Lecture 4 Flashcards
What are therapeutic modalities?
- include all the interventions used in health care that optimize the body’s ability to deal with PAIN & subsequent TISSUE healing
What is pain?
- an unpleasant sensory & emotional experience associated with actual or potential tissue damage
- Pain is the cause of a many-layered interplay of bodily, psychological and social triggers
- The experiencing of pain has a strong psychological component
What are 3 characteristics of pain ?
- pain is subjective
- pain has more than one dimension
- pain has an abundance of descriptors
What are the 6 dimensions of pain?
- physiological
- sensory
- affective
- cognitive
- behavioural
- sociocultural-ethnocultrual
What is the physiological dimension of pain?
- the physical aspects of pain perception, including the intensity, location, and quality of the pain sensation
What is the sensory dimension of pain?
- intensity, quality, pattern
What is the affective dimension of pain?
- the emotional & subjective experience of pain (i.e., the negative feelings & emotions associated with pain)
What is the cognitive dimension of pain?
- the mental processes, thoughts, beliefs, & attitudes a person has about their pain, including how they interpret & understand it
What is the behavioural dimension of pain?
- the observable actions & reactions a person exhibits in response to pain
What is the sociocultural-ethnocultrual dimension of pain?
- how an individual’s cultural background, beliefs, social norms, & experiences influence their perception, expression, & management of pain
What are 2 classifications of pain?
- acute
- chronic
What is acute pain?
- Immediate onset stimulus occurs for brief periods of time
- It should always be interpreted as an alarm signal that something may be wrong
What is chronic pain?
- is generally continuous & recurrent
- It is associated with chronic injury or diseases & is often one part of their symptoms
What are 4 types of pain?
- local tissue trauma
- referred visceral
- trigger points
- sclerotome
What is local tissue trauma pain?
- pain experienced directly at the site of an injury to soft tissues like muscles, tendons, or ligaments, caused by a sudden trauma
- caused by bio mechanical mediators (i.e., prostaglandins)
What is referred visceral pain?
- pain originating from internal organs (viscera) is felt in a different area of the body (not actual pain area) due to the shared nerve pathways
What is trigger point pain?
- discomfort caused by pressure on specific, sensitive areas within a muscle
What is sclerotome pain?
- referred pain that originates from irritation or injury to tissues derived from the same embryonic segment
What are 3 pain descriptors?
- Steady Pain (97%): Burning, aching, stinging, throbbing, itching, numbing, pins & needles, pulling
- Brief Pain (87%): Sharp, jabbing, shooting, electric
- Evoked Pain: Mechanical, thermal
What is the purpose of pain?
- Pain alerts us that there is something wrong
- Pain & the perception of pain can be subjectively modified by past experiences & expectations
- Most of what we do to treat an athlete’s pain is to change their perception of the pain
What are physical effects of pain?
- Increased muscle spasm (guarding); involuntary muscle contraction that occurs when the body is trying to protect an injured area by tensing up the surrounding muscles
- Prolonged spasm causes:
- Circulatory deficiency - Muscle atrophy - Disuse habits - Enhances disability
What are psychological effects of pain?
- Inhibits efforts to rehabilitation
- Decreased athletic performance
- Reflex sympathetic dystrophy (complex regional pain syndrome (CRPS))
What is complex regional pain syndrome (CRPS)?
- A chronic pain condition as a result of dysfunction in the central or peripheral nervous systems
- causes changes in the colour & temperature of the skin over the affected limb or body part, accompanied by intense burning pain, skin sensitivity, sweating, & swelling
What is complex regional pain syndrome I (CRPS I)?
- Triggered by tissue injury; meaning all patients have the symptoms but no underlying nerve injury
What are 2 factors that cause complex regional pain syndrome?
- sympathetic nervous system (SNS)
- post-injury CRPS
- CRPS does not necessarily have a single cause, but is rather the result of multiple causes that produce similar symptoms
What is the sympathetic nervous system in pain?
