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405 Cards in this Set
- Front
- Back
- 3rd side (hint)
What does the term "thermal" pertain to? ***
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heat
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What is thermotherapy? ***
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adding heat to the body
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What is cryotherapy? ***
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removing heat from the body; the therapeutic use of cold
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How does application of cold work? ***
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by removing heat from the body
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What are the superficial thermotherapy agents? ***
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hot packs, paraffin, and fluidotherapy
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How deep does the heat go with superficial heating agents? ***
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approximately 0.5 cm (about 0.2 inches)
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What are the deep heating thermotherapy agents? ***
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ultrasound and diathermy
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How deep does the heat go with deep heating agents? ***
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approximately 3 - 5 cm (about 1.2 to 2 inches)
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What is specific heat? ***
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the amount of energy required to raise the temperature of 1 gram of material 1 degree Celsius
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How does the composition of an item affect its specific heat? ***
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materials with a high specific heat require more energy to heat up and hold more energy at a given temperature than materials with a low specific heat.
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How is specific heat expressed? ***
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in Joules per gram per degree Celsius (J/g/C)
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What is the average specific heat for the human body? ***
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3.56 J/g/C
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Rank the following from highest to lowest specific heat:
bone, fat, muscle, skin. *** |
skin - 3.77 J/g/C
muscle - 3.75 J/g/C fat - 2.30 J/g/C bone - 1.59 J/g/C |
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Which has a higher specific heat, air or water? ***
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water - 4 J/g/C
air - 1 J/g/C |
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How are thermal agents with a high specific heat applied to patients?
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thermal agents with a high specific heat (e.g., water) are applied at a lower temperature than those with a lower specific heat (e.g., air--fluidotherapy)
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What is thermal conductivity? ***
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the rate at which heat transfers by conduction between two materials
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Which has greater thermal conductivity, bone/muscle or fat? ***
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bone and muscle - 0.001 cal/sec
fat - 0.0005 cal/sec |
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Name five factors that influence the extent of temperature change in the target tissue.
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- conductivity of agent and tissue,
- amount of area treated, - time of exposure, - temperature difference between thermal agent and target tissue, and - intensity of the agent |
CATTI
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By what five modes of transfer may heat be transferred to, from, or within the body? ***
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conduction
convection conversion radiation evaporation |
CCCRE
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How does heat flow when using a conduction method of thermotherapy? ***
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from the material at the higher temperature to the material at the lower temperature; there must be a temperature gradient (i.e., if the two materials are at the same temperature, no conduction will occur)
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How does conduction work at the molecular level?
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energy exchange by direct collision between molecules of two materials at different temperature; the molecules from the warmer material cause the molecules in the cooler material to accelerate
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What is required for conduction? ***
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direct contact
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How long does heat transfer in conduction continue?
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until the temperature (and speed of molecular movement) of both materials become equal
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Heat transfer by conduction occurs only between:
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materials of different temperatures that are in direct contact with each other
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What happens if there is air between a conductive thermal agent and the patient?
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the heat is first conducted from the thermal agent to the air, and then from the air to the patient
the heat transfer is much less effective (this also more closely resembles radiation) |
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Upon what does the rate at which heat is transferred by conduction between two materials depend?
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- temperature difference between the materials,
- area of contact, and - thermal conductivity of the materials |
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What are four methods for increasing/decreasing rate of heat transfer between two materials?
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- increase/decrease the temperature difference between the materials;
- use material with higher/lower level of thermal conductivity; - treat a larger/smaller area; - alter the composition of the agent (e.g., ice causes more rapid cooling than water, even at the same temperature) |
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Per Cameron, how many layers go between a patient and a hot pack?
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6 to 8 layers
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Why is the age of the towel used to wrap a hot pack something to consider?
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newer towels will have more fibers and be less conductive; older towels will likely conduct more heat
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Why should jewelry be removed from an area treated with a conductive thermal agent?
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to avoid overheating or cooling the skin in contact with the metal (metal being an excellent thermal conductor)
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Why does ice have tremendous thermal conductivity?
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it takes a lot of energy (which it will pull from the patient) to convert ice to water
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What is an important consideration to remember about cold packs?
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different brands use different materials. Do not assume they can all be applied using the same method, time, or layers of insulation.
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How does heat transfer by convection work? ***
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through mass motion of a circulating medium (liquid, gas, etc.), usually in a closed system (e.g., fluidotherapy)
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Which method transfers more heat: conduction or convection? Why?
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convection, because as the agent circulates, new material at the initial treatment temperature keeps coming into contact with the patient's body part
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How does blood circulating in the body transfer heat?
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by convection
blood that is warmer or cooler than the treatment area will bring heat in or take it away with circulation at each heartbeat |
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What is vasodilation?
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an increase in diameter of blood vessels that increases the rate of circulation, thus increasing the rate at which the tissue temperature returns to normal
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Why is impaired circulation a concern when applying thermal agents?
