PAIN

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PAIN PAIN CONTROL THEORIES

• Managing Pain

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What is Pain?

• An unpleasant sensory emotional experience
  associated with actual or potential tissue
  damage, or described in terms of such damage
• The International Association for the Study
  of Pain
• Subjective sensation
• Pain Perceptions based on expectations, past
  experience, anxiety, suggestions
• Affective ones emotional factors that can
  affect pain experience
• Behavioral how one expresses or controls pain
• Cognitive ones beliefs (attitudes) about pain
• Physiological response produced by activation of
  specific types of nerve fibers
• Experienced because of nociceptors being
  sensitive to extreme mechanical, thermal,
  chemical energy.
• Composed of a variety of discomforts
• One of the bodys defense mechanism (warns the
  brain that tissues may be in jeopardy)
• Acute vs. Chronic
• The total person must be considered. It may be
  worse at night when the person is alone. They
  are more aware of the pain because of no external
  diversions.

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Where Does Pain Come From?

• Cutaneous Pain sharp, bright, burning can have
  a fast or slow onset
• Deep Somatic Pain stems from tendons, muscles,
  joints, periosteum, b. vessels
• Visceral Pain originates from internal organs
  diffused _at_ 1st later may be localized (i.e.
  appendicitis)
• Psychogenic Pain individual feels pain but
  cause is emotional rather than physical

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Pain Sources

• Fast vs. Slow Pain
• Fast localized carried through A-delta axons
  in skin
• Slow aching, throbbing, burning carried by C
  fibers
• Nociceptive neuron transmits pain info to spinal
  cord via unmyelinated C fibers myelinated
  A-delta fibers.
• The smaller C fibers carry impulses _at_ rate of 0.5
  to 2.0 m/sec.
• The larger A-delta fibers carry impulses _at_ rate
  of 5 to 30 m/sec.
• Acute vs. Chronic

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What is Referred Pain?

• Occurs away from pain site
• Example Kerrs sign
• Types of referred pain
• Myofascial Pain trigger points, small
  hyperirritable areas within a m. in which n.
  impulses bombard CNS are expressed at referred
  pain
• Active hyperirritable causes obvious complaint
• Latent dormant produces no pain except loss of
  ROM
• Sclerotomic Dermatomic Pain deep pain may
  originate from sclerotomic, myotomic, or
  dermatomic n. irritation/injury
• Sclerotome area of bone/fascia that is supplied
  by a single n. root
• Myotome m. supplied by a single n. root
• Dermatome area of skin supplied by a single n.
  root

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Terminology

• Noxious harmful, injurious
• Noxious stimuli stimuli that activate
  nociceptors (pressure, cold/heat extremes,
  chemicals)
• Nociceptor nerve receptors that transmits pain
  impulses
• Pain Threshold level of noxious stimulus
  required to alert an individual of a potential
  threat to tissue
• Pain Tolerance amount of pain a person is
  willing or able to tolerate
• Accommodation phenomenon adaptation by the
  sensory receptors to various stimuli over an
  extended period of time (e.g. superficial hot
  cold agents). Less sensitive to stimuli.

• Hyperesthesia abnormal acuteness of sensitivity
  to touch, pain, or other sensory stimuli
• Paresthesia abnormal sensation, such as
  burning, pricking, tingling
• Inhibition depression or arrest of a function
• Inhibitor an agent that restrains/retards
  physiologic, chemical, or enzymatic action
• Analgesic a neurologic or pharmacologic state
  in which painful stimuli are no longer painful

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Questions to Ask about Pain

• Pattern onset duration
• Area location
• Intensity level
• Nature description

• P-Q-R-S-T format
• Provocation How the injury occurred what
  activities ? ? the pain
• Quality - characteristics of pain Aching
  (impingement), Burning (n. irritation), Sharp
  (acute injury), Radiating within dermatome
  (pressure on n.)?
• Referral/Radiation
• Referred site distant to damaged tissue that
  does not follow the course of a peripheral n.
• Radiating follows peripheral n. diffuse
• Severity How bad is it? Pain scale
• Timing When does it occur? p.m., a.m., before,
  during, after activity, all the time

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Pain Assessment Scales

• Visual Numeric Analog Scales
• None Severe
• 0 10
• Locate area of pain on a pictures
• McGill pain questionnaire
• Evaluate sensory, evaluative, affective
  components of pain
• 20 subcategories, 78 words

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McGill Pain Questionnaire

• 78 words that describe pain are grouped into 20
  sets and divided into 4 categories representing
  dimensions of the pain experience

