Pain managment with modalities 1


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Pain managment with modalities 1

  2. 2.  An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term of such damage. -International Association For the Study of pain
  3. 3. NOCICEPTIVE NEUROPATHICSomatic Visceral• bones, joints • Organs –• connective tissues heart, liver,• muscles pancreas, gut, etc. Deafferentation Sympathetic Peripheral Maintained
  4. 4. • Aching, often constant• May be dull or sharp• Often worse with movement• Well localizedEg– Bone & soft tissue– chest wall
  5. 5.  Somatic pain and visceral pain are actually two very different types of pain. Somatic pain comes from the skin and deep tissues, while visceral pain comes from the internal organs. Both somatic pain and visceral pain are detected the same way: Nociceptors, or pain-detecting nerves, send an impulse from the painful site up through the spinal cord and to the brain for interpretation and reaction. This is called nociceptive pain, and differs from neuropathic pain, which is caused by nerve damage. Though they are detected in similar ways, somatic pain and visceral pain do not feel the same
  6. 6.  How Somatic Pain Feels Somatic pain is generally described as musculoskeletal pain. Because many nerves supply the muscles, bones and other soft tissues, somatic pain is usually easier to locate than visceral pain. It also tends to be more intense. Some chronic pain conditions caused by somatic pain include:
  7. 7. • Constant or crampy• Aching• Poorly localized• ReferredEg– CA pancreas– Liver capsule distension– Bowel obstruction
  8. 8.  How Visceral Pain Feels Visceral pain is internal pain. It comes from the organs or the blood vessels, which are not as extensively innervated, or supplied by, sensory nerves. Unlike somatic pain, visceral pain may feel dull and vague, and may be harder to pinpoint. Some common types of visceral pain include:
  9. 9. COMPONENT DESCRIPTORS EXAMPLES Steady, • Burning, Tingling • Diabetic neuropathy Dysesthetic • Constant, Aching • Post-herpetic • Squeezing, Itching neuropathy • Allodynia • Hypersthesia Paroxysmal, • Stabbing • trigeminal neuralgia Neuralgic • Shock-like, electric • may be a component • Shooting of any neuropathic pain • Lancinating
  10. 10.  MECHANORECEPTORS -Meissner’s Corpuscles (light touch) - Pacinian corpuscles (deep pressure) - merkels corpuscles (deep pressure) THERMORECEPTOR -krauses end bulbs (decrease temperature, touch ) -ruffini corpuscles( in the skin) PROPRIOCEPTOR -muscle spindle , golgi tendon NOCICEPTOR
  11. 11.  ACUTE:  onset is well defined,  response to tissue injury,  responds to pain treatment,  associated with anxiety,  affects the individual CHRONIC PAIN:  Onset is ill defined,  response to change in nervous system,  less response to medication,  associated with depression,  involves social network
  12. 12.  MELZACK & WALL,1965- Substentia 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 B-delta and C neurons are stimulated- SG is blocked which closes the gate to A-beta neurons
  13. 13.  Gate - located in the dorsal horn of the spinal cord Smaller, slower nerve carry pain impulses Larger, faster nerve fibers carry other sensations Impulses from faster fibers arriving at gate 1st inhibit pain impulses (acupuncture/pressure, cold, heat, chem. skin irritation). Brain Pain Gate (T cells/ SG) Heat, Cold, Mechanical
  14. 14.  Descending neurons are activated by: stimulation of A-delta & C neurons, cognitive processes, anxiety, depression, previous experiences, expectations which Cause release of enkephalins (PAG). Enkephalin interneuron in area of the SG blocks A-delta & C neurons
  15. 15.  Least understood of all the theories Stimulation of A-delta & C fibers causes release of B- endorphins from the PAG Mechanism of action – similar to enkephalins to block ascending nerve impulses Examples: TENS (low freq. & long pulse duration)
  16. 16.  Unlike specificity theory, pattern theory suggests that there are no separate systems for receiving pain, but instead the nerves are shared with other senses like touch. The most important feature of pain is the pattern of activity in the nervous system. So, too much stimulation (eg too much touch) will cause pain.
