Foundations and Pain Flashcards
setting big goals
- reduce pain and other symptoms
- improve ROM
- increase strength, endurance, and power
- increase balance and coordination
- restore function for ADL, sport, occupation, etc
- educate client
designing programs
to design programs to support healing and optimize function:
1. ask questions about injury and client to obtain information
2. set goals using stage of healing to guide appropriate focus
3. create a plan for specific actions aligned with reaching each goal
pain as a process
- nociceptors detect polymodal threat (extreme stimulus), decreasing nociceptor thresholds in area during inflammatory stage increases sensitivity to pain (primary hyperalgesia)
- A-delta (high threshold, large diameter, myelinated, acute pain) and C (smaller diameter, chronic) afferent nerves send signals to the dorsal horn of the spinal cord
- dorsal horn signal through ascending tracts to multiple areas of the brain (mostly thalamus) where stimulus is processed as pain exp
- dorsal horn also send signal to sp cd to gen flexor withdrawal reflex which increases flexor muscle tone (fetal pos)
dimensions of pain
- cognitive is what we think of pain; beliefs (personal history/memory, cultural, social), expectation (placebo/nocebo), attention
- emotional is how we feel about pain; connect to coping strategies, mood, and self-efficacy, pain and emotional states can influence each other, and emotional stress of pain can activate SNS
- somatic is the physical/bodily/sensory aspects of pain; how we describe or evaluate the pain, how we localize pain to body sense of self (boy schema) which is not always accurate or permanent
- interactions between these dimension make pain a variable and dynamic experience that doesn’t directly correlate with injury serverity
gate control theory
when A beta afferent neurons which sense touch and are bigger diameter, faster, and lower threshold than A delta and C fibres send touch signals to brain, also send signal to dorsal horn enkephalin interneuron which blocks pain signal to brain therefore blocks pain perception
descending inhibition
PAG in midbrain and raphe nucleus in medulla send signals down descending neural tracts to activate enkephalin interneuron in dorsal horn to close gate of pain and increase release of beta endorphins (endogenous opioid) to decrease pain
central sensitization
- the practice of pain trains a stronger neural pattern, become more skilled at reproducing pain experience, creating chronic outlasting the tissue pathology even if you don’t need it
- pain patterns can be triggered by different switches associated with three dimensions of pain
central sensitization v. tissue pathology
features of central sensitization are:
1. >12 weeks of pain or hyperalgesia outlasting the inflammation phase
2. allodynia (pain response to non threatening stimuli)
3. unusual descriptions of pain
4. pain inconsistent with mechanical stress
5. skin around sensitized areas can be in heighted state (redness or sweating) for no reason
6. conditions such as chronic LBP, tendinopathy, migraine, osteoarthritis, carpal tunnel syndrome
types of ADLs
all are functional skills
1. transitioning: lying down, sitting, standing, reverse
2. walking: change in dir, slope, surfaces
3. stair climbing and descending
4. lifting and lowering object, carrying
5. pushing/pulling object
6. driving
7. writing/typing
8. kitchen skills: meal prep, clean up, eating
9. washroom skills: washing hands, showering, toliet
retraining a functional skills
identify a functional skill, break it down into smaller tasks/skills, and establish a progression based on current abilities
evidence for treatments
evidence for many treatments and tools is mixed or lacking since treatments have many variables to control for, pain is complex, and research is often split into physiological changes or clinically relevant outcomes which are not always equivalent; therefore safety, honesty about the effects of treatment, and consent come first
TENS
1. purpose
2. proposed physiological effects
3. client education
- use strong, non-painful, superficial electric stimulation from 1 or 2 channels (wires) each with 2 electrodes to reduce pain during and for a short duration after treatment (up to 30 mins)
- stimulate alpha beta fibres to close the gate
- feel like tingling, ants on skin, might be muscle contraction, let know if uncomfortable
considerations of TENS application
- use a conduction medium to bridge gap between electrode, air, and skin
- electrode size and placement: larger electrode has lower current density, place to trap pain, use anatomy knowledge to place electrode directly on the superficial nerve
- fat and bone impede current while muscle conducts current well
- freq (Hz or pps) and intensity (mA): lower freq (<30 Hz) causes muscle twitching, higher freq (80-120 Hz) more tolerable, intensity is subjective
- treatment usually 15-30 mins, can either use to decrease pain to do make other treatment more tolerable (exercise) or use at end of treatment to decrease pain in the moment
thermotherapy and cryotherapy
1. suggested effects
2. considerations
3. contraindications
- blood vesssel diameter, pain, heat can make CT more elastic, muscle relaxation
- keep skin safe using towel (can be moist to transmit temp better) to prevent direct contact
- poor skin integrity, impaired sensation or cognition, lack of consent, clotting disorders, not heat over active inflammation
when should cryotherapy be used?
immediately after minor injury to soft tissue during inflammation in the short term as long term use can delay muscle regen and compromise long term healing and mechanical integrity
massage
1. types of massage
2. procedures
3. suggested effects
- effleurage is superficial, long, rhythmic strokes gliding along skin to warm it up; petrissage is deep, focused, and targeted kneading
- cover uninvolved areas, ask about sensitive areas first, use hypoallergenic massage medium
- evidence base is limited but suggested primary global neuroendocrine effect (target emotional effect of pain by shifting towards PNS, deactivate HPA axis to decrease cortisol, and decrease anxiety from cognitive effect on pain) but also has mechanical benefits (increased local fluid flow and tissue extensibility)
self-myofascial release
1. overview
2. clinical recommendations
- not strong base of evidence but increases CNS pain pressure threshold with same effect on contralateral effect, mechanical motion increases local BF up to 30 mins after rolling
- one direction roll is 2-4 seconds depending on length of the limb, 1 set is 30-120 seconds of rolling, repeat up to 3 sets
static stretching
- does not change risk of inj, used to improve ROM
- neurologically increase stretch tolerance in short term, with consistent stretch over long term reduces musculotendinous stiffness with sarcomerogenesis (stretching promotes production of more sarcomeres to lengthen muscle) and plastic (permanent) deformation of CT (creep effect when you hold tissue at lengthened pos, it promotes lengthening over time)
static stretch variables
- hold duration 30 seconds up to 8 mins or more, 8+ mins to get creep effect
- intensity as % of stretch tolerance (max stretch without pain), higher intensity more likely to get gains in 75-100%
- higher frequency with consistency daily is more likely to induce sarcomerogneesis and CT deformation
proprioceptive neuromuscular facilitation
- neurologically decreases active muscle tone to increase ROM, the mechanism is unclear
- CRAC technique is to isometrically contract target muscle limiting ROM at 10-30% 1RM for under 10 seconds at the position where there is stretch sensation, relax, and antagonist isometrically contracts in new range
simple cyclic motion
at the start of rehab, joint or muscle may be limited by fluid, use repetitive, cyclic motions, move within current ROM to decrease fluid viscosity, induce mechanical muscle pump to increase circulation away, and loosen fluid to reduce joint or muscle stiffness after immobilization or surgery
why should exercise prescription be time contingent?
since it is not possible to dose exercise proportional to pain threshold as pain is highly variable and drawing more attention to pain increases the patient’s vigilance to it
Two concepts you want to help patients adopt
- explain pain to patients to change how they make sense of pain from pain as sign of structural damage to pain as a protective mechanism modulated by tissue damage and safety
- all exercise and physical activity is safe and meaningful despite symptoms, all tolerated exercise should be performed
three contraindications to electrotherapy
- pacemaker user
- cardiac problems
- is pregnant
