exudates. Increasing blood flow to the area leads to absorption of tissue debris and waste products of the inflammatory process effectively into the blood stream. Electrotherapy modalities will be discussed in later chapters of this course. Movement Total immobilization is not recommended and a mild degree of appropriate movements should be allowed in the acute stage. Medical referral If the injury is severe and cannot be managed by this basic prac- tice, refer the patient to a relevant medical practitioner as soon as possible. Alcohol Drinking alcohol after an injury is also harmful. Alcohol increases the capillary permeability, which results in more blood leaking out of the vessels. This can cause an edema, which will lengthen the recovery time. Running (activities) Any type of exercise or repetitive movement that involves the af- fected area will cause further damage and reduce the rate of heal- ing. Therefore, the patient should avoid these types of activities for 72 hours after an injury. Massage Massage increases blood leakage and thereby promotes swelling at the affected site. So, it is best not to massage the area for 72 hours after the trauma.
Guidelines for elevation: ● The injured area should be placed above the heart level. ● It should begin as soon after the injury as possible and con- tinue for 3 days (72 hours). ● The elevated area should be adequately supported (with pillows or slings). Modalities Electrotherapy modalities can be used to promote recovery. In the acute stage, ultrasound therapy can be used for soft tissue injuries. As the blood flow increases to the area, the amount of oxygen and healing nutrients are rapidly transported to the dam- aged tissues. However, this will also promote evacuation of the Not only is giving the correct treatment important, but so is avoid- ing possible damage, which is where the HARM protocol comes into play. It emphasizes the things that should not be done during an acute injury. No HARM should be initiated within the initial 48 to 72 hours of the onset of the injury [8] . Heat Heating modalities (hot packs, hot water fermentation, hot baths, hot water bottles, or even rubbing) should not be applied over or close to the injured area. Heat increases the blood flow to the area; therefore, it should be avoided for at least 72 hours from an injury.
HARM PROTOCOL
PAIN MANAGEMENT
mote healing. Thus, pain can be identified as the profound protec- tor of the body from an external and/or internal injury. Though pain is a valuable indicator, its perception is often very uncomfortable. Therefore strategies to alleviate pain have devel- oped. In this section, factors regarding pain and the strategies of pain management are discussed. fects. A basic bodily sensation that is induced by a noxious stimulus, is received by naked nerve endings, is characterized by physical discomfort (as pricking, throbbing, or aching), and typically leads to evasive action [12] . Pain can be categorized according to type, onset, duration, inten- sity, and location: ● Type : Sharp/dull/aching/burning/shooting/catching/throb- bing pain/electric shock-like pain/toothache-like pain/psycho- genic/idiopathic. ● Onset : Sudden/gradual. ● Duration : Acute/chronic/episodic/breakthrough pain. ● Intensity : Mild/moderate/severe. ● Location : Localized/radiating/referred. Intensity theory This theory describes pain as an emotional experience, not merely a sensation. It has been discovered that, when a stimulus is given in sufficient intensity over a lengthy period of time, that stimulus appears as a painful experience though it is actually not [13] . Pattern theory In this theory, the concept of specific receptors and/or intensity specification of pain are noted. In pattern theory, the pain is trans- mitted to the brain according a certain pattern or a combination of neural impulses generated in the presence of a stimulus [13][14] . The brain encodes the type and the intensity of the stimulus cor- responding to the pattern of peripheral neural firing. It is the pat- tern theory that initiated the discovery of gate control theory.
The first sign of any damage to the body is pain. Hence, pain is considered the initial indicator of actual or potential tissue damage. Pain invokes the protective mechanism of the injured body part. For an example, a tear of the supraspinatus tendon may invoke the protective mechanism and reduce the movements of the shoulder musculature in order to give rest to the damaged muscle to pro- Definition of pain In general, pain can be described as the physical feeling caused by disease, injury, or something that hurts the body. Though pain is physical, it has a psychological and emotional component as well. Hence, pain can be denoted as emotional or psychological suffering. A more specific definition for healthcare professionals is: “A state of physical, emotional, or mental lack of well-being or physical, emotional, or mental uneasiness that ranges from mild discomfort or dull distress to acute often unbearable agony, may be generalized or localized, and is the consequence of being injured or hurt physically or mentally or of some derangement of or lack of equilibrium in the physical or mental functions (as through disease), and that usually produces a reaction of want- ing to avoid, escape, or destroy the causative factor and its ef- Theories about pain The mechanism of pain perception is a topic to debate. There are various theories depicting the way an individual perceives pain. Specificity theory, intensity theory, pattern theory, and gate control theory are the most commonly applied theories of pain perception, with the gate control theory being the most scientific and accepted concept. Specificity theory According to this theory, there are specific pathways adapted to transmit signals from each of the somatosensory modalities. In other words, a certain stimulus is captured by a specific recep- tor and taken to the specific areas in the brain for that particu- lar modality via precise afferent sensory fibers [13][14] . Because this theory does not address the psychological aspect of pain, more advanced theories have evolved.
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