The document provides a comprehensive overview of pain, including its definitions, types (acute, chronic, referred, neuropathic), and mechanisms of pain perception and modulation. It discusses various assessment methods and treatment approaches, such as physical interventions, cognitive strategies, and behavioral manipulations, highlighting the importance of effectively managing pain. Detailed descriptions of assessment scales and specific treatment modalities, including thermotherapy, cryotherapy, and TENS, are also covered.

1. PAIN
DR. DHRUVI MISTRY
MPT Neuro

2.  Definition
 Types
 Pain pathway
 Pain modulation
 Assessment
 Treatment

3. DEFINITION
It is an unpleasant & emotional
experience associated with or without
actual tissue damage
Protective mechanism

4. CATEGORY
Due to
physiological
changes
Perceptual
Cognitive
Behavioral
Affective
objective subjective

5. TYPES OF PAIN
ACUTE
CHRONIC
REFERRED
CENTRAL NEUROPATHIC
AUTONOMIC
PERIPHERAL
VISCERAL

6. ACUTE PAIN
 Normal predicted physiological response
 Serves as a warning
 Alert- tissues are exposed to damaging
 Localized pain
 Directly proportional to the intensity of stimuli
 It lasts as long as tissue damage exist
 Upto 3 months

7. CHRONIC PAIN
 Persists 3-6 months
 Pain continues after the stimulus has been removed
or tissue damage heals
 Results from hypersensitization of the pain receptors
& enlargement of the receptor field in response to
the localized inflammation that follows the tissue
damage
 Poorly localized

8. REFERRED PAIN
 Pain location other than its origin
 It follows specific pattern
 Results of a convergence of the primary afferent
neurons from deep structures & muscles to
secondary neurons that also have a cutaneous
receptive field

9. CENTRAL NEUROPATHIC PAIN
 Due to primary lesion or dysfunction of CNS
 Levels – nerve,
nerve root
central pain pathway in BRAIN/SC
 Onset may occur during the phase of recovery
from neurological deficit
 Eg., allodynia , dysesthesia

10. PERIPHERAL PAIN
Due to noxious irritation of the
nociceptors
It depends on the intensity of the stimulus
& types of the fibers carry the info into
dorsal gray matter i.e. A delta and C

11. AUTONOMIC PAIN
arises from the abnormal activity within
ANS
Eg. CRPS

12. VISCERAL PAIN
 It results from the activation of the thoracic,
pelvic or abdominal viscera
 Pain is diffuse, difficult to localize
 Eg. Appendicitis, gallstone, pelvic pain

13. ANATOMY
 Center for pain perception – post central gyrus in
parietal lobe
 Receptor - nociceptors
specialized peripheral free nerve
endings
 Presents in the skin & tissue throught the body

14. thermal
• Cold/hot
• <5 or >45
degree
• A delta
mechanical
• Pressure
applied to
the skin
• A delta
polymodal
• More than
one
sensory
modalities
• C

15. PAIN IS TRANSMITTED BY
 Fast conducting
 myelinated
 Sharp pain
 Slow conducting
 Non myelinated
 Dull pain
A delta fiber C fiber

16. Pain sensation is carried out by
1st order
neuron
• Present in dorsal
nerve root
2nd order
neuron
• Substantia
gelatinosa
• Lateral
spinothalamic
tract
3rd order
neuron
• Thalamic
nucleus
• Reticular
formation
• Gray matter
around
aqueduct of
sylvius

18. A DELTA FIBER
Stimulation of A delta fiber
dorsal ganglion
Dorsal root of spinal cord
Lamina 1 in SG
Lateral spinothalamic tract
reticular formation
VPL thalamus
sensory cortex

19. C FIBER
Stimulation of c fiber
dorsal ganglion
Dorsal nerve root of spinal cord
Lamina 2 & 3 of SG
lateral spinothalamic tract
reticular formation
Posterior thalamus
Sensory cortex

20. NEUROTRANSMITTER
 Glutamate - a delta and c
 Substance p - c fiber

21. Pain
modulation
ascending descending

22. ASCENDING PATHWAY
 Pain gate theory
 Melzack & wall 1965
 Process ocuur in SG
 T cells inhibited by Aβ by mechanoreceptors

23. Stimulation of A beta fiber
Dorsal nerve root
Substantia gelatinosa
Inhibition of T cells or activation of T cells and
substantia gelatinosa
Supress the pain

25. DESCENDING PATHWAY
 Supraspinal pain supression system
 It involves the action of neurotransmitter and
neuro modulator

26. DESCENDING PAIN PATHWAY
Peri aqueductal gyrus of mid brain
Rostroventero-medial medulla
Substantia gelatinosa
Release of neurotransmitter
pain suppression

28. EXAMINATION OF PATIENT
OPQRST
OBSERVATION : entry to exit
gait
movement
ONSET : mechanism
how starts
date of onset
POSITION : location
PATTERN : constant /periodic
PAF/PRF
Improving/worsening
QUALITY : type of pain

