Worksheet 2

Question 1

1) “Massage therapy performed on a healthy person increases muscle flexibility and relaxation, and decreases stress levels.” These are considered physiological effects of massage.– what is meant by “stress” in this sentence?

Answer 1

Massage changes stress levels, the person benefits, not only psychologically but physiologically as well. Massage can reduce stress levels physically such as high levels of Cortisol, that are shown to decrease the immune response, resulting in susceptibility to illness. Massage can reduce emotional stress thereby reducing these “stress hormones” and improves immune function by affecting the Sympathetic (fight or flight) or Parasympathetic (feed and breed) divisions of the autonomic nervous system taking it from “stressed” levels to homeostasis. The ANS functions include control of respiration, cardiac regulation, vasomotor activity and certain reflex actions.

Question 2

2) “A feeling of well being, which usually accompanies massage, reduces pain perception even more” – WHY? Make reference to the autonomic nervous system in your answer.

Answer 2

Massage can also affect the processing of nociceptive firing by the peripheral nervous system. For example, cross-fibre frictions have been shown to create analgesic effects when used on tendon and ligament injuries. In most cases , soothing touch creates a sense of well being for the client. Finally, as massage changes stress levels, the person benefits, not only psychologically but physiologically as well. ultimately people are going to trace nearly all disease to stress, to disequilibrium in the physiology and biochemistry. I think that’s why we invariably get reductions in Cortisol levels and anxiety, because all of these conditions (asthma, depression, dermatitis, post-traumatic stress disorder) become more aggravated by knowing that you have a disease…It’s almost as though the stress increases exponentially with the disease” (Knaster, 1994). Massage can reduce emotional stress thereby reducing these “stress hormones” and improves immune function by affecting the Sympathetic (fight or flight) or Parasympathetic (feed and breed) divisions of the autonomic nervous system taking it from “stressed” levels to homeostasis. The ANS functions include control of respiration, cardiac regulation, vasomotor activity and certain reflex actions. In summary, massage reduces emotional stress levels, giving people a sense of well being and relaxation.

Question 3

3) Describe what is meant by muscle tone:

Answer 3

Muscle tone has been described as the resistance of a relaxed muscle to passive stretch or elongation (Taber’s Cyclopedic Medical Dictionary 1981; Vancier et ai, 1994). Yet, while palpating a relaxed muscle, the therapist notices a certain resistance of the tissue to direct compression. Therefore, a more complete definition of muscle tone also includes both the resistance of the muscles and connective tissue to palpation and the active, but not continuous, contraction of muscle in response to the stimulation of the nervous system

Question 4

4) What is the difference between muscle tone and tension?

Answer 4

One explanation of tension is muscle fibres that tend to shorten, causing them to perform work (Thomas, 1981). While some shortening of the muscle fibres may be noted with a length test of the muscle, the client with the whiplash injury may be incapable of normally working the injured trapezius clue to pain. A more applicable definition of muscular tension is a muscle held in a sustained contraction

Question 5

tone is described as

Answer 5

the resistance of a relaxed muscle to passive stretch or elongation including both the resistance of the muscles and connective tissue to palpation and the active, but not continuous, contraction of muscle in response to the stimulation of the nervous system

Question 6

5) Describe what is happening (involving Ca+) that causes trigger point pain:

Answer 6

Muscle contraction is normally controlled by the rapid release and reabsorption of calcium by the sarcoplasmic reticulum of individual muscle fibres. Adenosine triphosphate (ATP) provides the energy for contraction of the sarcomeres, which are the contractile units of muscle fibres. The combination of calcium and ATP causes the sarcomeres to shorten. When the calcium is reabsorbed, contraction stops. A damaged sarcoplasmic reticulum would allow calcium to spill onto the sarcomeres. This would set up an uncontrolled, sustained contraction (called a contracture) of the affected sarcomeres for as long as their ATP energy supply lasted. The theory, however, only partially explains the physiology of trigge r points, since the calcium would eventually disperse throughout the tissue. Various studies have revealed the trigger point to be an area of both increased metabolism and decreased circulation. This local vasoconstriction or ischemia is likely a reflexive attempt by the body to contain the uncontrolled metabolic processes occurring at the site of the sustained sarcomere contraction. Both the contracture and the runaway metabolism will stop if the muscle is slowly stretched, disengaging the interlocked contractile components of the sarcomeres (actin and myosin).

