Lecture 2

Background to the use of EPAs

‘The healing cascade and pain
control’

Steve Milanese
Specific Learning Goals
1. Describe the four stages of the healing process of
soft tissue
2. Understand the aims of therapy related to each of
these stages.
3. Describe the process by which the patient feels pain,
in terms of pain reception and pain transmission.
4. Describe the two main mechanisms for pain control
underpinning the use of Electrophysical Agents.
5. Explain the mechanism by which physiotherapy may
help reduce a patient’s pain levels
Musculoskeletal Physiotherapy is most often
provided for two reasons:
a) To improve recovery from injury
b) To reduce pain

Therefore we need to understand

A: How injuries heal i.e. the healing process

C: How our patients feel pain

 Soft Tissue Healing
The body's replacement of destroyed tissue and
comprises two essential components –
• Regeneration: specialised tissues is replaced
by the proliferation of surrounding
undamaged specialised cells, and/or
• Repair: lost tissue is replaced by granulation
tissue which matures to form scar tissue.
 Repair
Generally described in four phases

1. BLEEDING,
2. INFLAMMATION,
3. PROLIFERATION and
4. REMODELLING
 The 4 stages of healing
Theoretically Realistically

•
 Stage 1: BLEEDING
Immediately following trauma

Degree of bleeding depends on

A) Nature of tissue i.e. vascularity
B) Nature of injury i.e. crush versus strain

• Usually lasts up to 48 hours

 Stage 2: INFLAMMATORY PHASE
• Rapid onset, peaks in 1-3 days and lasts for
weeks.

• A complex chemically-mediated amplification

cascade .

• Two responses – vascular and cellular

Stage 2: INFLAMMATORY PHASE
 Stage 2: INFLAMMATORY PHASE
Vascular Response
• Initial reflex vasoconstriction followed by
vasodilation (prostaglandins/histamine)
• Increased flow in capillary bed
• Increased vascular permeability
(prostaglandins/ histamine / serotonin /
bradykinin)
 Stage 2: INFLAMMATORY PHASE
Cellular Response
• Chemotactic reaction, i.e. Movement of
phagocytes, macrophages etc. into interstitial
tissue.?? Galvataxic influences
• Leads to phagocytosis of dead tissue
• Results in Lactic Acid production – stimulates
the next stage
 Stage 3: PROLIFERATIVE PHASE
Involves two fundamental processes
• Fibroplasia – secondary to action of
fibroblasts in repairing connective tissue

• Angiogenesis – Repair of vascular supply,

provides oxygen for further healing
Stage 3: PROLIFERATIVE PHASE
 Stage 4 : REMODELLING PHASE
Involves refinement of the collagen and its
associated extracellular matrix
• Re-orientation of collagen fibres in response
to stress
• May take months
Stage 4 : REMODELLING PHASE
Linking healing to assessment
Stage 2 – The Inflammatory Phase
 Linking healing to Management
Stage 2 – The Inflammatory Phase

• Aims of treatment
– Reduce pain
– Reduce oedema
– Reduce aggravation of cellular/vascular response
Linking healing to assessment
Stage 3 – The Proliferative Phase
 Linking healing to Management
Stage 3 – The Proliferative Phase
• Aims of treatment
– Reduce pain
– Stimulate fibroplasia
– Stimulate angiogenesis
– Reduce secondary problems developing
Linking healing to assessment
Stage 4 – The Remodelling Phase
 Linking healing to Management
Stage 4 – The Remodelling Phase

• Aims of treatment
– Stimulate replacement of Type III with Type I
Collagen
– Promote re-orientation of collagen fibres
– Function
 The Pain Pathways

“an unpleasant sensory and emotional experience associated with actual or

potential tissue damage or described in terms of such damage” (Merksey 1990)
 Pain
We will consider pain in three parts

• Nociception

• Transmittal

• Perception
 Pain - Nociception
Three main types of nociceptors
A) Mechanosensitive (Aδ fibres)
B) Mechanothermal (Aδ fibres)
C) Polymodal (C fibres)

Both bradykinin and histamine sensitize the

nociceptors - Hyperalgesia
 Pain - Transmittal
• Pain messages transmitted via peripheral
nerves to spinal cord.
• Synapse on neurons within the spinal cord
segment that they entered and also on
neurons one to two segments above and
below.
• Pass up to brain via Spinothalamic Tract
 Pain - Perception
• Pain is a psycho-neuro-biological phenomena
i.e. It is affected by many different systems.

• Descending pathways will also affect pain

sensation
 Pain Gate theory
• When the peripheral nerves synapse in the
spinal column with T-cells (Transmission cells)

• These T-cells also receive inputs from large

diameter (A beta) mechanosensitive afferents.
• Descending pathways close the gate by
inhibiting the projector neurons and
diminishing pain perception.
Pain Gate
Theory
 Endorphin Pain Control
• The body produces endorphins whenever the
body senses pain. Endorphins are a morphine-
like molecule that serve as an analgesic.
• Morphine acts on the C fibre system (slow
pain) and hence controls tissue damage pain
but not other types of pain.
 Endorphin Pain Control

Via posterior horn

In the substantia gelatinosa there are
interneurones which can produce encephalin to
inhibit the C system cells. Collateral branches of
Aδ fibres in the posterior horn connect with
these interneurones. Stimulation of the Aδ fibre
will damp down the C fibre system type pain.
 Endorphin Pain Control
Via Descending pathway
It is thought that stimulation of the Aδ pain
fibres provokes impulses to the mid brain that
then travel back down the spinal cord to inhibit
nociceptor neurones via generation of
encephalin in the substantia gelatinosa ie. a
descending pain suppression
 So What???
To control pain

A) Firstly treat the pathology i.e. Improve the

healing process.

B) Secondly treat the pain.

The Alternative Approach