29. QUANTITY : intensity
RADIATION :
SIGN & SYMPTOMS : Is pain affect ADL ?
how?
TREATMENT : any previous or present
medical or therapeutic treatment and its
effectiveness

30. PAIN MEASUREMENT
SCALES
VAS NRS FPS

33. INTERPRETATION
 Unidimensional
 VAS : 0-100
0-4 : no pain
5-44 : mild pain
45-74 : moderate pain
75-100 : severe pain

35. INTERPRETATION
 Multidimential
 It measure the sensory, affective, evaluative aspects
of pain
 4 subscales : sensory, affective, evaluative,
miscellaneous
 It contains 78 descriptor items categorized into 20
subclasses

36.  Sensory : 1-10
 Affective : 11-15
 Evaluative : 16
 Miscellaneous : 17-20

37. .
 On examination
end feel : empty
ROM : active and passive
- restricted in same direction that is arthrogenic
- restricted in opposite direction that is muscular
- restricted PM in capsular pattern that is arthritis
- no restriction in PM but can’t perform AM that
is problem in neural pathway

38.  Muscle strength
- movt is strong but painful : minor lesion in
muscle
- movt is weak & painful : major lesion
- movt is weak but doesn’t increase Pain
: complete tear or neurological
problem

39. MANAGEMENT OF PAIN
Mx
Physical
intervention
Cognitive
strategies
Behavioral
manipulation

40. PHYSICAL INTERVENTION
 Passive
 Directed at pt’s body
 Goal is healing the tissue injury & relieve the
pain

41. IT INCLUDES:
1) Thermotherapy
2) Cryotherapy
3) TENS
4) IFT
5) DRY NEEDLING
6) IASTM
7) KT Technique
8) SHOCK WAVE Therapy
9) Iontophoresis
10) Joint mobilization
11) Massage therapy
12) MFR

42. THERMOTHERAPY
 Physiological effects :
1. pain relieve
2. reduce spasm
3. promote healing

43.  Hydrocollatoral pack
 Paraffin wax bath
 Hydrotherapy
 Fluidotherapy
 IRR
 UVR
 Depth of penetration
is ≤1cm
 Alteration of one form
of energy into another
 SWD
 MWD
 US
 PHONOPHORESIS
Superficial heating Deep heating

44. SWD
 High frequency heating modality
 Frequency – 27.12MHz
 Wavelength – 11m
 Mechanism :
 Dosage : 20-30 mins
 Because 10-15mins are taken for vascular response
 Contraindication : metal implants
cancer
pregnancy
haemorrhage
open wound
infection

45. ULTRASOUND
 It consist of sound wave delivery at a frequency too
high to be perceived by human hearing >20kHz
 Therapeutic frequency : 1MHz & 3 MHz
 Depth of penetration : 4 cm 2.5cm
 It can’t travel through the air so as a coupling medium
gel is used
 Tissue with high collagen content ( tendon, ligament,
capsule) are heated more efficiently than low collagen
content ( fat , muscle , bone)

46. EFFECTS
 Sound wave absorbed
 Heat is produced
 Pain , spasm reduces
 Circulation imorove
 Cavitation
 Micromassage
 Acoustic streaming
 Pulsed mode
Thermal Mechanical

47. DOSAGE
 Pulse mode
 .2 to .5w/cm2
 2-3 mins
 Improvement-
 .8 w/cm2
 5 mins
 Continous mode
 2w/cm2
 8min
 Max dose
Acute condition Chronic condition

48. PHONOPHORESIS
 Use of US to deliver pain relieving chemicals to the
tissue
 Chemicals are delivered by ultrasound wave
broken down into ions
taken up into cells
Drugs : 5% lidocaine
10% hydrocortisone

50. CRYOTHERAPY
 Cold receptors > warm receptors
 As cold stimulus is applied
stimulation of cold receptor
slow the nerve conduction in peripheral nerve
sends back impulses which have to pass into the SC
blocks pain gate

51. LEWIS’S HUNTING REACTION
 Vasoconstriction
 Vasodilatation
 Exchange in tissue fluid and metabolic waste
 Improve circulation
 Reduce swelling

52. TYPES
 Conductive evaporative convective
ice pack vapocoolant movt of
ice immersion spray air over
massage the skin
eg. fanning

53. TENS
 Transcutaneous electrical nerve stimulation
 Used to control the pain perception
 3 types : high TENS
low TENS
burst TENS

54.  Convential TENS
 50-100Hz
 Low intensity
 Pain inhibited by ascending
pain pathway
 Onset of pain relief is fast
(seconds to 15 mins) upto
some hours
 Short lived
 Acute condition
 Acupuncture like
(AL)TENS
 2-4Hz
 High intensity
 Pain inhibited by descending
pathway
 It takes 20-30 mins to start
relief but effect is long
lasting for hours to days
 Chronic pain
High TENS Low TENS

