Management of pain can be approached through physical, cognitive, and behavioral means. Physical interventions include therapies like thermotherapy, ultrasound, phonophoresis, cryotherapy, TENS, iontophoresis, massage, myofascial release, joint mobilization, therapeutic touch, and point stimulation. Cognitive strategies involve relaxation exercises, body scanning, and humor to change thoughts about pain. Behavioral manipulations use exercise, operant conditioning, hypnosis, and biofeedback to produce behavioral changes that reduce pain.

1. Management of Pain

2. It is broadly divided into 3 approaches:
1) Physical intervention
These are directed directly over the patient’s
body with goal of healing the tissue injury.
2) Cognitive strategies
These are directed at patient’s thoughts with
goal of changing patient’s pain paradigm.
3) Behavioural manipulations
These involve behavioural change on the part
of the patient to bring about desired response.

3. Physical Interventions
1) Thermotherapy
2) Ultrasound
3) Phonophoresis
4) Cryotherapy
5) TENS
6) Iontophoresis
7) Massage
8) Myofascial release
9) Joint mobilization
10) Therapeutic touch
11) Point stimulation

4. 1)Thermotherapy
 Cellular metabolic rate increases with rising
temperature until tissues reach 113 0 F , after which
there is a gradual slowing of metabolic activity until cell
death occurs.
 Blood flow increases both in the treatment area and
systemically.
 If the area remains below the core temperature,
increased blood flow results in heat transfer from the
core. And if the area becomes warmer than core
temperature, heat is carried centrally.

5. 1)Thermotherapy
 Capillary permeability, capillary hydrostatic
pressure and capillary filtration rate all
increases.
 There is escape of protein into interstitial space ,
leading to oedema.
 Anastomoses that connect arterioles to venules
open and blood is shunted past the capillaries.
 Blood remains in venules , allowing greater time
for heat transfer to the tissues.

6. 1)Thermotherapy
 Decrease in activity of gamma motor
efferents , decreased excitability of
muscle spindle and increased activity
of golgi tendon organ results in
decrease muscle spasm , thus
reducing the peripheral pain.

7. 1)Thermotherapy
Heating can be applied :
1) Superficially : a) Conduction
b) Convection
c) Radiation
2) Deep

8. 1)Thermotherapy
Precautions to be taken while using
superficial heat:
1) Very young and healthy individuals.
2) Impaired circulation, diminished
sensation and open wounds.
3) Inadequate cardiac or respiratory
reserves.
4) Directly over topical areas where
counterirritants have recently been
applied.

9. 1)Thermotherapy
Contraindications for superficial heating
:
1) Acute thrombophlebitis
2) Malignancy
3) Haemorrhage or recent trauma

10. 1)Thermotherapy
Contraindications to deep heating
modalities are :
1) Metal implants
2) Cardiac pacemakers
3) Cancer
4) Pregnancy
5) Disturbed skin sensation
6) Tumours
7) Venous thrombosis

11. 2) Ultrasound
 Ultrasound consist of sound waves
delivered at a frequency too high to be
perceived by human hearing.
 Ultrasound waves are longitudinal , with
alternating areas of compression and
rarefaction , which move along the line of
propogation.

12. 2) Ultrasound

13. 2) Ultrasound
Ultrasound can be delivered in 2 modes :
1) Continuous mode
This mode is responsible for temperature increase in
deep tissues, that is , high collagen contents are heated
more efficiently than low collagen content.
2) Pulsed mode
To pulse the ultrasonic beam, a circuit in ultrasonic
generator is arranged to turn the ultrasound on in short
burst or pulses.

14. 2) Ultrasound
Mark : space ratio

15. Frequency
2)Ultrasound
1 MHz 3 MHz
 Has larger wavelength
 Penetrates the tissues
up to 5 cm
 Considerably for longer
distance
 Smaller wavelength
 Penetrates the tissue up
to 2 cm
 Considerably for shorter
distance

16. 2)
Ultrasound
Thermal effects :
1) Increase tissue
extensibility
2) Increase cellular
metabolic process
3) Increase
circulation
4) Decrease pain
5) Decrease muscle
spasm
Non-thermal effects:
1) Cavitation
2) Standing waves
3) Acoustic
streaming
4) Micromassage

17. 3) Phonophoresis
 It is the movement of drugs through skin into the
subcutaneous tissues under the influence of
ultrasound.
 Chemicals are delivered to the cells by
ultrasound wave , where they are broken down
into ions and taken up the cells.
 Lower ultrasound frequency leads to deeper
penetration of drugs.

