Fund. PT Exam 2 Flashcards
1
Q
Sensory input plays major roles in __ and protection from __. Sensory acuity [incr/decr] with age and is affected in certain disease/trauma states.
A
Sensory input plays major role in MOTOR CONTROL (postural control, balance, fine motor control, ability to learn new skills/motor learning) and PROTECTION FROM INJURY. Sensory acuity DECREASES with age. Affected in disease states e.g. diabetes, neuropathies, CNS problems, stroke, etc.
2
Q
The sensory system is a __ (#) neuronal system for conscious sensation. Your goal is to get the signal from the __ to the __.
A
3 neuron system. Get signal from RECEPTOR to CORTEX.
3
Q
The first order fiber in the sensory conduction system begins at a ___ related to the axon of a sensory neuron. Therefore, this fiber’s cell body lies [inside/outside] of CNS either in a __ or __. Its central process enters the ___ via the ___ and terminates in the ___. It relays information from ___.
A
The first order fiber in the sensory conduction system begins at a RECEPTOR related to the axon of a sensory neuron. Therefore, this fiber’s cell body lies OUTSIDE of CNS either in a DORSAL ROOT GANGLION or CRANIAL NERVE GANGLION. Its central process enters the SPINAL CORD via the DORSAL ROOT and terminates in the SPINAL CORD (or brainstem if it’s a CN). It relays information from ITS OWN RECEPTIVE FIELD IN THE PERIPHERY.
4
Q
The second order fiber in the sensory conduction system begins at its cell body within the ___ of the [periphery/ spinal cord/ brain] or in analogous areas of the ___. So basically, it starts somewhere in the [PNS/CNS], and ascends [ipsilaterally / by crossing the midline]
A
The second order fiber in the sensory conduction system begins at its cell body within the DORSAL GRAY MATTER of the SPINAL CORD or in analogous areas of the BRAINSTEM. So basically, it starts somewhere in the CNS, and ascends BY CROSSING THE MIDLINE
5
Q
The third order sensory fiber’s cell body lies within the ___ and projects onto ____ areas of the __ cortex.
A
The third order sensory fiber’s cell body lies within the THALAMUS and projects onto SOMATOSENSORY areas of the CEREBRAL cortex.
6
Q
Different receptors respond to different stimuli. This is determined by the \_\_ of the receptor. Describe what the following receptors respond to... Mechanoreceptors Thermoreceptors Nociceptors Chemoreceptors Photoreceptors
A
The STRUCTURE of a receptor determines what stimulus will activate it.
Mechanoreceptors: mechanical deformation, pressure, touch
Thermoreceptors: Temperature
Nociceptors: painful stimuli, any stimulus of sufficient intensity may be noxious (responds to thresholds of tissue damage)
Chemoreceptors: chemical irritation, taste, smell, osmolarity of blood (chemical changes)
Photoreceptors: respond to light (rods and cones)
7
Q
Name 7 types of cutaneous sensory receptors
A
Free nerve endings Ruffini Endings Merkel's Disks Meissner's Corpuscles Pacinian Corpuscles Hair Endings Temperature Receptors
8
Q
Free nerve endings are usually attached to [myelinated/unmyelinated] axons. They [are/are not] encapsulated and are found [in the CNS/ PNS/ throughout the body]. They can provide perception of what stimuli? (6!) They are [fast/slow] adapting and in the presence of a stimulus, they send a [constant/singular] signal to the CNS>
A
Free nerve endings are usually attached to UNMYELINATED axons. They ARE NOT ENCAPSULATED and are found THROUGHOUT THE BODY. They can provide perception of PAIN, TEMPERATURE, TOUCH, PRESSURE, TICKLE, and ITCH. They are SLOW adapting and in the presence of a stimulus, they send a CONSTANT signal to the CNS>
9
Q
Ruffini endings are [encapsulated/not encapsulated] with a special ending. They’re located in the deep layers of the __. They’re involved in the perception of ___ & ___ - this makes them important in signaling continuous states of skin ___. They’re [fast/slow] adapting.
A
Ruffini endings are NONENCAPSULATED with a special ending. They’re located in the deep layers of the DERMIS. They’re involved in the perception of TOUCH & PRESSURE - this makes them important in signaling continuous states of skin DEFORMATION. They’re SLOW adapting.
10
Q
Merkel’s disks are [encapsulated/ not encapsulated] and are sensitive to ___ touch and the __ of touch. They play a role in ___ and ___ of touch. They’re [slow/fast] adapting and send a [continuous/burst of] response when sensation begins and then [goes quiet/continues sending signals]. The actual receptor is a separate cell that communicates with and surrounds the sensory axon (and looks like a disc! Fun fact.). It’s associated with a [myelinated/ unmyelinated] axon.
A
Merkel’s disks are ENCAPSULATED and are sensitive to FINE touch and the VELOCITY of touch. They play a role in 2-POINT DISCRIMINATION and LOCALIZATION of touch. They’re RAPIDLY adapting and send a BURST OF response when sensation begins and then GOES QUIET. The actual receptor is a separate cell that communicates with and surrounds the sensory axon (and looks like a disc! Fun fact.). It’s associated with a MYELINATED axon. Basically, they’re a bit fancier. Swag.
11
Q
Meissner’s corpuscles are located in the ___. They are [encapsulated/ not encapsulated] and are [slow/fast] adapting. They’re [tonic/phasic], so they can detect __. Visually, they look like a spool of thread that contains __ fibers, and a nerve ending of the sensory axon wraps around it.
A
Meissner’s corpuscles are located in the DERMIS. They are ENCAPSULATED and are FAST adapting (and very sensitive). They’re PHASIC, so they can detect TAPS (fire at onset, detect a quick on/off). Visually, they look like a spool of thread that contains COLLAGEN fibers, and a nerve ending of the sensory axon wraps around it.
12
Q
Pacinian corpuscles look like a sliced ___. They’re located in the __ layer of the skin and deep tissues of the body. They are [encapsulated/ not encapsulated] with ___. The nerve ending is located at the center core within this. These are stimulated by [slow/fast] movement. They’re the [fastest/slowest] adapting receptor - this is the only one that can detect ____. It plays a role in the perception of __ and ___. These
A
Pacinian corpuscles look like a sliced ONION!. They’re located in the SUBCUTANEOUS layer of the skin (JUNCTION BTWN DERMIS AND HYPODERMIS) and deep tissues of the body. They are ENCAPSULATED with A LAYERED CAPSULE. The nerve ending is located at the center core within this. These are stimulated by FAST movement. They’re the FASTEST adapting receptor - this is the only one that can detect VIBRATION (tuning fork oscillation at 250 cycles/second!). It plays a role in the perception of DEEP TOUCH and VIBRATION. This is the high end of the sensory system.
13
Q
Hair endings are [encapsulated/non encapsulated] sensory axon endings that wrap around a ___. They are [slow/fast] adapting.
A
Hair endings are NON-ENCAPSULATED sensory axon endings that wrap around a BULB OF HAIR. They are RAPIDLY adapting.
14
Q
Temperature receptors are ____ and are [slow/fast] adapting.
A
Temp receptors = FREE NERVE ENDINGS, RAPIDLY adapting
15
Q
Muscle spindles involve both primary (___) endings that are associated with fiber type __ and secondary (___) endings associated with type __ endings. The muscle spindle lies in parallel to the __ fibers and play a vital role in ___ and movement sense, [phasic/tonic/both]
A
Muscle spindles involve both primary (ANNULOSPIRAL) endings that are associated with fiber type Ia and secondary (FLOWER SPRAY) endings associated with type II endings. The muscle spindle lies in parallel to the EXTRAFUSAL fibers and play a vital role in POSITION and movement sense, BOTH PHASIC & TONIC
16
Q
What receptors contribute to joint and muscle perception? (6)
A
Muscle spindle Golgi Tendon Organs Joint and Muscle free nerve endings Golgi-type endings Ruffini Endings Paciniform endings
17
Q
Golgi Tendon Organs lie in series at [proximal/ distal/ both] tendinous insertions of muscles and provide information about __.