- Plays an important role in sustaining the pain
- Pain receptors in the affected part of the body become responsive to catecholamines
- catecholamines released from sympathetic nerves, acquires the capacity to activate pain pathways long after tissue or nerve injury has occurred
What is post-injury complex regional pain syndrome?
- Caused by a triggering of the immune response
- characterized with inflammatory symptoms of redness, warmth, & swelling in the affected area
- CRPS may represent a disruption of the healing process
What are 3 symptoms of complex regional pain syndrome?
- Continuous, intense pain due to the severity of the injury (if an injury has occurred)
- The pain gets worse rather than better over time
- affects one of the extremities & is also often accompanied by many specific signs & symptoms
What is Afferent nerve function?
- The information about touch & pain is transmitted to the spinal cord & brain by primary afferent axons
- fibers are connected to the different types of receptors in the skin, muscle & internal organs
What are 2 types of Afferent nerve fibres?
- large diameter
- small diameter
What are large diameter Afferent nerve fibers? What are 2 types of large diameter nerve fibers?
- myelinated nerve fibers that transmit signals to the brain & spinal cord
- A - Alpha (Aa): largest diameter & fastest conduction speed. They have both sensory & motor function protective reflex
- A - beta (AB): carry sensory information such as touch, temperature, & pressure
What are small diameter Afferent nerve fibers?
- unmyelinated fibres that carry information related to pain, temperature, & other sensations, usually with a slow conduction velocity
What is transcutaneous electrical nerve stimulation (TENS)?
- electrotherapeutic modality that functions to alter or modulate a patients perception of a painful stimulus from an injured area
What are the 3 theories of Transcutaneous Electrical Nerve Stimulation?
- gate control theory
- central biasing theory
- opiate theory
What is the gate control theory?
- Basic principle involves the idea that the brain will only deal effectively with a single sensory impulse at a time
- I.e., Large diameter fibre afferent pathways when stimulated effectively will inhibit the small diameter fibre transmission of pain signal to the brain
What is the central biasing theory?
- the brain plays a significant role in modulating pain signals that can amplify or dampen pain perception based on various factors
- essentially allowing the brain to actively influence how much pain is felt from a given stimulus
What is the opiate theory?
- the body naturally produces opioid-like substances (endorphins) which bind to specific receptors in the nervous system, effectively acting as a built-in pain-relief mechanism
- These chemicals will inhibit transmission along the small diameter pain fibers
What is a therapeutic massage? What are the 6 soft tissues included?
- a systematic manipulation of the soft tissues of the body for therapeutic purposes
- Soft Tissues Include:, Muscles, Fascia, Ligaments, Tendons, Blood & Lymphatic Vessels, Nerves
What are the 4 general concepts of a massage?
- optimize recovery & aid the body’s natural healing process; 15-20 mins
- Increases local circulation & results in a concomitant increase in temp
- May help break down scar tissue, muscle adhesion
- May help to decrease viscosity within tissue & increase pliability
What are 6 physiological effects of a massage?
- mechanical
- neurological
- vasoconstriction
- vasodilation
- reduces muscle spasm
- decrease in pain
What is the mechanical effect of a massage?
- increase in circulation especially in the venous & lymphatic systems
- The capillaries dilate which allows for a greater inter-change of metabolic substances from the injured area
- Lymph system helps carry exudates from injured area
What is the neurological effect of a massage?
- an Afferent sensory with motor & sensory relaxation
- stimulation of large diameter afferent nerve fibers decrease efferent output to the muscle producing relaxation
- In non injury situation relaxation is achieved via stimulation & release of endorphins
What is the vasodilation effect of a massage?
- After ice, blood vessels dilate & local blood flow is increased; This is known as the Hunter’s response (the body’s protection against prolonged exposure to cold)
- is an undesirable effect in the acute stage of an injury because it will cause an increase in the volume of edema & effusion
How does a massage reduce muscle spasm ?