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because the reduced circulation will not bring warmer/cooler blood into the treatment area as effectively and tissue could become too cold/warm
risk of thermal injury is increased |
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What is conversion? ***
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heat transfer by conversion involves converting a nonthermal form of energy (electrical, mechanical, acoustic, chemical, etc.) into heat
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How does ultrasound work?
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it converts mechanical ultrasound energy into heat when it is applied to an absorbent tissue
the tissue vibrates, causing friction, which generates heat and increases tissue temperature. |
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What factors affect rate of heat transfer when using conversion?
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- power of the energy source (Watts = J/sec)
- size of the area being treated - size of the applicator - the efficiency of transmission from applicator to patient - type of tissue being treated |
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Does conversion require direct contact?
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no, but an intervening material must be a good transmitter of that type of energy (e.g., ultrasound gel)
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What is radiation? ***
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direct transfer and absorption of (electromagnetic) energy without the need for contact or an intervening material
requires a temperature gradient |
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What affects the rate of temperature increase caused by radiation?
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- intensity of the radiation,
- relative sizes of the source and area being treated, - distance of the source from the treatment area, and - angle of the radiation to the tissue |
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What is evaporation? ***
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a heat exchange that occurs when liquid changes to gas or vapor; results in cooling
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What are thermotherapy's primary uses? ***
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- control pain,
- increase soft tissue extensibility (ROM) and circulation, - decrease stiffness, and - accelerate healing (by increasing oxygen to tissues) |
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What hemodynamic effect does thermotherapy have?
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causes vasodilation, thus an increase in the rate of blood flow
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Where does vasodilation occur during thermotherapy?
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in the treated area, but to a lesser degree, systemically, in areas distant from the application.
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What benefit can whole-body thermotherapy have?
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generalized vasodilation can improve vascular endothelial function in patients with cardiac risk factors and in chronic heart failure, and has been shown in vitro to promote growth of new blood vessels in the heart.
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By what means does thermotherapy cause vasodilation?
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- causing inflammation that promotes vasodilator (histamine and prostaglandin) release
- through cutaneous thermoreceptors that either: a) relax the smooth muscles in the vessels, or b) activate spinal cord dorsal root ganglion and sympathetic adrenergic activation |
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How can distant vasodilative effects of thermotherapy be used to increase cutaneous blood flow where it is difficult or unsafe to apply direct heat?
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e.g., if a patient has an ulcer on his leg due to arterial insufficiency, thermotherapy to the lower back could be used to facilitate wound healing through vasodilation.
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How is blood flow in skeletal muscles affected by superficial heating?
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superficial heating generally doesn't penetrate deeply enough to affect skeletal muscle blood flow; exercise or deep-heating modalities are required
superficial heating agents do not heat to the depth of most muscles |
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What neuromuscular effects are seen with thermotherapy?
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- collagen tissue extensibility increases,
- muscle strength changes, - metabolic rate increases, - nerve conduction velocity increases, - nerve conduction firing rate decreases for type II muscle spindles, and increases for type Ib fibers from GTOs (this is thought to reduce muscle spasm and increase relaxation), and - pain threshold increases |
CMMNNP
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Why should caution be used when applying thermotherapy to demyelinated peripheral nerves (such as in carpal tunnel syndrome or multiple sclerosis)?
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because the nerve could undergo a conduction block
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How is thermotherapy thought to increase the pain threshold?
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- by activation of the spinal gating mechanism, and later
- through reduction of ischemia and muscle spasm, or - facilitation of tissue healing |
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What effects does thermotherapy have on muscular strength and endurance?
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it decreases for the 30 minutes following treatment, then increases from the 30-minute to the 2-hour mark;
this is likely due to changes in nerve firing rates initially, followed by an increase in the pain threshold. |
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What must the therapist consider when wishing to gauge muscle strength in a patient undergoing thermotherapy?
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test the strength before treatment, as initially (the first 30 minutes post-treatment) strength decreases and you won't have a true measurement
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What metabolic effects does thermotherapy have?
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it can increase enzymatic biological reactions, cellular biochemical reactions, and oxygen availability, thus increasing oxygen uptake and accelerating healing
however, it may also increase the rate of destructive processes (by increasing activity of collagenase, (e.g., therefore increasing destruction of articular cartilage in RA patients) |
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What is plastic deformation?
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collagenous soft tissues (such as tendons, ligaments, scar tissues, or joint capsules) that are heated before prolonged stretching increase in length and maintain most of the increase after cooling
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What is elastic deformation?
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collagenous soft tissues (such as tendons, ligaments, scar tissues, or joint capsules) that are not heated before prolonged stretching increase in length, but do not maintain most of the increase after the force is removed
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What is thought to cause plastic deformation?