Question 7

Peripheralization -

Answer 7

the area of pain enlarges or becomes more distal as the lesion worsens

Question 8

Centralization -

Answer 8

the area of pain becomes smaller or more localized as it improves

Question 9

7) What is referred pain?

Answer 9

The term referred pain means that the pain is felt at a site other than the injured tissue because the referred site is supplied by the same or adjacent neural segments. In the case of referred pain, the patient usually points out a general area. Referred pain tends to be felt deeply; its boundaries are indistinct, and it radiates segmentally without crossing the midline.

Question 10

type/behavior of pain caused by systemic factors

Answer 10

-Disturbs sleep,Deep aching or throbbing, Reduced by pressure, Constant or waves of pain and spasm, Is not aggravated by mechanical stress, Associated with- jaundice, migratory arthralgias, skin rash, fatigue, weight loss, low-grade fever, generalized weakness, cyclic and progressive symptoms, history of infection

Question 11

type/behavior of pain caused by musculoskeletal factors-

Answer 11

Generally lessens at night, Sharp or superficial ache, Usually decreases with cessation of activity, Usually continuous or intermittent, Is aggravated by mechanical stress, Usually associated with nothing specific

Question 12

Episodic pain:

Answer 12

is related to specific activities.

Question 13

Constant pain:

Answer 13

is suggestive of chemical irritation, tumors, or possibly visceral lesions. It is always there, although its intensity may vary.

Question 14

Somatic pain -

Answer 14

is a severe chronic or aching pain that is inconsistent with injury or pathology to specific anatomical structures and cannot be explained by any physical cause because the sensory input can come from so many different structures supplied by the same nerve root.

Question 15

Neuropathic pain -

Answer 15

follows specific anatomical pathways and affect specific anatomical structures.

Question 16

Psychogenic pain -

Answer 16

also called psychalgia, is physical pain that is caused, increased, or prolonged by mental, emotional, or behavioral factors. Headache, back pain, or stomach pain are some of the most common types of psychogenic pain.

Question 17

11) Why would physiological, cognitive, and emotional reactions result from stress? Describe the physiology

Answer 17

Activation of the stress system heightens arousal, accelerates motor reflexes, improves attention and cognitive function, decreases appetite and sexual arousal, and increases the tolerance of pain. Interactions between the hypothalamic–pituitary–adrenal axis and the systemic sympathetic and adrenomedullary (sympathetic) system are to maintain basal and stress-related homeostasis. The activated system also changes cardiovascular function and intermediary metabolism and inhibits immune-mediated inflammation.

Question 18

The physiological effects of stress

Answer 18

• The hypothalamus secretes a cortisol-releasing factor, which stimulates the pituitary gland to release adrenocorticotrophic hormone (ACTH)
• This hormone communicates to the adrenal glands to release cortisol and epinephrine.
• Cortisol is involved with glucose levels, fat metabolism and influencing vascular flow and breathing.
• Epinephrine circulates in the blood and dilates blood vessels, increases cellular metabolism and heart activity.
• The reticular activating system is stimulated through a variety of sensory input, somatic, visual and auditory and well as through signals from the cerebral cortex, hypothalamus and limbic system. When excited, the RAS moves the entire brain to activity promoting the sympathetic nervous system to function and affects stimulation of the musculoskeletal system. This increases mm hypertonicity, trigger points and stiffness in the body.
• The exact mechanism by which stress affects the immune response is unknown. It is known that the stress response induces hormonal activity that can suppress some aspects of the immune response. Increased corticosteroid levels and atrophy of the thymus are present with the stress response, both of which would result in suppression of the immune response.