- Ice numbs the efferent nerve fibres over which the contraction or spasm “signal’ is transmitted
- These nerve fibers affect the muscle spindles where the muscle fails to relax
How does a massage decrease pain?
- It reduces the excitability of free nerve endings & peripheral nerve fibres over which pain is transmitted
- It also increase the firing of the large diameter sensory nerves
What are 5 tissues a massage has an effect on?
- skin
- ligaments & tendons
- adipose (fatty) tissue
- muscle
- bone
How does a massage affect the skin?
- can help in restoring pliability to skin
How does a massage affect ligaments & tendons?
- May help to reduce adhesions & scar tissue increasing pliability of the structure
How does a massage effect adipose (fatty) tissue?
- Massage has no effect on the tissue (i.e., it can’t be massaged away)
How does a massage effect muscle?
- Can break down scar tissue
- Scar tissue is non elastic, the more you get rid of early, the increase or return of elasticity to muscle occurs
- Helps relief of muscle fatigue
How does a massage effect bone?
- Massage does not do anything to bone directly
- In case of fracture — massage on the other side of the fracture after soft callus is formed may aid in healing the surrounding tissue
What are 5 indications for a massage?
- Pain relief-reduces spasm
- Relaxation of muscle-after injury or before exercise
- Assists in lymphatic & venous circulation by pumping mechanically prevents pooling & decreases swelling
- Increases waste product breakdown & absorption through metabolism
- Stretches adhesions; mobilizes scar tissue
What are 5 contraindications for massage?
- Never use within 48 hours of injury - injury bleeds & massage increases blood flow this hampers healing
- Skin diseases; practitioner can contract disease
- Never over malignant areas
- Arteriosclerosis - thickening & loss of elasticity of artery
- Patient is hypersensitivity to touch
What are 4 benefits of a massage?
- Easily done; Can be done almost anywhere
- Easy to learn or teach
- Before competition - good tool if the individual is susceptible to stiffness & muscle soreness
- Psychological effect is important to some
What is the ideal room temperature for a massage?
- 70-72 degrees with no drafts
What are 3 types of lubricants used for massage? Which one is recommended?
- Powder (ie: baby powder petroleum base - very messy)
- Mineral Oil - requires a shower after as it leaves a residue
- Lotion – alcohol/water based & emollients leaves a cool, clean feeling (best option)
What are 4 types of massage strokes?
- effleurage
- petrissage (kneading)
- friction
- percussion (tapotement)
What is an effleurage stroke?
- Allows the individual to get a feel of the muscle tissue
- light: nervous reflex relaxation
- deep mechanical reflex milking effect
What is a petrissage (kneading) stroke?
- wringing, lifting, pulling
- applies deep pressure to underlying muscles
What is a friction stroke?
- Circular: deep local massage, breaks up adhesions between fibres
- Transverse: used on ligaments to break down excessive scar tissue
What is a percussion (tapotement) stroke?
- Stimulating strokes involves rapid rhythmic movements with the hands or finger tips (hacking, cupping, beating, pincement)
What is acute injury within cryotherapy management ?
- Cold is considered effective in controlling the inflammatory response
- preferred mode of treatment for injuries in the acute (inflammatory) stage
- Ice immediately after an injury occurs & frequently throughout the remaining 48-72 hours of the inflammatory stage
What is the sub acute phase in cryotherapy management ?
- can be used to ward off the effects of micro-trauma after exercise or during rehabilitation & works well to modulate pain
What are 6 methods of cryotherapy treatment?
- ice packs
- ice massage
- ice bath
- ice towels
- chill whirlpool
- chemical cold sprays
How are ice packs used in cryotherapy treatment?
- Ice is placed into a plastic bag and then placed onto the injury; crushed is best
- easy to mould around body parts & leaves no air pockets as it may cause skin frostbite & blistering
- To avoid this, place a towel or some sort of protection over the skin before applying the ice
How is an ice massage used in cryotherapy treatment?