• Completion may take 20 minutes
• Administered every 2-4 weeks

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Goals In Managing Pain

• To control acute pain and protect patient from
  further injury while encouraging progressive
  exercise in a supervised environment.
• Reducing pain is an essential part of treatment

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Goals In Managing Pain

• 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

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Transmission of Pain

• Types of Nerves
• Neurotransmitters

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Types of Nerves

• Afferent (Ascending) transmit impulses from the
  periphery to the brain
• First Order neuron
• Second Order neuron
• Third Order neuron
• Efferent (Descending) transmit impulses from
  the brain to the periphery

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First Order Neurons

• Stimulated by sensory receptors
• End in the dorsal horn of the spinal cord
• Types
• A-alpha non-pain impulses
• A-beta non-pain impulses
• Large, myelinated
• Low threshold mechanoreceptor respond to light
  touch low-intensity mechanical info
• A-delta pain impulses due to mechanical
  pressure
• Large diameter, thinly myelinated
• Short duration, sharp, fast, bright, localized
  sensation (prickling, stinging, burning)
• C pain impulses due to chemicals or mechanical
• Small diameter, unmyelinated
• Delayed onset, diffuse nagging sensation (aching,
  throbbing)

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Neural Transmission (First Order Neurons)

• First order or primary afferents transmit
  impulses from the sensory receptor to the dorsal
  horn of the spinal cord

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Afferent First Order Neurons
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Second Order Neurons

• Receive impulses from the FON in the dorsal horn
• Lamina II, Substantia Gelatinosa (SG) -
  determines the input sent to T cells from
  peripheral nerve
• T Cells (transmission cells) transmission cell
  that connects sensory n. to CNS neurons that
  organize stimulus input transmit stimulus to
  the brain
• Travel along the spinothalmic tract
• Pass through Reticular Formation
• Types
• Wide range specific
• Receive impulses from A-beta, A-delta, C
• Nociceptive specific
• Receive impulses from A-delta C
• Ends in thalamus

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Neural Transmission (Second Order Neurons)

• Second order afferent fibers carry sensory
  messages from the dorsal horn to the brain
• Second order afferent fibers are categorized as
  wide dynamic range or nociceptive specific

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Neural Transmission(Second Order Neurons)

• Wide dynamic range second order afferents receive
  input from A?, A? and C fibers.
• Second order afferents serve relatively large,
  overlapping receptor fields
• Nociceptive specific second order afferents
  respond exclusively to noxious stimulation
• Receive input only from A? and C fibers

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Third Order Neurons

• Begins in thalamus
• Ends in specific brain centers (cerebral cortex)
• Perceive location, quality, intensity
• Allows to feel pain, integrate past experiences
  emotions and determine reaction to stimulus

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Neural Transmission(Third Order Neurons)

• All of these neurons synapse with third order
  neurons which carry information to various brain
  centers where the input in integrated,
  interpreted and acted upon

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Descending Neurons

• Descending Pain Modulation (Descending Pain
  Control Mechanism)
• Transmit impulses from the brain (corticospinal
  tract in the cortex) to the spinal cord (lamina)
• Periaquaductal Gray Area (PGA) release
  enkephalins
• Nucleus Raphe Magnus (NRM) release serotonin
• The release of these neurotransmitters inhibit
  ascending neurons
• Stimulation of the PGA in the midbrain NRM in
  the pons medulla causes analgesia.
• Endogenous opioid peptides - endorphins
  enkephalins

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Neurotransmitters

• Chemical substances that allow nerve impulses to
  move from one neuron to another
• Found in synapses
• Substance P - thought to be responsible for the
  transmission of pain-producing impulses
• Acetylcholine responsible for transmitting
  motor nerve impulses
• Enkephalins reduces pain perception by bonding
  to pain receptor sites
• Norepinephrine causes vasoconstriction
• 2 types of chemical neurotransmitters that
  mediate pain
• Endorphins - morphine-like neurohormone thought
  to ? pain threshold by binding to receptor sites
• Serotonin - substance that causes local
  vasodilation ? permeability of capillaries
• Both are generated by noxious stimuli, which
  activate the inhibition of pain transmission
• Can be either excitatory or inhibitory

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Sensory Receptors

• Mechanoreceptors touch, light or deep pressure
• Meissners corpuscles (light touch), Pacinian
  corpuscles (deep pressure), Merkels corpuscles
  (deep pressure)
• Thermoreceptors - heat, cold
• Krauses end bulbs (? temp touch), Ruffini
  corpuscles (in the skin) touch, tension, heat
  (in joint capsules ligaments change of
  position)
• Proprioceptors change in length or tension
• Muscle Spindles, Golgi Tendon Organs
• Nociceptors painful stimuli
• mechanosensitive
• chemosensitive