Question 19

The physiological effects of stress

Answer 19

• The hypothalamus secretes a cortisol-releasing factor, which stimulates the pituitary gland to release adrenocorticotrophic hormone (ACTH)
• This hormone communicates to the adrenal glands to release cortisol and epinephrine.
• Cortisol is involved with glucose levels, fat metabolism and influencing vascular flow and breathing.
• Epinephrine circulates in the blood and dilates blood vessels, increases cellular metabolism and heart activity.
• The reticular activating system is stimulated through a variety of sensory input, somatic, visual and auditory and well as through signals from the cerebral cortex, hypothalamus and limbic system. When excited, the RAS moves the entire brain to activity promoting the sympathetic nervous system to function and affects stimulation of the musculoskeletal system. This increases mm hypertonicity, trigger points and stiffness in the body.
• The exact mechanism by which stress affects the immune response is unknown. It is known that the stress response induces hormonal activity that can suppress some aspects of the immune response. Increased corticosteroid levels and atrophy of the thymus are present with the stress response, both of which would result in suppression of the immune response.

Question 20

12) Is chronic pain properly-, under-, or over-treated in our culture? Explain why.

Answer 20

“Pain of deep-tissue origin still goes widely unrecognized by clinicians. Patients continue to receive injections, ultrasound, or massage about the scapulae for disorders arising from the neck; the sacroiliac joint or sciatic nerve is often blamed for pain originating in the lumbar spine; and on occasion, an adolescent presenting with slipped capital femoral epiphysis may receive treatment for “knee pain.”

Question 21

13) Describe the nature of “myofascial pain” as experienced in Myofascial Pain Syndrome:

Answer 21

Myofascial pain is perceived as a continual dull ache often located in the head, neck, shoulder and low back areas. The trapezius muscle is one of the most commonly affected muscles. MF pain may result from an a cute strain caused by a sudden overload or over stretching of a muscle.

Question 22

14) What is the difference between Myofascial Pain Syndrome, and Fibromyalgia, as described by these authors?

Answer 22

MPS refers to a large group of muscle disorders characterized by highly sensitive trigger points within muscles or connective tissue. Skeletal muscles have been implicated as the cause of Fibromyalgia but no specific abnormalities have been identified. Abnormalities of the neuroendocrine system, AI dysfunction, immune regulation, sleep disturbances and cerebral blood flow difficulties have also been suggested. They should therefore not be confused. Although they may overlap clinically they ae two distinct pain syndromes.

Question 23

15) What is/are the most common kind/s of pain experienced by adults following spinal cord injury?
79% of SCI adults report a recurrent pain problem.

Answer 23

Chronic pain is a common problem following SCI.

Question 24

What is believed to be the cause of this pain?

Answer 24

Neuropathic or central pain is the most frequent type of chronic pain in SCI and is believed to originate from abnormal proccessing of sensory imput oweing to damage to the CNS. MSK pain may result from a variety of factors including use of a W/C.

Question 25

16) Describe the Specificity Theory of pain:

Answer 25

Specificity Theory of pain was an initial attempt to explain the way the nervous system processes nociceptive information.(1894) The sensation of pain resulted from direct communication of specific pain receptors in the periphery to a central pain center in the brain.

Question 26

17) Describe the Pattern Theory of pain:

Answer 26

Pattern Theory of pain transmission was proposed to address some limitations of the specific theory. It was suggested that it is not the direct stimulation of specific pain receptors, but the transmission of nerve impulse patterns coded at the periphery that cause the pain sensation. This theory proposes all nerve endings are alike and the perception of pain is produced by by intense stimulation of nonspecific receptors.