18. 3) Phonophoresis

19. 3) Phonophoresis
Following are the chemicals used :
1) Lidocaine ointment- for immediate pain
relief
2) Hydrocortisone ointment – where pain is
the result of inflammation
3) Salicylate ointment – where a combined
analgesic anti-inflammatory agent is
needed.

20. 4) Cryotherapy
 Physiological effects :
Peripheral nerve conduction velocity decreases in
both myelinated and unmyelinated fibres.
Diminish pain perception and muscle contractility
Less excitibility of peripheral receptors
Muscle spindle response to stretch decreases
Muscle spasm diminishes

21. 4) Cryotherapy

22. 4) Cryotherapy
Hunting response:
 It is a protective mechanism which brings
the core temperature blood to the surface
and prevents tissue injury resulting from
prolong cooling.
 Cold application for more than 15 minutes
results in increased blood flow.

23. 5) TENS
 TENS stimulates selectively large
diameter, myelinated A-beta in
dermatomes related to the pain.
 These fibres can be stimulated at lower
current intensities than A-gamma or C-
fibres.
 This inhibits activity in second order
nociceptive transmission neurones in the
central nervous system.

24. 5) TENS

25. 5) TENS

26. Modes of TENS 5)
TENS

27. 6) Iontophoresis
 It is process in which chemical ions
are driven through the skin by small
electrical currents.
 Ionized compounds are placed on the
skin under the electrode , which when
polarized by direct current , repels the
ion of like charge into the tissues.

28. 6) Iontophoresis

29. 6) Iontophoresis
Commonly used analgesics are :
1) Lidocaine – acute pain
2) Hydrocortisone – inflammatory pain
3) Magnesium – muscle spasm
4) Iodine – relief of pain by adhesions or
scar tissue
5) Salicylate – inflammatory pain (especially
arthritic pain)

30. 7) Massage
 Strokes used in massage increases the
circulation through mechanical compression of
the tissues , thus resulting in reflex relaxation of
muscle tissue.
 It indirectly stimulates the A-delta and A-beta
fibres that causes activation of gating
mechanism and descending pain modulating
system.
 Movements are classified by pressure and part

31. 7) Massage
 Stroking involves running of hand over large
portion of body.
 Compression is applied with intermittent
pressure using lifting , rolling or pressing
movements.
 Friction massage is performed by fingertips to
perform cross - fiber movement to break the
adhesions.
 Percussion is performed to stimulate circulation.

32. 7) Massage
 Clapping is done with palms flat whereas
cupping is done with palm formed the concave
surface.
 Contraindications:
1) Infected areas
2) Diseased skin
3) Thrombophlebitic region

33. 8) Myofascial Release
 Fascia is an uninterrupted framework
around viscera , stabilized
articulations and in conjunction with
muscle activity assists in movement of
blood and lymph.
 It contains sensory nerves and tension
bands of varying thickness.

34. 8) Myofascial Release
 Myofascial release techniques (MFR) are
used to release the in built imbalance and
restrictions within the fascia and restore
the fascial mechanism.
 Application of pressure and stretching to
altered structures in specific direction ,
decreases the myofascial tension ,
lengthens and softens the myofascia ,
thus, restoring pain-free movements.

35. 9) Joint Mobilization
Physiological
Movement
1) Gross ROM
2) Performed by
internal forces
(muscles)
Accessory
Movement
1) Motion occurring
between
articulating
surfaces.
2) Requires
application of
external forces.

36. 9) Joint Mobilization
 Normal accessory movement is necessary for
normal physiological movement.
 Joint mobilization consists of passive oscillations
that allows collagen fibres to rearrange and
loosen.
 Pain reduction and decreased muscle tension
are achieved through the stimulation of fast-
conducting fibers (type A-β and A-α fibers) to
block small pain fibers (type C afferent fibers)
and through the activation of dynamic
mechanoreceptors to produce reflexive
relaxation

37. 10) Therapeutic touch
 Therapeutic touch is a concept that the
healthy human body has an excess of
energy , which can be shared with another
for purpose of healing.
 During this technique, the healer contacts
the patient’s energy field by scanning the
patient’s body with his or her hand.
 When tension is encountered , the healer
slowly moves his/her hand over the area to
redirect the accumulated energy.

38. 10) Therapeutic touch
 It results first in an energy transfer from healer
to patient , then in repatterning of patient’s
energy state.
 At the end , patient reports a subjective sense of
heat in the painful area followed by overall
sense of well-being and relaxation.