A
GTO: lie in series at BOTH proximal and distal tendinous insertions of muscles. Provide info on TENSION
18
Q
Joint and muscle free nerve endings are located in the ___ and ___. They provide [fine/crude] awareness to joint movement tissues. They’re associated with several types of sensation including …(4)
A
Joint and muscle free nerve endings are located in the JOINT CAPSULE and LIGAMENTS. They provide CRUDE awareness to joint movement tissues. They’re associated with several types of sensation including NOXIOUS STIMULATION, CRUDE TOUCH, PRESSURE, CHEMORECEPTION
19
Q
Golgi-type endings are located in ___ and detect ___
A
Golgi-type endings are located in LIGAMENTS and detect TENSION
20
Q
Ruffini endings are located in the __ and __. They respond at [mid-range/ extremes] of ROM and more to [passive/active] than [passive/active] ROM.
A
Ruffini endings are located in the JOINT CAPSULE and LIGAMENTS. They respond at EXTREMES of ROM and more to PASSIVE than ACTIVE ROM
21
Q
Paciniform endings are located in the ___ and monitor [active/passive], [phasic/tonic] movement.
A
Paciniform endings are located in the JOINT CAPSULE and monitor ACTIVE, PHASIC movement.
22
Q
Receptor types in the CNS encode different sensory information based on their structure through a process called ___. This is the conversion of one form of energy (light, mechanical, etc.) into __ that the nervous system can make sense of.
A
Receptor types in the CNS encode different sensory information based on their structure through a process called TRANSDUCTION. This is the conversion of one form of energy (light, mechanical, etc.) into ACTION POTENTIALS that the nervous system can make sense of.
23
Q
The process of transduction requires an adequate ___. The receptors sensing the sensory input are [slow/fast/ either] adapting, determined by the ___ around the receptors. Those that are [fast/slow] adapting detect constant pressure. Those that are [fast/slow] adapting are more phasic and can detect, for example, a series of taps (___ - which receptor type?) or vibration (___ - which receptor type?).
A
The process of transduction requires an adequate STIMULUS. The receptors sensing the sensory input CAN BE RAPIDLY OR SLOWLY adapting, determined by the CAPSULE around the receptors. Those that are SLOW adapting detect constant pressure. Those that are FAST adapting are more phasic and can detect, for example, a series of taps (MEISSNER’S CORPUSCLES - which receptor type?) or vibration (PACINIAN CORPUSCLE - which receptor type?).
24
Q
The intensity of stimulation to a receptor is determined by the frequency of ___ and the number of ___ activated.
A
Intensity related to FREQUENCY OF ACTION POTENTIALS (feel more pressure –> more APs) and the NUMBER OF RECEPTORS activated
25
___ is the area innervated by receptors and the SINGLE sensory axon associated with them.
RECEPTOR FIELD
26
The sensory system is ___ organized in the CNS at all levels and stays that way as you go up the neuronal axis. The ___ in the [premotor/ motor/ prefrontal/ somatosensory] cortex is a map of the body in which the body parts are adjacently arranged.
The sensory system is SOMATOTOPICALLY organized in the CNS at all levels and stays that way as you go up the neuronal axis. The HOMUNCULUS in the SOMATOSENSORY cortex is a map of the body in which the body parts are adjacently arranged.
27
What types of sensory input receptors are associated with unmyelinated and lightly myelinated axons?
Crude touch
Pain
Temperature
28
What types of sensory receptors are associated with large myelinated axons?
Discriminative touch
Vibration
Joint position
29
Which types of axons are lost first in peripheral neuropathies? As such, what sensations would you be likely to lose first and which would you likely preserve through initial losses in sensation?
In diabetes/peripheral neuropathies, BIGGEST axons are lost first.
You first lose FINE TOUCH
May preserve some PAIN, TEMPERATURE, and CRUDE TOUCH (from smaller, unmyelinated axons)
30
Pain, temperature, and crude touch are carried on the ___ tract (aka ____ system). This is a mostly unmyelinated and lightly myelinated system
SPINOTHALAMIC TRACT
| aka ANTEROLATERAL system
31
Fine, discriminative touch, vibration, and proprioception are carried on the ___ system. This is a mostly heavily myelinated system.
DORSAL COLUMN MEDIAL LEMNISCAL system
32
Some sensations we experience are the result of the integration of individual sensations at the cortical level. These are called combined cortical sensations and they require intact ___ and ___ areas. Examples of combined cortical sensations include... (give 5!)
Combined cortical sensations require intact CORTICAL SENSORY ASSOCIATION AREAS and RECEPTORS
Examples...
Stereognosis (ability to feel an object and recognize what it is)
2-pt discrimination
Graphesthesia (when you write a letter on skin and they know what you'er writing)
Tactile localization (localize touch to a certain body part)
Recognition of texture
33
List the 4 primary reflex tests in a sensory exam
Deep tendon reflex
```
Withdrawal reflex
(flex 1st toe, usual response is a slight withdrawal. Abnormal: exaggerated withdrawal = CNS damage)
```
Plantar Response (Babinski Reflex)
- Tests integrity of corticospinal tract
- Normal: Downward (flexor) plantar response = NEGATIVE Babinski
- Abnormal: Upward flare of toes, upward (extensor) plantar response = POSITIVE Babinski = UMN disorder
Hoffman's Reflex (quick flick/squeeze of middle finger tip)
- Tests integrity of spinal cord reflex loop
- Normal = no response
- Abnormal/Positive = flexion of index finger and thumb after flicking middle finger from flexed position. Indicates UMN disorder
34
Norms exist for the 2-point discrimination test. Where are the smallest receptor fields? The biggest?
```
Smallest = finger tips (~2mm!)
Biggest = Lower back part of neck, Back of calves, upper back
```
35
What potential confounders in performing sensory testing? (5)
- Cognitive status and/or attentional problems
- Scarring/skin integrity
- Language (e.g. aphasia)
- Visual, hearing acuity
- Pain
36
During sensory testing, you gather info on what structures? (6)
```
Receptors
Axons in peripheral nerves
Dorsal roots
Spinal cord segment
Sensory tracts through CNS
Cortex
```
37
Find your dermatomes!
| C1 - S3,4...go!
C1 --- No Skin Innervation
C2 --- Posterior Cranium
C3 --- Posterior Neck
C4 --- AC Joint, top of shoulder
C5 --- Lateral Upper Arm
C6 --- Lateral Forearm/Tip of Thumb
C7 --- Palmar Distal Phalanx (3rd)
C8 --- Palmar Distal Phalanx (5th), medial hand
T1 --- Medial Forearm
T2 --- Medial Upper Arm to axilla
L1 --- Groin area
L2 --- Ventral Thigh, 2 - 3” below ASIS
L3 --- Middle 1/3 ventral/medial thigh to medial knee
L4 --- Medial leg to Medial Malleolus
L5 --- Dorsum of Foot, especially great toe
S1 --- Lateral side & Plantar Surface of Foot, back of calf
S2 --- Posterior Thigh
S3, 4 --- Perianal Area (base of sacrum)
38
```
How do you evaluate myotomal loss? Give muscle/actions for the following myotome:
C5
C6
C7
L2
L3
L4
L5
S1
```
DTR or Strength Testing (not all are amenable to DTR)
```
C5- Biceps, musculocutaneous
C6 - Wrist Extension, DTR
C6 - Brachioradialis, radial
C7 - Triceps, radial
L2 - Hip Flexion
L3 - Quadriceps (patellar), femoral
L4 - Anterior Tibialis, deep peroneal
L5 - Extensor hallicus longus, deep peroneal
S1 - Achilles, tibial
```
39
Describe DTR scoring
0 = Absent
1+ = Hyporeflexive
(0 & 1 generally indicate LMN lesion...could be nerve root or peripheral n)
2+ = Normal
3+ = Hyperreflexive
4+ = Clonus
(3+ and 4+ indicative of UMN CNS lesions)
40
In the trunk, the intercostal nerves innervate a single ___. In the limbs, peripheral nerves are formed by contributions of more than one ___ that combine in a ___.