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changes in the organization of the collagen fibers and changes in the viscoelasticity of the fibers
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What is the ideal thermotherapeutic temperature range and time for inducing maximal plastic deformation?
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maximum increase in residual length is achieved when the tissue temperature is maintained at 40-45° C (104-113° F) for 5 to 10 minutes, and if a low-load, prolonged stretch is applied during the heating period and while the tissue is cooling
(note: this is for cutaneous or superficial tissues; deep-heating agents are required for joint capsules or deep tendons) (Like the picture on page 156 of an ankle weight on a prone patient receiving thermotherapy to the back of the knee.) |
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What are indications for use of superficial heat? ***
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- pain control
- increase range of motion - decrease stiffness - accelerate healing (by increasing oxygen to tissues) |
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How is the patient's psychological reaction to heat important?
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possibly the psychological experience of heat as comfortable and relaxing may also influence the patient's perception of pain
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Is thermotherapy a good option for treatment of acute inflammation or injury?
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no
initially after injury or inflammation, increase in temperature is likely to aggravate the inflammation (heat, redness, edema) (some recent studies have shown, however, that heat can reduce pain from acute low back pain, pelvic pain, and renal colic) |
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What are contraindications for thermotherapy? ***
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- acute injury or inflammation
- thrombophlebitis - recent or potential hemorrhage - malignancy - impaired sensation/mentation |
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What are the precautions for thermotherapy? ***
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- pregnancy (low back/abdomen--may treat distal extremities)
- impaired circulation (blood vessels may not adequately dilate and carry away heat) - in those with poor thermal regulation (generally the elderly and very young) - edema - cardiac insufficiency (vasodilation increases demands on the heart) - metal in the area (generally not the deep metal like joint replacement, but shrapnel, bullets, etc.) - over an open wound - over areas where topical counterirritants have recently been applied (e.g., Icy Hot--may burn skin), and - Over demyelinated nerves (may cause nerve block) |
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How does thermotherapy help to accelerate healing?
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through increasing circulation, which increases delivery of blood and oxygen
also by increasing enzymatic activity, which increases the rate of metabolic reactions and allows the processes of inflammation and healing to proceed more rapidly |
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Is thermotherapy appropriate during the proliferative or remodeling stages, or when chronic inflammation is present?
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yes, as tolerated; but if it increases edema or inflammation, discontinue.
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How does increasing the temperature of blood aid healing?
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increasing the temperature of the blood increases the dissociation of oxygen from hemoglobin, making more oxygen available for the processes of tissue repair
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What may IR radiation be used for?
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treatment of psoriasis
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What should be included in patient instructions for use of thermotherapy (hot packs, paraffin, IR lamps) at home?
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- how to use the modality,
- location to apply, - temperature to use, - safety precautions, - duration and frequency of treatment, - how to identify possible adverse reactions |
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Why is thermotherapy contraindicated in the case of recent or potential hemorrhage?
What should the therapist check for? |
heat causes vasodilation and increased blood flow, which could open/reopen a vascular lesion.
therapist should check for bruising/bleeding. |
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For how long following bruising/bleeding/acute injury should thermotherapy be avoided?
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48 to 72 hours
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Why is thermotherapy contraindicated in the case of thrombophlebitis?
What should the therapist check for? |
the vasodilation and increased circulation could dislodge the clot
the therapist should ask if there is a clot in the area and check the calf for swelling and tenderness (Homan's sign) before applying heat |
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Why is thermotherapy contraindicated in the case of impaired sensation or mentation?
What should the therapist check for? |
the patient's ability to understand and report discomfort are the primary indicators of maximum safe temperature
the therapist should ask if the patient has normal feeling in the treatment area and attempt to verify note that sensation is often impaired in the distal extremities of patients with diabetes |
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Is the lack of sensation in the treatment area an absolute contraindication for thermotherapy?
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no, it is possible to apply treatment proximally to increase peripheral circulation via the spinal cord reflex.
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What precautions should be used when treating patients with diabetes mellitus?
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they may have neuropathy and reduced sensation, along with diminished circulation in the extremities
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Why is thermotherapy contraindicated in the case of malignant tissue?
What should the therapist check for? |
thermotherapy may increase growth rate or rate of metastasis of malignant tissue, either by increasing circulation to the area or by increasing the metabolic rate
the therapist could ask if the patient is under a doctor's care for any major medical issues, has experienced unexplained weight loss, has a pain that does not change, or knows he/she has a tumor |
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Why is thermotherapy applied with caution to areas of acute injury or inflammation?
What should the therapist check for? |
thermotherapy on an acute injury or inflammation could increase edema and bleeding due to vasodilation and increased blood flow
the therapist should inspect the skin for bruising and swelling, and ask when the injury occurred; assess color of skin and local edema |
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What precautions should be undertaken in providing thermotherapy to a pregnant patient?
