MANAGING PAIN WITH THERAPEUTIC MODALITY

Rezki Amalia Nurshal Pembimbing : Prof. DR. dr. Angela BM Tulaar, Sp.KFR-K

OVERVIEW
1. PAIN

2. THERAPEUTICAL MODALITIES 3. PAIN MANAGEMENT

PAIN
Pain is 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) The most chief complain Subjective sensation

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

PAIN
Can persist after its no longer useful

Warning

Protection

Enhancing disability

Inhibiting efforts to rehabilitate

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

PAIN
Acute : tissue damage and after injury. Chronic : lasting for more than 6 months. Persistent : Pain that Referred : defies intervention pain that is Radiating pain from perceived to : irritation of conditions be in an area nerve root where that seems to can cause continuing have little radiating (persistent) relation to pain. the existing pain is a pathology symptom of a treatable condition

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

PAIN ASSESMENT SCALES

Visual Analog Scales Pain Charts McGill PainQuestionnaire

Using a line : 1 - 10 1 -> NO PAIN 10 -> SEVERE PAIN

To asses the location of pain and a number of subjective components. Blue -> aching pain Yellow -> numbness or tingling Red -> burning pain Green -> cramping pain Prentice WE, Therapeutic Modalities in
Rehabilitation, 3ed.2005

A tool with 78 words that describe pain Commonly administered to LBP patients. May take 20 minutes and often frustating the patient

PAIN ASSESMENT SCALES

Activity Pain Indicators Profile Measures patient activity. 64 question, self report tools. Numeric Pain Scales The most common Pain scale 1-10

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

PAIN PERCEPTION
Sharp (tajam) Dull (tumpul)
subjective

Aching (nyeri)
Throbbing (berdenyut) Burning (terbakar)

Piercing (menusuk)
Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Sensory Receptors

PAIN PERCEPTION
Pain receptor / nociceptors / free nerve endings
noxious stimuli = extreme mechanical, Cognitive thermal, chemical Influences energy Anxiety,to Attention, respond noxious Depression, Past pain stimuli to impending experiences, or actual tissue Cultural(e.g Influences damage cuts, burns, sprains, etc) -> superficial heat, cold, analgesic balms, massage

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005 Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities.

PAIN STIMULATION
1st order neuron A, A (large, fast) A, C fibers (small, slow) 2nd order neuron Wide dynamic range (A, A, C fibers ) Nociceptive specific (A, C fibers ; noxious stimulation)

1.

2.

Spinothalamicus Lateralis Tract (effect of concious sensation of pain) Spinoreticularis Tract (arousal emotional aspects of pain)

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Nociception

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

SYNAPTIC TRANSMISSION
Neuroactive peptides can facilitate or inhibit synaptic activity Enkephalin Serotonin Norepinephrine -endorphine Dynorphin
Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

PAIN CONTROL (Melzack, Wall and Castle)

The Gate Control Theory of Pain

Descending Pain Control -endorphin & Dynorphin

Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities. Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

The Gate Control Theory of Pain

Rubbing Moist Heat Massage Cold TENS Ultrasound

Prentica, WE. Denegar, CR. Managing Pain with Prentice WE, Therapeutic Modalities in Therapeutic Modalities. Rehabilitation, 3ed.2005

HOT AND COLD MODALITIES

APPLY TO THE SKIN HEAT VASODILATATION COLD VASOCONSTRICTION

SKIN RECEPTORS

GATE CONTROL THEORY ANALGESIC EFFECT

Prentice WE, Therapeutic Modalities in Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Rehabilitation, 3ed.2005 Modalities.

Descending Pain Control

TENS

Prentica, WE. Denegar, CR. Managing Pain with Prentice WE, Therapeutic Modalities in Therapeutic Modalities. Rehabilitation, 3ed.2005

-endorphin & Dynorphin Release

TENS

Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities. Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Uses of physical agent to relieve pain:

1. Stimulate large-diameter afferent fibers. This can be done with TENS, massage, and analgesic balms.

2. Decrease pain fiber transmission velocity with cold or ultrasound.

3. Stimulate small-diameter afferent fibers and descending pain control mechanisms with acupressure, deep massage, or TENS over acupuncture points or trigger points.
4. Stimulate a release of Beta-endorphine or other endogenous opioids through prolonged small-diameter fiber stimulation with Prentice WE, Therapeutic Modalities in TENS
Rehabilitation, 3ed.2005

Other pain control strategy

1.Encourage central biasing through cognitive processes, such as motivation, tension diversion, focusing, relaxation techniques, positive thinking, thought stopping, and self-control. 2. Minimize the tissue damage through the application of proper first aid and immobilization. 3. Maintain a line of communication with the patient. Let the patient know what to expect following an injury.