Trunk = intercostal nn. innervate a single DERMATOME
Peripherally, peripheral nn formed by contributions of more than one VENTRAL PRIMARY RAMUS that combine in a PLEXUS
41
In metabolic disorders and aging, we see sensory loss in a ___ pattern. The longest/largest axons are affected first because ___. This means that ___ sensation is affected first, and you lose ___ later on. In aging, __ die off as well.
In metabolic disorders and aging, we see sensory loss in a STOCKING GLOVE pattern. The longest/largest axons are affected first because THEY ARE THE MOST METABOLICALLY DEMANDING. This means that VIBRATION, PROPRIOCEPTION, & JOINT POSITION sensation is affected first, and you lose PAIN, TEMP, CRUDE TOUCH later on. In aging, RECEPTORS die off as well.
42
If motor and sensory changes are present, they should [match/not match] if they stem from the same pathology. It's most common to detect [motor/sensory] changes associated with aging and metabolic disorders first because this system is more sensitive to loss.
Motor and sensory changes should MATCH! Most common to lose sensory first because it's mores sensitive to loss.
43
With lesions of the ___, we will see a pattern of sensory loss involving half of the body [on the same side as/opposite] the lesion. With ___ lesions, we may see loss of combined cortical modalities.
Lesion of CNS above spinal cord = sensory loss on half of body OPPOSITE lesion.
With CORTICAL LESIONS (of the parietal lobe), may see loss of combined cortical modalities.
44
Pain receptors are ___, and they [are/are not] encapsulated. Most are associated with ___, e.g. a stimulus that can cause tissue damage.
Pain receptors are FREE NERVE ENDINGS, and they ARE NOT encapsulated. Most are associated with NOCICEPTION, e.g. a stimulus that can cause tissue damage.
45
Pain receptors can be of what types? The key is that they're reaching a threshold that causes tissue damage. You [can/cannot] distinguish between them.
Pain receptors can be THERMORECEPTORS, MECHANORECEPTORS, CHEMORECEPTORS, or POLYMODAL
You CANNOT distinguish between them morphologically
46
Chemoreceptors are stimulated by ...(4!)
- External chemicals
- Inflammatory process by prostoglandins, arachindonic acid and leukotrienes, substance P, serotonin
- Local edema by bradykinin
- Mast cell degranulation by release of histamine and serotonin
47
___ is complete lack of sensation.
Anasthesia
48
___ is generalized decrease in sensation. ___ is generalized increase in sensitivity. ___ is pain to light touch.
HYPOESTHESIA = generalized DECREASE in sensation
```
HYPERESTHESIA = generalized increase in sensitvity
*Allodynia = pain to light touch
```
49
___ is unpleasant pain. ___ is burning pain. ___ is tingling pain.
```
DYESESTHESIA = unpleasant pain
CAUSALGIA = burning pain
PARESTHESIA = tingling pain
```
50
The pain pathways (how many?) are both part of the ___ system, AKA the ___ pathway. These pain pathways include the __ and __ pathways.
There are 2 pain pathways:
The "Where?" Pathway
The "What are you going to do about it?" pathway
Both are part of the SPINOTHALMIC system aka ANTERIOLATERAL PATHWAY
51
The "Where?" pathway helps you to ____ pain. It conveys info regarding the ___ of the source of the pain. The signal is carried on ___ fibers which are [heavily/lightly/not] myelinated so they travel ~___m/s. It conveys information about what type of pain?
The "Where?" pathway helps you to LOCALIZE pain. It conveys info regarding the LOCATION of the source of the pain. The signal is carried on A DELTA fibers which are LIGHTLY/FINELY myelinated so they travel ~5-30/s.
Conveys info about localized, SHARP, FIRST, FAST, EPICRITIC pain (arrives sooner than 2nd part of system)
52
The "where?" pathway creates a more or less direct root from the periphery to the ___ (___ gyrus). It uses __ (#) neurons in the pathway. Describe where each originates and terminates.
Where pathway creates a route from the periphery to the SENSORY CORTEX (POST CENTRAL GYRUS). It uses 3 NEURONS.
1st order neuron:
- Associated with peripheral receptor
- Cell body in DORSAL ROOT GANGLION
- Comes in and synapses in DORSAL HORN
2nd order neuron:
- Crosses spinal cord
- Forms SPINOTHALAMIC TRACT in anterolateral white matter
- Ascends up to THALAMUS (VPL nucleus)
3rd order neuron:
- Thalamus to sensory cortex (postcentral gyrus)
53
The "Whatareyagonnadoaboutit?" pathway conveys [localized/poorly localized], [sharp/aching], [fast/slow], protopathic pain to widespread areas of the cortex. It affects ___, __, and ___ systems. Carried on ___ fibers, [myelinated/ unmyelinated/ finely myelinated] at ~___m/s. It is a __(#) system.
The "Whatareyagonnadoaboutit?" pathway conveys POORLY LOCALIZED, ACHING, SLOW, protopathic pain to widespread areas of the cortex. It affects AROUSAL, AUTONOMIC, and LIMBIC systems. Carried on C FIBERS, UNMYELINATED at ~0.5-2m/s. 3 neuron system
54
Describe the neuronal origins and synapses in the "whatareyagonnnadoaboutit?" pathway.
1st order neuron:
- Synapses in dorsal horn
2nd order neuron
- Transmission cell in dorsal horn
- Crosses and joins spinothalamic tract
- Branches into brainstem as it ascends to activate central pain mechanisms
- Fibers take an indirect course and form a polysynaptic pathway through a portion of the brainstem, aka RETICULAR FORMATION then goes to thalamus
3rd order neuron:
- From thalamus (intralaminar nuclei)
- To widespread areas of cortex (NOT just somatosensory cortex)
55
Effects of nociception include overall [increase/decrease] in CNS arousal, [increased/decreased] sympathetic tone, and [increased/decreased] alpha MN excitability.
Nociception --->
- INCREASED CNS arousal
- INCREASED SYMPATHETIC tone
- INCREASED alpha MN excitability
56
[Nociceptive/neuropathic] pain could be soft tissue damage, muscle, chemo irritant. [Nociceptive/neuropathic] pain arises when nervous tissue dysfunctions.
NOCICEPTIVE pain = soft tissue damage, muscle, chemo irritant
NEUROPATHIC pain = arises when nervous tissue dysfunctions
(can be peripheral nn or CNS)
57
Nociceptive chronic pain stems from ___. Chronic stimulation can [raise/lower] threshold of receptors contributing to chronic pain. Give an example.
Nociceptive chronic pain stems from CHRONICALLY-STIMULATED PERIPHERAL RECEPTORS.
This can LOWER threshold of receptors contributing to chronic pain. E.g. KNEE OA (innervated bone --> chronically stimulated pain)
58
Neuropathic chronic pain stems from ___ or ___. The symptoms are [the same as/different from] nociceptive chronic pain and include ___, ___, and ___.
Neuropathic chronic pain stems from a NERVE INJURY or SYNAPTIC REORGANIZATION. Symptoms are DIFFERENT from nociceptive chronic pain and include PARASTHESIA (tingling), DYSESTHESIA (unpleasant, often burning = causalgia), AND HYPERALGESIA (excessive pain in response to mildly painful stimulus, e.g. allodynia)
59
Neuropathic pain can have peripheral or central changes/mechanisms. Peripheral mechanisms include ___ and ___. Central changes include __, ___, and __.
Peripheral mechanisms
- Ectopic foci
- Ephatic transmission
Central changes
- Central sensitization
- Structural Reorganization
- Altered top-down modulation
60
Describe the difference between ectopic foci and ephatic transmission
ECTOPIC FOCI is one mechanism of peripheral neuropathic pain. It is generally the result of neuronal damage (direct injury to neuron) APs are generated from DEMYELINATED areas of axons:
- The recovering neuron makes mechanosensitive and chemosensitive sodium channels that are inserted in demyelinated portions of the membrane.
- Pressure on that portion of the nerve causes an AP (and pain!).
