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Pain Management

Moderator: Mrs.Kavitha.Vishal
Presented by : Ms. Rajitha.A
Overview….
 Introduction
 Painmodels
 Physiotherapy management
 Psychological management
 Medical management
 Surgical management
Introduction….
 Pain is defined by international association
study of pain as unpleasant sensory and
emotional response to a stimulus associated
with actual or potential damage or described
in terms of such damage.
 To perceive pain there must be:-
◦ A specific form of energy which activates a sense
organ
◦ The connection within the spinal cord and brain
must be so arranged that the activity becomes
conscious
Classification……
 Acute :-
◦ Caused by tissue damage or irritating stimulation in
relation to bodily insult or disease.

 Chronic:-
◦ Described as a persistent pain that is not amenable
to treatments based on specific remedies or to
routine methods of pain control
◦ It does not serve as a biologic purpose indicative of
tissue damage or irritation.
 Other types :

Radiating

Non radiating
Subjective classification ..
 Dull ache – discomfort during activity
 Slight pain – awareness of pain without

distress
 More than – pain that distracts attention

slight pain during physical exertion


 Painful – pain that distracts attention

from routine occupations


such as reading and writing
 Very painful – pain that fills the field of
consciousness to the
exclusion of other events
 Unbearable pain – comparable to the worst

pain you can imagine


Pain models….

 Biomedical model.
 Linear bottom up model.
 Top down model.
 Biopyschosocial model.
 Fear and avoidance.
Biomedical model….
 Disability and impairment reflection of
underlying tissue and system pathology.
Biophyschosocial model..
 Seven stages:
1.pain and deconditioning
2.fear and avoidance
3. depression , anxiety and frustration
4. iatrogenic
5. family
6.socioeconomic
7. occupational factors
Factors influencing pain perception
and pain behaviour…….
1. Personality
2. Social context
3. Culture
4. Attitudes and behaviour of health
professionals
5. Past experience
6. State of mind
7. Avoidance behaviour and cognitive
processes
Pain modulation…..
 Pain is modulated by two primary types of
drugs:
1. analgesic
2. anesthesia
 Neural circuits that modulate the pain:
1. gate control theory
2.biochemical theory
3. neuromatrix theory
Physical therapy management
for pain ……
Various forms of modalities and techniques
are available:
Modalities: TENS, IFT , US , ELECTRICAL
STIMULATION, TRACTION .

Cryotherapy and heat therapy

Techiques: mobilization, manipulation.

Therapeutic exercise
TENS….
 Works on the principles of pain gate theory.
 Large myelinated A-beta fibres act as the

vehicle for tens


 These fast transmitting fibres will conduct

electrical impulse quickly making the slower


conducting C fibres unable to pass their
message
 Pre synaptic inhibition.
 Studies (wall and gutnik 1974) shows that
proximal application of vibration or electrical
stimulation dampens or stops abnormal firing
at the damaged end of the nerve
 Thus TENS have a mechanical effect on the e

damaged nerve to lessen the abnormal firing


TENS apparatus....
 Amp:- 0-50 mA

 Pulse width 200µs

 Pulse frequency:- 1-150 Hz


 The gate control theory is based :
on presynaptic inhibition of pain
information produced by mechanical
stimulation, and provides the basic rationale
for the TENS.
 Does four weeks of TENS and/or isometric
exercise produce
cumulative reduction of osteoarthritis knee
pain?
Clinical Rehabilitation 2002; 1 6: 749–760
Interferential stimulation.....
 Effects on pain relief

◦ Activate pain gate


◦ Activation of nociceptive fibres
◦ Physiological block
◦ Increased blood flow
◦ Placebo effect
◦ Can also achieved by reticular formation by
reticular formation by 10-25hz by blocking
C fibre transmission.
 A good number of studies (Hurley et al 2004,
Jhonson and Tabssam et al 2003) provide
substantive evidence for pain relief effect of
IFT.
 Comparison of the analgesic efficacy of
interferential therapy and transcutaneous
electrical nerve stimulation ?

Physiotherapy 92 (2006) 247–253


Ultrasonic therapy.....
 Effects
◦ Thermal effects
◦ Non thermal effects
1.Micro massaging
Dosage
Frequency:-
1-3 MHz
Intensity
1.Varies
2.Usually a max of 3W/Cm2
Heat and cold therapy…
 Heat therapy:
 Increased circulation.
 Increased collagen extensibility.
 Eliminates waste products.

