Subjective feeling

An adaptive function*
An unpleasant sensory and emotional* experience
associated with actual or potential tissue damage, or
described in terms of such damage. (IASP)
Influenced by anxiety, depression expectation and other
factors.
 COMMON CONDITIONS:
o Arthritis
o Persistent neck/back pain
o Neuralgias
o Peripheral neuropathies
o Peripheral vascular disease
o Chronic regional pain syndrome (CRPS -1, -2, -NOS)
o Hyperesthesia
o Myofascial pain syndrome
o Fibromyalgia syndrome
o Phantom limb pain
o Cancer
o Postoperative pain
o Spinal stenosis
 Correlates with the prevalence of the conditions
Back pain affects ~75 % of most industrialized nations
Intermediate-stage cancer 40 % of pts
Advanced cancer 60-80% of pts

Can occur at any age but mostly adults

Regardless of gender
 IASP classification
1. Anatomic region
2. Organ system
3. Temporal characteristics of pain and pattern of
occurrence
4. Persons statement of intensity and time since onset
of pain
5. Etiologic factors
 Can be
o Psychologically based
-memories of trauma, transference of psychological distress,
decrease immune response and healing

o Result of general medical conditions

-musculoskeletal conditions, neuropathies, and malignancies

o Both
 Widespread pain that covers half of the body (R or L half, upper or
lower half) plus axial skeleton
> 3 mos
11/18 tender points
Muscular pain
 > 18 y/o
women> men
Prevalence increases with age
 May be from physical trauma or viral infection

Higher incidence of tendonitis, headaches, irritable bowel,

tmj dysfunction, restless leg syndrome, mitral valve
prolapse, anxiety, and memory problems.
 Regional pain syndrome
Hallmark: myofascial trigger points
o Dull, aching, and deep
o May be active or latent
 Possible causes
o Chronic overload of muscles
o Acute overload
o Poorly conditioned muscles
o Postural stresses
o Poor body mechanics

 Pain that does not go away
Pain described as shooting, burning, aching or electrical
Discomfort, soreness, tightness, stiffness
 Fatigue
Sleeplessness
Weakened immune system
Depression
Disability
Anxiety
Stress

 Distinction: Physiological Dimension
1. Acute Processes 1. Sensory-
2. Subacute 1. Nociceptive discriminative
3. Chronic 2. Inflammatory 2. Motivational-
3. Neurogenic discriminative
Body Region 4. Maladaptive 3. Cognitive-
evaluative
1. LBP
2. Headache

Pathology
1. Phantom limb
2. MS
3. Malignant

 Physical
Psychological
Environmental

 Workers Compensation
Litigation
 AFFECTIVE
o Depression
o Anxiety
o Anger

COGNITIVE

LEARNING
o Operant Learning
o Fear of Movement
 Pain beliefs and Coping
Anxiety and Fear Avoidance
Catastrophizing
Depression and Grieving
Nonorganic Findings
Stress
Personality Disorders
Social Support

How do we feel pain?

By: Jamie
Transduction (receptor
activation)
Transmission
Modulation
Perception
Peripheral free nerve endings that
responds to noxious stimuli and
result in perception of pain
Found in:
o Interstitial Tissues -> mechanical,
thermal, & chemical stimulation
o Vessel Walls -> same, plus constriction
and dilation of the vessels
ThermalNociceptor
Mechanical Nociceptor
Polymodal Nociceptor
A-delta fiber -> Fast, myelinated, localized
o Stimulus: pinprick, heat
o Sensation: sharp, pricking, burning,
dermatomal
C fiber -> slow, unmyelinated, poorly
localized
o Stimulus: tissue damage
o Sensation: slow, dull, crawling, sclerotomal
Spinothalamic Tract
Spinoreticular Tract
Spinomesencephalic
Tract
GateControl Theory
Descending Pain
Modulation System
Substantia Gelatinosa contains
ascending gating mechanism to
block nociceptive impulses from
leaving the dorsal horn of the spinal
cord
Two Descending Pain Modulation
System
o Action of Neurotransmitters
Serotonin, Dopamine, Norepinephrine,
Substance P
o Mediated by Neuromodulators
Enkephalin, B-endorphin

Quilang, Cris Michael S.
Idiopathic.

.
Idiopathic pala, uwi na tayo
 Considered early as Somatic Manifestation of Affective
Disorder(Mood Disorder).
But further research show that FMS pain is causing
depression.
 Affective FMSCausing
Dysfunction Affective
Causing FMS. Vs. Dysfunction.
 Skeletal muscles have FMS have low levels of
shown abnormalities energy due to lower
that cause pain. than normal ATP values
although others argue in the blood.
that it is due to Chronic Prolonged work will
Deconditioning caused proceed to an
by FMS anaerobic respiration
which cause to
increase lactic acid
production .
 Dysfunctions in the Hypothalamic-Pituitary-Adrenal axis,
Sympathoadrenal gland, and Hypothalamic-Pituitary growth
hormone axis.
Causing hormonal imbalances which leads to the disruption
in the Homeostasis. (e.g. Dizziness and lightheadedness
due to Orthostatic hypotension; dysregulated blood
pressure, High sympathetic activity at night, dysregulated
circadian rhythm, etc.)
These are probably directly related or secondary causes of
FMS.
 Serotonin (5-HT) and Substance P were the primary
neurotransmitters that play a role for FMS
 Activated type A
and C fiber
afferent neurons
release substance
P into the spinal
cord dorsal horn.
Substance P can
contact with the
neurokinin-1
receptors and
facilitate
nociception.
 Production of
Serotonin from
Raphe nuclei from
the brainstem.
Serotonin inhibits
production of
Substance P.
Dysfunction to the
Production of
Serotonin in the
brainstem is the
most likely
Pathophysiology for
FMS.

