class 1 Flashcards
DEFINITION OF PAIN:
the physical feeling caused by disease, injury, or something that hurts the body
mental or emotional suffering; sadness caused by some emotional or mental problem
Hertling & Kessler (4th ed) pain is multi-dimensional.
Pain can affect a person
physically, emotionally or psychologically. Other the other hand, emotional or psychological
problems can cause pain. How one experiences pain and ones interpretation of it is personal,
has no outside comparison, and is influenced by culture & community.
Subjective:
relating to the way a person experiences things in his or her own mind; based on
feelings or opinions rather than facts
Objective:
based on facts rather that feelings or opinions; not influenced by feelings
It is very difficult for RMT’s to objectively measure pain when assessing patients.
Pain caused by Injury:
It is caused by tissue damage.
Pain caused by bone:
deep, boring, very localized
Pain caused by vascular:
diffuse, aching, throbbing, poorly localized; may refer to other areas of the
body
Pain caused by nerve:
sharp (lancinating), bright, burning, runs in the distribution of a specific nerve;
a.k.a. neuropathic pain
Pain caused by muscle:
hard to localize, dull aching, cramping
Pain caused by Muscle Spasm:
Spasm: “an involuntary, sustained contraction of a muscle; a.k.a. cramp” The rapid, uncontrolled contraction, or spasm, happens unexpectedly, with either no stimulation or some trivially small one. Fasciculation is a type of painless muscle spasm, marked by rapid, uncoordinated contraction of many small muscle fibers.
Pain caused by Muscle cramp
Cramps may affect any muscle, but are most common in the calves, feet, and hands. While painful, they are harmless, and in most cases, not related to any underlying disorder. The muscle contraction and pain last for several minutes, and then slowly ease.
There are 6 causes of muscle spasms.
Pain: from inflammation, trauma, infection
Circulatory stasis: from reflex muscle guarding, restricted movement, decreased circulation
Inc. gamma neuron firing: due to stress, anxiety, fatigue, overstretch injury
chilling: causes reflex muscle contraction
impaired nutrition: low calcium intake, loss of sodium via perspiration, dehydration, electrolyte loss through vomiting, hypocalcemia from diarrhea, heat stress
decreased Vit D; helps synthesize enzymes that transport calcium for normal muscle
contraction
Pain caused by Tension: (Rattray Ludwig, pg. 10)
.
Chronic muscle tension or fascial restrictions result in tissue ischemia
why tissue ischemia results in pain.
decreased availability of oxygen
build up of metabolites
release of histamines/bradykinin from constricted mm cells
Reflex muscle guarding: (Rattray Ludwig: Pg. 193)
This is a muscle spasm in response to pain. The pain is due to local tissue injury and is present
in the acute stages of a condition. However, the guarding may also be brought on by referred
pain. The spasm acts to splint the injury to prevent further injury. The guarding usually stops
when the pain is relieved.
Subjective pain descriptors & what they indicate (Magee pg 4):
Severe: intensity of pain is such that the patient is unable to move in a certain direction
or hold a certain posture due to pain
Irritable: progressively worse with movement or the longer the position is held
Acute: new pain; often severe, continuous, and perhaps disabling; pain earlier in
movement
Chronic: pain not as intense; has been experienced before; often associated with
depression
The duration of pain and what it indicates (Magee pg 5)
acute: 7 - 10 days
sub-acute: 10 days to 7 weeks
chronic: more than 7 weeks
We ask: “How long have you had this pain?”
Pain - Local
well localized
radicular- nerve root compression
cutaneous- superficial tissue damage
psychogenic - arises from emotions or psyche
Pain - Diffuse
Diffuse
deep somatic- muscles, tendons, joints, periosteum
visceral - visceral distension or ischemia
Pain Tension Cycle
Sometimes pain continues well after the injury should be healed. Or there is constant pain when
there has been no injury. This could be due to a pain-tension cycle
Sometimes pain continues well after the injury should be healed. Or there is constant pain when
there has been no injury. The pain results from direct or indirect trauma, inflammation or infection, which can initiate a
reflex muscle contraction. The contraction restricts movement of the joint crossed by the muscle (protective muscle
guarding). This lack of movement leads to:
Tissue ischemia
Circulatory stasis
Metabolite retention
…which in turn irritate the nerve endings = PAIN
The muscle responds to pain by staying in spasm. This “intrinsic spasm” will remain, even when
the tissue injury that caused the initial reflex muscle guarding is no longer acute.”
