Pain

Pain

1. Pain

   • An unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage
     • Pain Perceptions determined by
       • Psychological
         • Fear of pain
         • Pain “catastrophizing”
         • Depression
         • stress
       • Biological
         • Person’s sex, genetics and number of nociceptors, in the body.
       • Social components
         • Person’s beliefs, attitudes or expectations
     • Subjective sensation
     • Localization
       • Cutaneous Pain
         • sharp, bright, burning
       • Deep Somatic Pain
         • tendons, fascia, muscles, joints, periosteum, and blood vessels
       • Visceral Pain
         • internal organs; diffused first & later may be localized
       • Psychogenic Pain
         • emotional rather than physical
     • Referred Pain
       • pain felt in a part of the body other than its actual source.
     • Types
       • Fast
         • Acute
           • Myelinated and a nerve fiber with a large diameter
             • Aδ fiber axons (NeospinothalamicTract)
       • Slow
         • chronic
           • Unmyelinated and a nerve fiber with a small diameter
             • C fiber axons (Paleospinothalamic Pathway)
     • How is pain perceived?
       • 1-Transduction of stimulus to action potentials (receptor potential)
         • 2-Transmission of action potentials to the cerebral cortex.
           • 3-interpretation of this input through association areas.
             • 4-Modulation by intrinsic neurons or by descending input from higher centers
     • Central processing of pain
       • cortex, thalamus and brainstem
         • Interconnected with
           • hypothalamus and autonomic nervous system,
             • associated with an autonomic response
   • Nociceptors or pain receptors
     • Unimodal- nociceptors
     • Polymodal nociceptors
     • Silent Nociceptors
   • Pain suppression
     • Analegisa
       • Endogenous opiates released from descending analgesic pathway bind with opiate receptors at the synaptic knob of the afferent pain fiber
         • This binding Inhibits the release of substance P, thereby blocking transmission of pain Impulses along the ascending pain pathways.

2. Dermatomes

   • -Distribution of sensory nerve fibers
     • two dermatome maps
       • Foerster (1933) :correlates with clinical findings
       • Keegan and Garret (1948):correlates with development

3. History Taking

   • basic patient details and statement of presenting problem.
     • Onset and Duration
     • Where
     • Progression
     • Quality
     • Quantity
     • Aggravating factors
     • Alleviating factors
     • Beliefs

4. physical Examination of the upper limb

   • Inspection
     • Initially there was no signs of any rash
       • a vesicular rash has appeared.
         • Types of Rashes
           • A macule
             • a flat, distinct, discolored area of skin less than 1 centimeter (cm) wide.
               • vitiligo, rubella, measles
           • A papule
             • is an area of abnormal skin tissue that is less than 1 centimeter around
               • dermatitis, chicken pox, eczema
           • Pustules
             • small bumps on the skin that contain fluid or pus
               • acne
         • small, fluid-filled sacs that can appear on your skin
           • cold sores, contact dermatitis, impetigo
   • Palpation
   • ROM
   • Clinical Diagnosis
     • pink or red blotchy patches on one side of your body
       • rash quickly develops fluid-filled blisters similar to chickenpox
         • Blisters sometimes erupt and ooze
           • Shingles often appears around the rib cage or waist, and may look like a “belt,” or a half belt
             • Most people can expect the rash to heal within two to four weeks.

5. shingles

   • painful condition that makes it difficult to sleep
     • LATS in neurons and sensory ganglia. single dermatome distribution
       • often with the accompanying condition postherpetic neuralgia
     • classic, rash that begins on the head and torso and then spreads to the arms and legs.
       • an area of redness with a small, superficial blister in the center
         • blister ruptures and the lesion will form a crusty scab that will fall off
     • signs and symptoms
       • Pain, burning, numbness or tingling
       • Sensitivity to touch and light
       • A red rash that begins a few days after the pain
       • Fluid-filled blisters that break open and crust over
       • Fever
       • Itching
       • Headache
       • Fatigue
   • Caused or activated by (low immunity)
     • old age
     • physical and emotional stress
     • HIV & AIDS
     • bone marrow transplant
     • chemotherapy
   • Complications
     • Allodynia
     • Hyperalgesia
     • Constant / intermittent burning, aching, throbbing, stabbing or shooting pain
     • Eye problems
   • Vaccination
     • Zostavax.
       • The vaccine won't treat a current outbreak of shingles, but it can prevent future attacks if you have already had shingles

