PAIN

CONTENTS

1) Definition of Pain
2) Types of Pain
3) The Pain receptors and their Stimulation
4) Different types of Pain stimuli
5) Classification of nerve fibres
6) Receptor nerve ending
7) Pain pathway
8) Pain theories(Neurophysiologic explanation of pain control)
9) Pain modulation
10) Pain Assessment
11) Pain Management

Definition of Pain:
Pain is defined as unpleasant sensory and emotional experience that is associated
with actual or potential tissue damage
Pain is a protective Mechanism, It occurs whenever any tissue damaged and causes the
individual to respond to remove the Pain stimulus.
Eg: Prolonged sitting on the Escher can cause tissue damage due to lack of blood flow to the
skin.
The perception of pain in turn prevents potential damage by making us respond with an
alteration of posture.

Types of Skin
Pain has been classified into 2 major types
i) Fast pain
ii) Slow pain

Fast pain
It occurs within 0.1 second after the pain stimulus is applied. It is also described by many
alternate names such as
Sharp pain
Prickling pain
Acute pain
Electric pain

This type of pain felt when a needle is stuck into the skin or when the skin is cut with a knife.
It is felt only superficial tissues of body.

Slow Pain
It begins only after a second or more and then increase slowly over many seconds and
sometimes even minutes.
It is also called by names such as:
Burning pain
Aching pain
Throbbing pain
Nervous pain
Chronic Pain

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It is associated with tissue distruction. It can occur both in the skin and almost any deep tissue
or organ.
Fast type of pain – A d fibers
Slow type of pain – C fibers

PAIN RECEPTORS AND THEIR STIMULATION:

All pain receptors are free nerve endings that line the skin tissues.
Pain receptor’s Classification includes:
i) Touch Sensitive- Meissner’s corpuscles
ii) Cold sensitive- Krausels end bulb
iii) Heat Sensitive- Ruffinie’s end organ
iv) Pain sensitive- free nerve endings
v) Pressure sensitive- Pacininian Corpuscles

Different types of Pain stimuli:

1) Based on physical energy source:
a) Electro magnetic
b) Chemical
c) Gravity
d) Mechanical displacement
e) Sensibility
f) Mechanical
g) Thermal
h) Others
-Social
- Psychology
-Behavioral
Classification of nerve fibers
Fiber A Fiber B Fiber C
Myelinated Myelinated unmyelinated
Afferent pre ganglionic somatic
Efferent sympathetic efferent

Pattern Theory:-
The sensation of pain results from an appropriate intensity (or) frequency of stimulation of
receptors that also respond to other stimuli such as touch, pressure, or temperature.

This theory denotes pattern or coding of sensory information is the key element the coding is
temporal and spatial sequency of action – potentials are generated in periphery.
This theory considers the intense stimulation of non specific receptors as the adequate
stimulus for eliciting pain sensation.

A touch stimulus applied to a receptor produces a particular pattern of action potentials the
resultant sensation is touch.

A potentially damaging touch stimulus applied to the receptors produces a different pattern of
action potentials resulted sensation is pain.

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Fig: shows (a & b) pattern of action potentials resulting in sensation of pain
According to this theory neural impulses from the periphery are combined and modified to
summate in CNS structures, where the pain is then localized and interpreted.

According to pattern theory, Temporal and spatial summation of impulses along the pathway
from the skin to the cerebral levels determines the individuals sensation of pain (fig B)

Gate Control Theory:

Postulated by Melzack & Wall, 1965
Dorsal horn of spinal cord act like a gate that can increase or decrease the flow of nerve
impulses, from peripheral fibers to spinal cord cells that project to the brain.
(Pre synaptic inhibition of pain)

Stimulation of A B receptors mechano receptors (Deep pressure like massage manual theory)

Pre synaptic inhibition

Suppression of pain from A δ and C fibers (Nociceptors)

Stimulation of A δ fiber (Low Tens)
Interneuron (Encephalin)
Presynaptic inhibition of C fiber pains

Assessment of pain:-

OPQRST Format : Normal musculoskeletal Examination

Origin\ onset : Gradual\sudden
How did pain started.

