Faculty of physical therapy

Cairo university

Basic sciences department

“ Pain “
By

Sarah AbdelWahab

Presented to
<< PROF. DR. RAGIA M. KAMEL >>
Definition of Pain :
 It’s an unpleasant sensory and emotional experience arising from actual or potential
tissue damage.

Causes of pain :
1- Ischemia : Decrease in O2 supply to tissues depend on an aerobic metabolism
Increase lactic acid Increase pain .
2- Muscular spasm :
a) Direct : Stimulation of mechano-sensitive pain receptor , also Ischemia also
contribute to the production of pain in this condition .
b) Indirect :
 Compression on blood vessels Decrease blood flow.
 Ischemia due to squeezing blood vessels may contribute to pain (Intestinal, renal or
billiard colic ) .
3- Bone Injury: It’s painful because of the chemical and mechanical irritation of the
overlying patriotism ( Note : Bone is insensitive to pain ) .
4- Inflammation of joints : It’s painful due to chemical and mechanical irritation of the
surrounding tendons and ligaments .
5- Over Distension of a hollow viscous : Over stretch of the tissues stimulates mechano-
sensitive pain receptors .
6- Traction on the mesentery : Like Abdominal tumor .

Physiology of pain :
1) Types of pain receptors :
 Mechano sensitive pain receptors : Which are stimulated by strong
mechanical stimuli .
 Thermo Sensitive pain receptors : Which are stimulated by temperatures
below 15C or above 45C .
 Chemo sensitive pain receptors : Which are stimulated by chemicals ( P-
FACTOR , Bradykinin , Lactic acid , Potassium ions ) .
2) Types of pain according to its site of origin :
A) Cutaneous Pain : Arises from the skin and is transmitted by cutaneous somatic
nerves .
B) Deep Pain : Arises from deep structures like muscles , tendons , ligaments ,
periosteum and is transmitted by deep somatic nerves .
C) Visceral Pain : Arises from Viscera like Heart , Kidney and Intestine , transmitted by
the visceral afferent fibres in the autonomic nerves .
3) Types of pain according to the speed of its conduction :
A) Fast pain : Is conducted by type III fibres .
B) Slow pain : is conducted by type IV fibres .

Pain Pathway :
Criterion Fast pain Slow pain
Site of origin Only cutaneous Cutaneous , deep , visceral
Conducting nerves Type III fibers Type IV fibers
Sensory pathway Neospinothalamic pathway Paleo Spinothalamic pathway
Center of perception Cerebral cortex Thalamus
Relay in dorsal horn Laminae II & V Laminae II & III
Relay nuclei in the thalamus Ventro posterior laminar nuclei Inferior laminar nuclei
Relay in reticular formation No relay Relay
Final destination in CNS Sensory cerebral cortex All areas of the cerebral
sensory cortex

Pain Pathway :
A. The 1st order neuron :
 Is the cell of the posterior root ganglion & its axon.
 The Axon is divided into Lateral & Medial branch .
 The Lateral branch forms the afferent sensory nerve .
 The Medial branch enters the spinal cord to ascend a few segments forming “
Lissauer’s tract and relays in the cells of the Substania gelatinosa of Rolandi
( SGR ) capping the posterior horn of gray matter .
B. The 2nd order neuron :
 Is the cell of S.G.R & its axon .
 This Axon crosses to the OPPOSITE side & ascend in the Lateral Spino
thalamic tract if the spinal cord then in the lateral lemniscus of the brain stem
to relay in the thalamus .

C. The 3rd order neuron :

 Starts in the cell of the thalamus .
 Its Axon ascends to pass through the posterior limb of the internal capsule
conduction the impulse to the cortical sensory area .

Pain Inhibition :
 ANALGESIA : Suppression of pain .
 There is an analgesia system in the body which can suppress pain sensibility.
 Analgesia system in the body is divided into : I- Peripheral System II- Central System .
 I- Peripheral Analgesia system :
 It consists of the type II sensory nerve fibers which conduct
Mechanoreceptive immediately after they enter the spinal cord .
 Type II fibers divide into Medial and Lateral branches :
a) Medial Branch : ascends to form the Gracile and Cuneate tracts .
b) Lateral Branch : Stimulate pain inhibitory complex to inhibit pain
transmission .
 Note : Pain sensation can be suppressed by scratching or rubbing
of the skin .