What should the therapist ask? |
since maternal hyperthermia could damage the fetus, avoid applying hot packs to the abdomen or lower back, or conducting any full-body heating (e.g., whirlpool)
the therapist should ask if the patient is pregnant, could be pregnant, or is trying to get pregnant |
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What precautions should be undertaken in providing thermotherapy to patients with impaired circulation or poor thermal regulation?
Who is most at risk for these conditions? What should the therapist do? |
if circulation is impaired, blood vessels may not vasodilate normally, or blood flow may not be sufficient to protect tissues from burns.
generally the risk is higher in the elderly and very young the therapist should check skin temperature and quality and nail quality, and look for ulceration or swelling; milder heat should be used, and the patients should be checked more frequently |
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What precautions should be undertaken in providing thermotherapy to a patient with edema?
What should the therapist do? |
thermotherapy can increase edema, so if heat is to be used, the limb should be elevated and heat applied with caution
the therapist should measure the limb to be treated and compare to the opposite, palpate for pitting/edema, and check for any other signs of inflammation |
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What precautions should be undertaken in providing thermotherapy to a patient with cardiac insufficiency?
What should the therapist ask/check? |
heat-induced vasodilation can increase cardiac demand.
the therapist should ask if the patient has any heart problems, and if so, check heart rate and blood pressure before, during, and after treatment; monitoring is especially important if the treatment area is large |
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What are normal, consensual cardiac responses to thermotherapy?
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slight decrease in blood pressure and increase in heart rate
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What precautions should be undertaken in providing thermotherapy to patients with metal in the area?
What should the therapist ask/check? |
as metal has a higher thermal conductivity, it can cause burns [this is more important with superficial metal (staples, pins, shrapnel) than with deeper metals (joint replacements)]
the therapist should check for and ask the patient to remove jewelry, and ask the patient if there is any metal in the area; the area could then be treated cautiously, with lower heat or more insulation and frequent checks for burning |
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What precautions should be undertaken in providing thermotherapy to patients with open wounds?
What should the therapist ask/check? |
treat the area cautiously, as loss of epidermis reduces insulation; use a lower temperature or intensity, or more insulation and check the area more often for signs of burning
if the goal is increasing circulation and accelerating healing, hydrotherapy with clean, warm water can be used directly on the wound other superficial agents should be used close to, but not directly on the wound to reduce the risk of contamination |
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What precautions should be undertaken in providing thermotherapy to areas where topical counterirritants have been applied recently?
What should the therapist ask/check? |
if a thermal agent is applied to an area already vasodilated by a topical counterirritant, the vessels may not be able to vasodilate further to dissipate the heat and a burn may result
the therapist should ask if the patient applied any cream or ointment and if so, what type; if topical counterirritant was used, treatment should not proceed |
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What precautions should be undertaken in providing thermotherapy to patients with demyelinated nerves?
What should the therapist ask/check? |
apply heat with caution, as demyelinated nerves are at risk for conduction blocks
the therapist should ask if patient has carpal tunnel syndrome or ulnar nerve entrapment |
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What are the potential adverse effects of heat in general?
(Explain at least 4 adverse effects of thermotherapy.) *** |
- burns
- fainting (vasodilation can lower blood pressure) - bleeding (primarily in patients with acute trauma or hemophilia) - skin/eye damage from IR radiation |
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Excessive heat can cause protein ________ and cell _______.
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denaturation (breakdown of proteins that permanently alters their biological activity)
death |
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At what temperature does protein denaturation begin?
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45° C (113° F)
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At what times/temperatures does cell death begin?
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43° C (109° F) for 60 minutes or
46° C (115° F) for only 7 1/2 minutes |
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How can overheating and tissue damage be avoided?
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- using superficial heating agents that cool during application,
- limiting the initial temperature of the agent, or - using insulation between the agent and the patient's skin |
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What is the most common cause of fainting?
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inadequate cerebral blood flow caused by peripheral vasodilation and decreased blood pressure, generally in association with a decreased heart rate
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What should the therapist do if the patient feels faint during thermotherapy?
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lower the head and raise the feet to bring more blood to the brain
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Why may a patient feel faint after thermotherapy?
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the heat is hypotensive, and the act of sitting up adds postural (orthostatic) hypotension to the mix
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Specifications for hot packs: ***
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- hydrocollator packs
- silicate gel (bentonite) that holds water well for moist heat - unit kept at 70-75° C (158-167° F) (go with about 165°) - treatment time: 20 minutes - heat by conduction - initial heating of the hot packs - 2 hours - reheating of the hot packs - 30 minutes |
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How many layers for hot packs?
