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Cardinal Sign of Inflammation

Mechanical deformation - trauma


Chemical irritation released by body
Prostaglandin; Bradykinin; Serotonin; Histamine

Warning Sign

Limits Function
Has psychological/emotional affect

An unpleasant physical and emotional experience


which signifies tissue damage or potential for such
damage -IASP, 1979

Must have knowledge to help athletes understand

May facilitate return to competition sooner


Acute injury care = Pain control
Investigate: Where, What, When

Not completely Negative


Necessary for survival

Protective
Warning of impending injury
Something is wrong

Modalities
Use to decrease pain
Facilitate return to normal function

EFFERENT: signals travel away from a central


structure, those nerves leaving the CNS; motor signals
AFFERENT: signals travel toward a central structure,
ex: brain; sensory signal

RECEPTORS

Mechanoreceptors - pressure and touch;


stretch
Thermoreceptors - temperature and
change
Proprioceptors - muscle length, tension,
joint position
NOCICEPTORS - PAIN

Meissners Corpuscles (M) pressure, light touch


Pacinian Corpuscles (M) deep pressure
(P) joint position, vibration (superficial)

Merkels Cells (M) skin stretch, light touch


Ruffini Endings (P) change in position
Krausess End Bulbs (T) heat, cold
Golgi Tendon Organs (P) length, tension

Free Nerve Endings - pain impulses are sent to


the brain via afferent pathways
Brain interprets these signals
Individualized response

Reflex loops
Afferent to spinal cord
Efferent back to site (motor); Afferent to brain (signal)

Very Sensitive

Skin, Joint Capsule, Bone (periosteum),


Viscera
ex: knee study
Sensitive

Subchondral Bone, Tendons, Ligaments

Limited Sensitivity

Muscle
Insensitive

Cartilage, Brain Tissue, Disc Nucleus


ex: chondromalacia

First Order (Primary) Afferents

sensory nerve that courses outside the CNS


nerve fibers that transmit impulses from the
sensory receptors
Subclassified

type A- myelinated
type C- unmyelinated

Categorized by diameter, conduction velocity, origin,


and function.
Group I, II, IIIA

originate in deep muscle receptors


get progressively slower- less myelinated
serve proprioception, kinesthesia, pain from
deep tissue damage

FIBERS

DIAMETER

CONDUCTION
VELOCITY

IA

12-20 m 72-120 s

IIA

6-12 m 36-72 s

IIIA

1-6 m

6-36 s

More superficial - skin receptors


Large, myelinated mechanoreceptor
Respond to touch and low-intensity mechanical info
(vibration)
Similar to AII fibers characteristics
Play role in Gate Control Theory

Superficial - skin receptors


Large, thinly myelinated
Transmit information from warm/cold receptors and
free nerve endings

touch, pressure, thermal


Respond to noxious mechanical stimulus (pinching,
etc.) - PAIN

Muscle and skin receptors


Small, slow conducting, unmyelinated
Deep: mechano- and noci-; few thermoSuperficial: noci- (50%), thermo- (30%), mechanoMajor player in relay of pain signals

Primary afferents synapse with secondary afferent


fibers in the dorsal horn of the spinal cord (AIII, beta,
delta, C) or travel to m2 edulla in the dorsal column of
cord (AI, AII)
Many pathways/tracts to carry sensory info to brain - 4
in dorsal spinal cord, 3 ventral

*Dorsal column-medial lemniscus pathway

Directly to medulla; provides proprioception,


touch, pressure
Spinocervical- superficial info
Postsynaptic dorsal column- mechano, noci
Dorsal spinocerebellar- joint receptors

*Spinothalamic tract- 2nd order afferents


classified as wide dynamic range (wide range of
stimuli) or nociceptive (pain stimuli)

Spinoreticular tract- noxious stimulus;


terminate in reticular formation

Spinomesencephalic tract- noxious stim;


terminate in the periaqueductal gray (midbrain)

Medulla Oblongata
Controls autonomic functions
Heart Rate
Respiration
Vomitting

Connects spinal cord to brain

Reticular Formation
Located in brain stem
Influences alertness, waking, sleeping, and certain
reflexes
Evokes motor, sensory, and autonomic response to
noxious stimuli (rapid response)
Important relay in pain control mechanisms

Thalamus
Divided into 2 nuclei
Ventral posterior lateral (VPL)
Synapses with fibers from body

Ventral posterior medial (VPM)


Synapses with fibers from head and face

Transmits stimuli to somatosensory cortex


Transmits stimuli to limbic system
Regulates emotional, autonomic, and endocrine response to
pain

Periaqueductal Gray
Significant role in pain modulation
Relay center for ascending and descending tracts
Hormonally controls the release of beta-endorphins and
other pain reducing chemicals
Endorphins increase pain threshold

Trauma

Receptors

A-delta
C fibers

Afferent Pathway

Cortex
Higher centers

ouch
mommy

Thalamus
Reticular Formation
PAG

Pain

Inflammation

Spasm

Pain

Historical
Aristotle: soul is the center of the sensory process; pain
located in the heart
19th century: Germans proved that the brain was
involved with sensory and motor function
Specificity Theory: direct pathway, continuous fiber
Pattern Theory: generic nerve transmits code based on
sensation; various frequency, pattern

Gate Control Theory


Melzack and Wall 1965
A non-painful stimulus can block the transmission
of a painful stimulus
Substantia Gelatinosa: dorsal horn; acts as a gate for
sensory info; A-beta fibers vs. A-delta and C fibers
T Cells: transmission cell that connects sensory
nerves to afferent tracts; receives from SG
Example: rubbing injury; modalities

Levels Model (Castel, 1979)


Gate theory doesnt cover it all
Three levels
Involves higher central control
Endogenous Opiates

Ascending Influence Pain Control


Similar to Gate Control Theory

Mechanics
Large diameter afferents synapse on enkephalin
interneurons
Release of enkephalins into synapse of nociceptive
pathways
Enkephalins believed to inhibit release of Substance P
Prohibits synaptic transmission of pain

Descending Influence Pain Control


Higher brain centers modulate synaptic transmission in
dorsal horn

Mechanics
Stimulus is received in Peri-Aqueductal Gray (PAG)
Third-order neurons from Raphe Nucleus are activiated
Dorsolateral tract descends from RN and synapse on
enkephalin interneurons in lamina II releasing
serotonin
Release of enkephalins into 1st and 2nd order afferent nociceptive
pathway

Beta-Endorphin Mediated Pain Control


Release of beta-endorphins has analgesic response

Mechanics
Hypothalamus is stimulated and synapses with PAG
Beta-endorphin released and activates dorsolateral tract
Serotonin released and enkephalin influence

Can be initiated by long term (20-40 min)


electrical stimulation (motor level)
High intensity w/ long pulse duration

Subjective finding
better, worse, same comparative
Scales, Questionnaires
Regardless of situation, must understand that
individuals experience and respond to pain differently

Local - self defined; symptoms are at the site of the


problem
Referred - pain in an area of the body not related
to the injury
Radiating - usually associate with a spinal nerve;
seen in a dermatomal pattern
Trigger Points - localized area of spasm within a
muscle

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