Modalities & Exercise Exam 2

Question 1

Why Do We Need To Learn This?

Answer 1

Most TM applications are directed at relieving pain.
This information will make it make sense later.

Knowledge of all aspects of pain improves the ability to evaluate the individual on a multidimensional level and progress them through rehab safely.

Necessary to understand that not all pain experiences are related to an acute inflammatory response.

The whole evidence based practice thing .

Question 2

What is Pain?

Answer 2

“an unpleasant physical and emotional experience which signifies tissue damage or the potential for such damage”
International Association for the Study of Pain (IASP)

Pain exists if the individual says it exists

Pain is essential to survival

Pain motivates the injured athlete to seek care and can help us make assessments

Question 3

Etiological factors

Answer 3

factors that cause a condition

Question 4

Sensory component

Answer 4

Rate your pain on a 1-10 scale, Visual Analog Scale, other pain scales
Pain Disability Index – comprehensive questionnaire
Oswestry Pain and Disability Index (p.98)
Validated?

Question 5

Sensory + Affective-Motivational Component

Answer 5

Varies between individuals
Previous pain experiences, family experiences, cultural background, situation specific… these can create somatic markers (emotional memories)
Persistent pain outlasts its usefulness in identifying and injury, A-M aspect

Question 6

Four types of peripheral sensory receptor

Answer 6

Special
Visceral
Superficial
Deep

Question 7

Special Sensory Receptors

Answer 7

Sight
Taste
Smell
Hearing
Balance

little impact on the perception of (and response to) musculoskeletal pain

Question 8

Visceral Sensory Receptors

Answer 8

Hunger
Nausea
Distension
Visceral pain

Question 9

Superficial Sensory Receptors

Answer 9

AKA cutaneous receptors

“peripheral” because they are on the periphery (outside CNS)

Question 10

Superficial Sensory Receptors

Mechanoreceptors

Answer 10

Stroking, touch and pressure
Some adapt rapidly (pressure and touch)
-Meissner’s corpuscles and Pacinian corpuscles (hair follicle receptors)
Some are more slowly adapting (pressure and skin stretch)
-Merkle cell endings and Ruffini endings

Question 11

Superficial Sensory Receptors

Thermoreceptors

Answer 11

Temperature and temperature change
Slowly adapting, but discharge in bursts with rapid temperature change
Warm receptors stop discharging at temps that damage the skin
Cold receptors continue to discharge when tissue cooling is perceived as painful
Why don’t freezing injuries such as frostbite hurt as much?

Question 12

Superficial Sensory Receptors

Nociceptors

Answer 12

Free nerve endings
Stimulated by: potentially damaging mechanical, chemical, and thermal stress
Sensitized by: prostaglandins, bradykinin, substance P, serotonin and others…
Contain the neurotransmitter L-glutamate which increases pain sensation

Question 13

Deep Tissue Receptors

Answer 13

Muscle
Muscle Spindles and Golgi Tendon Organs (GTOs)
Sense changes in muscle length and tension
May also be sensitive to chemical stimuli

Joint Structures
Pacinian Corpuscles: Adapt rapidly and respond to changes in joint position and vibration
Ruffini Endings: Adapt slowly and are most active at the end ranges of joint motion

Both have Nocioceptors
Free nerve endings that say ‘Whoops, this is/that was too far!”

Question 14

The Acute Pain Pathway

Answer 14

Ascending Pathways
Afferent Pathways
“First Pain”
Neocortical Tract

Fast, three-neuron pathway from the periphery (outside the CNS) to the cortex (area of the brain that identifies the location of pain)

Important Parts
Nociceptor (skin, soft tissue, periosteum)
Sensory nerve (first order neuron)
T-cell (second-order neuron)
Thalamus
Sensory Cortex

Question 15

Afferent Pathways

Answer 15

Impulses from sensory receptors are transmitted to higher brain centers by AFFERENT (OR SENSORY) NERVES

Question 16

FIRST ORDER AFFERENT NERVE

Answer 16

In the periphery (outside the CNS)
Cell body in the DORSAL ROOT GANGLION
Synapses in the dorsal horn of the spinal cord

Question 17

A-Beta Fibers (1st order afferent sensory nerve)

Answer 17

Originate from hair follicles, Meissner’s corpuscles, Pacinian corpuscles, Merkle cell endings, and Ruffini endings

Transmit info regarding touch, vibration and hair deflection

Large diameter and myelinated = FAST CONDUCTING
Relatively low threshold = EASILY STIMULATED

Question 18

A-Delta Fibers (1st order afferent sensory nerve)

Answer 18

Get info from warm and cold receptors, a few hair receptors, and free nerve endings

Transmit info regarding touch, pressure, temperature pain
Free nerve endings primarily respond to pain: pinching, pricking, crushing

Small diameter and myelinated = SLOWER CONDUCTING
Higher threshold = NOT AS EASILY STIMULATED

Question 19

C- Fibers (1st order afferent sensory nerve)

Answer 19

Smallest afferent peipheral nerves associated with pain
Also include efferent postganlionic fibers of the SNS
Primarily mechano and nocioceptors
A few are themoreceptors

Smallest diameter and NON-myelinated = SLOWEST CONDUCTING
Highest Threshold= REQUIRE MUCH HIGHER STIMULATION

Question 20

where did that first order afferent sensory nerve synapse?