II- Central Analgesia system :

1. The Cerebral cortex :
 Many areas of the cerebral cortex , especially the limbic
association area , project cotricofugal fibers ( B- endorphenrgic
fibers ) to :
a- The thalamus : these fibres block pain at the level of thalamus
b- The Periaquiductal gray matters of the mesencephalon .
2. The Hypothalamus :
 B- endorphenrgic fibers project from the periventricular nuclei to
the periaqueductal gray matter of the mesencephalon .
3. The Peri Aquiductal gray matter of the mid brain :
 Neurons from this project Enkephalinergic fibres to the reticular
formation of the brain stem and the raphemagnus .
4. The reticular formation of the brain stem :
 It sends Serotonergic descending fibres to the raphe magnus
nucleus .
5. The Raphe Magnus nucleus :
 Is found in lower pons and upper medulla .
 Serotogenic nerve fibers descend from the nucleus down the
lateral reticulo spinal tract to activate the spinal PIC .

Summary :
1- When pain reach thalamus , Peri Ventricular and Peri Aquiductal gray matter in the
mid brain release Enkephaline , leading to stimulation of Reticularis magnus
celluaris and raphe magnus nucleus .
2- Release of Enkephaline and Serotonin to Spinal Cord ( Dorsla root ganglion ) .
Stress Analgesia :
 Is the Suppression of pain sensation during stressful situation ( Fight or Flight ) , in
these conditions pain impulses are blocked at 2 levels :

A) 1st gate of pain transmission :

- Dorsal horn of the spinal gray matter is the site of relay in
the sensory pathway of pain .
- At this level there is a group of inhibitory enkephalinegic
interneurons, these interneurons block the transmission
of pain sensation by presynaptic inhibition of the primary
pain conducting fibres .
B) 2nd gate of pain transmission ( Thalamus ) :
- Corticofugal fibers to the thalamus block by presynaptic
inhibition , the transmission of pain signals in the
thalamus before they reach the cerebral cortex .

Complication :
a. Mood alteration
b. Death wish
c. Depression
d. Anxiety
e. Loss of appetite
f. Muscle Weakness
g. Malaise
h. Muscle spasm
i. Nausea
j. Loss of interest
Management :

I – Assessment :
A) Subjective Measures
 Patient Self-report using a single dimension pain scale
1. Verbal descriptor scales
2. Numerical pain scales
3. Visual Analogue pain scale ( VAS )
4. Behavioral rating scale
5. Numerical rating scale
6. Point box scale
7. Pain relief scale
 Patient Self-report using a Multi dimension pain scale
 McGill pain questionnaire
  Pain Diagram
 Picture Scale
B) Objective Measures
 Biological measures

A) Subjective Measures :

1. Patient Self-report using a single dimension pain scale

A. Verbal descriptor scales :
 Malzack and Torgerson introduced the following five word scale that
is often used :

A- Mild

B- Discomforting

C- Distressing

D- Horrible

E- Excruciating

 The major concern with this test was that it was open ended .
 This Problem was remedied when Aitken added defined end points ,
no pain and “ Unendurable “
 Advantages  Disadvantages
 They correlate with  They have limited number
Visual analogue scale in many of possible responses.
situations , while potentially
being more useful in
experimental pain situation than
VAS .
 More patients may be  The scale is non
able to complete the verbal continuous so that the use of non
descriptor scale than VAS or parametric statistics for analysis is
numerical scales. required , which potentially
makes this scale weaker than the
VAS .
B. Numerical pain scales
 The numerical pain scale is an ordinal method of assessing pain using 11 point
scale where 0 = no pain and 10 = most excruciating pain imaginable .
 Advantages Disadvantages
 No special training is  It can be statistically
required to administer it . weak because of the required
 It gives consistent non parametric analysis ,
measurements . however , this is probably
 It allows for inter patient clinically in significant .
assessment and the changes
within a patient during
treatment.
 This scale may be a
better assessment of
remembered chronic pain .
 It can be used for small
children .

C. Visual Analogue Scale ( VAS ) :
 The VAS is a simple robust pain management tool .
 It can be used to record pain severity and/or improvement .
 It can be reliably used in children over the age of five .
 Is usually designed as a 10 cm line with descriptions at each end .

