The this case, pain provides an essential warning

The current accepted definition of
pain, as recommended by the International Association for the Study of Pain
(IASP) states that pain is:

“an unpleasant sensory and emotional experience associated with
actual or potential damage or describe in terms of such damage.”

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Acute pain is mainly acknowledged to
be the pain related with acute tissue damage. Once the injured structure is
re-established, the inflammation processes is settled and healing takes place.
Hence the acute pain will be resolved. In this case, pain provides an essential
warning sign, protecting the vulnerable tissues from further damage. In acute
pain, pain is an outcome of a particular pathological condition or injury. When
pain does not resolve it is then categorized as chronic pain. Different to
acute pain, chronic pain constitutes low levels of underlying pathology that
can justify the presence and extent of pain. Hence, one can classify pain as a
pathological condition in itself.

Physiotherapists are autonomous
practitioners, taking treatment decisions independently. Therefore, it is
essential to perform an assessment to determine the patient’s problem and to
establish a treatment plan. Assessment of a patient experiencing pain is
considered to be the basis in obtaining optimal pain management. The assessment
carried out by the physiotherapist usually follows the SOAP approach. The SOAP
is an acronym for: subjective, objective, assessment and plan. The purpose of
the subjective assessment includes to gather all relevant information about the
pain such as the nature of pain together with the onset of symptoms and any
past treatment that the patient had tried. The physiotherapist asks questions
about the irritability of pain, any aggravating and easing factors. After the
subjective assessment testing procedures are performed in order to support or
refute the physiotherapist’s hypothesis about the source of pain. The last
section of the SOAP approach refers to plan, which involve the method in which
the physiotherapist addresses the patient’s problem and reach to the
therapeutical goals. Showing emphatic understanding of the patient’s pain
experience when carrying out the assessment is crucial. The patient gets the
feeling that the physiotherapist has a genuine interest, that can influence a
positive pain management outcome in the long run.

Pain management is an essential
aspect of rehabilitation. Components of pain management include resolving the
underlying pathology when attainable, decreasing the patient’s discomfort and
suffering, and maximizing the patient’s function within the limitations caused
by the underling pathology or injury.


Multiple modalities are commonly
used to reduce pain. One of the modalities involve the application of cold
temperatures which is known as cryotherapy. 
Cryotherapy has shown to be a positive treatment for pain management. It
has the most substantial effect on conduction by myelination and small fibers
and the minimal effect on conduction by unmyelinated and large fibers. The
A-delta fibers show the greatest decrease in pain in response to cryotherapy as
they are small in diameter and myelinated. Hence, this shows that this modality
is most effective when applied to the acute type of pain. Another mechanism in
which cryotherapy relief pain is by increasing the pain threshold and the
decrease the sensation of pain. The suggested mechanism that bring about an
increase in pain threshold include counterirritation. Controlling the oedema at
the site of injury can also ease the pain caused by nerve compression or any
other structures that are sensitive to pressure. Therapeutically cryotherapy is
carried out either by the direct application of ice using the ice bag
technique, by local immersion for structures in the extremities or by
vapocollant spray. A study carried out by Dambros et al., investigating the
effectiveness of cryotherapy after anterior cruciate ligament reconstruction,
showed that cryotherapy has a positive effect on relieving pain when compared
to the control group.


Various thermal modalities can be
used in the management of pain. Several studies suggested that the application
of local heat can increase the pain threshold. The proposed mechanism of this
effect include the direct and immediate reduction of pain by activation of the
spinal gating mechanism according to the gate control theory proposed by
Melzack and Wall (1965). This theory suggests that within the spinal cord there
is a pain gating mechanism that modulated pain transmission. Painful impulses
carried towards the spinal cord via the small diameter sensory fibers open the
gate to allow the pain signals to be transmitted to the brain. In contrast,
impulses carried out by large diameter sensory fibers that response to heat can
close the gate. Hence, modulating the transmission of painful impulses and
leading to pain relief. An indirect mechanism, that provide a prolonged pain
relief is thought to brought about by reduction of ischemia due to
vasodilation. The vasodilation brought about as a physiogical outcome of an
increase in temperature also facilitate tissue healing and flush the noxious
substances such as substance P relieving the pain. Several modalities can be
used to administer head in a controlled and save method. Superficial heat can
be delivered using techniques that use conduction such as hot packs and
infrared. On the other hand, heat to deeper structures can be delivered using
energy conversion techniques such as short wave diathermy. A study
investigating the effect of infrared therapy for chronic low back pain carried
out by Gale, Rothbart and Li, (2006) showed a drop in
the numerical pain rating scale demonstrating that infrared is effective
application in reducing chronic low back pain.

Hydrotherapy is
commonly applied to patients with painful neurological or musculoskeletal
alterations. Since, the heat and floatability of water aids in blocking
nociceptors by acting on thermal receptors and mechanoreceptors. This leads to
a positive effect on spinal segmental mechanism. The warm water can also
increase the blood flow, helping to dissipate noxious substances are already
discussed before and enhance muscle relaxation. 


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