class 1

Question 1

DEFINITION OF PAIN:

Answer 1

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

Question 2

Hertling & Kessler (4th ed) pain is multi-dimensional.

Answer 2

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.

Question 3

Subjective:

Answer 3

relating to the way a person experiences things in his or her own mind; based on
feelings or opinions rather than facts

Question 4

Objective:

Answer 4

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.

Question 5

Pain caused by Injury:

Answer 5

It is caused by tissue damage.

Question 6

Pain caused by bone:

Answer 6

deep, boring, very localized

Question 7

Pain caused by vascular:

Answer 7

diffuse, aching, throbbing, poorly localized; may refer to other areas of the
body

Question 8

Pain caused by nerve:

Answer 8

sharp (lancinating), bright, burning, runs in the distribution of a specific nerve;
a.k.a. neuropathic pain

Question 9

Pain caused by muscle:

Answer 9

hard to localize, dull aching, cramping

Question 10

Pain caused by Muscle Spasm:

Answer 10

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.

Question 11

Pain caused by Muscle cramp

Answer 11

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.

Question 12

There are 6 causes of muscle spasms.

Answer 12

 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

Question 13

Pain caused by Tension: (Rattray Ludwig, pg. 10)

.

Answer 13

Chronic muscle tension or fascial restrictions result in tissue ischemia

Question 14

why tissue ischemia results in pain.

Answer 14

 decreased availability of oxygen
 build up of metabolites
 release of histamines/bradykinin from constricted mm cells

Question 15

Reflex muscle guarding: (Rattray Ludwig: Pg. 193)

Answer 15

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.

Question 16

Subjective pain descriptors & what they indicate (Magee pg 4):

Answer 16

 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

Question 17

The duration of pain and what it indicates (Magee pg 5)

Answer 17

 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?”

Question 18

Pain - Local

Answer 18

well localized
radicular- nerve root compression
cutaneous- superficial tissue damage
psychogenic - arises from emotions or psyche

Question 19

Pain - Diffuse

Answer 19

Diffuse
deep somatic- muscles, tendons, joints, periosteum
visceral - visceral distension or ischemia

Question 20

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

Answer 20

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.”

Question 21

Reflex muscle contraction can also be caused by:

Answer 21

 Increase in SNS firing
 Emotional stresses
 Cold or chilling of the tissue
 Immobilization

Question 22

lack of movement leads to:

Answer 22

 Tissue ischemia
 Circulatory stasis
 Metabolite retention

Question 23

There are 3 principle ways in which massage can relieve pain:

Answer 23

1. Allieviation of nociceptive input
2. Alteration of central processing of nociceptive input
3. Application of ice massage

Question 24

1) Massage may act directly on the source of pain to alleviate nociceptive stimulation

Answer 24

 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

Question 25

2) Massage may act centrally to alter the processing of nociceptive input

Answer 25

 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

Question 26

3) Ice massage may affect the conduction of pain impulses in the peripheral nerves

Answer 26

 Ice massage may help in reduction in local circulation & metabolism, affecting the
generation & rate of conduction of nociceptive impulses

Question 27

Pain Gate Theory

Dr. Ronald Melzack, a Canadian psychologist, (who proposed the Pain Gate Theory)

Answer 27

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.

Question 28

how Wall and Melzack hypothesizes the perception of pain and how it is suppressed sometimes

Answer 28

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.

Question 29

There are three cases of pain transmission scenarios:

Answer 29

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.

Question 30

massage therapy and its various techniques stimulate……

Answer 30

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.

Question 31

Chronic pain syndrome has been described as

Answer 31

“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

Question 32

Pain perception is also affected by various inputs to the brain:

Answer 32

 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)

Question 33

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….

Answer 33

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.

Question 34

Our clients can tell us all about their pain or stress, but how can we measure it??
What do you notice about your client?

Answer 34

 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)