Advantages
 It gives a valid data for
chronic and experimental pain
that can be assessed
parametrically.
 The VAS can be derived
from other scores or that VAS
can be modified to a 5cm scale in
order to facilitate its use .
Disadvantages
 Some patients especially
elderly ones may not be able to
complete the scale .
 Around 11% to 26% of
patients could not complete VAS
or found it confusing .
 Neither derivation or
modification has proven reliable .
D. Behavioral rating scale ( BRS-6 ) :
 It consists of six sentences , each one describe present pain .
 Ask patient to mark on that one that describes his pain :
 No pain
 Pain present but can easily
ignored.
 Pain present but cannot easily
ignored but doesn’t interfere
with the everyday activities .
 Pain present , cannot be ignored
and interfere with concentration
.
 Pain present , cannot be ignored
and interferes with all tasks
except taking care of basic needs
such as toileting and eating .
 Pain present cannot be ignored ,
rest or bed required .
E. Numerical Rating scale ( NRS-101 ):
 It’s an ordinal method of assessing pain using a 10 points , ask the patient
to mark on the line below the number between 0 and 100 which indicates
how strong your pain is right now , A zero would mean no pain and a 100
would mean worst pain .
F. Point box scale ( PBS – 11 ) :
 This scale contains 11 boxes from 0 to 10 as Zero means no pain and 10
means worst pain .


G. Pain relief scale :
 This scale is represented by a line and ask patient to mark on it to indicates
amount of relief you feel from your pain right now as compared to
yesterday .
 These methods have similar accuracy and validity to VAS .
 A problem common to all numerical and descriptive pain scales is that they
rely on the intact language skills of an intelligent patient; facial drawing is
reliable markers of pain designed specifically for use with children, the
mentally handicapped or patient with poor language skills.
2. Patient Self-report using a single dimension pain scale

A. The McGill pain Questionnaire :

 The MPQ was developed in 1975 by Melzack and Colleagues at
McGill University in an attempt to organize pain descriptors into a
comprehensive evaluative tool. It consist of 3 major measures :
1. Pain rating index , which is based on the numerical score.
2. Total number of words chosen .
3. The present pain intensity , which is a modification of the single
dimension five point verbal descriptive scale that is used to evaluate the
intensity of pain at the time completing the questionnaire .
 The major strength of MPQ is the pain rating index which is an
organized list of words divided into Sub-categories of related
words which are rated on a common – intensity scale , Also the
pain rating scale are designed to assess the three components of
pain postulated by the gate control index section of the MPQ has
been used in a variety of clinical setting including dentistry , post
operative pain , low back pain and obstetric pain .
 It consists of a series of 102 pain descriptors that are grouped into
classes and sub-classes describing different aspects of the pain
experience.
 The McGill questionnaire usually takes around five to ten minutes
to complete.
Pain Diagrams :

 Allow for rapid communication .

 Facilitate patient flow .
 Patients appreciate the opportunity for enhanced communication .
  Patients will frequently reveal more on a pain diagram than they will
verbally .
 Reluctant patients understand the saying that “ One picture = 1000 words “
Translations of Wong-Baker faces pain rating :

B) Objective Measures :
1- Heart rate initially decreases and then increases is response to Short sharp pain , Vagal
tone and heart rate variability such as Breathing have been used as indices of pain and
distress .
2- Oxygen Saturation decreases during painful procedures such as Lumbar punctures and
intubations .
3- Surgery or trauma triggers the release of stress hormones .
4- Cortisol release : Plasma Cortisol levels rise significantly during operation , however ,
sick adult may have unstable levels and small changes during painful procedures may
not be detectable .

Treatment :
a) Pharmacology therapy :
 Drugs such as : Aspirin , Paracetamol , NSAIDs .
 If Pain control is not achieved , the 2nd part of the ladder is to introduce weak
opioid drugs such as codeine or dextropropoxyphene together with appropriate
agents to control and minimize side effects .
 If pain persists , the final part of the ladder is used , Strong opioid drugs such as
Morphine is used .
b) Physiotherapy :

1- Electrical stimulating current :

 E.S.C that affect Nerve and muscle tissue have the longest wave lengths and low
frequency of any of the modalities .
 The wave length of the Electrical stimulating units are extremely long ranging
around 15000 Km , Clinically used frequencies range from ( 1 to 4000 Hz ) .
 Most stimulations have the flexibility to alter the frequency output of the device to
elicit a desired physiologic response .
 The nerve & muscle stimulating currents are capable of :
4. Pain Modulation either through stimulation of cutaneous sensory nerves
at high TENS frequencies .
 5. Producing muscle contraction and relaxation or tetany , depending on
the type of current ( Alternating , Direct and frequency ) .
6. Facilitating soft tissue and bone healing .
7. Producing a net movement of Ions through the use of continuous direct
current and thus electing a chemical change in the tissues (
Iontophoresis ) .