Reflex muscle contraction can also be caused by:
Increase in SNS firing
Emotional stresses
Cold or chilling of the tissue
Immobilization
lack of movement leads to:
Tissue ischemia
Circulatory stasis
Metabolite retention
There are 3 principle ways in which massage can relieve pain:
- Allieviation of nociceptive input
- Alteration of central processing of nociceptive input
- Application of ice massage
1) Massage may act directly on the source of pain to alleviate nociceptive stimulation
Muscle pain can arise from sustained muscle contraction due to decreased blood flow
produced by compression of blood vessels within the muscle.
Massage relieves muscle tension/spasm, thus increasing blood flow and reducing
ischemic pain
2) Massage may act centrally to alter the processing of nociceptive input
Due to neural gating (pain gate theory)
Possibly due to release of endorphins in CNS
These processes distract the brain, interfering with the perception of pain
3) Ice massage may affect the conduction of pain impulses in the peripheral nerves
Ice massage may help in reduction in local circulation & metabolism, affecting the
generation & rate of conduction of nociceptive impulses
Pain Gate Theory
Dr. Ronald Melzack, a Canadian psychologist, (who proposed the Pain Gate Theory)
theory to explain how emotions and your own thinking can affect your perception of pain. A certain set of initial conditions need to be met for the pain sensation signal to be passed or not
passed through the gate constituted by specific cells in the spine that control their transmission
through spinothalamic tract to the central nervous system.
how Wall and Melzack hypothesizes the perception of pain and how it is suppressed sometimes
input signals to this gate is of two
types, which includes small nerve fibers (pain pathway fibers) and large fibers (sensory neural
pathways) which are both connected to the projection cells that carry signals through the
spinothalamic tract. The projection cells are the control element of the gate. Both the types of
nerve fibers (pain receptors and sensory receptors ) are also connected with inhibitory inter
neurons which are situated in dorsal horn of the spinal vertebrae. They can suppress
transmission through the spinothalamic tract by controlling the projection cells.
There are three cases of pain transmission scenarios:
No Input - Gate Stays Closed: When there is no incoming response from both fibers, inhibitory neurons prevent
transmission of signals to the CNS through projection cells.
Large Sensory Input Closes Gate: In case of a large input signal from the sensory nerves, the inhibitory neurons get
activated and again prevent transmission of signals through the projection cells and we feel no pain.
Pain Receptor Nerve Input Opens Gate: Only when there is an input signal from the small pain receptor neurons and sensory neuron input is not large enough to activate inhibitory cells, then projection cells pass the signal to the CNS (central nervous system). That is the gate opens for only pain reception and otherwise it’s closed.
massage therapy and its various techniques stimulate……
Large Sensory Input, which closes the gate. Massage
stimulates the receptors for light touch, deep touch, vibration,
heat, cold, etc. This sensory input over-rides the pain
impulse, and the brain does not perceive the pain.
Chronic pain syndrome has been described as
“severe pain associated with little or no
discernible injury or pathology”. There is no longer a direct relationship between the pain and
the apparent disability. Treatment of the painful symptoms usually does not change the
condition
Pain perception is also affected by various inputs to the brain:
Memories of past experiences, meaning, anxiety: the context of the injury can influence
pain patterns; eg: someone with a history of serious whiplash injury may develop neck
tension every time they drive a car
Cutaneous, visceral, musculoskeletal input: stress & strain to tissue, which may cause
pain (or not)
Melzack believes that some forms of chronic pain may occur due to the
cumulative destructive effect of cortisol on muscle, bone & neural tissue. Injury does
not merely produce pain; it also disrupts the brains homeostatic regulation systems, thereby
producing “stress” and initiating complex programs to reinstate homeostasis. describe this process….
Cortisol is an
important hormone for re-establishing this homeostasis. It is needed to provide high levels of
blood glucose which the body requires to respond to injury, threat or other emergency. To
provide this high level of glucose, cortisol breaks down the protein in muscle & inhibits the
replacement of calcium in bones. This can lead to myopathy, weakness, fatigue, & bone
degeneration. It also inhibits the immune system, and can also accelerate neural degeneration
of the hippocampus during aging. These are classic symptoms in many chronic pain & autoimmune
disorders.
Our clients can tell us all about their pain or stress, but how can we measure it??
What do you notice about your client?
Change in appetite (eating lots, too little) Change in sleep pattern – ie. How many hours? Sweaty hands, etc. Dilated pupils Trembling Rapid heart rate (measurable) Rapid, shallow breathing (measurable) Increased blood pressure (measurable)