EPHATIC TRANSMISSION involves cross talk between neurons in areas of demyelinization. APs in touch neuron can cause APs in an adjacent pain neuron (because previously myelinated axons are now not myelinated). This may be a mechanism for allodynia in which touch causes pain.
61
Describe the differences between central sensitization, structural reorganization, and altered top down modulation in central changes associated with neuropathic chronic pain.
Central Sensitization
- Pain may be result of abnormally prolonged pain transmission in CNS cells
- Chronic stimulus --> stronger response centrally
- Intense signaling from periphery --> increased sensitivity due to upregulation of transmitters and receptors, making a mild stimulus very painful.
- This can happen at every level of pain transmission (SC, BS, Thalamus, Cortex)
Structural Reorganization
- Collateral growth from touch axons (which can be painful) that may start to communicate with pain transmission cells.
- Touch may be perceived as pain (aka allodynia)
Altered Top Down Modulation
- Reduced antinociceptive influence from higher centers to spinal cord, pronoception is increased
- Sometimes related to genetic susceptibility relative to neurotransmitter levels
- Doesn't necessarily involve the periphery (no real source of incoming pain!).
62
Somatosensory representation changes with chronic pain. The cortical representation of the involved body part may [increase/decrease/either]. In Complex Regional Pain Syndrome (CRPS), the representation of the painful [enlarges/shrinks]...why?
Cortical representation of painful body part in the somatosensory cortex may change EITHER increasing or decreasing! In CRPS, representation of the painful hand SHRINKS because they aren't using it! In LBP, you can't not use your LBP, so those neurons continue to be active and maintain/enlarge somatosensory representation.
63
Phantom limb pain involves sensations felt in a body part that is ___. This involves complex plastic changes in the CNS, including the ___, following amputation. There is an [increase in/lack of] sensory info that causes neurons in CNS pathway to become overactive. Significant rewiring has to take place in brain. Phantom pain is [easy/difficult] to treat.
Phantom pain involves sensations felt after amputation in body part that is no longer there. Changes in CNS, including sensory cortex, following amputation leads to a LACK of sensory info that causes neurons in CNS pathway to become OVERACTIVE. DIFFICULT to treat.
64
What is referred pain? Why do we have referred pain? Example?
Referred pain is when you feel pain in a somatic body area (usually on the skin when you're really having visceral pain). This occurs because cutaneous and visceral afferents both converge on the SAME PAIN TRANSMISSION NEURON in thes pinal cord! Spinal cord gets a little confused as per source of pain and "feels it" in an area that isn't the source of the stimulus.
E.g. Angina (<3 ischemia) - heart is innervated by upper cervical segments so angina is felt over pecs and deltoid region
65
Discuss pain threshold differences in...
- Children
- Girls vs. boys
- Ethnic groups
- Children: experience more pain than adults
- Girls vs. boys: girls experience more pain than boys
- Ethnic groups: African Americans and Latinos have lower pain thresholds than non-hispanic whites. Whites have lower pain thresholds than people from India. Culture or genetics?? We don't know.
66
Pain thresholds are __% inheritable.
pain = 50% heritable
67
___ is a molecule involved in the upregulation neurotransmitters involved in pain (nitrous oxide, serotonin, dopamine, and norepinephrine). There is a gene that relates to less production of this molecule and is associated with [more/less] sensitivity to pain.
BH4
- Gene related to LESS BH4 production is associated with LESS SENSITIVITY to pain
68
What else will cause pain threshold to vary? (5)
LOWER threshold
- Sympathetic NS tone
- Chronic pain
RAISE threshold
- Exercise
- Modalities (e.g. TENS, heat, etc.)
- Descending systems can either INCREASE or DECREASE pain threshold
69
In the ___ Theory for pain modulation, it was proposed that in the dorsal horn of the spinal cord, pain was being modified as MN came in and touch receptors could decrease transmission of pain b/c they interact on the same interneuron. It is based on __.
GATE CONTROL THEORY: first to propose a theory of why touch receptors can inhibit pain.
Based on SPINAL CORD CIRCUITRY (the "gate" for pain transmission)
70
In the Counter Irritant Theory, touch receptors synapse with ___ producing interneurons in the [dorsal/ventral] horn. ___ inhibits pain transmission cells (thereby diminishing the transmission of pain)
Touch receptors synapse with ENKEPHALIN-producing interneurons in DORSAL horn. The INTERNEURON inhibits pain transmission cells and thus diminish the transmission of pain
71
The descending anti-nociceptive systems are considered an [intrinsic/extrinsic] mechanism for the modulation of pain. Ascending fibers en route to the __ give off collaterals to areas of the __. These collaterals from the ascending pain pathways activate [ascending/descending] projections from brainstem that can inhibit pain transmission neurons through interneurons. Some of these systems use endogenous opiate neurotransmitters (e.g. ___/___), others use ___. When opiate-derived drugs are given for pain control, these bind with receptors associated with the ___ system and create stress-induced analgesia.
The descending anti-nociceptive systems are considered an INTRINSIC mechanism for the modulation of pain. Ascending fibers en route to the CORTEX give off collaterals to areas of the BRAINSTEM. These collaterals from the ascending pain pathways activate DESCENDING projections from brainstem that can inhibit pain transmission neurons through interneurons. Some of these systems use endogenous opiate neurotransmitters (e.g. ENKEPHALINS/ENDORPHINS), others use CATECHOLAMINES. When opiate-derived drugs are given for pain control, these bind with receptors associated with the ENKEPHALIN/ENDORPHIN system and create stress-induced analgesia.
72
In a high-stress situation, stress signals descend and interact with the ___ system and affect pain signals. We know this because this process can be blocked with an ___.
In a high-stress situation, stress signals descend and interact with the LIMBIC system and affect pain signals. We know this because this process can be blocked with an OPIATE BLOCKER.
73
What other forms of analgesia have been shown to use the enkephalin/endorphin system?
- Certain applications of TENS (low frequency, high intensity)
- Acupuncture
- Exercise
74
What are the peripheral and central mechanisms contributing to PROnociception?
Peripheral Mechanisms
- Edema and endogenous chemicals can amplify pain by sensitizing FREE NERVE ENDINGS
* NSAIDs address these!
Central Mechanisms
- Increased pronociception in chronic stress and depression (somatic pain might be associated in some chronic depression!)
- Genetic variations in balance between anti- and pronociceptive systems (some people produce less enkephalin/endorphine or different amt of catecholamines within the dif systems
- Ppl with hx of opioid use have LESS effective endogenous mechanisms b/c artificial enkephalin (ie heroin), their natural opioids are down regulated
75
Opiate addiction occurs in less than ___. Predisposing factors include... (4)
Opiate addiction occurs in <1% of people who are prescribed opiates. Predisposing factors:
- Genetic predisposition (40-60% of risk is genetic!!)
- Hx of prior abuse
- Hx of psychiatric disorder
- Environmental/social factors (peer pressure, effective relationships with parents)
76
People with long-term opioid use will have [incr/decr] sensitivity to pain with a [higher/lower] pain threshold. Why? They will likely require [higher/lower] doses of pain meds for relief.
Long-term opioid use --> INCREASED sensitivty to pain and LOWER pain threshold because the INTRINSIC SYSTEM HAS BEEN DOWNREGULATED and replaced with ARTIFICIAL/EXTERNAL DRUG. This can be a permanent change even after opiate use has stopped.
HIGHER doses of pain meds in this population.
77
What are non-opiate approaches to pain control?
Modalities
Non-opiate meds (nalaxone, NSAIDs, etc.)
Meditation
Exercise
78
__ is the interstitial fluid once it enters the lymph vessels. It is secreted by every body organ except the __ and __. It consists of what?
LYMPH. Secreted by all organs EXCEPT SPINAL CORD & BRAIN
Lymph fluid consists of PROTEIN, WATER, FATTY ACIDS, and cellular components of BACTERIA, VIRUSES, AND DEBRIS
79
The function of the lymph system is to keep __ in a healthy state, remove __, __, and __ from tissues and ___ from the intestines and return those things back to the bloodstream. Finally, it protects the body from infection and disease via ___.