Question 27

18) describe Melzack and Wall’s Gate Control Theory of pain:

Answer 27

Melzack and Wall’s Gate Control Theory of pain offered a variation of the pattern and specificity theories to explain pain transmission. They suggested that skin receptors have specific physiological properties by which the transmit particular types and ranges of stimuli in the form of impulse patterns. According to this theory , pain is modulated by a “gating” mechanism located in the spinal column that can increase or decrease the flow of nerve impulses to the brain.
Afferent impulses can travel to the dorsal horn via large (A fiber) and small diameter (A-delta or C fiber) nerves associated with pain impulses. At the dorsal horn, these impulses encounter a gate thought to be gelatinousa cells. The gate which may be pre or postsynaptic may be closed, partially opened or opened. When the gate is closed, pain impulses cannot proceed. When the gate is at least partially open, impulses stimulate T (transmission or trigger) cells in the dorsal horn which then ascend the spinal cord to the brain and pain perception results. Once the pain impulses are perceived , higher central nervous system structures (ie the brainstem, thalamus, and cerebral cortex) can then modify pain by influencing T-cell activity.

Question 28

19) A biopsychosocial model of pain that suggests a phenominom of pain that can essentially be divided into four domains including;

Answer 28

a) Nociception: the detection of tissue damage by transducers in the skin and deeper structures and the central transmission of this information by A-delta and C fibers in the peripheral nerves.
b) Pain: is the perception and interpretation of the nociceptive input by the highest levels of the brain.
c) Suffering: the negative affective response to pain. It may be difficult to differentiate suffering from fear, anxiety, isolation or depression.
d) Pain Behavior: is what an individual says/does or does not say/do (ie taking medication, time off work) which leads others to believe they are suffering from noxious stimuli. Only pain behaviors are observable and measurable

Question 29

20) What is the primary assumption of an “Active Rehabilitation Program”?

Answer 29

Active Rehabilitation Program emphasizes behavioral stratagies to help consumers better cope with and manage pain. 1* assumption is that the physical deficit is the “deconditioning syndrome” consequent to prolonging disuse of spinal joints and muscles.

Question 30

How does physical therapy address this issue?

Answer 30

PT treatment consists of individualized physical reconditioning exercises/activities based on the objective quantification of physical functioning. Treatment also needs to address long term adaptations the body makes in its movement patterns and adaptatios in CT.

Question 31

Autogenics -

Answer 31

involves the daily practice of sessions that last around 15 minutes, usually in the morning, at lunch time, and in the evening. During each session, the practitioner will repeat a set of visualisations that induce a state ofrelaxation. Each session can be practiced in a position chosen amongst a set of recommended postures (for example, lying down, sitting meditation, sitting like a rag doll). The technique can be used to alleviate manystress-inducedpsychosomaticdisorders.
And what is the rationale behind why these seem to be effective in managing chronic pain?

Question 32

Progressive, deep muscle relaxation-

Answer 32

technique involves learning to monitor tension in each specific muscle group in the body by deliberately inducing tension in each group. This tension is then released, with attention paid to the contrast between tension and relaxation. the training sessions which are started in a darkened room with the learner in a reclined position and eyes closed. The learner is told to relax, just let go. If the learner has any thoughts or physical distractions, just relax. Do not try to solve the problem. In each session the teacher reviews tensing one particular muscle group. If the student is slow in learning how to let the tension go for a particular muscle group, that group is focused on in the next session. The learner is told to continue to practice the relaxation technique in their daily lives. It is not our natural response to relax when there is an external or internal stimulant. However, as in many other physical conditions that we have no control over, the body’s best response would be no response at all.[2]
Jacobson’s Progressive Relaxation has remained popular with modern physical therapists.