6. Peripheral Neuropathy

   • Viruses: VZV HSV HSV Rabies virus Polio HIV
     • A late complication of chickenpox is
       • Mechanism of spread of VZ
   • Bacteria: Mycobacteria leprae Lyme disease
   • Auto-immune:Gullian Barre syndrome

7. Management of Pain

   • Nonpharmacological
     • Transcutaneous Nerve Stimulation (TENS)
     • Heat and cold
     • Physical and occupational therapy
     • Lifestyle changes
     • Psychotherapy
       • Cognitive and behavioral therapy
         • Behaviour: when specific goals can be established
       • Mind-Body therapies
       • ‘talking cures’ to treat mental disorders over time
       • Relaxation therapy-exercises, meditation
       • Coping: remove or reduce the cause of the stressor (loneliness, isolation)
     • Rest
     • Dietary approaches to treating pain:
     • Acupuncture
   • Pharmcological
     • NSAIDS
       • Aspirin-voltaren (diclofenacl)
       • MoA ,Inhibit cyclooxygenase enzymes
       • Gastric problems(nausea-pain-ulcers-bleeding)
       • Paracetamol
         • Not known weak inhibitor of the synthesis of prostaglandins (PGs)
           • Normal dose: 2 tablets(500mg) 4 times a day More then 4000mg: serious liver damage
     • Opoids
       • Mild opioids: codeine, hydrocodone, oxycodone.
       • Major opioids: Morphine, Demerol, Hydromorphone, Fentanyl, Methadone
     • Opiates
     • Narcotics: (numbness)
     • Antiviral drugs
       • Classified based on the type of infection
         • HIV
         • HSV
           • Acyclovir
             • is used to decrease pain and speed the healing of sores or blisters in people who have varicella (chickenpox)), herpes zoster
               • it can Prevent complications of shingles , such as postherpetic neuralgia
         • Hepatitis
         • Respiratory viral infections

8. Anatomy

   • Capsule of the elbow joint
     • Humerus
     • Radius
     • Ulna
     • Ligaments
       • Ulnar collateral ligament
         • thick triangular ligament
           • a-Anterior band
           • b-Posterior band
           • c-Oblique band
       • Radial collateral ligament:
         • band that connect the lateral epicondyle with the annular ligament
   • Elbow Anastomosis
     • In front of the lateral epicondyle
       • Anterior descending of the profunda A
       • Radial recurrent A
     • Behind lateral epicondyle:
       • Posterior descending of profunda A
       • Interosseous recurrent A.
     • Infront of the medial epicondyle:
       • Ant. Br. Of inferior ulnar collateral A.
       • Anterior ulnar recurrent A.
     • Behind the medial epicondyle:
       • Posterior ulnar recurrent A.
   • Cubital Fossa
     • It is a triangular space in front of the elbow
       • Base: An imaginary line between the two Humeral epicondyle
       • Medial side: It is formed by the lateral border of pronator teres M
       • Lateral side: It is formed by the medial border of brachioradialisM .
     • The apex of the triangle is directed downwards, where the brachioradialis overlaps the pronator teres.
     • The Roof: It is formed by: -Skin -Superficial fascia median cubital vein, Part of cephalic and basilic veins, The medial and lateral cutaneous nerves of the forearm. -The deep fascia Bicipital aponeurosis.
   • Muscles of the anterior of the forearm
   • Muscles of the posterior of the forearm

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