TENS Therapy :
1. Definition :
 Is a transcutaneous electrical nerve stimulation .
 Is application of a pulsed triangular wave current via surface electrodes on the
patients’ skin .
 Is Low intensity , short impulse current applied largely for pain relief .
 Used for Acute pain & Non malignant Chronic pain .
 But it can also be used in palliative care to manage pain caused by metastatic bone
disease and neoplasm .
 It has antiemetic & tissue healing effects .
2. Advantages of TENS :
 In medicine , TENS is the most frequently used electrotherapy for producing pain
relief .
 It’s Non-invasive , easy to administer and has few side effects or drug interactions .
 No potential for toxicity or overdose , patients can administer TENS themselves and
titrate the dosage of treatment as required .
 Its effects are rapid in onset for patients so benefit can be achieved almost
immediately .
 Is cheap when compared with long term drug therapy .
3. Types of TENS :
a. Conventional ( High frequency ) :
 Frequency 50 Hz to 100 Hz .
 Intensity : Till patient receives strong paraesthesia without muscle
contraction ( 0mA to 30 mA ) , the intensity is turned up gradually until a
prickling or tingling sensation is felt , it should be neither painful nor
should it cause muscle contraction .
b. Low Frequency :
 Frequency 1 Hz to 4 Hz
 Intensity : Till patient receives muscle contraction of related myotome ( 30
mA to 60 mA ) , This type is usually applied to Acupuncture points and
sometimes to motor points of muscle .

c. Burst TENS :
 It’s a series of pulses repeated 1-5 times a second , commonly twice .
 Each burst consists of a num,ber of individual pulses at the usual
conventional TENS frequencies of 50 Hz to 100 Hz but a higher intensity .
4. Mechanism of action for pain inhibition
A) Conventional TENS :
 The Aim is to activate selectively large diameter Aβ fibres without concurrently
activating small diameter Að and C (pain related)fibres or muscle efferent .
 Presynaptic inhibition by pain gate mechanism by stimulating Aα and Aβ fibres
 Uses – Acute pain .
B) Low frequency TENS :
 Aim is to activate small diameter fibers (Að or group III ) , This stimulates the
high threshold Að and C fibres , which lead to release of Endogenous opioids .
 Uses – Chronic pain .
C) Burst TENS :
 Activating the Aβ Fibres and the pain gate mechanism , each burst will
produce excitation in the Að fibres , therefore stimulating opioid mechanisms
 It’s Advantageous because it allows stimulation of pain carrying fibres while
the patient perceives a relatively comfortable sensation because of the high
internal frequency .
5. Biological effects of TENS :

Analgesic Effects :

 Relief of acute pain

 Relief of chronic pain

Non Analgesic Effects :

 Antiemetic effects
 Improving blood flow
6. Indications of TENS :

a- Acute Pain : Minor Sports Injuries , Acute Spinal pain , Acute tendinitis .

b- Chronic Pain : Low back pain , Rheumatoid arthritis . Neuropathy , Phantom limb pain ,
Cancer .

c- Post operative pain : Abdominal surgery , Thoracic surgery , Orthopedic Surgery .

d- Other Clinical conditions : Morning sickness , Labour & Delivery , Motion & travel sickness .

7. Electrodes :

I- Types of Electrodes :

 Carbon Silicone which is coated with a conductive gel prior to attachment to

the skin.
 Metal mesh with solid conductive gel which is self-adhesive and have
become more popular.
 II- Electrode placement for TENS:

A) General placement:

1- Painful region : Electrodes are most frequently placed within or around the area
of pain .
2- Dernatome : Consists of the cutaneous region innervated by one spinal nerve
through both of its rami .
3- Spinal Cord segment: give rise to a specific nerve root conveying nociceptive
input provide another choice for electrode placements .
4- Peripheral nerves : Can be stimulated at along their course using superficial
electrodes .
5- Nerve plexus : Brachial plexus can be stimulated at Erb’s Point ( proximal ) the
distal electrode can be placed over a superficial peripheral nerve .

B) Alternative methods :

1. Dual channel placement : uses 4 electrodes for TENS simultaneously .

2. Bilateral placement : extremely beneficial and can be used for unilateral pain
conditions .
3. Contralateral placement : When stimulation of painful region exacerbate pain
stimulation of the corresponding contralateral peripheral nerve or
dermatome may sometimes be effective using this method may need longer
time and higher intensity to be effective .
4. Bracket and Crossed placement : Using a dual channel or multiple , a specific
area of pain can be bracketed by electrodes in a triangular or square
formation .

9. Contraindications :

1- Pacemaker
2- Epilepsy
3- Heart diseases
4- First trimester in Pregnancy
5- Broken skin
6- Dermatological conditions

LASER Therapy
1. Definition
 It’s an acronym for Light amplification by stimulated emission of Radiation .
 It’s a form of Electromagnetic radiation that is classified within both the infrared
and visible portions of the spectrum .
 Is either Low power or high power .
2. Types of Laser Therapy :
A) High power laser : used in surgery for purposes of incision , co-agulation of vessels and
thermolysis owing to their thermal effects .
B) Low power of Cold Laser : produces little or no thermal effects but seems to have
more significant clinical effect on soft tissue and fracture healing .