Question 33

Guided Imagery-

Answer 33

a mind-body intervention by which a trained practitioner or teacher helps a participant or patient to evoke and generate mental images that simulate or re-create the sensory perception of sights, Sounds tastes, smells, movements,and images associated with touch, such as texture, temperature, and pressure,as well as imaginative or mental content that the participant or patient experiences as defying conventional sensory categories,and that may precipitate strong emotions or feelings in the absence of the stimuli to which correlating sensory receptors are receptive

Question 34

22) Describe the tissue response during chronic inflammation.

Answer 34

Because of the way immature collagen molecules are held together (hydrogen bonding) and adhere to surrounding tissue, they can be easily remodeled with gentle and persistent treatment. This is possible for up to 10 weeks. If not properly stressed, the fibers adhere to surrounding tissue and form a restricting scar. As the structure of collagen changes to covalent bonding and thickens, it becomes stronger and resistant to remodeling. At 14 weeks, the scar tissue is unresponsive to remodeling. Consequently, an old scar has a poor response to stretch.7 Treatment under these conditions requires either adaptive lengthening in the tissue surrounding the scar or surgical release.
in connective tissue that is repetitively stressed beyond the ability to repair itself, the inflammatory process is perpetuated. Proliferation of fibroblasts with increased collagen production and degradation of mature collagen leads to a predominance of new, immature collagen. This has an overall weakening effect on the tissue. In addition, myofibroblastic activity continues, which may lead to progressive limitation of motion.22 Efforts to stretch the inflamed tissue perpetuate irritation and progressive limitation. Repetitive microtrauma or repeated strain over-load over time results in structural weakening, or fatigue breakdown, of connective tissue, with collagen fiber crosslink breakdown and inflammation. Initially, the inflammatory response from the microtrauma is subthreshold but eventually builds to the point of perceived pain and resulting dysfunction.

Question 35

How/why does it lead to progressively limited range of motion?

Answer 35

If the scar adheres to the surrounding tissues or is not properly aligned to the stresses imposed on the tissue, there is an alteration in the force transmission and energy absorption. This region becomes more susceptible to injury with stresses that normal, healthy tissue could sustain. Contractures or poor mobility. Faulty postural habits or prolonged immobility may lead to connective tissue contractures that became stressed with repeated or vigorous activity.

Question 36

23) Under what conditions is resistance training contraindicated?
Why?

Answer 36

Most often during periods of acute inflammation and with some acute diseases and disorders.

Resistance exercises may actually cause irreversable deterioration of strength as a result of damage to muscle. Dynamic resistance exercises can irritate the joint and cause more inflamation. Setting exercises against negligable resistance are acceptable.

Question 37

“pain threshold” -

Answer 37

The smallest intensity of pain stimulus at which a person perceives pain.
All individuals have the same pain threshold

Question 38

“pain tolerance” –

Answer 38

The greatest intensity of pain stimulation that the person is able to tolerate. Individuals vary in their tolerance to pain.

Question 39

Nociception refers to

Answer 39

the peripheral and central nervous system (CNS) processing of information about the internal or external environment, as generated by the activation of nociceptors. Typically, noxious stimuli, including tissue injury, activate nociceptors that are present in peripheral structures and that transmit information to the spinal cord dorsal horn or its trigeminal homologue, the nucleus caudalis. From there, the information continues to the brainstem and ultimately the cerebral cortex, where the perception of pain is generated.

Question 40

Pain is a product of

Answer 40

higher brain center processing, whereas nociception can occur in the absence of pain. For example, the spinal cord of an individual who suffered a complete spinal cord transection can still process information transmitted by nociceptors, but because the information cannot be transmitted beyond the transection stimulus-evoked pain is unlikely
Pain may persist even after a pain-producing stimulus is removed because pain-mediating chemicals linger, and because nociceptors exhibit very little adaptation. Conditions that elicit pain include excessive distention (stretching) of a structure, prolonged muscular contractions, muscle spasms, or ischemia (inadequate blood flow to an organ). Individuals vary in their tolerance to pain and culture or upbringing may alter the way you perceive or report pain