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6 - 8 layers of dry towels
hot pack cover can substitute for 2-3 layers of towels for us: supine lower back: oversized hot pack with 1 hotpack cover under, 3 hotpack covers over, and a towel wrapped around the whole thing, mainly for sanitary reasons prone lower back: oversized hot pack wrapped as above, except with 2 hotpack covers over instead of 3 pretty much all else: cervical hot pack in a cervical hot pack cover, with 4 layers of towel between it and patient |
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What is a concern with a heavy (higher body fat) patient during thermotherapy?
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if the area treated has a high fat contact, the heat won't disperse as well (fat is less thermoconducive) and it may feel very hot to the patient at skin surface
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How should the hot pack wraps be adjusted if the hot pack is under the patient? On top of the patient?
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rule of thumb, if the patient is on top of the hot pack, use more layers as the table and the weight of the patient will slow heat loss
for us, one less hot pack cover if hot pack is on top of patient |
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What should you do if the patient complains of feeling too much heat? Too little heat?
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add a layer of terry towel
if the patient complains of not feeling enough heat, use fewer layers NEXT treatment, as the increased skin temperature may decrease patient's thermal sensitivity and ability to safely judge tissue's heat tolerance. |
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What should the therapist do after 5 minutes of thermotherapy?
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check the area for excessive redness, blistering, or other signs of burning
discontinue treatment and apply cold/ice pack if signs of burning to reduce inflammatory response |
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How long is a typical hot pack treatment?
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20 minutes
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What should the therapist do at conclusion of thermotherapy?
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inspect skin for excessive redness, blistering, or other signs of burns
(also watch patient for signs of lightheadedness, especially if treatment area was large) |
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Advantages of hot packs?
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- easy to use
- inexpensive materials (packs and towels) - short use of clinician's time - low level of skill needed for application - can be used to cover moderate to large areas - safe, because packs begin to cool immediately on removal from water - readily available for patient purchase and home use |
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Disadvantages of hot packs?
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- hot pack must be moved to observe the treatment area during treatment
- patient may not tolerate the weight of the hot pack - pack may not be able to maintain good contact with small or contoured areas - active motion is not practical during treatment - moderately expensive equipment (hydrocollator) |
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Specifics for paraffin: ***
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- paraffin:mineral oil ratio = 6:1 (or 7:1 says book)
- paraffin heater about 126-134° F (go with 130° F) - Rx: Dip-and-wrap – 20 min - Rx: Dip-immersion – 20 min (may need lower temperature) - Rx: Brush on (with paintbrush) – 20 minutes - heats by conduction |
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Why is paraffin mixed with mineral oil?
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to lower the melting point from 54° C (129° F) to between
45-50° C (113-122° F) |
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Paraffin can be applied safely to skin because of:
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its low specific heat and thermal conductivity
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The paraffin bath unit heats the paraffin to: ***
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52-57° C (126-134° F)
go with about 130° F (54° C) |
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How do you convert Celsius to Fahrenheit? ***
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Tf = (9/5) * Tc+32
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How do you convert Fahrenheit to Celsius? ***
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Tc = (5/9) * (Tf - 32)
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Advantages of paraffin?
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- maintains good contact with highly contoured areas
- easy to use - inexpensive - body part can be elevated (dip & wrap or brush) - oil lubricates and conditions skin - can be used by patient at home |
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Disadvantages of paraffin?
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- messy and time-consuming to apply
- cannot be used over open skin lesion as it may contaminate the lesion - risk of cross-contamination if paraffin is reused - part in dependent position for dip-immersion method |
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Specifics for fluidotherapy: ***
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- cellulose particles from corn cobs
- cabinet with portals for extremities - 38-48° C (100-118° F) (go with 117° F) - Rx: 20 minutes - heats by convection |
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How does cryotherapy decrease blood flow? ***
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- decreases vasodilator (histamine and prostaglandin) release
- increases blood viscosity - causes smooth muscle contraction - affects spinal cord dorsal root ganglion - causes vasoconstriction |
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What are two categories of therapeutic heat? What are some examples of each? ***
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Thermotherapy and cryotherapy
- Thermo - hot pack, paraffin, fluidotherapy, ultrasound, diathermy - Cryo - cold pack, ice pack, ice massage, controlled cold compression |
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What are the five types of heat exchange utilized with application of heat/cold modalities? ***
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- conduction
- convection - conversion - radiation - evaporation |
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Explain at least 6 physiologic effects of heat application. ***
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- vasodilation,
- nerve conduction velocity increases, - pain threshold increases, - changes in muscle strength, - metabolic rate increases, - tissue extensibility increases |
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Explain at least four uses (indications) of treatment with therapeutic heat. ***
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- pain control,
- increase ROM, - decrease stiffness, - accelerate healing, - increasing oxygen to tissue |
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Explain at least seven physiological effects with general application of cold and how this benefits the patient. ***
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- initial vasoconstriction (reduces flow, inflammation)
- delayed vasodilation (potential rebound increase metabolism/oxygen) - increased blood viscosity (reduces flow) - nerve conduction velocity decreased (mostly a-delta fibers) - pain threshold increased (probably gating mechanism) - muscle strength altered (after 5 mins increase, after 30 mins decrease, then increase) - spasticity decreased - facilitation of flaccid muscle - metabolic rate decreased |
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How is cryotherapy primarily used outside of rehabilitation?