55. BURST TENS
 Combination of these two
 Impulses are generated in pulse train
 Machine generates low rate impulses which
contain high rate pulses
 It is beneficial wherever low TENS is not
tolerable and high TENS is not beneficial

56. DRY NEEDLING
 Inserting a needle into trigger point without injecting
drug
 Intoduced in 1979 bu Dr. Karel Lewit
 1984 in US first to allow needling by physiotherapist

57. PHYSIOLOGY
Needle insertion
microtrauma
Release of histamine stimulation of Aβ
inflammation & release of endorph
vasodilatation in , enkephalin
Circulation improve pain reduces
Pain reduces

58. IASTM
 Instrument assisted soft tissue mobilization
 It is introduced by James Cyriax
 Concept of soft tissue mobilization, mechanical
loading & fibroblast production
 It is applied by using specially design instrument
 It helps in release soft tissur, adhesion, fascial
restriction
 Study shows , Duration : 2 session per week for 2-6
weeks

60. SHOCK WAVE THERAPY
 It is an acoustic wave which carries high energy to
painful spot and myoskeletal tissue
 Energy promotes regeneration & reparative process of
bone, soft tissue & tendon
 It acts by 3 mechanism:
- new blood vessel formation
- dispersion of substance p
- release trigger point

62. New blood vessels : microrupture of vessels
- expression of growth factor
- helps in arteriole remodeling
- increase blood and O2 supply
Dispersion of substance P :
- it lower the level of substance P
- reduces pain
Release trigger point:
acoustic energy break ca++ channel

63. IONTOPHORESIS
 Process in which chemical ions are drive through the
skin by a small electrical current(direct current)
 Ions are placed on the skin under the electrode
 ions are charged and free to combine with
physiological ions
physiological effect starts

65.  Drugs are used:
1) 5% lidocaine ointment
-short lived immediate effect
- pain reduce
2) 1-10% hydrocortisone & dexamethasone
- relieve inflammatory pain
3) 2% magnesium
- relieve pain of muscle spasm
- by inhibit muscle contraction
4)Iodine ointment
-pain reduce from adhesion
5)salicylate
- reduces inflammatory pain

66. JOINT MOBILIZATION
 It is passive oscillation
 It works by improving blood supply to the joint
- altering activity in nervous system
- stretching the joint structure
 Maitland oscillatory mobilization
grade 1 and 2 is used for pain relief
G1-rhythmic oscillatory movt in initial range
G2- rhythmic oscillatory movt within available
range

67. MASSAGE
 It has been recognized as a remedy for pain for at least
3000years
 Hippocrates advocated massage for sprain and dislocation
 It reduces pain by:
direct indirect
in. circulation through stimulation of A delta and
mechanical compression Aβ fiber
reflex relaxation of muscle activation of gate mech.
direct relieve from ischemic descending pain pathway
pain

68. TWO TECHNIQUES HELPS IN REDUCING PAIN
 Effleurage
 Relaxation
 Relieve spasm
 Improve circulation
 Reduces pain
 Kneading
 Petrissage
 Lifting, rolling
stretch the tissue
loosen adhesion
assist in circulation
Stroking Compression

69. COGNITIVE & BEHAVIORAL
STRATEGIES
 Directed at pt’s thoughts
 goal of changing the pt’s pain paradigms
 Self initiated
Behavioral :
 Involve a behavioral change on the part of the pt to
bring about the desired response
 It include relaxation exercise
meditation
humor

70.  It works in two ways
descending pain they teach individual
pathway to control the pain

71. RELAXATION EXERCISE
 It brings about muscle relaxation by
increasing blood flow
more O2 supply
reducing muscle tension
interrupting spasm cycle

72. RELAXATION
 Breathing  Active passive
involve in
meditation
task
humor
Single focus Attention diversion

73.  Involve quiting the mind
 Focusing attention on
thoughts, word , phrase,
object, movement.
 It calms the body through
relaxation response
 Laughing increase blood O2
by ventilation
 Helps in ex of heart muscle
by speeding HR, enhance
circulation, more O2 ,
nutrients
 Reduces serum cortisol
 10mins daily belly laugh
provide 2 hours of pain free
sleep
Meditation Humor

74. REFERENCES
1. UMPHRED’S NEUROLOGICAL REHABILITATION, SIXTH
EDITION
2. ELECTROTHERAPY EXPLAINED
PRINCIPLES AND PRACTICE, FOURTH EDITION
3. CLAYTON’S ELECTROTHERAPY, EIGHTH EDITION
4. INTERNATIONAL JOURNAL OF SPORTS PHYSICAL
THERAPY
5. THE JOURNAL OF THE CANADIAN CHIROPRACTIC
ASSOCIATION
6. THE PHYSICIAN AND SPORTSMEDICINE 42(2) : 48-57
7. THE JOURNAL OF BONE AND JOINT SURGERY
8. ARTHRITIS CARE & RESEARCH / VOLUME 63, ISSUE S11