Position\pattern :Constant\ periodic

Localized\ Radiating
Aggravating & Relieving factory
Improving\ non screening\ remaining

Quality of pain : Mechanical – pressing – bursting - stabbing

Chemical – burning
Neural – Numbness\ pins & needles
Vascular – Throbbing

Quantity of pain : Intensity of pain.

Radiation - Characteristics of pain radiations

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Symptom\signs – Functional\ Psychological

Treatment – previous Rx, Current Rx effectiveness

2) Pain Rating Scales.
3) Body diagram scale - used to show location
4) Sickness impact profile scale
5) Visual Analog scale (VAS scale)
6) MCGILL pain Questionnaire - Examines Quality and Complexity of pain experience
7) (OSTDS pattern - Onset, Site, Type, Time, Duration, Severity, Aggravating and relieving
factor)

Neurobiology and Molecular Biology of Pain:

Chemical agents released as a result of local tissue damage mainly stimulate nociceptors

1) Substances that stimulate nociceptors

a) Protons
b) Neuro transmitters
Serotonin
Histamine
Ach

c) Poly peptides - Bradykinin

Kallidin
d) Prostaglandins
e) Cellular Metabolities
f) Spicy plants – Capacin (red pepper)
Capsicum (Black pepper)

Chemical Class Facilitation/ Excitations Inhibitory

Neurotransmitter Neurotransmitter
Amino Acids Aspartate GABA
Glutamate Glycine
Peptides Substance P Enkaphalis
Dynorphilis
Vaso Intestine Peptide Endorphins
Histamine
Seratonin
Ach
Bradykinin
Kallidin
Prostaglandin

Leukotrins

Physiotherapy in Pain Management:

Such as

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 • Heat – superficial heat –Hot pack
• Ice/Cold/Cryotherapy
• TENS
• IFT
• UVR
• Ultra Sound Therapy
• MWD
• SWD
• IRR
• Laser

Heat:

Pain decreases

Ischemic Pain is relieved by the influx of oxygen – rich blood into the dilated vessels’' and

Muscle tension pain is decreased by inhition of the pain/spasm cycle.

1) Conductive heating – Moist heat packs

Paraffin Wax bath
2) Corrective heating - Hydrotherapy
Contrast bath

3) Radient heat Superficial 1) Infra. Red

2) Ultraviolet

Deep Diathermy- Short

- Micro
Micro therm

PT Treatment of patient with pain

Successful treatment of pain involves identifying and connecting its cause.

Numerous physical modalities can be applied to the tissues to relieve pain.
These include
1) Superficial heat
2) Deep heat
3) Cryotherapy
4) Phonophoresis
5) Iorstophoresis
6) Laser therapy
7) Tens
8) Point stimulation (Electro Acupuncture)
9) Joint mobilisation
10) Therapeutic touch
11) Myofacial release (MFR)
12) Massage and as well as effective cognitive measures

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Moist Heat

Moist heat is a safe analgesic muscle relaxant

a) Mechanism for pain relief
i) Heat is gamma fibre activity by decreasing muscle spindle activity via the direct effect of heat
on skin receptors.
ii) Quick worming of the spindles causes a temporary complete inhibition of the firing of the
spindles.
iii) Central proprioception mechanism is also affected by reflex action of heat. Raising the
body temperature causes decreases gamma activity.

b) Heat reduces the conduction velocity of the ‘C’ Nerve fibres.

Injury/disease alters the thermal threshold of pain – Heat alters this thermal threshold of pain
thereby decreasing pain.

C) Counter irritant effect of heat also relieves pain.

d) Rise in a temperatures also causes circulation, which in turn removes pain

metabolities thus breakdown of the vicious cycle of pain and muscle spasm.

Effect of heat of pain relief

1) increased metabolism: Output of waste products from the cells in ed

2) Heat has a direct effect on the blood vessels: Causes vasodilatation of blood vessels, flow
of blood through the area, so necessary oxygen and nutritive materials are supplied and
waste products are removed less pain.

