Pain is the most common reason patients seek treatment by physicians. Biologically, the pain signal represents potentially dangerous tissue damage. Pain is a warning to the organism to stop or escape from damaging activity and allow regenerative processes to work. However, pain is a complex interplay of peripheral nerve, spinal cord, and brain processes which are incompletely understood. If, for unknown reasons, the pain signal continues despite the removal of the painful stimulus, pain loses its adaptive value and may result in significant physical and psychosocial disability.
Most acute pain can be eliminated by discontinuing the source of tissue damage, resting the damaged part, and using simple analgesia. Physical medicine techniques enhance physical recovery from many painful conditions, particularly if simple measures have not eliminated the pain or significant loss of function has occurred.
Neuroanatomy and Neurophysiology of Pain Pathways
Most nociceptor afferent input is transmitted from the peripheral pain sensors through the small (0.1 – 1.0 µm diameter) unmyelinated C-fibers to the central nervous system (CNS). Some pain impulse, particularly thermal and mechanical pressure stimuli , reach the CNS through myelinated A-delta fibers (1 – 4 µm diameter). Peripheral stimuli enter the dorsal horn of the spinal cord where most of the C-fibers synapse in the substantia gelatinosa (laminaII). Pain impulses ascend the spinothalamic and spenoretinacular tracts to project on the lateral and medial thalamic nuclei and the brainstem, respectively. Projection of these impulses to the sensory cortical areas brings the pain to consciousness and makes locating it in the dorsal horn of the spinal cord. Endogenous opiods such as beta endorphin and enkephalins in the CNS and periphery inhibit pain.
Pain is universal phenomenon. Everyone will experience pain during his/her lifetime. Atleast 80% of the population at some time will have low back pain, the most common cause of worker absence and loss of productivity in industrialized countries. Neck pain may be present in up to 50% of the population at some time in life, and up to 20% of the female population experiences fibromyalgia. About 1.6% of the population has an on going problem with temporomandibular joint pain.
Etiology and Pathophysiology
Aute pai can usually be linked to a precipitating event, usually traumatic. Assume that all pain is real. However, remember that pain is subjective; there can be no objective measurement of it. Pain that is incapacitating to one may be incosequential to another, or to the same person under different circumstances. All pain perception is individual.
In general, the longer pain persist, the less likely complete resolution becomes. This assumes that adequate work-up for etiologic and contributing factors has been performed and that perpetuating factors have been controlled as much as possible. Patients who are adaptable, educable and willing to take responsibiity for aspects of treatment within their conrtol generally have better outcomes than those with significant psychosocial issues, lack of insight, or secondary gain motives.
Treatment of acutely painful conditions differs from the treatment of chronic pain. In acute pain management, resting the damaged structure is essential for recovery. This contrasts with the management of chronic pain, where the patient usually needs mobilization due to underuse of affected areas. Contracture of collagenous structures, including tendon, ligament, and joint capsules, occurs rapidly in patients with painful range of motion. These may require gentle passive range of motion (PROM) to avoid the vicious cycle of pain to immobility to contracture to increased pain. Similarly, atrophy of immobilized muscle should be avoided, if possible, through the use of isometric exercise.
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