By: Rosalin, Cristina Veronica A.
Section: BSPT 4-2
 FMS has striking similarities to
chronic fatigue syndrome (CFS)
Diagnostic criteria for CFS focuses
on fatigue, whereas the criteria for
FMS focuses on pain, the two most
prominent symptoms of these
syndromes.
Studies have shown that CFS and
FMS are characterized by greater
similarities than differences and
involve both the central and
peripheral nervous systems as well
as the body tissues themselves*
 A thorough hx, physical examination and appropriate selected
laboratory or imaging studies can usually differentiate FM
from connective tissue or other systemic dses.
o Chronic (>3 mos), widespread pain
Fatigue, tenderness, depression/anxiety, nonrestorative sleep, cognitive
difficulties (the so called fibrofog), and fxnal impairment

o The 1990 American College of Rheumatology (ACR) FM Classification

Criteria was used for clinical studies:
1. Chronic, widespread pain in all four quadrants of the body and the
axial skeleton
2. Pain on digital palpation of at least 11 0f 18 tender points.
 The 2010 ACR preliminary diagnostic criteria for
FM do not require a tender point examination; it
requires the exclusion of other dso that would
otherwise explain the pain.
 A diagnostic screening tool (Fibromyalgia
Diagnostic Screen) developed by Arnold and
colleagues was found to accurately screen for FM. This tool
includes a patient self-reported questionnaire and an
abbreviated physical examination with targeted lab tests.
 Selective use of ancillary tests complements the history and
physical examination in the diagnosis of FM. Testing should be highly focused on
the exclusion of FM mimickers or suspected concurrent diseases.
Complete blood cell count, routine chemistries, thyroid-stimulating hormone
(TSH), 25-hydroxyl vitamin D level (low levels can cause muscle pain),
vitamin B12 level (low levels can cause fatigue and pain), iron studies (low
levels can cause fatigue and depressive symptoms), and magnesium levels (low
levels can cause muscle spasms).
Erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are normal in
FM.
Routine testing for antinuclear antibody (ANA) and/or rheumatoid factor should
be avoided unless history and physical examination suggest an autoimmune
disease.

 Commonly seen when evaluating and treating patient for
chronic pain
Have localized changes in muscles
Define as a chronic, regional pain syndrome (Kisner)
Hallmark Classification of MPS: _____________
 Are characterized by pain originating from small circumscribed
areas of local hyperirritability and myofascial structure, resulting in
local and referred pain. (De Lisa)
Sometimes referred to as myofascial TrPs
Are hyperirritable spots within a taut band of skeletal muscle or in
the fascia.
Taut Band*
 TrPs are reproduce with palpation or resisted motions
When pressing on the TrPs, you may elicit ___________
TrPs can be categorized as:
o Active
o Latent
o Key
o Satellite
 Commonly found in any muscle or muscle group of the body .
The group of muscle involved commonly in the upper body are:
_______, _______, ______,
The group of muscle involved commonly in the lower body are:
________, ________, ________, _________.

FIBROMYALGIA SYNDROME
 Analgesics
-drugs designed to relieve pain
1. Anti-inflammatory medications
- Traditional NSAIDs (Non-Steroidal Anti-
Inflammatory Drugs)
- Among the traditional prescription NSAIDs are:
Indocin (indomethacin), Voltaren (diclofenac),
Toradol (ketorolac), Orudis (ketoprofen) Naprosyn
(naproxen), Feldene (piroxicam), Relafen
(nabumetone), Daypro (oxaprozin), Lodine (etodolac),
Mobic (meloxicam)
- Side effects: Stomach Irritation & G.I Bleeding
2. Narcotic medications (opioids)
- Very useful in the treatment of patients who are suffering
from acute flare- ups of FM
- Controversial in the management of fibromyalgia just as
they are in other chronic pain conditions
- Examples of drugs used in fibromyalgia treatment are:
Vicodin (hydrocodone + acetaminophen) Darvocet
(propoxyphene napsylate) Percocet (oxycodone +
acetaminophen) Oxycontin (oxycodone hydrochloride)
- Effectiveness of narcotics in treating long-term, chronic
pain is still uncertain
 The Treatment Of Centrally Mediated Pain and other
symptoms