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for destruction of malignant and nonmalignant tissue growths
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What type of cooling does rehabilitation/physical therapy use?
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mild cooling
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For what is cryotherapy used (indications)? ***
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- control inflammation
- reduce pain - control edema - reduce spasticity - control symptoms of multiple sclerosis - facilitate movement |
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How does cryotherapy exert its therapeutic effects?
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by influencing hemodynamic, neuromuscular, and metabolic processes
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What hemodynamic effects does application of cryotherapy have?
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initial decrease in blood flow, followed by a later increase in blood flow
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When cold is applied to the skin, it causes an immediate ______ of the cutaneous vessels and a ______ in blood flow.
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vasoconstriction
reduction |
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For how long will vasoconstriction persist with cold application?
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it will persist as long as the cold application is limited to 15-20 minutes or less
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How can vasoconstriction be induced even more effectively with cold?
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use an initial 20-minute application, then two cycles on/off for 10 minutes each (this cools more effectively than a second 20-minute session)
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Where is the vasoconstriction and reduction in blood flow produced by cryotherapy most pronounced?
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in the area of application, because this is where the tissue temperature decrease is greatest. (Not as pronounced of a "traveling effect" as with thermotherapy)
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Cold causes cutaneous vasoconstriction both directly and ______.
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indirectly
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Cold application causes cutaneous vasoconstriction directly through what mechanisms?
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through activation of the cutaneous cold receptors, which stimulate contraction of the smooth muscles lining blood vessels
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Cold application causes cutaneous vasoconstriction indirectly through what mechanisms?
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- it reduces vasodilator (histamine and prostaglandin) release, and
- it causes a reflex activation of sympathetic adrenergic neurons which, in turn, cause vasoconstriction in the cooled area and to a lesser extent in areas distant to the site of application |
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Why is it thought the body reduces blood flow in response to decreased tissue temperature?
|
to protect other areas from excessive decreases in temperature and stabilize the core body temperature--the less blood flowing through a cooled area, the smaller amount of blood that is cooled and less other areas are affected
|
|
|
Why does reduced circulation result in a greater decrease in temperature of area to which a cooling agent is applied?
|
less circulating, warm blood is brought into the area to raise the temperature by convection
|
|
|
Why does reduced circulation result in a lesser decrease in temperature of the rest of the body when a cooling agent is applied?
|
the colder blood tends to remain in the cooled area, and not circulate to cool the rest of the body
|
|
|
What causes cold-induced vasodilation (CIVD) or the "hunting response"?
|
cold applied for longer period of time (> 15 minutes) or tissue temperature reduced to less than 10° C (50° F) may induce vasodilation (but it's not a given in everyone)
|
|
|
Who first reported CIVD, and when?
|
Lewis in 1930
|
|
|
Is vasodilation a consistent response to prolonged cold application?
|
no, therefore it should not be counted on in selecting a treatment modality
|
|
|
What did Lewis find with application of cold?
|
after 15 minutes, patient's temperature began to cyclically increase and decrease
|
|
|
What is the "hunting response"?
|
the cyclic increase and decrease in temperature/alternating vasoconstriction and vasodilation associated with application of cold for more than 15 minutes
|
|
|
It is proposed that the hunting response is mediated by:
|
an axon reflex in response to the pain of prolonged cold or very low temperatures; or that it is caused by inhibition of contraction of the smooth muscles of the blood vessel walls by extreme cold
|
|
|
Where is CIVD most likely to occur?
|
in the distal extremities
|
|
|
Under what situations may CIVD (without cycling) be induced?
|
application of cold for more than 15 minutes at temperatures below 1° C
|
|
|
To what is the increase in skin redness with cold application attributed?
|
it is likely not CIVD, but is actually thought to be primarily the result of an increase in the oxyhemoglobin concentration of the blood as a result of the decrease in oxygen-hemoglobin dissociation that occurs at lower temperatures
|
|
|
Is CIVD an effective means of increasing oxygen delivery to an area?
|
no, because cooling decreases oxygen-hemoglobin dissociation, making less oxygen available to the tissues
|
|
|
What neuromuscular effects does cryotherapy have? ***
|
- decreased nerve conduction velocity (mostly a-delta fibers)
- increased pain threshold (probably gating mechanism) - altered muscle strength - decreased spasticity - facilitation of muscle contraction |
|
|
How long does it take application of cryotherapy to induce reduction in nerve conduction velocity?
|
5 minutes or more
|
|
|
How long does it take to reverse reduction in nerve conduction velocity with 5 minutes of cooling? With 20 minutes?