- Water is frozen in paper cups & stored in freezer until needed
- Inflamed area is then iced by rubbing the ice cup over the injured area
How is an ice bath used in cryotherapy treatment?
- The injured part is immersed in a bucket or pail of ice water
- This method is usually reserved for treating ankles, hands & wrists as it is difficult to treat larger body parts with this method
How are ice towels used in cryotherapy treatment?
- Ice can be placed on a towel & then directly over area to be treated
- Towels may be soaked in cold water or be pre-frozen & applied without ice
What are sensations caused by ice?
- Cold: 1-3 minutes becomes progressively uncomfortable
- Burning: 5 minutes
- Aching: 5-7 minutes
- Analgesia: inability to feel pain - 10 minute ( approx. )
What is Thermotherapy ?
- Superficial Heat is applied to an injury in the subacute or post-inflammatory stage
- If inflammation symptoms are absent, heat may be applied to the injury to help speed up the healing process
What is the vasodilation effect of heat?
- heat causes an increase in circulation to & from the injury site
- delivers more oxygen, nutrients & repair cells required for healing & increases lymphatic & venous drainage of the exudates
How does heat decrease pain perception?
- increased drainage relieves pressure within the the tissues & on free nerve endings thereby decreasing pain
How does heat decrease muscle spasm?
- the heat increases the firing of large diameter afferent nerves which decreases efferent signal that is responsible for the muscle spasms
How beneficial is heat treatment?
- heat treatment does not penetrate to deep tissue because the skin is a poor heat conductor
- tissue located just below the skin derives the most benefit from heat application
- deeper injuries may require treatment with electrical modalities whose therapeutic effects penetrate deeper below the surface of the skin
What are heat packs in Thermotherapy treatment?
- reusable heat packs that contain a silicon gel or clay & kept in a heating unit that is filled with water
- The unit heats the water which transfers heat to the packs
- wrapped in approximately 3-5 layers of towels before being applied to the skin as they are very hot (150 –160°F) & could easily cause scalding burns
What are hot water bottles in Thermotherapy treatment?
- A thick rubber bottle filled with hot water (150 –160°F)
- do not place directly against the skin (always wrap prior to applying)
- Applying the heat over a moist towel placed on the skin first, helps in increasing the depth of heat penetration
What is a heat immersion bath in Thermotherapy treatment?
- Injured part is immersed in a tub of water ranging from 100-105 F
What is a whirlpool hydrotherapy in Thermotherapy treatment?
- Water temperature ranges from 100-105°F (38 to 40.5 °C)
- heating effect from the water & massaging action which physically helps reduce edema & effusion
What is a contrast bath in Thermotherapy treatment?
- the alternating of hot & cold application to have intermittent blood vessel dilation & constriction
- creates a pumping effect in the tissue which moves blood to & from the injury site
- most effective on the extremity injuries but can also work over other areas of the body
- about 20 min with an alternating between the hot & cold every 2 min
What is electric muscle stimulation (EMS)?
- Used to create controlled muscle contractions bypassing the CNS
- Acts on local motor units to help maintain normal muscle physiology
- usually 10 sec. ON with 25 - 30 sec. OFF this helps to prevent muscles fatigue
What is electric muscle stimulation used for?
- Prevent disuse atrophy
- Muscle re-education
- Muscle Pump
- Unit parameters: 30-60 Hz to achieve tetanic contraction
What is an ultrasound?
- A form of acoustical (sound wave) energy
- Traditionally a deep heating modality used to increase tissue temp & subsequently increase local tissue blood flow
- used to stimulate repair of soft tissue injuries as the high frequency helps reduce pain
What is the Piezoelectric effect within an ultrasound?
- electrical energy converted to mechanical energy via passing of an electrical current across a crystal within the transducer head
What are the 4 physiological effects of an ultrasound?