1. Tricyclic anti-depressants
- Have been adopted for use in the treatment of fibromyalgia
because of their ability to boost levels of the brain neurochemical
serotonin (usually deficient in FM patients) and to control pain
and promote sleep.
- Common tricyclics include:
- Elavil (Amitriptyline) Pamelor (Nortriptyline) Sinequan (Doxepin)
Desyrel (Trazadone)
- Side effects: dry mouth, drowsiness, morning hangover,
constipation, weight gain, and sometimes anxiety. Because of
their sedating qualities, tricyclics are usually taken at bedtime.
2. Muscle relaxants
- Decrease pain in fibromyalgia patients by minimizing muscle
spasms and muscle pain. Because of their sedating qualities, they
also help to increase sleep and are usually taken at bedtime.
- Typically used muscle relaxants are:
- Flexeril (cyclobenzaprine hydrochloride) Norflex (orphenadrine
citrate) Soma (carisoprodol) Skelaxin (metaxalone) Robaxin
(methocarbamol)
- Side Effects: drowsiness, dry mouth, constipation, headache, and
heart palpitations
3.Selective Serotonin and Norepinephrine Reuptake Inhibitors (SSNRIs)
- Increase the activity of chemicals called serotonin and norepinephrine
in the brain.
- Examples of SSNRIs:
- Effexor XR (venlafaxine hydrochloride) and two drugs approved by the
U.S. Food and Drug Administration (FDA) for the treatment of
fibromyalgia: Cymbalta (duloxetine) and Savella (milnacipran).
4. Anti-convulsant medications
- Relief of neuropathic pain in fibromyalgia patients (i.e., burning and
electric shock-like feelings in the extremities). If tolerated, these
medications can help relieve nerve irritation.
- Examples of anti-convulsants are:
- Neurontin (gabapentin) Lyrica (pregabalin) Depakote (divalproex)
Dilantin (phenytoin) Tegretol (carbamazepine)
- Side effects: sedation, dry mouth, and dizziness
 RESEARCH
Newer FDA- licensed drugs the two SSNRIs duloxetine (Cymbalta) and
milnacipran (Savella) and the anti-epileptic drug, pregabalin (Lyrica)
Patients with unstable hypertension or chronic liver disease should use
duloxetine or milnacipran with caution.
When depression is co-morbid with fibromyalgia, individuals taking milnacipran
or duloxetine should be monitored for suicidal thoughts or signs of aggression.
When gastrointestinal issues like dyspepsia or irri- table bowel syndrome are
present in a patient, pregabalin might be the best drug choice.
FM patients who also have tension or migraine headaches need to keep an
eye on the severity of head- aches when either duloxetine or milnacipran is
taken.
FM patients with chronic heart failure or obesity should use pregabalin with
caution. In addition, the neurocognitive side effects of pregabalin such as
confu- sion, disturbed attention, and euphoric mood might dictate limited use
in patients with severe fibro fog.
5. Sleep medicines
- Used to treat insomnia and other sleep disorders. By improving sleep, it is
also possible to decrease pain and achieve better daytime functioning.
- Examples of commonly prescribed drugs include the central nervous system
depressants Ambien (zolpidem tartrate) and Sonata (zaleplon). These drugs
can be habit-forming and are therefore usually prescribed for short periods
of time.
- A new product, Lunesta (eszopiclone), is one of the generation of sleep aids
like Ambien which helps people to fall asleep without the next day hangover
characteristic of older-generation sleep drugs.
6. Benzodiazepines
- Very sedating and usually taken at bedtime, are sometimes used to help
patients feel calmer and cope with pain more effectively.
- They include the following:
Klonopin (clonazepam) Valium (diazepam) Restoril (temazapam) Xanax
(alprazolam).

MYOFASCIAL PAIN SYNDROME
 Analgesics, Non-steroidal anti-inflammatory drugs, Muscle
relaxants and Tricyclic antidepressants, anxiolytics and
anticonvulsants
 Non-steroidal anti-inflammatory drugs (NSAIDs) and other
analgesics usually provide moderate symptomatic relief.
Tricyclic antidepressant drugs, which modulate pain at the central
level, are often of benefit, especially in those patients with an
associated sleep disturbance.
Tizanidine (a muscle relaxant which also ameliorates pain by
activating a2-adrenergic receptors) is often a useful adjunct in
difficult-to-treat myofascial pain syndromes.
Diazepam is also recommended for the relaxation of reflex
spasms and the management of anxiety in MPS patients

o Graded exercise
As tolerated then progressed
o Postural exercise
Improve posture and body mechanics, decrease
muscle imbalance and decrease stress on
musculoskeletal structures
o Aerobic conditioning
Counteract deconditioning
o Balance and proprioceptive training
 Pain
Massage
 Relax muscles
Diaphragmatic breathing
Yoga, Tai Chi, or Qigong
 heat, cold, ultrasound, laser, traction, or
TENS
Fibromyalgia Myofascial Pain

Exercise - (aerobic, Spray and stretch

strengthening, and stretching
exercises) TENS unit, ultrasound, massage
therapy, myofascial release
technique.
 Esteban, Ruth
Evangelista, Neomi
Magnaye, Jerika
Martinez, Ivy
Panganiban, Jesica
Quilang, Cris
Rosalin, Veronica
Sosa, Jamie