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Sensory Receptors
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Nerve Endings

• A nerve ending is the termination of a nerve
  fiber in a peripheral structure. (Prentice, p.
  37)
• Nerve endings may be sensory (receptor) or motor
  (effector).
• Nerve endings may be
• Respond to phasic activity - produce an impulse
  when the stimulus is ? or ?, but not during
  sustained stimulus adapt to a constant stimulus
  (Meissners corpuscles Pacinian corpuscles)
• Respond to tonic receptors produce impulses as
  long as the stimulus is present. (muscle
  spindles, free n. endings, Krauses end bulbs)
• Superficial Merkels corpuscles/disks,
  Meissners corpuscles
• Deep Pacinian corpuscles,

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Nerve Endings

• Merkels corpuscles/disks -
• Sensitive to touch vibration
• Slow adapting
• Superficial location
• Most sensitive
• Meissners corpuscles
• Sensitive to light touch vibrations
• Rapid adapting
• Superficial location
• Pacinian corpuscles -
• Sensitive to deep pressure vibrations
• Rapid adapting
• Deep subcutaneous tissue location

• Krauses end bulbs
• Thermoreceptor
• Ruffini corpuscles/endings
• Thermoreceptor
• Sensitive to touch tension
• Slow adapting
• Free nerve endings -
• Afferent
• Detects pain, touch, temperature, mechanical
  stimuli

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Nociceptors

• Sensitive to repeated or prolonged stimulation
• Mechanosensitive excited by stress tissue
  damage
• Chemosensitive excited by the release of
  chemical mediators
• Bradykinin, Histamine, Prostaglandins,
  Arachadonic Acid
• Primary Hyperalgesia due to injury
• Secondary Hyperalgesia due to spreading of
  chemical mediators

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Pain Control Theories

• Gate Control Theory
• Central Biasing Theory
• Endogenous Opiates Theory

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Gate Control Theory

• Melzack Wall, 1965
• Substantia Gelatinosa (SG) in dorsal horn of
  spinal cord acts as a gate only allows one
  type of impulses to connect with the SON
• Transmission Cell (T-cell) distal end of the
  Second or neurons (SON)
• If A-beta neurons are stimulated SG is
  activated which closes the gate to A-delta C
  neurons
• If A-delta C neurons are stimulated SG is
  blocked which closes the gate to A-beta neurons

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Gate Control Theory

• Gate - located in the dorsal horn of the spinal
  cord
• Smaller, slower n. carry pain impulses
• Larger, faster n. fibers carry other sensations
• Impulses from faster fibers arriving _at_ gate 1st
  inhibit pain impulses (acupuncture/pressure,
  cold, heat, chem. skin irritation).

Brain
Pain
Gate (T cells/ SG)
Heat, Cold, Mechanical
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Gate Control Theory

• Sensory information coming from A? fibers is
  transmitted to higher centers in brain
• Pain message" carried along A? C fibers is not
  transmitted to second-order neurons and never
  reaches sensory centers

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Central Biasing Theory

• Descending neurons are activated by stimulation
  of A-delta C neurons, cognitive processes,
  anxiety, depression, previous experiences,
  expectations
• Cause release of enkephalins (PAG) and serotonin
  (NRM)
• Enkephalin interneuron in area of the SG blocks
  A-delta C neurons

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Endogenous Opiates Theory

• Least understood of all the theories
• Stimulation of A-delta C fibers causes release
  of B-endorphins from the PAG NRM
• Or
• ACTH/B-lipotropin is released from the anterior
  pituitary in response to pain broken down into
  B-endorphins and corticosteroids
• Mechanism of action similar to enkephalins to
  block ascending nerve impulses
• Examples TENS (low freq. long pulse duration)

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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

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Pain Management

• Therapeutic modalities can be used to
• Stimulate large-diameter afferent fibers( TENS,
  massage, analgesic balms)
• Decrease pain fiber transmission velocity (cold,
  ultrasound)
• Stimulate small-diameter afferent fibers and
  descending pain control mechanisms (accupressure,
  deep massage, TENS)

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Pain Management

• Therapeutic modalities can be used to
• Stimulate release of endogenous opioids through
  prolonged small diameter fiber stimulation with
  TENS

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Goals in Managing Pain

• Reduce pain!
• Control acute pain!
• Protect the patient from further injury while
  encouraging progressive exercise

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Other ways to control pain

• Encourage central biasing motivation,
  relaxation, positive thinking
• Minimize tissue damage
• Maintain communication w/ the athlete
• If possible, allow exercise
• Medications