The function of the lymph system is to:
1) keep CT in a healthy state
2) remove FLUID, FOREIGN PARTICLES, and PROTEINS from tissues and FATS from the intestines and return those things back to the bloodstream
3) Finally, it protects the body from infection and disease via IMMUNE RESPONSE (produce, maintain, and distribute lymphocytes).
80
The lymphatic system consists of lymph vessels and nodes, ___ (organ), ___ gland, ___, ___, and lymphocytes.
lymph vessels and nodes, SPLEEN), THYMUS gland, TONSILS, PEYERS PATCHES, and lymphocytes.
81
Lymph vessels can be either superficial or deep. Describe the difference in function
Superficial - NO valves, so fluid can flow in any direction it wants. These are CAPILLARIES (pre-collectors) in the layer of skin
Deep: these are the COLLECTORS, or the "trunks." They run deep to the fascia
82
[Collectors/pre-collectors] are separated by valves into functional segments called ___. These vessels resemble veins in structure, but have [thinner/thicker] walls and valves in [longer/shorter] intervals. Lymphatic fluid flow is [passive/relies on intrinsic muscle contractions from smooth muscle in vessel wall]. Frequency of contraction is regulated by the [sympathetic/parasympathetic] NS and lymph volume. These contract ___x/min at rest, but increase x__ with exercise, heat or inflammation.
COLLECTORS are separated by valves into functional segments called LYMPHANGIONS. These vessels resemble veins in structure, but have THINNER walls and valves in SHORTER intervals. Lymphatic fluid flow is RELIES ON INTRINSIC MUSCLE CONTRACTIONS FROM SMOOTH MUSCLE IN VESSEL WALL. Frequency of contraction is regulated by the SYMPATHETIC NS and lymph volume. These contract 6-10X/min at rest, but increase X10 with exercise, heat or inflammation.
83
A ____ is a distinct, anatomic area of lymph drainage that can drain to regional lymph nodes. You can also drain lymph across this area via ___.
A WATERSHED/ LYMPHOTOME is a distinct anatomic area of lymph drainage that can drain to regional lymph nodes. Lymph can also drain across a watershed via ANASTOMOSES
84
The first lymph node in a chain of them (remember they're arranged like pearls!) is called the ___ lymph node. There are __-__ (#) lymph nodes in the body, __% of which are in the head neck and trunk. Each node is __-__mm in diameter. They act to ___. Lymph fluid becomes very concentrated because ___ remove excess water.
The first lymph node in a chain of them (remember they're arranged like pearls!) is called the SENTINEL lymph node. There are 600-700 (#) lymph nodes in the body, 50% of which are in the head neck and trunk. Each node is 2-25mm in diameter. They act to FILTER WASTE (BACTERIA, CANCER CELLS). Lymph fluid becomes very concentrated because VEINS remove excess water.
85
Compare/contrast the Lymphatic vs. Circulatory system.
The LYMPHATIC system is:
- 1 way vs. circular?
- # liters/day
- How they get fluid pumped around
- Continuous vs. non continuous column of fluid
- Peripheral pressure affected by dependent position?
- What happens if it's obstructed?
- Any filtration?
Lymphatics
- One way
- 1-2 liters/day
- Intrinsic contractions
- No continuous column of fluid
- Peripheral pressure unaffected by dependant position
- Obstruction leads to accumulation of HIGH protein fluid (>1.5 gm/dl)
- Fluid is filtered by lymph nodes
86
Compare/contrast the Lymphatic vs. Circulatory system.
The CIRCULATORY system is:
- 1 way vs. circular?
- # liters/day
- How they get fluid pumped around
- Continuous vs. non continuous column of fluid
- Peripheral pressure affected by dependent position?
- What happens if it's obstructed?
- Any filtration?
CIRCULATORY
- Circular
- Many liters /minute
- Separate pump ( heart)
- Continuous column of fluid
- Dependent position increases peripheral pressure
- Obstruction leads to collection of LOW protein fluid (
87
The lymphatic system also controls overflow from the venous system. __% of fluid leaving arterial end of capillary is reabsorbed by venous end. The remaining __% returns via the lymphatic system.
90% fluid from arterial capillaries is reabsorbed by venous end; 10% returns via lymphatic system
88
An impaired lymphatic system leads to a [lack/build up] of proteins in the interstitium because protein molecules are too big to pass through cell membrane back into __ system. Proteins then pull water across membrane to create __ equilibrium. Over time, protein accumulation in the interstitium will cause physiological changes in tissue and result in loss of skin ___ through __ and continued pull of water into the interstitium. What can help to slow this ultrafiltration?
An impaired lymphatic system leads to a BUILD UP of proteins in the interstitium because protein molecules are too big to pass through cell membrane back into VENOUS system. Proteins then pull water across membrane to create OSMOTIC equilibrium. Over time, protein accumulation in the interstitium will cause physiological changes in tissue and result in loss of skin ELASTICITY through FIBROSIS and continued pull of water into the interstitium. APPLICATION OF EXTERNAL PRESSURE USING COMPRESSION BANDAGES/ STOCKINGS can help to slow this ultrafiltration
89
___ is the amount of fluid and cells to be removed from the interstitium.
LYMPHATIC LOAD (LL)
90
___ is the amount of lymph transported per unit time.
__ is the maximum lymph time volume.
LYMPH TIME VOLUME (LTV) = amount of lymph transported per unit time
TRANSPORT CAPACITY (TC) = max lymph time volume
91
The lymph system will react to an increase in lymphatic load by increasing ___ until it reaches __
The lymph system will react to an increase in lymphatic load by increasing LYMPH TIME VOLUME until it reaches TRANSPORT CAPACITY
92
Dynamic insufficiency describes a [healthy/diseased] lymphatic system. A [normal/impaired] LL exceeds [normal/impaired] TC. Examples include...
This may happen following [low protein edema / lymph node removal]
Dynamic insufficiency describes a HEALTHY lymphatic system. A NORMAL LL exceeds NORMAL TC. Examples include SPRAINED ANKLE, DVT, CARDIAC EDEMA
This may happen following LOW PROTEIN EDEMA
93
Mechanical insufficiency describes a [healthy/diseased] lymphatic system. A [normal/impaired] LL exceeds [normal/impaired] TC. Examples include...
This may happen following [low protein edema / lymph node removal]
Mechanical insufficiency describes a DISEASED lymphatic system. A NORMAL LL exceeds IMPAIRED TC.
This may happen following LYMPH NODE REMOVAL
94
___ is an abnormal accumulation of protein-rich fluid in the interstitium that occurs when lymph load exceeds the lymph transport capacity in any body segment. Signs/symptoms include [fast/slow] progressive onset. Limb feels ___, but [painful/not painful]. Usually starts [proximally/distally] and is [symmetrical/asymemtrical]
LYMPHEDEMA is an abnormal accumulation of protein-rich fluid in the interstitium that occurs when lymph load exceeds the lymph transport capacity in any body segment. Signs/symptoms include SLOW progressive onset. Limb feels HEAVY, but NOT PAINFUL. Usually starts DISTALLY and is ASYMMETRICAL
95
[Primary/secondary] lymphedema is hereditary and congenital. ___% of this occurs in females. Lymphadema ___ (83%) occurs before age 35, and lymphadema __ (17%) occurs after age 35. Generally seen in [upper/lower] extremities. Symptoms can be triggered/exacerbated by __,__, or ___. What diseases/syndromes are associated with this?
PRIMARY
87% of this occurs in females. Lymphadema PREACOX (83%) occurs before age 35, and lymphadema TARDUM (17%) occurs after age 35. Generally seen in LOWER extremities. Symptoms can be triggered/exacerbated by INFECTION, TRAUMA, or PREGNANCY.