  17. 17.  Reduce pain! Control acute pain! Improve healing process Reduce inflammation and edema Decrease spasm and improve muscle contraction
  18. 18.  Use to control pain Muscle spasm decrease as result of  decrease activity in gamma motor efferent,  decrease excitability of muscle spindle and  increase activity of Golgi tendon organs
  19. 19.  Moist heat packs and paraffin are examples of therapeutic conductive heating Therapeutic convective heating take place during hydrotherapy Therapeutic radiant is supplied infrared
  20. 20.  Cold therapy is the best modality for acute inflammatory reactions like:  Acute inflammation of the bursa (bursitis)  Epicondylitis (tennis elbow, golfer’s elbow)  Acute trauma Cold therapy reduce:  Muscle spasm secondary to:  Underlying joint and skeletal pathology  Nerve root irritation  Edema, hyperemia (excess blood in tissue) and pain  Due to its vasoconstrictive (constriction of blood vessels) effect
  21. 21.  A local decrease in tissue temperature Reduction in metabolism Vasoconstriction (initially) Reduce blood flow (initially), Reduce muscle excitability, muscle spindle activity Reduce nerve conduction velocity Reduction in lymphatic and venous drainage Reduce Decrease formation and accumulation of edema Anesthesia
  22. 22.  After some minutes the vasoconstriction may give way to a marked vasodilatation which it self may last some 15minute before being replaced by another episode of vasoconstriction This alteration is called the “Lewis hunting reaction” (Lewis, 1930), in the sense that the vessels hunts about its mean position
  23. 23.  Electromagnetic waves that produce heat Frequency of 27.12 MHz and wavelength > 11 m. Use in  muscle spasm- pain relief,  Delayed healing  Chronic inflammation- increase blood circulation  Fibrosis- increases extensibility of fibrous tissue
  24. 24.  Principle effect is production of heat in the tissues ↓ rise temperature of that part ↓ Relaxation of muscle and increase the efficiency of their action ↓ Increase blood supply ensuring the optimum condition for the muscle contraction.
  25. 25. parameters Chronic condition Acute conditionIntensity comfortable warmth Below sensation of warmthDuration 20 minutes 10 minutesFrequency Daily Twice a day
  26. 26.  Electromagnetic radiation Frequency 2450 MHz and wavelength 12.245 cm Relief pain- in traumatic and rheumatic condition Muscle spasm Inflammation- increase blood supply and resorption of edema Delayed healing- promote healing
  27. 27.  Principle effect is production of heat in the tissues ↓ rise temperature of that part ↓ Relaxation of muscle and increase the efficiency of their action ↓ Increase blood supply ensuring the optimum condition for the muscle contraction.
  28. 28.  To produce deep tissue heat by molecular friction It helps to:  Decrease the joint pain  Prepare the joint for mobilization/manipulation  It can break adhesions and calcification (e.g. calcific bursitis)  Combined with deep tissue massage (trigger point therapy) it is effective for treatment of myofascitis
  29. 29.  It is impossible to treat C or A fiber selectively, ultrasound provides both pain relief and relief from muscle spasm Sounding of C fibers produce pain relief whereas sounding of large diameter fibers bring relief of spasm by changing gamma fiber activity, making muscle fiber less sensitive to stretch.
  30. 30.  Transcutaneous Electrical Nerve stimulation TYPES  High tens or conventional tens (high freq:100-150Hz, law intensity:12-30mamp)  Low tens or acupuncture tens (high intensity:300mamp, law freq:1-5Hz)  Burst tens(50-150Hz)  Brieftens (high freq:100Hz, law intensity:20-50mamp)  Modulated tens
  31. 31.  Tens selectively stimulates the low- threshold, large-diameter A-beta fibers It resulting in presynaptic inhibition within the dorsal horns Tens delivered at low rate is thought to facilitate elevation of the level of endogenous opiates in the CNS
  32. 32. Pulse shape Rectangular type impulses Pulse width 100 microsecond, generally 50 microsec- 300 microsec Inensity 0 – 60 milliamp, satisfactory intensity till tingling sensationFrequency range effect1 – 250 pulse per second decrease pain50 – 100 pps sensory level (high level)2 – 3 pps Motor level (low level)2 pps Increase in the pain threshold
  33. 33.  short frequency therapeutic current Types  Plain  Surged faradic Its use  Muscle contraction that is inhibited by pain  Pumping action which result in increase venous and lymphatic returns
  34. 34.  Chemical ions are driven through the skin by small electrical current Ionizable compounds are placed on the skin under the electrode, which when polarized by direct(galvanic) current, repels the ion of like charge into the tissue Ions are known to be effective analgesics:  Xylocain  Hydrocortisone  Manesium  Iodine  salicylate
  35. 35.  Light amplification by stimulated emission of radiation A low intensity laser therapy is used It resolve inflammation and infection Reduce pain Increase speed, quality and strength of tissue repair TYPES:  Rubby laser,  Helium-neon laser,  Diod laser
  36. 36. Laser―photons ↓ Visible red light absorbed in the mitochondria, infrared light absorbed at the cell membrane ↓Single oxygen production ↓Formation of proton gradients across cell membrane and across membrane of mitochondria ↓Physiological changesChange in cell membrane permeabilityIncrease ATP levels-DNA productionInfluences cell metabolism ↓Activation of regulatory process
  37. 37. 1) Power Density (W/cm2) = Laser Output Power (W)/Beam area (cm2)2) Beam Area (cm2) = Diameter(cm)2 x 0.78543) Energy (Joules)=Laser Output Power (Watts) x Time(Sec)4) Energy Density (Joule/cm2)=Laser Output Power (Watts) x Time(Sec)/Beam Area (cm2)5) Treatment Time (Seconds)=Energy Density (Joules/cm2)/Output Power Density (W/cm2)
  38. 38. THANK YOU!