Dr.FOUZIA BATOOL PT.

PP-DPT Lecturer, RCRS

 Electrical

Nerves Pain Assessment Scales Pain Gate Theories

Stimulation of

Electrical Stimulation of Nerves

Normal physiology of nerves:

Difference

in potential between the inside and outside of a nerve Difference in concentration of ions inside and outside the plasma membranes

Polarized stage of the membrane

Resting

nerve is positive outside and negative inside Plasma membrane is not permeable to sodium ions

Resting Membrane Potential

OUTSIDE
K+

Na+

ClForce of Diffusion

Electrostatic Force

+++++++++++++++++++++++++++++++++++++++++++

open channel

Closed channe l

3Na/2K no pump channe l

open channel

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - Force of Diffusion Electrostatic Force

INSIDE
- 65 mV

K+

Na
+

Cl-

Pr7

K+ = Potassium; Na+ = Sodium; Cl- = Chloride; Pr- = proteins

 Stimulation

of nerve by the stimulus Fall in the potential difference Alteration in the permeability of the membrane to sodium ions Alteration in the concentration of ions inside and outside the nerve membrane Reversal of polarity

Phase 0

Phase 1

Stable resting potential When a stimulus above the threshold potential strikes the cell the cell begins to depolarize. Sodium ions rush into the cell causing the electrochemical difference potential between the inside and outside of the cell to race toward zero
The depolarization phase The electrochemical voltage change is so rapid that the voltage overshoots the zero potential and tops out around +20mV

Phase 2

Phase 3

Plateau phase The trans-membrane action potential is maintained near 0mV by the infusion of calcium ions. At the end of this phase, the cell begins to repolarize.
Rapid repolarization phase The cell restores itself to the original polarized state of -70mV

Initiated by Electrical Stimulus A varying current of adequate intensity must be applied PD is set up across it as the current flows If the PD falls below the level at which the membrane become permeable to sodium ions, these ions begin to enter the axon and initiates the series of events for initiation of nerve impulse

 Adaptation

of nerve due to constant flow of current Unvarying current is not effective in initiating an impulse

Sensory nerve is stimulated the downward traveling impulse has no effect, but upward traveling impulse is appreciated when it reaches brain Sensory stimulation experienced varies with the duration of the impulse Long duration produce an uncomfortable, stabbing sensation Less duration produces less uncomfortable, stabbing sensation Impulses of 1ms and less produces a mild prickling sensation

The upward traveling impulse is unable to pass the first synapse, as it is traveling in the wrong direction, but the downward-traveling impulse to the muscles supplied by the nerves, causing them to contract Stimulus applied to a motor trunk, impulses pass to all the muscles that the nerve supplies below the point at which it is stimulated, causing them to contract

Single stimulus____ simultaneously to a number of motor units resulting in brisk contraction, followed by immediate relaxation If one stimulus is applied per second, each produces an isolated contraction and there is time for complete relaxation between the impulses

Increase frequency shortens the periods of relaxation Frequency more than 20Hz there is no time for complete relaxation between the contraction_____ resulting in partial tetany Frequency more than 60Hz there is no perceptible relaxation ____resulting in full tetany

Factors influences: Number of motor units activated Intensity of current applied Rate of change of current If intensity of current suddenly rises there is no time for accommodation to take place and a muscle contraction results

If the current rises more slowly, there is some accommodation and a greater intensity is needed to produce a contraction

Pain Assessment scale

PAIN RATING SCALE

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

Physiological response produced by activation of specific types of nerve fibers Experienced because of nociceptors being sensitive to extreme mechanical, thermal, & chemical energy. Behavioral indicators of pain are crying, mood changes and from facial expression. One of the bodys defense mechanism Acute vs. Chronic

Visual & Numeric Analogue 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

0 No pain Feeling perfectly normal

1 (Very Mild):

Does not interfere with most activities Able to adapt to pain psychologically and with medication or devices such as cushions

Very light barely noticable pain 2 (Discomforting)

Minor pain, like lightly pinching the fold of skin between the thumb and first finger with the other hand, using the fingernails Very noticable pain, like an accidental cut, a blow to the nose causing a bloody nose, or a doctor giving you an injection

3 (Tolerable):

Interferes with many activities, Interferes with many activities Requires lifestyle changes but patient remains independent

4 Distressing

Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard Strong, deep, piercing pain, such as a sprained ankle when you stand on it wrong, or mild back pain

5 Very Distressing

6 Intense

At this point you begin to have trouble holding a job or maintaining normal social relationships

Unable to engage in normal activities Patient is disabled and unable to function independently The pain completely dominates your senses, causing you to think unclearly about half the time Pain so intense you can no longer think clearly at all, and have often undergone severe personality change if the pain has been present for a long time

7 Very Intense

8 Utterly Horrible

9 Excruciating Unbearable

Pain so intense you cannot tolerate it and demand pain killers or surgery, no matter what the side effects or risk Those who have suffered a severe accident, such as a crushed hand, and lost consciousness as a result of the pain and not blood loss, have experienced level 10. Pain so intense you will go unconscious shortly

10 Excruciating

Cutaneous Pain sharp, bright, burning; can have a fast or slow onset Deep Somatic Pain from tendons, muscles, joints, periosteum, & blood 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

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 @ rate of 15 pulses/sec. The larger A-delta fibers carry impulses @ rate of 40 pulses/sec.

Types of Nerves 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

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

Types

Stimulated by sensory receptors End in the dorsal horn of the spinal cord

A-alpha non-pain impulses A-beta non-pain impulses

A-delta pain impulses due to mechanical pressure

C pain impulses due to chemicals or mechanical

Large, myelinated Low threshold mechanoreceptor; respond to light touch & lowintensity mechanical response Large diameter, thinly myelinated Short duration, sharp, fast, bright, localized sensation (prickling, stinging, burning)

Small diameter, unmyelinated Delayed onset, diffuse nagging sensation (aching, throbbing)

Receive impulses from the FON in the 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

Types

Travel along the spinothalmic tract Pass through Reticular Formation Ends in thalamus

Wide range specific Nociceptive specific

Receive impulses from A-delta & C Receive impulses from A-beta, A-delta, & C

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

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

Mechanoreceptors touch, light or deep pressure

Thermoreceptors - heat, cold

Meissners corpuscles (light touch), Pacinian corpuscles (deep pressure), Merkels corpuscles (deep pressure) Ruffini corpuscles (in the skin) touch, tension, heat; (in joint capsules & ligaments change of position)

Proprioceptors change in length or tension Nociceptors painful stimuli

Mechanosensitive Chemosensitive

Muscle Spindles, Golgi Tendon Organs

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

 Gate

Control Theory Central Biasing Theory Endogenous Opiates 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 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

Gate - located in the dorsal horn of the spinal cord Smaller, slower n. carry pain impulses Larger, faster n. fibers carry other sensations
Brain

Gate (T

Pain Heat, Cold, Mechanical

cells/ SG)

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

Least understood of all the theories Stimulation of A-delta & C fibers causes release of B-endorphins from the PAG & NRM
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)
Or

 Claytons

Electrotherapy Electrotherapy by Muhammad Salabat Khan