4. Recognize that all pain, even psychosomatic pain, is very real to the patient.

5. Encourage supervised exercise to encourage blood flow, promote nutrition, increase metabolic activity, and reduce stiffness and guarding if the activity will Prentice WE, Therapeutic Modalities in not cause further harm to the patient. Rehabilitation, 3ed.2005

PAIN MANAGEMENT
CHOOSING THERAPEUTICAL MODALITIES :
1. ACUTE PAIN a. Cold Therapeutical Modalities b. TENS 2. SUBACUTE AND CHRONIC PAIN a. Hot Therapeutical Modalities b. MWD, SWD c. Laser d. Ultrasound
Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities. Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

CRYOTHERAPY
INDICATIONS Acute pain Acute swelling (controlling hemorrhage and edema) Myofascial trigger points Muscle guarding Muscle spasm Acute muscle strain Acute ligament sprain Acute contusion Bursitis, Tenosynovitis, Tendinitis Delayed onset muscle soreness

CONTRAINDICATIONS
Impaired circulation (i.e., Raynauds phenomenon) Peripheral vascular disease Hypersensitivity to cold Skin anesthesia Open wounds or skin conditions (cold whirlpools and contrast baths) Infection

Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities. Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

THERMOTHERAPY
Indications Subacute and chronic inflammatory conditions and pain Decreased ROM Resolution of swelling Myofascial trigger points Muscle guarding Muscle spasm Subacute muscle strain Subacute ligament sprain Subacute contusion Infectio

Contraindications
Acute musculoskeletal conditions Impaired circulation Peripheral vascular disease Skin anesthesia Open wounds or skin conditions (cold whirlpools and contrast baths

Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities. Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Ultrasound
INDICATIONS Soft tissue healing and repair Scar tissue Joint contracture Chronic inflammation Increase extensibility of collagen Reduction of muscle spasm Pain modulation Increase blood flow Soft tissue repair Bone healing Repair of nonunion fractures Inflammation associated with myositis ossificans Myofascial trigger points

CONTRAINDICATIONS Acute conditions Areas of decreased temperature sensation Areas of decreased circulation Vascular insufficiency Thrombophlebitis Eyes Reproductive organs Pelvis immediately following menses Pregnancy Pacemaker Malignancy Epiphyseal areas in young children Total joint replacements Infection

Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities. Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

SWD
INDICATIONS Postacute musculoskeletal injuries Increased blood flow Vasodilation Increased metabolism Decreased joint stiffness Muscle relaxation Increased pain threshold Enhanced recovery from injury Improved joint range of motion Increased extensibility of collagen Increased circulation Reduced subacute and chronic pain Resorption of hematoma Increased nerve growth and repair

CONTRAINDICATIONS Acute traumatic musculoskeletal injuries Acute inflammatory conditions Areas with ischemia Areas of reduced sensitivity to temperature or pain Fluid-filled areas or organs Joint effusion Synovitis Eyes Contact lenses Moist wound dressings Malignancies Infection Pelvic area during menstruation Testes Pregnancy Epiphyseal plates in adolescents Metal implants Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities. Unshielded cardiac pacemakers Prentice WE, Therapeutic Modalities in Rehabilitation, Intrauterine 3ed.2005 devices

Mechanisms of Pain Control

The theories presented are only models Pain control is the result of overlapping mechanisms Useful in conceptualizing the perception of pain and pain relief

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Summary
The goal of rehabilitation programs is to encourage early, pain-free exercise while promoting optimal healing processes

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Noxious Mediator

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005

Prentice WE, Therapeutic Modalities in Rehabilitation, 3ed.2005