Chapter 10 Pain

Copyright 2005 Lippincott Williams & Wilkins

Chapter 10Pain


Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue

damage, or described in terms of such damage.

International Association for the Study

of Pain


Types of Pain

Acute Pain

Usually short lived and is associated with muscle strains, tendinitis, contusions, surgery or ligament injuries

Chronic Pain

Pain that persists after noxious stimulus has been removed.

Referred Pain

Pain that is felt at a site distant from the location of injury or disease.


Physiology of Pain – Source of Pain

Microtrauma

A long-standing or recurrent musculoskeletal problem that was not initiated by

an acute injury.

Macrotrauma

An immediately noticeable injury involving a sudden, direct, or indirect trauma.


Non-nociceptive Pain

Damage to central nociceptive system triggers non-nociceptive activity may elicit pain –

non-nociceptive pain (NNP)


Pain Pathway

NociceptionA&C fibers

Spinal cord

Spinothalamic tract

Ascending afferents

CNS

Lowered firing threshold

Receptive threshold expansion

Spontaneous discharge

Aberrant muscle activity

Articular dysfunction

Disordered proprioception

Non-nociceptive input


Pain Theory – Gate Control


Examination and Evaluation

Use of Questionnaires

Assess affective qualities of painAssess pain intensityAssess psychological aspects of pain


Pain Scales

Visual analogue scale (VAS) – Pain intensity

McGill Pain Questionnaire (MPQ) – More sensitive, but longer than VAS; three categories (sensory, affective, evaluative)


Disability and Health-Related Quality of Life Scales

Quality of Well-Being Scale (QWB) Sickness Impact Profile (SIP) Duke Health Profile (DHP) Short Form-36 (SF-36)

The Oswestry Low Back Disability Questionnaire Waddell Disability Index Disability Questionnaire Arthritis Impact Measurement Scales


Therapeutic Exercise Intervention for Pain

AcuteCombination of medication, gentle exercise,

ice (within first 24 hours).Exercise directed at restoring motion,

strength, and function.


Exercise Intervention for Chronic Pain

Often requires a team approach.Realistic goals and patient education are crucial.Goals may extend beyond treatment of

impairments.Exercise is used to inhibit pain, facilitate non-

nociceptive input, while addressing impairments and functional limitations.


Activity and Mode

Depends on source of pain and results of evaluation.

Should focus on awareness and use of proper posture.

Incorporation of movement therapies (e.g., Feldenkrais) is helpful in restoring movement patterns.

Aerobic exercise (low impact) is helpful for chronic pain.


Dosage

Dosage should not increase pain.Sessions may be brief initially to assess

response.Frequency is determined by activity type,

purpose, and quantity prior to experience of pain = “pain-free dosage.”

Functional progression to previous activity levels.


Adjunctive Agents

MedicationsMassage therapyRelaxation techniquesBiofeedbackPsychological care

AcupunctureHeatColdTranscutaneous

electrical stimulation (TENS)


Summary

Pain impairment occurs with most musculoskeletal conditions and must be treated as a primary impairment along with any secondary limitations that may result.

Nociceptors transmit pain via A&C fibers.

Information is processed w/in SC and then ascends via contralateral spinothalamic tract to thalamus.

Gate theory – Incoming information from non-pain receptors can close the gate to pain information.


Summary – (cont.)

Chronic pain may result from increased sensitization of nociceptors and spinal level changes that perpetuate + feedback loops in the pain-spasm pain cycle.

Descending impulses can influence pain perceptions through several mechanisms, including endogenous opiates.

Pain can be assessed through direct measurement tools (questionnaires).


Summary – (cont.)

Therapeutic exercise is a cornerstone of treatment for chronic pain.

TENS, heat, cold, and medications are components of a comprehensive treatment program.

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Chapter 10 Pain