Pain modulation by heat:pain gate theory


Thermal sensation is carried to the posterior
horn cells in large diameter fibres
It closes the gate to small diameter fibres
 Thermotherpy:

SWD
MWD
IRR
 Cold therapy…

Indirect effect on the nerve fibers and sensory


end organs
Decreased temperature reduces the firing rate
of the muscle spindle and decreases the
painful muscle tone
 Physiological and therapeutic effects:

Circulatory effects

Neural effects
 Contrast bath:
circulatory effect modulates the pain.
Therapeutic exercise…
 Prescribed to correct a specific abnormal
condition , is often used to treat the acute as
well as chronic painful conditions.
 Recent studies report that therapeutic

stretching exercises , similar to the YMCA


program developed by Kraus are effective in
the management of chronic low back pain.
 Advice to rest in bed versus advice to stay
active for acute low-back pain and sciatica?

Cochrane Database of Systematic Reviews


2010, Issue 6.
Manipulation….
 Pain and restricted movement or occasionally
excessive movement has resulted in trauma,
Degenerative change and long term postural
stress.

 Efeects:
To decrease pain

Decrease muscle spasm

Improve mobility of soft tissues and joints


Mechanism…

1.Alteration in the bias of sensory input from


the joints and soft tissues by an increase of
stimulation in the mechanoreceptors located
in them
2.Reflex effects upon spasm
3.Prevention of inelastic scar formation and
restoration of extensibility
4. Improvement of tissue fluid exchange
5. Improvement of mobility of nervous system
and alteration in the state of neural
hyperplasia
6. Psychological effects of being carefully
assessed and treated sympathetically
 Classification…

1. Soft tissue techniques (massage)


2. Regional mobilisation
3. Localised mobilisation
4. Regional manipulation
5. Localised manipulation
 Ergonomic modification….

o Prevention of work related pain should be


prioritized.
o Acute and chronic pain.
Adjunct therapy
Acupuncture….
 Pain relief:
o Acupuncture is form of neuromodulation.
o Pain control is based on two theories.
o Firstly, acupuncture may stimulates the large
sensory fibers and suppress pain perception,
as explained by the gate control theory of pain.
o Secondly, the needle insertion may act as a
noxious and induce endogenous production of
opiatelike substance effect pain control.
 Electroaccupuncture:

needles are connected to electrical stimulator.


Psychological treatment strategies..
 Placebo effect
 Biofeedback
 Hypnosis
 Counselling
 Behaviour modification
 Group therapy
 Music therapy
 Improving confidence and morale
 Cognitive therapy
Cognitive behavioral therapy(CBT)…
 Education
 Goal setting and pacing
 Physical Exercise
 Exercise adherence
 Reducing pain behavior
 Relaxation
 Sleep management
 Relapse self – management
Biofeedback….
 Teaches the muscle relaxation .
 Self regulation of pain.
 Commonly used in chronic pain.
Pharmacology of pain relief…
 Systemic agents…

o Non opoid analgesics:


1. Non steroidal drugs : paracetomol,nefopam
2. Non steroidal anti-inflammatory drugs:
aspirin,azapropazone
Opoid analgesics:
 Anaesthetic treatments:
1. local anesthesia
2.nerve block
3. steroid injections
Surgical procedure….
1. Peripheral neurectomy
2. sympthectomy
3. Spinal dorsal rhizotomy
4. Anterolateral cordotomy spinothalamic
tractotomy
5. Dorsal root entry zone (DREZ) procedures,
spinal and medullary
6. Commissural myelotomy
7. Facet rhizolysis
8.Neurostimulation procedures:
peripheral nerve stimulation
spinal cord stimulation
deep brain stimulation
9. Epidural spinal and intrathecal opioid
administration
Reference…
1.Pain management by physiotherapy .
By Peter E.Wells , Victoria Frampton , David
Browsher.second eddition
2. Therapeutic Modalities Fog Musculoskeletal
Injuries (second edition) – Craig R. Denegar,
Ethan Saliba, Susan Saliba.
3.Management of Common Musculoskeletal
Disorders (fourth edition) – Darlene Hertling,
Randolph M. Kessler.
4. Rehabilitation medicine. Principles and
practice . Second edition. By Joel A, Delisa J.B
Lippincott company .1993.
5.Surgical pain management. Core Curriculum
for Professional Education in Pain. 2005.
6. Electrotherapy .org
7. Cochrane review.
THANK YOU……

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