Answer 20

Dorsal Horn of the spinal cord

Question 21

SECOND ORDER AFFERENT NERVE

Answer 21

Cell body is within the DORSAL HORN (grey)
2nd order neuron’s axon (white) makes up the ascending pathway
Synapses in the thalamus for both pleasant and noxious input

AKA “T-Cell” because they transmit info on
different tracts
T-Cells (2nd order neurons) cross the spinal cord (decussate) to transmit information up to the thalamus

Pain, temperature, touch, vibration and deep pressure

Question 22

THIRD ORDER AFFERENT NERVE

Answer 22

Cell body is within the THALAMUS
Thalamus becomes a relay center
Sensory information is organized here
Facilitatory and inhibitory circuits established
Basically gets it ready to send to the somatosensory cortex of the brain

ALSO – the thalamus transfers input to the limbic system
Emotional, autonomic, and endocrine response to pain

Question 23

Paleocortical Tract Pain

Answer 23

“Second Pain”
Slower and more complex than the acute pain pathway
Deals with the complex emotional components of pain

More intense stimuli activate polymodal nociceptors
These promote a more diffuse, unpleasant and persistent burning sensation that continues past the acutely painful stimulus

Question 24

Peripheral Pain Modulation Techniques

Answer 24

GOAL: Desensitize the peripheral nocioceptors

ATCs try to counteract the effects of acute inflammation that sensitizes free nerve endings and peripheral nocioceptors
Bradykinin, prostaglandin E2 and serotonin facilitate nociceptor sensitivity

How can we do this?
Cryotherapy
Ice lessens the effects on chemical mediators and slow conduction velocity of all sensory input
Subsensory-level Estim and Non-thermal US
Microcurrent… proposed to affect pain modulation at peripheral level
Non-thermal ultrasound… empirical results

Question 25

Descending Pathways

Answer 25

Any activity AFTER the cortex has received the input

These pathways ultimately have an excitatory or inhibitory action on new impulses being transmitted in the spinal cord

The Raphe Nucleus, Reticular Formation and PAG all have the potential to affect pain perception on the way back down

Question 26

Raphe Nucleus

Reticular Formation

Answer 26

Controls level of arousal
Affects the individuals perception of well-being
In the brainstem

Controls autonomic functions and some motor functions
Helps provide collateral sensory signals to higher brain centers

Question 27

When there is PAIN

Answer 27

PAG is activated and its network calms the person and helps filter pain signals by exciting the Raphe Nucleus and Reticular Formation

Pituitary gland can help regulate signals at spinal cord level which lessens impulses to the cortex

• The goal of pain management, through meds, modalities, or stress relief is to modulate the pain through these relay centers

Question 28

Synaptic Transmission & Transmitter Substances

Answer 28

Synapse – where communication from one nerve fiber to another takes place

Transmitter Substance – a substance that may help or block transmission of neural impulses across a synapse

Glutamate and Substance P – facilitate/help
Beta Endorphins – inhibit/block

Question 29

Gate

Answer 29

substansia gelatino

Question 30

Supraspinal and Descending Pain Modulation

Answer 30

GOAL: to cause inhibitory signals to decrease the continued propagation of the pain message back to the spinal cord

Periaqueductal Gray (PAG) contains enkephalin-rich neurons that excite the Raphe Nucleus

Pharmacological Agents
Two techniques ATs can use to “recruit descending pain modulation”
Strong, pulsed motor stimulation
Noxious stimulation

Question 31

Motor Pain Modulation

Answer 31

GOAL: to enhance the production of endorphins

No TENS treatment can eliminate pain, but can decrease it enough for therapeutic exercise

Theory: endogenous opioids (endorphins) production is enhanced by low-frequency, high-intensity stimulation of peripheral nerve fibers
Enough to evoke a muscular contraction
Rhythmic muscle contractions + A-delta fiber stimulation = enhancement of noxoius pain (descending tract) modulation

Question 32

Noxious Pain Modulation

Answer 32

Electrical stim of the PAG matter of rat and human brains results in profound analgesia
Not something ATs do… obviously.

Basically,
Inhibitors are “turned on” by stimulation of C (pain) fibers in the affected region
ATs can do this… with a long phase duration
Point stimulator
Cryotherapy : CBAN
Burning and aching are caused by Cfibers and might evoke descending pain modulation

Question 33

Nerve Block Pain Modulation

Answer 33

Law of Dubois Reymond
If stim is applied long enough to overcome capacitance, and applied rapidly enough to prevent accommodation then an action potential will occur

Wedinski’s inhibition
When the membrane cannot keep up and action potential failure occurs
Refractory period… if stimulation keeps occurring it actually hyperpolarizes the membrane and creates an inhibitory effect

Question 34

Chronic Pain

Answer 34

Likely involves changes in nervous system operation
Nocioceptive system has “Plasticity” – ability to change
If these changes are permanent  true chronic pain

Not all pain is permanent though!
Could truly be a biomechanical, structural injury
Could be psychological and able to be treated

Question 35

Biomechanics

Answer 35

Failure to identify (AND TREAT!) real cause can explain persistent pain

Question 36

Somatic Dysfunction

Answer 36

The biomechanics of the kinetic chain are altered by a state or dysfunction or malalignment

Address the underlying dysfunctions of the kinetic chain

Takes practice and skill!

Question 37

Plan of Care

Answer 37

Persistent pain can be caused by_incomplete_ or inappropriate treatment plans

Question 38

Rest-Reinjury Cycle

Answer 38

Patient education is key!
Have to earn their trust…

Reconditioning = careful control of exercise intensity, frequency, and duration

Rule: You should be able to do tomorrow what you did today

Be judicious with pallative care

Question 39

The role of Therapeutic Modalities

Answer 39

Some electrical stimulation available
NMES
EMG Biofeedback

No direct modality application will retrain protective reflex responses and complex movements

Modalities can help decrease painful exercises aimed at restoring NM control