Physical therapy physical modalities are often applied to control pain so that other Physical Therapy Goals May be achieved.







"HAVEN'T I HEALED YET? I STILL HAVE PAIN"



Pain may precipitate a variety of physiological responses. These responses can be categorized as sympathetic and local.


Local responses are all interrelated. They include:

Muscle Spasm

Edema

Endogenous Chemical Release


Muscle spasm is the reflexive tendency to attempt to immobilize the injured part, perhaps in an attempt to prevent further injury. Muscle spasm requires a relatively high level of metabolic activity and causes compression of blood vessels. The compromised circulation could become inadequate to meet the higher metabolic needs leading to ischemia and a new source of pain.


Edema (swelling) may result due to a disruption of capillaries and lymphatics by trauma or secondary compression from muscle spasm. Edema may complicate the problems of waste removal and nutrient supply and may cause more pain.


Endogenous Chemical Release The release of potassium, serotonin, bradykinin, histamine, prostaglandins, leukotrines, as a consequence of trauma can directly activate nociceptors or may act alone or in combination to sensitize nociceptors to other agents.


Pain-Spasm-Pain Cycle

As the responses interact a cycle of pain may arise. The pain may cause spasm. The spasm may disrupt the local vascular system and impair the delivery of nutrients and waste removal precipitating pain, which in turn may lead to more spasm and so on....


Physical therapy procedures may be directed at breaking the cycle an any point to mitigate the pain.




“Physical THERAPY! Are you kidding me!”



Imagine you walk into a patient's room just a few hours post surgery. You are all cheery and friendly as you explain that you are there to get them out of bed and get rehabilitation underway.


The patient is in pain, might have gastrointestinal discomfort, and her eyes may be sensitive to light. Her skin feels cold. She is having mild difficulty breathing, she feels fatigue, and her hospital gown is again wet with sweat.


Perhaps if it was "just" pain she would be more willing or able to greet you with the demeanor that you have presented. However, the last thing on her mind at this moment is being cheery or getting up to "do some therapy"


Though this may be an extreme example, physical therapist assistants must remember that pain is real, people respond differently, and that there are real physiological consequences associated with it.


Physical therapist assistants must be familiar with these consequences and be sensitive to them as they attempt to provide physical therapy care.





pain classifications



Acute Pain





Resulting from infection, injury, or internal disease. If the cause is diagnosed and treated or removed, the pain is eliminated relatively quickly (pull the pin out of your finger the pain goes away)



Chronic Pain





May or may not relate to an actual physical injury, and often persists despite treatment. Not completely understood. Chronic pain is usually treated by a team approach with heavy emphasis on psychologic support and guidance. The team includes physician/nurse practitioner, psychologist, physical therapist, occupational therapist, social worker, vocational rehabilitation counselor, recreational therapists, dieticians, biofeedback technicians and other health professionals.



Referred Pain





Pain arising from deep body structures but felt at another distant site. Referred pain may arise as a consequence of the convergence of cutaneous (skin) and visceral afferent nerve fibers within the spinal cord and dermatomes, sclerotomes and myotomes.



Mechanisms of Chronic Pain





Mechanical - entrapments (CTS)

Chemical - Endogenous releases setting up loops

Regeneration - Increase discharges of pain nerves during regeneration

Reflexes - Protective reflexes set up pain-spasm-pain cycles

Inhibitory failure - Failure of CNS release of endogenous opiates



Simple But Essential Assessment of Pain
The Visual Analog Scale (VAS)



Because of its subjective nature, pain is difficult to objectively assess. However it is important that some objective measure is attempted. Without it, it is more difficult to assess the efficacy of treatment.


The visual analog scale requires the patient to attend to their own perception of pain by providing a number describing its relative severity.


Interestingly, patients want to feel better and also do not want to disappoint the clinician, so reports of slight differences of pain reduction are common. Physical therapist assistants must look for other clues such as willingness to move, changes in functional range of motion, etc. as evidence of decreased pain.




The Human Body is Specialized to Modulate Pain







Pain is often a consequence of dysfunction. It therefore makes sense that the body employs endogenous ways to attenuate pain. The Gate Control Theory of Pain as well as the neural and peripheral release of opiate like chemicals are potential examples of how the body "fights pain."









Effective physical therapist assistants are aware of the varied means of pain management that may be applied by physicians and other healthcare professionals.

Clearly the presence of persistent moderate to severe pain may significantly slow the rehabilitation process.

Given the peripheral and central neurological basis of pain, physical therapist assistants must possess a sound understanding of nervous system anatomy and physiology


Medical personnel use a variety of pharmaceutical interventions, acting at various neurological levels to manage pain. All have varying levels of effectiveness, precautions and side effects.

Since about 2014, a non-pharmaceutical option for the management of OA pain—especially for the knees as part of TKA protocol is becoming more popular. Cryoneurolysis temporarily stops targeted afferent conduction leading to potentially significant decrease in pain.
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—CHECKPOINT—



This is a good time to pause and assess your knowledge of key concepts. Below are links to a few learning activities that might assist your mastery of the material.


Completing some of the tasks may also earn you class participation credit! However, most importantly it will assist in your learning.


You should attempt to complete the assignments without using your text, notes, etc., as they are designed to test your knowledge—just like taking a test in class—but without the grade consequences.

Tasks include mock exams, games, clinical scenarios, and more. Click/tap on the activities and see how much you know!



Pain Cryptogram
Short Essay
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