- Ultrasound in biological tissue can produce both Thermal & Non-Thermal (mechanical effects)
- Ultrasound will affect both normal & damaged cells
- Greater effects on the damaged tissue
- Tissue temp must be Increased 40 to 45 C for min. of 5 minutes
What are 5 thermal effects of an ultrasound?
- Increased Blood Flow
- Increased extensibility of collagen tissue; greatest in tendons, capsule, ligaments
- Decreased joint stiffness & muscle spasm
- Mild Inflammatory reaction
What is the treatment protocol for an ultrasound?
- Heating effect is contraindicated in the acute phase of healing
- Sub acute condition & chronic - every other day for 10-12 days
- Don’t use again for 2 weeks
- Each treatment duration: 5-8 minutes
What are the general uses of an ultrasound?
- Soft tissue healing & repair
- Decrease scar tissue, joint contracture & chronic inflammation
- May stimulate increase in bone healing in delayed union situations
- Plantar warts
- Phonophoresis (medicines to the skin)
What is musculoskeletal evaluation?
- The order of assessment is specific & followed the same way every time you evaluate a problem
- The evaluation process follows the basic principles as initially laid out by James Cyriax
What are the 7 assessments of a musculoskeletal evaluation?
- patient history
- history of the present injury
- past history
- index of suspicion
- observation
- functional exam
- special tests
How do you check a patients history?
- General background, age, activities (work, recreational, sport, etc), current health status, alcohol, smoker, meds
How do you identify the history of the patients present injury?
- want the patient to paint a picture; What was the specific cause of the injury?
- mechanism of injury (MOI); get them to be as specific as possible so you can see what is possibly happening to the anatomical structures as they are being stressed i.e. compression, tension, shear?
- Get them to put a finger on the area of injury or pain
What is the acronym to help lead you through the patients sign & symptoms?
- P - What provokes or makes the problem worse ?
- P - What palliates or makes the problem better ? (ie. rest, heat, ice, etc.)
- Q - What is the quality of the pain ?
- R - Where is the pain region or does it radiate?
- S - How severe-is the pain ?
- T- When did the pain begin or the time of day it is the worse ?
How do you identify the past history of the patient?
- find out if there were any previous problems or injuries to the body part
- find out how recent & what extent of injury did they suffer
- were they immobilized for any length of time or if they had to use crutches
What is the index of suspicion?
- The information you gathered should allow you to develop, with (80% or better) confidence an index of 3 things that you feel are the most involved tissue or structures with respect to your patients problem
How do you do an observation on a musculoskeletal evaluation ? What should you look for?
- This should include a full body postural scan but can be made specific to lower or upper body injuries
- Back injuries will almost always require a full body scan
- Specific things to look for include: Atrophy, Asymmetry, Swelling, Deformity, Discolouration
What is a functional exam in a musculoskeletal evaluation?
- broken down into three parts & done in the following order to be the least stressful on the injured area
- Active Test
- Passive Tests
- Isometric Resisted Tests
What are special tests in a musculoskeletal evaluation?
- specific tests that practitioners have developed to mimic or cause stress to specific tissue structures
What are 3 special tests for a musculoskeletal evaluation?
- Empty Can: a test used to recreate impingement of the Supraspinatus tendon.
- Lachman Test: used to determine if the ACL is damaged
- Thompson Test: used to determine if the Achilles tendon is damaged
What are 4 cautions & contraindications of Thermotherapy?
- Circulatory problems
- Injury in the acute stage
- Sensory impairment
- Heat exhaustion/full body immersion
What are cautions & contraindications of cryotherapy?
- Hypersensitivity to cold (ask for a history)
- Circulatory problems
- Anaemia
- Frostbite
- Areas of decrease skin sensation
What are cautions & contraindications of ultrasound?
- Acute injury first 24 hours
- Areas of decreased sensation
- Areas of poor circulation
- Thrombophlebitis
- During pregnancy (over the abdomen only)
- Cardiac pacemakers
