Managing Pain With Therapeutic Modalities - Kiky

MANAGING PAIN WITH THERAPEUTIC MODALITY

Rezki Amalia Nurshal

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

1. PAIN

2. THERAPEUTICAL MODALITIES

3. PAIN MANAGEMENT

OVERVIEW

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

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


PAIN

Warning ProtectionCan persist after its no

longer useful

Enhancing disability

Inhibiting efforts to

rehabilitate


PAIN

Acute : tissue damage and after injury.

Chronic : lasting for

more than 6 months.

Persistent : Pain that

defies intervention

from conditions

where continuing (persistent)

pain is a symptom of a

treatable condition

Referred : pain that is

perceived to be in an area that seems to

have little relation to the existing pathology

Radiating pain : irritation of nerve root can cause radiating

pain.


PAIN ASSESMENT SCALES

Visual Analog Scales

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

Pain Charts

• 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

McGill PainQuestionnaire

• 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


PAIN PERCEPTION

Sharp (tajam)

Dull (tumpul)

Aching (nyeri)

Throbbing (berdenyut)

Burning (terbakar)

Piercing (menusuk)

subjective


PAIN PERCEPTION

Pain receptor / nociceptors / free nerve endings

noxious stimuli = extreme mechanical, thermal, chemical energy respond to noxious stimuli – to impending or actual tissue damage (e.g cuts, burns, sprains, etc)-> superficial heat, cold, analgesic balms, massage

Prentica, WE. Denegar, CR. Managing Pain with Therapeutic Modalities.

Sensory Receptors

Cognitive Influences

Anxiety, Attention, Depression, Past pain

experiences, Cultural Influences

PAIN STIMULATION1st order neuron• Aα, Aβ (large, fast)• Aδ, C fibers (small, slow)

2nd order neuron• Wide dynamic range

(Aβ, Aδ, C fibers )• Nociceptive specific

(Aδ, C fibers ; noxious stimulation)

1. Spinothalamicus Lateralis Tract (effect of concious sensation of pain)

2. Spinoreticularis Tract (arousal emotional aspects of pain)

Nociception



SYNAPTIC TRANSMISSION

• Neuroactive peptides can facilitate or inhibit synaptic activity ◦  Enkephalin ◦  Serotonin ◦  Norepinephrine ◦  β-endorphine ◦  Dynorphin


PAIN CONTROL(Melzack, Wall and Castle)

The Gate Control Theory of Pain

Descending Pain Control

Β-endorphin & Dynorphin



The Gate Control

Theory of Pain


RubbingMoist Heat

MassageColdTENS

Ultrasound


HOT AND COLD MODALITIES

HEAT COLD

APPLY TO THE SKIN

VASODILATATION VASOCONSTRICTION

GATE CONTROL THEORY

ANALGESIC EFFECT

SKIN RECEPTORS



Descending Pain Control


TENS


Β-endorphin & Dynorphin

Release


TENS

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 TENS Prentice WE, Therapeutic Modalities in

Rehabilitation, 3ed.2005

Other pain control strategy1.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 not cause further harm to the patient.Prentice WE, Therapeutic Modalities in

Rehabilitation, 3ed.2005


PAIN MANAGEMENT

CHOOSING THERAPEUTICAL MODALITIES :

1. ACUTE PAINa. Cold Therapeutical Modalitiesb. TENS

2. SUBACUTE AND CHRONIC PAINa. Hot Therapeutical Modalitiesb. MWD, SWDc. Laserd. Ultrasound



CRYOTHERAPYINDICATIONS• 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., Raynaud’s phenomenon)

• Peripheral vascular disease• Hypersensitivity to cold• Skin anesthesia• Open wounds or skin conditions (cold

whirlpools and• contrast baths)• Infection



THERMOTHERAPYIndications

• 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



UltrasoundINDICATIONS• 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



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

CONTRAINDICATIONSAcute traumatic musculoskeletal injuriesAcute inflammatory conditionsAreas with ischemiaAreas of reduced sensitivity to temperature or painFluid-filled areas or organsJoint effusionSynovitisEyesContact lensesMoist wound dressingsMalignanciesInfectionPelvic area during menstruationTestesPregnancyEpiphyseal plates in adolescentsMetal implantsUnshielded cardiac pacemakersIntrauterine devicesWatches or jewelry



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


Summary

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


THANK YOU


Noxious Mediator

Managing Pain With Therapeutic Modalities - Kiky

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