|
15 minutes
30 minutes or longer |
|
|
What types of nerves can cold decrease conduction velocity of?
|
sensory and motor
|
|
|
On which nerves does cold have the greatest effect?
|
cold has the greatest effect on conduction by myelinated and small fibers and the least effect on conduction by unmyelinated and large fibers
|
|
|
What are A-delta fibers and how are they affected by cold?
|
A-delta fibers, which are small-diameter, myelinated, pain-transmitting fibers, demonstrate the greatest decrease in conduction velocity in response to cooling
|
|
|
Is total nerve conduction block reversible?
|
yes
|
|
|
How can total nerve conduction block occur with application of cold?
|
reversible total nerve conduction block can occur with application of ice over superficially located major nerve branches (e.g., peroneal nerve at lateral aspect of the knee)
|
|
|
What is the proposed mechanism for the decreased sensation of pain/increased pain threshold with the application of cold?
|
counter-irritation via the gate control mechanism, thereby blocking transmission of painful stimuli to the brain cortex; and the reduction of muscle spasm, sensory nerve conduction velocity, or post-injury edema
|
|
|
Gating of the sensation of pain can also reduce:
|
muscle spasm by interrupting the pain-spasm-pain cycle
|
|
|
How may cryotherapy help reduce pain of an acute injury?
|
by reducing the rate of blood flow in an area and by decreasing the rate of reactions related to acute inflammation, thus controlling post-injury edema formation
|
|
|
How does reducing edema reduce pain?
|
it reduces compression of nerves and other sensitive structures
|
|
|
Is cryotherapy associated with increases or decreases in muscle strength?
|
both, depending on duration of treatment and time of measurement
|
|
|
When is muscle strength increased by cryotherapy? ***
|
after 5 minutes or less of application (it is not known, however, how long this effect lasts)
|
|
|
What happens to isometric muscle strength following cooling of 30 minutes or longer? ***
|
initially it decreases, then begins to increase after about an hour
|
|
|
What are the proposed mechanisms for increased strength after brief (5 minutes or less) cooling?
|
facilitation of motor nerve excitability and an increased psychological motivation to perform
|
|
|
How long-lasting is the effect of increased muscle strength with cooling of 30 minutes or more? ***
|
following the initial decrease (up to an hour afterward) the increase exceeds the precooling strength (at about 90 minutes) and this effect lasts 3 hours or more
|
|
|
What must the therapist consider when wishing to gauge muscle strength in a patient undergoing cryotherapy?
|
since the muscle strength is temporarily altered by cooling, test the patient before the cryotherapy application.
|
|
|
What are the proposed mechanisms for reduced strength after prolonged cooling?
|
- reduction of blood flow to the muscles
- slowed motor nerve conduction - increased muscle viscosity - increased joint or soft tissue stiffness |
|
|
What mechanisms are thought to decrease spasticity with cryotherapy?
|
- decrease in gamma motor neuron activity initially, then
- a decrease in afferent spindle and Golgi tendon organ (GTO) activity |
|
|
After prolonged cooling (10-30 minutes) how is spasticity affected?
|
it is temporarily decreased or eliminated
|
|
|
How long-lasting are the effects of decreased or eliminated spasticity due to prolonged (10-30 minutes) cooling?
|
1 to 1 1/2 hours
|
|
|
How can the decrease or elimination of spasticity following prolonged (10-30 minutes) cooling be taken advantage of?
|
apply the cooling to hypertonic areas before other interventions to reduce spasticity during functional or therapeutic activities
|
|
|
How can cryotherapy be useful in treating flaccid muscles?
|
brief application of cryotherapy is thought to facilitate alpha motor neuron activity to produce contraction in flaccid muscle (not often used)
|
|
|
How long are flaccid muscles cooled to induce contraction?
|
A few seconds (and the effect is short-lived)
|
|
|
What happens to muscle contractions with prolonged cooling of even a few minutes?
|
a decrease in gamma motor neuron activity reduces the force of muscle contractions
|
|
|
Cold _______ the rate of all metabolic reactions.
|
decreases
|
|
|
Cold decreases the rate of all metabolic reactions, including those involved in _____ and _____
|
inflammation and healing
|
|
|
Can application of cold delay healing?
|
yes
|
|
|
How is cryotherapy useful for treatment of RA and other inflammatory joint diseases?
|
it inhibits activity of cartilage-degrading enzymes, including collagenase, elastase, hyaluronidase, and protease, almost completely stopping them at joint temperatures of 30° C (86° F)
(pg. 137) |
|
|
When should cold be used to control acute inflammation and accelerate recovery?
|
The first 48 (to 72) hours
|
|
|
How does cryotherapy help in healing of acute inflammation?
