Chapter 10
Pain
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Pain
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
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Types of Pain
Acute Pain
Chronic Pain
Referred Pain
Usually short lived and is
associated with muscle
strains, tendinitis,
contusions, surgery or
ligament injuries
Pain that persists
after noxious
stimulus has been
removed.
Pain that is felt at a
site distant from the
location of injury or
disease.
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Physiology of Pain – Source of Pain
Microtrauma
Macrotrauma
A long-standing or recurrent
musculoskeletal problem
that was not initiated by
an acute injury.
An immediately noticeable
injury involving a sudden,
direct, or indirect trauma.
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Non-nociceptive Pain
Damage to central nociceptive system triggers
non-nociceptive activity may elicit pain –
non-nociceptive pain (NNP)
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Pain Pathway
Lowered firing threshold
Aberrant
muscle
activity
Receptive threshold
expansion
CNS
Spontaneous discharge
Articular
dysfunction
Ascending afferents
Disordered
proprioception
Non-nociceptive
input
Nociception
Spinothalamic tract
Spinal cord
A&C fibers
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Pain Theory – Gate Control
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Examination and Evaluation
Use of Questionnaires
Assess affective qualities of pain
Assess pain intensity
Assess psychological aspects of pain
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Pain Scales
Visual analogue scale (VAS) – Pain
intensity
McGill Pain Questionnaire (MPQ) – More
sensitive, but longer than VAS; three
categories (sensory, affective, evaluative)
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Disability and Health-Related Quality of
Life Scales
 Quality of Well-Being Scale (QWB)
 Sickness Impact Profile (SIP)
 Duke Health Profile (DHP)
 Short Form-36 (SF-36)
 The Oswestry Low Back Disability Questionnaire
 Waddell Disability Index
 Disability Questionnaire
 Arthritis Impact Measurement Scales
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Therapeutic Exercise Intervention
for Pain
Acute
Combination of medication, gentle exercise,
ice (within first 24 hours).
Exercise directed at restoring motion,
strength, and function.
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Exercise Intervention for Chronic Pain
Often requires a team approach.
Realistic goals and patient education are crucial.
Goals may extend beyond treatment of
impairments.
Exercise is used to inhibit pain, facilitate nonnociceptive input, while addressing impairments
and functional limitations.
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Activity and Mode
Depends on source of pain and results of
evaluation.
Should focus on awareness and use of proper
posture.
Incorporation of movement therapies (e.g.,
Feldenkrais) is helpful in restoring movement
patterns.
Aerobic exercise (low impact) is helpful for
chronic pain.
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Dosage
Dosage should not increase pain.
Sessions may be brief initially to assess
response.
Frequency is determined by activity type,
purpose, and quantity prior to experience of pain
= “pain-free dosage.”
Functional progression to previous activity
levels.
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Adjunctive Agents
Medications
Massage therapy
Relaxation techniques
Biofeedback
Psychological care
Acupuncture
Heat
Cold
Transcutaneous
electrical stimulation
(TENS)
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Summary
 Pain impairment occurs with most musculoskeletal
conditions and must be treated as a primary impairment
along with any secondary limitations that may result.
 Nociceptors transmit pain via A&C fibers.
 Information is processed w/in SC and then ascends via
contralateral spinothalamic tract to thalamus.
 Gate theory – Incoming information from non-pain
receptors can close the gate to pain information.
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Summary – (cont.)
 Chronic pain may result from increased sensitization of
nociceptors and spinal level changes that perpetuate +
feedback loops in the pain-spasm pain cycle.
 Descending impulses can influence pain perceptions
through several mechanisms, including endogenous
opiates.
 Pain can be assessed through direct measurement
tools (questionnaires).
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Summary – (cont.)
 Therapeutic exercise is a cornerstone of treatment
for chronic pain.
 TENS, heat, cold, and medications are components
of a comprehensive treatment program.
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