2. CRYOTHERAPY:

i) Peripheral nerve conduction velocity decreases by 2.4m/s per degree Celsius.

ii) Peripheral receptors become less excitable
iii) Muscle spindle responsiveness to stretch decreases as a result muscle spasm
decreases.
iv) Circulatory effects – Lewis’s hunting reaction –following the application of cold there is
initial vasoconstriction, followed by vasodilatation.
v) Cellular metabolic activity: The oxygen required for the cell

Indications:
i) pain and muscle spasm
ii) Acute inflammation following trauma PRICER protocol
iii) Chronic inflammation following trauma
iv) Spasticity
v) Facilitation of movement.
Contra Indication:
i) PVD’s

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 ii) Cardiac disease
iii) Loss of sensation
iv) Cancer and sickle cell anemia
v) Brief icing over the posterior primary organs of the trunk

Disadvantages:
i) Impaired skin sensation
ii) Burns
iii) Neurological pain cryotherapy is better than thermotherapy

TENS

HIGH TENS LOW TENS

High frequency, low intensity
(100HZ, 50usec, 0-30mA)
Stimulates large diameter affrents( A B)
produces “Pre Oynaptic Inhibition” of
Aδ and C fibers at the level of SG(DHS)
Onset Pain relief: Fast
Relief is short lived
Resistance is more
Neural accommodation develops
Good for acute pain relief
Low frequency, high intensity
(2H2, 200usec, 30-80ms)
It gives a nociceptive stimulus acts by
descending pain inhibiting pathway by
stimulation of the release of enkephalinus and
endarphis
Onset pain relief: Slow
Relief lasts for hours or days
Good for chronic pain

4. IFT (Inter ferential Therapy)

Effects:
i) Activation of pain gate control mechanism
ii) Activation of nociceptive fibres
iii) Physical block
iv) Blood flow
v) The placebo effect

Advantages:

i) It is effective if pain is radiating type.

ii) Can penetrate skin by means of medium frequency currents.

5. UVR (Ultra Violet Radiation)

Effects: Counter irritant effect relieves pain, enhances healing of pain

6. ULTRA SOUND THERAPY

Deep heat also accomplished through use of ultrasound.

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Therapeutic effects are:
1) Selectively raise tissue temperature at the interfaces without causing substantial change
in the surrounding tissues.
2) The amount of heat produced depends directly on the dosage. At les than 1.0 watt there
is aminimal in tissue temperature. At 1.5 watt the superficial tissues are geated and at
greater than 2.0 watt temperature of the deeper tissues is raised.
3) Ultrasound therapy of C fibres yields pain relief distal to the point of application
4) Ultrasound therapy of large diameter Aδ fibers brings relief of spasm by changing
gamma fiber activity.

7. Microtherm

Microtherm converts electrical energy into the electrical magnetic energy that can be focused
on the tissue of choice.

Temperature results when the electromagnetic waves are absorbed by the tissues.

Microwave is far more exact than diathermy and is indicated where getting of individual deep
structure is desired.

8. PHONOPHORESIS

Molecules of a pain relieving chemical substance into the tissues. Once substance molecules
are broken down into ions and taken up into the cells, where they participate in intracellular
chemical reactions.

Chemical solutions + a conducting gel = conducting media

9. SHORT WAVE DIATHERMY

1) relief of pain: localized tissue temperature, blood circulation to that part, metabolism
processed, nutrients are supplied, ever already accumulated, metabolities noxious
substances are washed away from the part
2) by acting on superficial: sedative effect, muscle relaxation, pain
3) strong superficial heating probably relieves pain by counter irritation
4) S.W.D does the effecting resolution of inflammatory process, so indirectly relieving pain.

10. INFRA RED RADIATION

Therapeutic uses

i) Relief pain
ii) When healing is mild the relief of pain is probably due to the sedative effect on the
superficial sensory nerve ending.
iii) Stronger heating stimulates the superficial sensory nerve endings.

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iv) It has been found that pain may be due to the accumulation in the tissues of waste
products of metabolism and ed blood flow through the part removes these substances
and relieves pain.

In some cases the relief of pain is probably associated with muscle relaxation. Pain due to
acute inflammation/ recent injury is relieved effectively with mild heating.

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