Associated syndromes:
- Milroy's Disease
- Meige's Syndrome
- Turner's Syndrome
96
[Primary/secondary] lymphedema is acquired, generally as a result of damage to soft tissue, lymph vessels or nodes. It can occur after an infection, tumor, radiation, or surgery. In the tropics it can be acquired from a mosquito bite (termed Filariasis)
SECONDARY
97
```
Describe the stages of lymphedema
Sub-clinical Stage 0
Stage I
Stage II
Stage III
```
Sub-clinical Stage 0
- Feeling of heaviness in limb without any visible swelling
Stage I
- Pitting edema on pressure, high water content, reduces with elevation, REVERSIBLE
Stage II
- Non-pitting, NOT reduced with elevation; moderate to severe clinical fibrosis
Stage III
- Elephantiasis; skin changes, lobules
98
___ is a lack of lymphatics (nonviable dysfunction).
APLASIA
99
___ is the most common lymphatic dysfunction, and involves a decreased number of collectors and capillaries
HYPOplasia
100
___ involves increased width of collectors, insufficient valves (leaky valves --> backflow and system backup)
HYPERplasia
101
___ (AKA ___ syndrome) is leg edema. This looks similar to the effects of radiation in which that lymph node locally is shut down.
INGUINAL NODE FIBROSIS (Kinmoth Syndrome)
102
What are possible effects of radiation therapy on the lymphatic system?
- Shrinks lymph nodes
- Causes fibrosis
- Hinders regeneration of lymph vessels
- Decreases available collateral pathways
103
Most edemas related to breast cancer occur in the first __(#) years, but they can occur over __ years after surgery/radiation. Basically, lymphedema has a LARGE variation in clinical presentation.
Most occur in first 4 years, but they can occur over 10 years after surgery/radiation
104
Venous edema involves __ leaking from veins into tissue. We see ___ aka reddish staining along with fibrosed/brawn subcutaneous tissue, [no pitting/pitting], [thickened/atrophic = fragile] skin, and malleolar ulcerations.
Venous edema involves BLOOD leaking from veins into tissue. We see HEMOSIDERIN aka reddish staining along with fibrosed/brawn subcutaneous tissue, PITTING, ATROPHIC/FRAGILE/THIN skin, and malleolar ulcerations.
105
Acute DVT occurs via [sudden/gradual] onset. It may be painful. May see ___ or ___ (color changes in skin). You can see a positive or negative ___ Sign, but don't use that because it sucks. Use ___ to diagnose. Don't mobilize the clot --> potential for ___
Acute DVT occurs via SUDDEN onset. It may be painful. May see CYANOSIS or ERYTHEMIA (color changes in skin). You can see a positive or negative HOMAN'S Sign, but don't use that because it sucks. Use VENOUS DOPPLER ULTRASOUND to diagnose. Don't mobilize the clot --> potential for PULMONARY EMOBLUS
106
In congestive heart failure, swelling is greatest [proximally/distally] and it's associated with sudden weight gain >2lbs overnight. It is [bilateral/unilateral] and symmetric. Pain? Pitting? Venous distention of the __ vein. Swelling changes? Diagnose with?
Congestive Heart Failure:
- Swelling greatest DISTALLY
- BILATERAL and symmetric
- Pitting
- May decrease swelling with elevation
- Usually painless
- Dyspneas
- JUGULAR venous distention
- Dx with physical exam, chest XR, and echocardium
107
Lipidema occurs mainly in [men/women], [bilateral/unilaterally] and appears as swelling from the __ to the ___. The dorsum of feet are [always/sometimes/ never] involved. There is [pitting/no pitting] and [absence of/presence of] cellulitis. Palpation is [painful/ not painful] and bruising [occurs easily/ does not occur]. What can we do for these pts?
Lipidema occurs mainly in WOMEN, and appears as swelling from the ILIAC CREST to the ANKLES. The dorsum of feet are NEVER involved. There is LITTLE TO NO PITTING (soft tissue texture) and NO cellulitis. Palpation is PAINFUL and bruising OCCURS EASILY. Not much we can do for these pts.
108
Malignant lymphedema stems from a new or recurrent malignancy. Associated with ___, ___, and __ (symptoms). [Distal/proximal] swelling and [rapid/slow] development and [ stagnant/continuous] progression. We also see ___, lymph node [shrinkage/enlargement], and discoloration that looks like a __.
Malignant lymphedema stems from a new or recurrent malignancy. Associated with PAIN, PARAESTHESIAS, and PARALYSIS (symptoms). PROXIMAL swelling and RAPID development and CONTINUOUS progression. We also see ULCERS/NON-HEALING WOUNDS, lymph node ENLARGEMENT, and discoloration that looks like a HEMATOMA.
109
There are 3 stages of complex regional pain syndrome. Describe symptoms associated with each
Acute: warmth, erythema, burning, edema, hyperalgesia, hyperhidrosis
Dystrophic: coolness, mottling of skin, cyanosis, brawny edema, dry brittle nails, continuous pain, osteoporosis
Atrophic: atrophy of skin and appendages
110
Describe the different ways that you can measure volume in lymphedema. What are the problems?
Circumferential
Water displacement
Weight (not very sensitive)
Optoelectrical (perometer - expensive!)
Tonometry (gives tissue TENSION, not volume)
Bioimpedence (ratio of extracellular to intracellular fluid volumes)
PROBLEMS: none can measure trunk, face, hands, feet, breast. None factor inherent differences between dominant and nondom arms. Doesn't tell what's significant (a change of 180 mL in a skinny arm is a LOT more significant than in a huge arm when you consider % change)
111
What is Stemmer's sign? If it is positive, what does that mean?
Stemmer's sign tests to see if you can pinch the skin at the base of the MTP joint. +Stemmer's sign, you can't pinch skin because it's fibrotic and thick (indicates lymphedema)
112
Describe lymphedema staging in terms of pitting edema
```
Press with thumb pressure for 10 seconds and count time to return to normal:
visible edema: 1+
5-15 seconds: 2+
15-30 seconds: 3+
> 30 seconds: 4+
```
113
One goal of lymphedema treatment is to prevent angiosarcomas (Stewart-Treves Syndrome). What are these?
An angiosarcoma (AS) is an uncommon malignant neoplasms characterized by rapidly proliferating, extensively infiltrating anaplastic cells derived from blood vessels and lining irregular blood-filled spaces. Specialists apply the term angiosarcoma to a wide range of malignant endothelial vascular neoplasms that affect a variety of sites. Angiosarcomas are aggressive and tend to recur locally, spread widely, and have a high rate of lymph node and systemic metastases. The rate of tumor-related death is high.
114
Give 6 intervention options for lymphedema. What's the gold standard?
1) NO intervention
2) Pt education
3) Compression garment, no bandage
4) Bandage, then compression garment
5) Complete decongestive therapy- GOLD STANDARD
6) Compression pump
115
What is involved with CDT? Describe Phase 1 and Phase 2
CDT = skin care, compression, manual lymphatic drainage, exercise, AND education!
Phase 1: Skin care, manual lymph drainage, compression bandage UP TO 24h/day, Exercise in bandage
Phase2: Skin care, self/partner massage, compression stockings during day, bandages during night, Exercise in COMPRESSION stockings
116
General contraindications to CDT
```
Acute infection
Cardiac edema
Malignant disease (relative)
Renal dysfunction
Acute DVT
```
117
Contraindications to Bandaging for lymphedema control
Arterial disease
```
Precautions:
HTN
Paralysis
Diabetes
Bronchial asthma
CHF
```
118
Contraindications for MLD
Abdomen
- Pregnancy
- Recent abdominal surgery
- Intestinal problems
- Aortic aneurysm
Neck
- Cardiac arrhythmia
- Hypo/Hyperthyroidism
- Hypersensitivity of carotid sinus
- Over age 60 (relative)
119
The goal of manual lymphatic drainage is to increase the frequency of ____ contractions, increase the volume of ___ transported, increase pressure in the ___ to redirect lymph flow toward __ and across ___. This technique is [hard/light] and is aiming to [increase/decrease/not directly affect] blood flow. It targets a [deep/superficial] level including the __ and __. You use a ___ stretch and release every ___-___ seconds.