3. Types of Low laser as used by therapists :

a) Helium Neon laser ( HENE ) : wavelength = 632.8 nm , there is a direct depth
penetration to 0.8 mm & indirect depth penetration up to 10-15 mm .

b) Gallium Arsenide laser ( GASAS ) : wavelength = 910 nm , Penetration is indirect as

much as 5cm .

4. Role of laser in Pain Control :

 Indication :
1- Pain
2- Non united fracture
3- Acute and chronic soft tissue injuries ( Tendons , ligaments , muscle and nerve
injuries ) .
4- Acute and chronic sprain strain
5- Trigger point and acupuncture point stimulation
6- Neurogenic pain such as trigeminal neuralgia , post herptic neuralgia .
7- Acute and chronic inflammation of musculoskeletal system ( Rh. Arthritis ) .

 Mechanism of control :
1- Increase pain threshold
2- Alteration of nerve conduction velocity
3- Increase release and metabolism of serotonin
4- Neuro pharmacological effect by alteration of level of endogenous opioid .

 Techniques of laser :
Laser in general is applied using two main techniques :
A- Contact technique :
- This technique for optimum laser treatment using diode
system ( hand held probe ) the tip of the probe is held
perpendicular in contact with the skin .
- It allows deeper penetration of laser and maximize the
power density on the target tissues as reflection is
minimized
 B- Non Contact technique :

- This technique used in treatment of open wound .

- The distance between the laser probe and the wound bed
should be 1-5 cm , the probe should be perpendicular to
the site of radiation .
 Laser treatment for Pain Control :
1- Point of application : is used to irradiate localized painful spot , using hand held
probe which can use in contact and non contact technique , it’s applied in :
a) Over site of lesion or pain
b) Trigger points
c) Nerve roots and superficial nerve trunks
2- Dosage : Usually higher doses because the target treated tissue is deeply
usually 1-3j/point or 8-12j/cm

 Contraindications :
1- Over malignant tumors
2- Thyroid gland and other sensitive organs
3- Pregnant uterus .
NOTE : Physiotherapist &Patient must protect their eyes during application for
safety .

Cryotherapy
1. Definition : Is the therapeutic use of localized cold or freezing tempratures to treat pain
that primarily targets the body’s soft tissue .

2. Effects of Cold :

 Decrease local temperature

 Decrease Metabolism
 Vasoconstriction of arterioles and capillaries
 Decreased Nerve conduction velocity
 Decreased delivery of leukocytes and phagocytes
 Increase lymphatic and venous drainage
 Decrease Muscle excitability
 Decrease formation and accumulation of edema
 Extreme anaesthetic effects

3. Indications of Cryotherapy :

 During acute or subacute inflammation

 Acute pain
 Chronic pain
 Acute swelling
 Myofascial trigger points
  Muscle guarding
 Muscle spasm

4. Techniques :

 Ice Massage
 Hydrocollator packs
 Ice packs
 Cold Whirlpool
 Cold spray therapy
 Contrast bath

5. Application :

 At the beginning there is an uncomfortable sensation of cold followed by

Stinging then burning or aching feeling and finally numbness.
 Time required: 5 to 15 minutes .

6. Contraindications :

 Impaired circulation
 Peripheral vascular disease
 Hypersensitivity to cold
 Skin anaesthesia
 Open wounds or skin conditions
 Infection

Exercises :
 Proper exercises promote joint and muscular nutrition.
 Exercise have been proved effective in cases of Arthritis , Back pain , Neck pain , Calf
muscle pain , Cancer , depression , Aids .
 Stretching exercises improve ROM
 Breathing and relaxation exercises must be done twice a day.
 Repetition of exercises varies with the individual and the condition of the patient.
 The key point is BALANCED exercises, too much exercising can damage joints & muscles.
 Questions
I- True or False
1- Serum Cortisol level is a subjective measurement of pain sensation ( F )
2- Visual Analog scale is an objective measurement of pain sensation ( F )
3- GABA is a neurotransmitter that inhibit Substantia Gelatinosa of Rolandi ( T )
4- Stimulation of A beta fibers close the gait of pain ( T )
5- Descending pain inhibition may produce Pre & Post synaptic inhibition ( F )

II- Write short notes about the following :

1- Causes of Pain
2- Pain Pathway
3- Types of Analgesia system in human body
4- Types of TENS
5- Techniques of using LASER