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- Pain is a subjective sensation
- Pain is composed of a variety of human discomforts
- Perception of pain can be subjectively modified by past experiences and
expectations
- Much of what we do to treat pain is to change perception of pain
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- Control of pain is an essential aspect of caring for the injured patient
- Athletic trainer has several therapeutic agents with analgesic
properties from which to choose
- Selection of a therapeutic agent should be based on a sound
understanding of its physical properties and physiologic effects
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- Acute Pain- pain of sudden onset
- Chronic Pain- pain lasting for more than 6 months
- Referred Pain - pain that is perceived to be in an area that seems to
have little relation to the existing pathology
- Kehr’s Sign
- Myofascial trigger points
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- Radiating Pain - pain caused by irritating nerve roots and extending
distally
- Sclerotomic Pain - pain associated with a segment of bone innervated by
a spinal segment that is a deep somatic pain
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- Pain is a complex phenomenon which is difficult to evaluate and quantify
because it is subjective
- Thus obtaining an accurate and standardized assessment of pain is
problematic
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- Pain profiles
- Identify type of pain
- Quantify intensity of pain
- Evaluate the effect of the pain experience on patients’ level of
function
- Assess the psychosocial impact of pain
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- Scales are quick and simple tests
- Consist of a line, usually 10 cm in length, the extremes of which are
taken to represent the limits of the pain experience.
- Scales can be completed daily or more often
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- Used to establish spatial properties of pain
- Two-dimensional graphic portrayals assess location of pain and a number
of subjective components
- Patient colors pictures in areas that correspond to pain
- (blue = aching pain, yellow =numbness or tingling, red = burning pain,
green =cramping pain)
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- 78 words that describe pain are grouped into 20 sets and divided into 4 categories
representing dimensions of the pain experience
- Completion may take 20 minutes
- Administered every 2-4 weeks
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- A 64 question, self-report tool used to assess functional impairment
associated with pain
- Measures the frequency of certain
behaviors such as housework, recreation and social activities that
produce pain
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- Most common acute pain profile used in sports medicine clinics
- Patient is asked to rate pain on a scale from 1 to 10 with 10
representing the worst pain they have experienced or could imagine
- Question asked before and after treatment
- When treatments provide pain relief patients are asked about the extent
and duration of the relief
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- To control acute pain and protect patient from further injury while
encouraging progressive exercise in a supervised environment.
- Reducing pain is an essential part of treatment
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- Encourage body to heal through exercise designed to progressively
increase functional capacity and to return the patient to work,
recreational and other activities as swiftly and safely as possible
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- Afferent nerve fibers transmit impulses from the sensory receptors
toward the brain
- Efferent fibers such as motor neurons transmit impulses from the brain
toward the periphery
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- First order or primary afferents transmit impulses from the sensory
receptor to the dorsal horn of the spinal cord
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- Four different types of first order neurons
- Aa and Ab fibers are characterized as
being large diameter afferents and Ad and C fibers as small diameter afferents
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- Second order afferent fibers carry sensory messages from the dorsal horn
to the brain
- Second order afferent fibers are categorized as wide dynamic range or
nociceptive specific
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- Wide dynamic range second order afferents receive input from Ab, Ad and C fibers.
- Second order afferents serve relatively large, overlapping receptor
fields
- Nociceptive specific second order afferents respond exclusively to
noxious stimulation
- Receive input only from Ad and C fibers
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- All of these neurons synapse with third order neurons which carry
information to various brain centers where the input in integrated,
interpreted and acted upon
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- For information to pass between neurons, a transmitter substance must be
released from one neuron terminal-enter the synaptic cleft- and attach
to a receptor site on the next neuron
- This was thought to occur due to chemicals called neurotransmitters
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- Several compounds which are not true neurotransmitters can facilitate or
inhibit synaptic activity.
- Biogenic amine transmitters
- Serotonin- active in descending pathways
- Norepinephrine- inhibits pain
transmission between 1st
&2nd order neurons
- Neuroactive peptides
- Substance P- from small-diameter primary afferent neurons
- Enkephalins - opiod active in descending pathways
- ß-endorphin- opiod endogenous to CNS
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- A nociceptive neuron is one that transmits pain signals
- Once released substance P initiates electrical impulses along afferent
fiber toward spinal cord
- Substance P is also a transmitter substance between 1st & 2nd order
afferent fibers
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- Ad and C fibers transmit
sensations of pain and temperature (Ad fibers are larger)
- Ad neurons originate from
receptors located in skin and transmit “fast pain”
- C neurons originate from both superficial tissue (skin) and deeper
tissue (ligaments and muscle) and transmit “slow pain”
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- Gate control theory
- Descending mechanisms(Central Biasing)
- Release of endogenous opioids (ß-endorphin)
- Pain relief may result from combination of these 3 mechanisms
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- Information from ascending Ab afferents and (pain messages) carried along Ad and C afferent fibers enter
the dorsal horn
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- Impulses stimulate the substantia gelatinosa at dorsal horn of the
spinal cord inhibiting synaptic transmission in Ad & C fiber afferent pathways
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- Sensory information coming from Ab fibers is transmitted to higher centers in brain
- “Pain message" carried along Ad & C fibers is not transmitted to second-order
neurons and never reaches sensory centers
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- Stimulation of descending pathways in the dorsolateral tract of the
spinal cord by Ad and C
fiber afferent input results in a “closing of the gate” to impulses
carried along the Ad
and C afferent fibers
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- It is theorized that previous experiences, emotional influences, sensory
perception, and other factors could influence transmission of pain
message and perception of pain
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- Ascending neural input from Ad and C fiber afferents and
possibly central biasing stimulates periaquductal grey region in
midbrain which stimulates raphe nucleus in pons and medulla thus
activating descending mechanism in dorsolateral tract
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- Efferent fibers in dorso- lateral tract synapse with enkephalin
interneurons
- Serotonin is a neuro-transmitter
- Interneurons release enkephalin into the dorsal horn, inhibiting the
synaptic transmission of impulses to second-order afferent neurons
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- A second descending, pathway projecting from the pons to the dorsal horn
has been identified
- Thought to inhibit transmission due to release of norepinephrine
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- Stimulation of Ad and C
afferents can stimulate release of endogenous opioid ß-endorphin from hypothalamus
- Dynorphin released from periaqueductal grey
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- The theories presented are only models
- Pain control is the result of overlapping mechanisms
- Useful in conceptualizing the perception of pain and pain relief
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- Therapeutic modalities can be used to
- Stimulate large-diameter afferent fibers( TENS, massage, analgesic
balms)
- Decrease pain fiber transmission velocity (cold, ultrasound)
- Stimulate small-diameter afferent fibers and descending pain control
mechanisms (accupressure, deep massage, TENS)
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- Therapeutic modalities can be used to
- Stimulate release of endogenous opioids through prolonged small
diameter fiber stimulation with TENS
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