The goal of manual lymphatic drainage is to increase the frequency of LYMPH VESSEL contractions, increase the volume of LYMPH TRANSPORTED, increase pressure in the COLLECTORS to redirect lymph flow toward COLLATERAL VESSELS and across WATER SHEDS. This technique is LIGHT and DOES NOT CAUSE INCREASED BLOOD FLOW. It targets a SUPERFICIAL level including the DERMIS and SUB-DERMIS. You use a 2-PHASE stretch and release SLOW, EVERY 6-10 seconds.
120
Differentiate between short- and long-stretch bandages. Which one...
- High/low resting state
- Compresses at rest
- High/low working state
Short-Stretch Bandage
- LOW resting state ; do not constrict at rest
- HIGH working state; form strong support during muscle contraction raising total tissue pressure
Long-Stretch Bandage (Ace)
- HIGH resting state; compress at rest (this is contraindicated based on lymph physiology and function)
- LOW working state; due to their extensibility, they do not provide much resistance with muscle contraction. Total tissue pressure is not significantly raised
121
What's the goal of bandaging in lymphedema management?
Increases pressure in tissues
Prevents refilling of interstitium
Provides support for stretched tissue
Reduces rate of ultrafiltration
Improves the effect of the muscle pump in exercise
Provides localized pressure to soften fibrosis if necessary
Facilitates reabsorption of colloidal protein
Gives desirable mild increase in temperature
122
Compression garments are worn [24/7 / only during the day / only at night]. They are [custom made/ ready to wear] and come in different classes of compression. The patient's Ankle Brachial Index (ABI) must be >___ and patient must be ___ to use garment.
Compression garments are worn ONLY DURING THE DAY. They CAN BE EITHER READY TO WEAR OR CUSTOM and come in different classes of compression. The patient's Ankle Brachial Index (ABI) must be > 0.8 and patient must be STRONG ENOUGH to use garment.
123
Atmospheric pressure is __ mmHg. Describe the amount of pressure given by each class of compression stockings.
Class I: 20-30 mmHg
Class II: 30-40 mmHg
Class III: 40-50 mmHg
Class IV: 50-60 mmHg
124
Exercise is good or bad for lymphedema? Why? How about weight lifting?? How about aquatherapy??
GOOD: enhances muscle and joint pumps. Diaphragmatic breathing can excite lymph system to start contracting faster
SOME sources say to avoid lifting over 5#, but New studies say gradual progression of WEIGHT TRAINING IS BENEFICIAL (consider lifting a kid..it's an ADL)
AQUATHERAPY: Hydrostatic pressure increases with depth (22.4 mmHg per foot!) If lymphedema is stable (NOT acute) exercise and aquatherapy can help. Water viscosity is 12x air resistance, so it provides good exercise environment. NO hot tub, no scuba diving.
125
Therapeutic exercise is the systematic performance or execution of planned physical movements, postures, or activities intended to do 5 things...
- Remediate or prevent impairments
- Enhance function
- Reduce risk
- Optimize overall health
- Enhance fitness and well-being
126
Grade the tissue injury:
Moderate pain that requires STOPPING the activity. Stress and palpation of tissue greatly increases pain. When injury is to ligaments, some of the fibers are torn, resulting in some increased joint mobility.
Grade 2: SECOND DEGREE
127
Grade the tissue injury:
Mild pain at the time of injury or within first 24h. Mild swelling, local tenderness, and pain occur when tissue is stressed.
Grade 1: FIRST DEGREE
128
Grade the tissue injury:
Near-complete or complete tear or avulsion of the tissue (tendon or ligament) with SEVERE pain. Stress to tissue is usually PAINLESS. Palpation may reveal the defect. A torn ligament results in instability of the joint.
Grade 3: THIRD DEGREE
129
In which stage of healing is the goal to develop a mobile scar? What therex does this?
Sub acute Stage: Proliferation, Repair, Healing
PT: Controlled Motion Phase
DO: Selective stretching, mobilization/manipulation of restrictions
130
In which stage of healing is the goal to increase the tensile quality of the scar? What therex does this?
Chronic Stage: Maturation & Remodeling
PT: Return to Function Phase
DO: progressive strengthening and endurance exercises
131
In what stage of healing is the goal to control the effects of inflammation? What therex does this?
Acute Stage: Inflammatory
PT: Protection Phase
DO: selective rest, ice, compression, elevation
132
In what stage of healing is the goal to promote healing? What therex does this?
Sub acute Stage: Proliferation, Repair, Healing
PT: Controlled Motion Phase
DO: nondestructive active, resistive, open and closed chain stabilization, muscular endurance, and cardiopulmonary endurance exercises, carefully progressed in intensity and range
133
In what stage of healing is the goal to prevent the deleterious effects of rest? What therex does this?
Acute Stage: Inflammatory
PT: Protection Phase
DO: nondestructive movement: passive range of motion, massage, and muscle setting with caution
134
In what stage of healing is the goal to develop functional independence? What therex does this?
Chronic Stage: Maturation & Remodeling
PT: Return to Function Phase
DO: functional exercises, and specificity drills
135
Describe each stage of healing and the clinical signs associated with each as well as pain in relation to tissue resistance.
Acute: Inflammation, Pain BEFORE tissue resistance
Sub-Acute: Decreasing inflammation, pain SYNCHRONOUS with tissue resistance
Chronic: NO inflammation, Pain AFTER tissue resistance
136
Assign a phase (acute, sub-acute, or chronic) to each of the following tissue responses/characteristics:
- Remodeling of Scar tissue
- Collagen formation
- Vascular changes
- Early fibroblastic activity
- Very fragile, easily injured tissue
- Collagen aligns to stress
- Exudation of cells & chemicals
- Removal of noxious stimuli
- Maturation of connective tissue
- Clot formation
- Growth of capillary beds into -area
- Phagocytosis, neutralization of irritants
- Contracture of scar tissue
- Granulation tissue
```
A= Acute
SA = Sub-acute
C = Chronic
```
```
C - Remodeling of Scar tissue
SA -Collagen formation
A - Vascular changes
A - Early fibroblastic activity
SA - Very fragile, easily injured tissue
C - Collagen aligns to stress
A - Exudation of cells & chemicals
SA - Removal of noxious stimuli
C - Maturation of connective tissue
A - Clot formation
SA - Growth of capillary beds into -area
A - Phagocytosis, neutralization of irritants
C - Contracture of scar tissue
SA - Granulation tissue
```
137
ROM typically uses how many reps?
5-10
138
Describe the difference between PROM, AAROM, AROM, and RROM
Passive Range of Motion (PROM)
- Movement within the available range of motion that is produced by an external force. (PROM vs. stretching)
Active Assisted Range of Motion (AAROM)
- A type of range of motion in which assistance is provided by an outside force, either manually of mechanically.
Active Range of Motion (AROM)
- Movement of a segment that is produced by an ACTIVE contraction of the muscles crossing that joint.
Resisted Range of Motion (RROM)
STRENGTHENING
139
PROM:
- Indications
- What changes are you trying to induce/maintain?
- PROM can be used to evaluate __ tissues without interference of _ tissues
PROM will NOT ___, ___, or ___.
PROM
INDICATIONS
- Pain with motion
- Unable to do AROM
- Decrease complications of immobility
- Evaluate tissues
GOAL
- Maintain joint and soft tissue integrity
- Minimize effects of contracture
- Maintain elasticity of muscle
- Assist in CIRCULATION of vascular dynamics
- Enhance nutrition of cartilage via mvmt of synovial fluid
- Decrease or inhibit pain
- Promote healing
- Maintain awareness of mvmt
- Evaluate INERT (noncontractile) tissues without interference of contractile tissues
PROM will NOT:
- Prevent muscle atrophy
- Increase strength/endurance
- Assist circulation as much as active muscle contraction
140
What are indications for Active and Active Assisted ROM?
* What muscle grade does a pt need to do full AROM (with gravity? Gravity eliminated?)
* What muscle grade does a pt need to do AAROM?
