PAM Flashcards
Nerve Fiber types
C fibers (nociceptive)
-Small, unmyelinated (transmit slowly)
-Dull, achy, throbbing, burning
-Can be blocked by opiods
A-delta fibers (nociceptive)
-Small, myelinated (faster than C fibers)
-Sharp, localized, stabbing, or pricking
A-beta fibers (non-nociceptive)
-Large, myelinated (faster than A-delta or C fibers)
-Vibration, stretching of skin, mechanoreception
Pathway of the pain transmission
Dorsal horn of SC – up to thalmus via spinothalamic tracts – to sensory cortex to be processed as a conscious pain sensation
Gate Control Theory
A-alpha and A-beta provide input to these inhibitory interneurons. This can inhibit pain signals to the brain.
A-alpha and A-beta can be stimulated by electrical stimulation or massage.
Endogenous Opioid System
- opiopeptins (endorphins) bind to opioid receptors that inhibit pain signals
- inhibits by controlling amount of calcium and potassium that move into and out of cell during depolarization.
- also has an indirect effect on blocking GABA (GABA - inhibits A-beta)
Tolerable levels of topical preparations or TENS to create burning or prickling sensations stimulate the EOS for pain modulation
What is central sensitization
Facilitation of nociceptive impulses in CNS
Pain is real but no longer accurate to state of tissue
3 aspects
-Facilitation of synaptic transmission in spinal cord
-Inhibition of endogenous opioid system
-Altered processing of nociception in the brain
DTRs scale
O - absent
1+ - diminished
2+ - NORMAL
3+ - brisker than average
4+ - hyperactive
Modified Ashworth scale
0 - no increase in tone
1 - slight increase in muscle tone manifested by a catch and release at end of ROM
1+ - slight increase in muscle tone manifested by a catch and release less than halfway through the ROM
2 - more marked increase in muscle tone through most of ROM
3 - considerable increase in muscle tone, passive movement difficult
4 - affected part rigid
Types of heat transfer methods
- Conduction - direct contact (MHP, CP, paraffin)
- Convection - circulating medium; air or water moving in constant motion across body. (whirlpool, fluidotherapy)
- Conversion - non-thermal form of energy converted to heat (US and diathermy)
- Radiation - transfer of heat from energy source of higher temp to one of a lower temp (radiation lamp, laser, UV light)
- Evaporation - absorption of energy (vapocoolant spray)
Hunting response to cold
cycling between vasoconstriction and vasodilation occurs when exposure to cold for greater than 15 min (<35 deg F). Mostly occurs in distal appendages
Increased physiological responses to cryotherapy
Joint stiffness
Pain threshold (gate theory)
Increased blood viscosity
Muscle strength (for short duration 1-5 min) - facilitates alpha motor neuron
Decreased physiological responses to cryotherapy
Blood flow (vasoconstriction)
Capillary permeability
Decreased extensibility/elasticity of collagen
Decreased metabolism
Decreased in muscle spasm
Decrease in muscle strength
Decrease spasticity
Cryothearpy contraindication
Hypersensitivity - urticaria, hives, welts
Intolerance - severe pain, numbness, color changes
Cryoglobulinemia - aggregation of serum proteins distally
Paroxysmal cold hemoglobinuria - hemoglobin released into urine
Raynaud’s - digital cyanosis
Over regenerating peripheral nerves
Over area with circulatory compromise or PVD
Sequence of sensation with application of crytothearpy
Intense cold – burning – aching – analgesia – numbness
Cold Pack application
- shoulder be applied for ~20 min
- Remove jewelry.
- technically says used a moist towel
- Reaches 2cm deep
- Cold pack s can be applied every 1-2 hours for pain reduction and inflammation control.
- For spasticity – 30 min with inspection every 10 mins
Vapocoolant spray
- rapid cooling through evaporation
- most commonly used with trigger points (deep and hypersensitive localized spots in a m that cause referred pain pattern)
- Provides a counter-irritant stimulus to the cutaneous thermal afferent nerves that overlay the muscles…..causes reduction in motor neuron activity = decrease in resistance to stretch.
- Can help break cycle and allow the m to be stretched
- Process:
- 3-4 sweeps (proximal to distal…and only 1 direction) in the direction of the m fibers.
- 30 deg angle from skin
- 12-18 inches from skin
- Helpful with torticollis, neck or LBP caused by m spasms, acute bursitis, and hamstrings tightness.
Increased physiological responses to thermothearpy (heat)
Cardiac output (Increased blood flow)
Metabolic rate
pulse and respiratory rate
vasodialation
Edema
increased capillary pressure
Increase elasticity of tissue
Decreased physiological responses to thermotherapy (heat)
Decreased blood pressure
Decreased muscle activity (m spasm)
Decreased blood to internal organs
Blood flow to resting muscle
Decreased stroke volume
Decreased tone
Contraindications to thermotherapy (heat)
- Acute MSK trauma
- Arterial disease
- Bleeding or hemorrhage
- Over area of compromised circulation
- Over area of malignancy
- Peripheral vascular disease
- Thrombophlebitis
Hot pack time, temp, layers
Transmission: conduction
6-8 layers (hot pack covers are 2-3 layers)
Check within 5 mins
Total time: 15-20 mins
Temp: 158-167 deg in hydrocollator
- should not lay on it.
- Maximum surface temp is reached in 6-8 min….so must check during first 10 mins.
- don’t remove towel layers during the treatment session
- Must reheat 30 min in hydrocollator between uses (takes 2 hrs initially to heat in hydrocollator)
Paraffin bath
Transmission: conduction
* 6:1 to 7:1 ratio of paraffin wax to mineral oil ratio
* Glove method, immersion method, or pain method
* Time: 15-20 mins
* Temp: 113-122
* Best for small, irregularly shaped areas such as wrist, hand, foot for more even distribution of heat.
* Has a lower specific heat that allows the pts to tolerate better than water at the same temp
* Can’t be applied to area with open wound or infected skin lesions.
Dip-wrap (Glove method)
- place into bath and remove an let it harden
- re-dip 6-10 time
- the wrap with plastic bag and then towel wrapped around it
- 10-15 min
There is a paint application that is just pretty much like the above but the paraffin is painted on the extremity due to unable to place in paraffin for some reason. (Left on for ~20 mins)
Dip-Reimmersion (Immersion)
- Dip 6-10 times initially.
- Then put back in paraffin and keep in for the remainder (up to 20 mins)
- use lower head 113* and keep it off when hand is immersed.
Ice Massage
Transmission: conduction
treatment time 5-10 min or until analgesia.
Don’t go over bony areas or superficial nerves
Selecting sound head size for US? How fast should it move?
Select a sound head that has an ERA (effective radiating area) of 1/2 the size of the treatment area.
Don’t cover an area 2-3x the size of the ERA.
Move sound head ~1.5 inches/sec (slowly)
(according to PTFE exam 4cm/sec)