pain control pathway projecting from the projecting from the pons to the dorsal pons to the dorsal horn has been horn has been identifiedidentified

Thought to inhibit Thought to inhibit transmission due to transmission due to release of release of __________________________

-Endorphin and -Endorphin and DynorphinDynorphin

Stimulation of AStimulation of A and C afferent fibers and C afferent fibers can stimulate the can stimulate the release of release of endogenous opioidsendogenous opioids

______________ ______________ released from the released from the hypothalamus hypothalamus

_________ released _________ released from periaqueductal from periaqueductal grey regiongrey region

Dynorphinreleased

-Endorphin and -Endorphin and DynorphinDynorphin

-Endorphin and Dynorphin are -Endorphin and Dynorphin are __________________ __________________ with potent with potent analgesic affectsanalgesic affects

The pain control mechanisms The pain control mechanisms elicited from elicited from -Endorphin and -Endorphin and Dynorphin are not well understoodDynorphin are not well understood

Mechanisms of Pain Mechanisms of Pain ControlControl

The theories presented are only The theories presented are only models models

Pain control is the result of Pain control is the result of overlapping mechanisms overlapping mechanisms

Useful in conceptualizing the Useful in conceptualizing the perception of pain and pain reliefperception of pain and pain relief

Pain ManagementPain Management Therapeutic modalities can be used to…Therapeutic modalities can be used to…

Stimulate large-diameter afferent fibersStimulate large-diameter afferent fibers TENS, massage, analgesic balmsTENS, massage, analgesic balms

Decrease pain fiber transmission velocity Decrease pain fiber transmission velocity Cryotherapy, ultrasoundCryotherapy, ultrasound

Stimulate small-diameter afferent fibers Stimulate small-diameter afferent fibers and descending pain control mechanisms and descending pain control mechanisms Accupressure, deep massage, TENSAccupressure, deep massage, TENS

Stimulate release of endogenous opioids Stimulate release of endogenous opioids through prolonged small diameter fiber through prolonged small diameter fiber stimulation stimulation TENSTENS

SummarySummary

The goal of rehabilitation The goal of rehabilitation programs is to encourage early, programs is to encourage early, pain-free exercise while promoting pain-free exercise while promoting optimal healing processesoptimal healing processes

Therapeutic modalities used to Therapeutic modalities used to control pain DO NOT necessarily control pain DO NOT necessarily promote tissue healingpromote tissue healing

chapter 3: managing pain with therapeutic modalities jennifer doherty-restrepo, ms, lat, atc...

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