* *These include contractile component of tissues
- Maintain physiological elasticity and contractibility of muscles
- Provide sensory feedback from muscle contraction
- Provide a stimulus for bone integrity
- Increase circulation and prevent thrombus formation
- Develop coordination and motor skills for functional activities
* Pt needs 3/5 for full AROM with gravity, 2+/5 for full AROM with gravity eliminated
* Pt needs at least a 2- to do AAROM (has to help a little!)
141
Precautions and contraindications to ROM?
CONTRAINDICATIONS: When mvmt of a part is disruptive to healing, e.g. acute tears, acute fracture, and surgery
PRECAUTIONS: Cardiovascular
142
Intensity is the amount of ___ imposed on a contracting muscle during each rep of an exercise
Intensity is the amount of RESISTANCE (WEIGHT) imposed on a contracting muscle during each rep of an exercise
143
According to the ___ principle, for the performance of a muscle to improve, a load that [is less than/ meets/ exceeds] the muscle's metabolic capacity must be applied.
According to the OVERLOAD principle, for the performance of a muscle to improve, a load that EXCEEDS the muscle's metabolic capacity must be applied.
144
According to the __ principle, adaptive changes of a muscle are [permanent/ transient] unless they are maintained.
According to the REVERSIBILITY principle, adaptive changes of a muscle are TRANSIENT unless they are maintained.
145
Detraining can begin within ___ (time frame) after cessation of resistance exercise. With disuse/immobilization, you see a loss of [endurance/power/strength] up to __% per day.
Detraining can begin within 1-2 WEEKS after cessation of resistance exercise. With disuse/ immobilization, you see a loss of MUSCLE STRENGTH up to 5% per day.
146
Describe when in an exercise program and with which populations you'd use a SUBMAX load (mod to low) or a NEAR MAX or MAX load. What's the goal of each?
SUBMAX LOAD (Mod to Low)
- Beginning of exercise program
- Early stages of soft tissue healing
- After periods of immobilizlation (cartilage)
- Children and elderly
- Goal = ENDURANCE
- Warm up and cool down
- During slow velocity isokinetic training
NEAR MAX / MAX LOAD
- Goal: Increase muscle STRENGTH and POWER
- Otherwise healthy adults in the last phase of rehabilitation
- Conditioning program for individuals with no pathology
- Training for competitive lifting or body building
147
A repetition maximum is the greatest [amount of weight / number of times] a muscle can move through the available range of motion [at a specific weight / at a specific number of times]. Describe in terms of a 1RM. What's the purpose of RM?
A repetition maximum is the greatest AMOUNT OF WEIGHT a muscle can move through the available range of motion A SPECIFIC NUMBER OF TIMES. A 1 Rep Max (1RM) is the greatest amount that a subject can lift through the ROM just ONE time.
Purpose:
- Document baseline
- Determine exercise load
148
A 10RM is ~__% of a 1RM. Similarly, strength training zone is usually __-__% of the RM.
A 10RM is ~75% of a 1RM. Similarly, strength training zone is usually 70-85% of the RM.
149
Describe the correlations between # of reps and % of 1RM
```
90% 1RM
5-8 reps = 80% 1RM
8-12 reps = 60-80% 1RM
13-22 reps = 40-60% 1RM
>22 reps = <40% 1RM
```
150
If your goal is strength, you want to train at __-__% of 1RM (__-__ reps).
If your goal is ENDURANCE, you want to train at __-__% of 1RM (__-__ reps)
If your goal is STRENGTH, you want to train at 60-80% of 1RM (8-12 reps).
If your goal is ENDURANCE, you want to train at 40-__60 of 1RM (13-22 reps)
151
Volume = ___ x ___
There is a [direct/inverse] relationship between volume and intensity.
Volume = REPS x SETS
There is a INVERSE relationship between volume and intensity. (more reps/sets have to be done at a lower load)
152
How many sets should you use?
1-6 sets has been shown to be effective
153
Thinking about exercise order...
- [Large or small] muscle groups first?
- Multi or single angle joints first?
- After warm up, do higher or lower intensity first?
Exercise order impacts the fatigue and adaptive training effects
- LARGE groups before small groups
- MULTI angle joints (e.g. shoulder) before single angle joint
* * Multi joint movement is a more complex movement using more muscle groups. Encompasses more things, so do that first as to not diminish the reserve before doing a high intensity exercise
- After warm up, do HIGHER intensity before lower intensity exercises.
* * It’s when they’re the least fatigued! If we do low intensity exercises first, their ability to complete target high intensity activity will be diminished (diminished reserves)
154
When volume and intensity are low, frequency of exercise can be ___ (e.g. how many days/week?)
As volume & intensity are increased, frequency should be ~ ___.
For maintenance, frequency = __x/wk
For highly trained athletes, frequency = __x/wk
When volume and intensity are low, frequency of exercise can be HIGH (e.g. DAILY)
As volume & intensity are increased, frequency should be ~ EVERY OTHER DAY (5X/WK).
For maintenance, frequency = 2X/wk
For highly trained athletes, frequency = 6x/wk
155
Describe appropriate rest intervals when training with:
- 8-12 RM
- 3-5RM
Moderate intensity (time between sessions?)
- 8-12 RM: 30-60 seconds
- 3-5RM: 1-2 minutes
Moderate intensity: 48 h between sessions
156
The form of exercise, type of contraction, and manner in which the exercise is carried out describe the ___
MODE
157
In almost all instances, the [overflow/ training] effects are substantially less than the [overflow/training] effects that result from specificity of training.
In almost all instances, the OVERFLOW effects are substantially less than the TRAINING effects that result from specificity of training.
158
Training is highly [specific/ transferable]. Similarly, a program designed to develop muscle strength has been show to [moderately improve/have no effect on] endurance, and an endurance program demonstrates [a moderate improvement in/ little effect on] strength. Finally, training is [highly/ not very] speed specific.
Training is highly SPECIFIC, with limited transfer. Similarly, a program designed to develop muscle strength has been show to MODERATELY IMPROVE endurance, and an endurance program demonstrates LITTLE EFFECT strength. Finally, training is HIGHLY speed specific. There is very little transfer of training to other speeds.
159
Periodization is used to build systemic variation in exercise __ and __, __, or __ at regular intervals over a specified period of time. Describe changes in LOADS, REPS & SETS, # EXERCISES/Session, and FREQ of sessions for:
PREPARATION
COMPETITION
RECUPERATION
Periodization is used to build systemic variation in exercise INTENSITY and REPS, SETS, OR FREQUENCY at regular intervals over a specified period of time.
PREPARATION
- LOWER loads/intensity
- HIGH reps & sets
- MORE exercises/session
- MORE FREQUENT sessions
COMPETITION
- HIGHER loads/intensity
- DECREASED reps & sets
- FEWER exercises/session
- FEWER sessions
RECUPERATION
- Gradual DECREASE in loads/intensity
- DECREASE in reps & sets, exercises/session, and sessions
160
What precautions should you look out for with resistance training? (5)
VALSAVA maneuver
- Avoid! Don't hold breath. Exhale through the "sticking point" (end of concentric phase)
SUBSTITUTE MOTIONS/ FATIGUE
OVERTRAINING
- Can lead to a decline in physical performance
- Brought on by inadequate rest, too rapid progression, and inadequate diet/fluid
EXERCISE-INDUCED MUSCLE SORENESS
PATHOLOGICAL FRACTURES (OP)
161
There are two types of exercise-induced muscle soreness. ___ muscle soreness develops during or immediately after strenuous exercise performed to the point of exhaustion. It is due to lack of adequate ___ and ___, and a temporary build-up of ___ (specifically, __ and __). The second type, ___ muscle soreness, occurs between 12-24h after exercise.
There are two types of exercise-induced muscle soreness. ACUTE muscle soreness develops during or immediately after strenuous exercise performed to the point of exhaustion. It is due to lack of adequate BLOOD FLOW and OXYGEN, and a temporary build-up of METABOLITES (specifically, LACTIC ACID and POTASSIUM). The second type, DELAYED-ONSET muscle soreness, occurs between 12-24h after exercise.
162
Contraindications to resistance training include...(3)
Severe cardiopulmonary Dz
Acute inflammation
Pain
