Moderator: Mrs.Kavitha.Vishal Presented by : Ms. Rajitha.

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Introduction  Pain models  Physiotherapy management  Psychological management  Medical management  Surgical management 

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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.

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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

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Acute :Caused by tissue damage or irritating stimulation in relation to bodily insult or disease.

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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.

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Other types :

Radiating Non radiating

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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

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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

Biomedical model.  Linear bottom up model.  Top down model.  Biopyschosocial model.  Fear and avoidance. 

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Disability and impairment reflection of underlying tissue and system pathology.

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Seven stages: 1.pain and deconditioning 2.fear and avoidance 3. depression , anxiety and frustration 4. iatrogenic 5. family 6.socioeconomic 7. occupational factors

1. 2. 3. 4. 5. 6. 7.

Personality Social context Culture Attitudes and behaviour of health professionals Past experience State of mind Avoidance behaviour and cognitive processes

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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

Various forms of modalities and techniques are available: Modalities: TENS, IFT , US , ELECTRICAL STIMULATION, TRACTION .
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Cryotherapy and heat therapy Techiques: mobilization, manipulation. Therapeutic exercise

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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.

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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

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Amp:- 0-50 mA Pulse width 200µs Pulse frequency:- 1-150 Hz

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The gate control theory is based : on presynaptic inhibition of pain information produced by mechanical stimulation, and provides the basic rationale for the TENS.

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Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritis knee pain? Clinical Rehabilitation 2002; 1 6: 749±760

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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.

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A good number of studies (Hurley et al 2004, Jhonson and Tabssam et al 2003) provide substantive evidence for pain relief effect of IFT.

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Comparison of the analgesic efficacy of interferential therapy and transcutaneous electrical nerve stimulation ? Physiotherapy 92 (2006) 247±253

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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 therapy:  Increased circulation.  Increased collagen extensibility.  Eliminates waste products.
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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

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Thermotherpy: SWD MWD IRR

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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

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Physiological and therapeutic effects: Circulatory effects Neural effects

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Contrast bath: circulatory effect modulates the pain.

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. 

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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.

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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

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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

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Improvement of tissue fluid exchange Improvement of mobility of nervous system and alteration in the state of neural hyperplasia Psychological effects of being carefully assessed and treated sympathetically

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Classification« Soft tissue techniques (massage) Regional mobilisation Localised mobilisation Regional manipulation Localised manipulation

1. 2. 3. 4. 5.

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Ergonomic modification«. Prevention of work related pain should be prioritized. Acute and chronic pain.

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

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Electroaccupuncture: needles are connected to electrical stimulator.

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Placebo effect Biofeedback Hypnosis Counselling Behaviour modification Group therapy Music therapy Improving confidence and morale Cognitive therapy

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Education Goal setting and pacing Physical Exercise Exercise adherence Reducing pain behavior Relaxation Sleep management Relapse self ± management

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Teaches the muscle relaxation . Self regulation of pain. Commonly used in chronic pain.

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Systemic agents«

Non opoid analgesics: 1. Non steroidal drugs : paracetomol,nefopam 2. Non steroidal anti-inflammatory drugs: aspirin,azapropazone Opoid analgesics:
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Anaesthetic treatments: 1. local anesthesia 2.nerve block 3. steroid injections

1. 2. 3. 4.

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Peripheral neurectomy sympthectomy Spinal dorsal rhizotomy Anterolateral cordotomy spinothalamic tractotomy Dorsal root entry zone (DREZ) procedures, spinal and medullary Commissural myelotomy

7. Facet rhizolysis 8.Neurostimulation procedures: peripheral nerve stimulation spinal cord stimulation deep brain stimulation 9. Epidural spinal and intrathecal opioid administration

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.