39. 11) Point stimulation
 Point stimulation is other way known as
acupuncture.
 Needling of acupuncture point stimulates
the release of endorphins.
 Whereas acupressure that is applied with
fingers decreases the sensitivity of trigger
points

40. COGNITIVE STRATERGIES
1. Relaxation exercises
2. Body scanning
3. Humor

41. 1) Relaxation Exercises
 Both pain and stress causes increase
activity of sympathetic nervous system.
 Relaxation reduces the ischemic pain by
normalizing blood flow to the muscles ,
thus , increasing oxygen delivery to
tissues.
 The end product is to lower the activity of
sympathetic nervous system and
lessening of symptoms caused by stress.

42. 1) Relaxation Exercises
Deep relaxation :
1. Progressive relaxation
It involves alternately tensing and
relaxing muscles, until entire body is
relaxed.
2. Attention – diversion exercises:
a) Active : active participation in a task
b) Passive : meditation

43. 1) Relaxation Exercises
Imagery
It have 2 forms:
1) The individual imagines the experience
that are inconsistent with pain.
2) The individual imagines experiences that
modify specific features of pain
experience.

44. 2) Body scanning
 Body scanning is a technique that
attempts to separate the individual from
pain.
 This technique helps individual to focus
attention on each body are , one area at
a time.
 Individuals are instructed to breathe into
and out from each area, relaxing more
deeply with each exhalation.

45. 2) Body scanning
This technique separates the pain into 3
parts:
1) An awareness of pain sensation and
thoughts and feelings about it
2) An awareness of separation between
pain sensation and thoughts and feelings
about it
3) An awareness of separation between
themselves and their pain.

46. 3) Humor
Laughter speeds up the heart rate and
enhances the arterial and venous
circulation
Exercises the heart muscles
More oxygen and nutrients is delivered
to tissues
 Laughter also decreases the serum cortisol
levels ( cortisol levels increases with stress)

47. Behavioural Manipulations
1) Exercise
2) Operant conditioning
3) Hypnosis
4) Biofeedback

48. 1) Exercise
 Exercise has an analgesic effect
through the gating mechanism by
stimulation of A-delta fibres and pain
modulating effect through activation of
descending system.
 It improves overall ROM, strength,
neuromuscular control, coordination
and aerobic capacity.

49. 1) Exercise
 ROM and stretching exercises are
indicated where there is decreased
mobility.
 Strengthening when performed with high
intensity, short duration results in
increased muscle mass, improved
neuromuscular control and improved
coordination.
 And when performed with low intensity ,
long duration it increases the aerobic

50. 2)Operant Conditioning
 Operant conditioning is a type of
associative learning process through which
the strength of a behaviour is modified by
reinforcement or punishment.
 It involves separating the behaviour
and response from pain experience.

51. 3) Hypnosis
 Hypnosis is "a trance state characterized by
extreme suggestibility, relaxation and
heightened imagination".
 It is an altered state of consciousness (body
and conscious mind is relaxed; subconscious
mind remains alter, focused and open to
suggestion).
 In pain management, individual is first
assisted to achieve complete relaxation and
then given suggestions that reinterpret the

52. 4) Biofeedback
 Biofeedback is a training process in which the
individual becomes aware of and learns to
selectively change physiological processes
with the aid of external monitor.
 It utilizes the electronic sensors or electrodes
, attached to various parts of the body to
detect changes in physical responses.
 The signals then inform the individual of
these changes by means of auditory or visual
signals.

53. 4) Biofeedback
 While the individual views or listens to feedback,
he /she begins to recognize thoughts or feelings
and mental images that influences his/her
physical reactions.
 By monitoring this mind-body connection, the
individual can use the same thoughts, feeling
and mental images as cues to reminders to
become more relaxed or to change heartbeat,
body temperature and other body function.
 Commonly used biofeedback is
electromyography.

54. References
1) Darcy A. Umphred : Neurological rehabilitation
; Fourth edition
2) John Low and Ann Reed : Electrotherapy
Explained ; Fourth edition
3) Professor Mark Johnson : Transcutaneous
electrical nerve stimulation : mechanisms,
clinical application and evidence ; Reviews in
Pain, Volume 1 ;
https://doi.org/10.1177/204946370700100103
4) Jeff G. Konin PT : Range of Motion and
Flexibility ; Physical Rehabilitation of the
Injured Athlete (Fourth Edition), 2012

55. THANK YOU