|
cold slows the rate of the chemical reactions that occur during the acute inflammatory response, and also reduces the heat, redness, edema, pain, and loss of function associated with this phase of healing
|
|
|
How does cryotherapy affect fluid movement in cases of acute inflammation? ***
|
blood flow is decreased by vasoconstriction and increased blood viscosity
decreased capillary permeability impedes movement of fluid from capillaries to interstitial tissue, thereby controlling bleeding and fluid loss after acute trauma |
|
|
It is also thought that cryotherapy partially prevents microvascular damage by:
|
decreasing activity of leukocytes, which damage vessel walls and increase capillary permeability
|
|
|
How can one estimate the stage of healing for an acute injury?
|
by local skin temperature; if the skin is still warm, it's probably still inflamed and cryotherapy can help
|
|
|
How long does it normally take for acute inflammation to resolve?
|
48 to 72 hours
|
|
|
When may inflammation be prolonged?
|
- with severe trauma
- with inflammatory diseases like RA - with chronic, recurrent injuries |
|
|
What should the therapist consider if the temperature of an area remains elevated for longer than expected? What should he/she do?
|
infection
patient should be referred to a physician for further evaluation |
|
|
Why should cryotherapy be discontinued when the acute inflammation has resolved?
|
to avoid impeding recovery by slowing chemical reactions (metabolism/oxygenation) or impairing circulation
|
|
|
When is continuous, low-level cryotherapy potentially useful?
|
to reduce pain and inflammation for several days after orthopedic surgery (hip replacement, shoulder surgery, etc.) but although evidence in favor of this is mounting, it's not commonly used
|
|
|
What can cryotherapy do for Delayed-onset Muscle Soreness (DOMS)?
|
it can be used prophylactically after exercise to reduce severity of DOMS (b/c it's due to inflammation of muscle and connective tissue)
|
|
|
When cryotherapy is applied with the goal of controlling inflammation, the treatment time is generally limited to ______ because______
|
15 minutes or less
because longer application has been associated with vasodilation and increased circulation |
|
|
Has reflex vasodilation been shown to occur outside distal extremities?
|
no, so treatments longer than 15 minutes may be used for areas other than distal extremities
|
|
|
To limit probability of excessive decreases in tissue temperature and cold-induced injury, cryotherapy applications should be:
|
at least 1 hour apart so that the tissue temperature can return to normal between treatments
for distal extremities, limit treatment to 20-minute treatments (or shorter) at least 1 hour apart |
|
|
During acute inflammation, edema is caused by:
|
extravasation of fluid into the interstitial tissues as a result of increased intravascular fluid pressure and increased vascular permeability
|
|
|
Cryotherapy reduces intravascular fluid pressure by:
|
reducing blood flow into the area via vasoconstriction and increased blood viscosity
|
|
|
Cryotherapy also controls increases in capillary permeability by: ***
|
reducing the release of vasoactive substances such as histamine
|
|
|
To minimize edema formation, cryotherapy should be applied:
|
as soon as possible after an acute trauma
|
|
|
How is edema associated with inflammation most effectively controlled?
|
Rest
Ice Compression Elevation |
|
|
Compression and elevation reduce edema by driving extravascular fluid out of the swollen area and into:
|
the venous and lymphatic drainage systems
|
|
|
Is cryotherapy effective in reducing edema associated with immobility and poor circulation?
|
No
|
|
|
How is edema associated with immobility and poor circulation best handled?
|
increased venous or lymphatic circulation is required and this is best accomplished with compression, elevation, heat, exercise, and massage
|
|
|
The analgesic effect of cold is exploited when used to cool the skin before _____
|
stretching the muscles below;
the reduced sensation of pain allows the stretch to be more forceful and potentially more effective |
|
|
Applying cryotherapy for 10-15 minutes or longer can control pain for _____
|
1 or more hours because the temperature of the area remains lower than normal for 1-2 hours after removal of the treatment
|
|
|
Reduction of pain by cryotherapy can also interrupt: ***
|
the pain-spasm-pain cycle (even after the temperature of the area returns to normal)
|
|
|
To reduce spasticity in patients with upper motor neuron dysfunctions, cryotherapy can be applied for up to
|
30 minutes
|
|
|
What patients in particular benefit from cold over heat?
|
MS patients, whose symptoms are often aggravated by heat
|
|
|
Cooling an MS patient with a vest has been shown to:
|
improve fatigue, muscle strength, visual function, and postural stability
|
|
|
Peripheral cooling has been found to decrease _____ in MS patients.
|
tremor
|
|
|
What is quick icing?
|
rapid application of ice as a stimulus to elicit desired motor patterns in patients with flaccidity resulting from upper motor neuron dysfunction
|
|
|
Who developed the technique of quick icing?
|
Rood
|
|
|
Is quick icing often used?
|
no, as its results are unreliable and may actually cause a rebound movement opposite of the desired direction
|
|
|
What is cryokinetics?
|
combined use of cold and exercise to treat a pathology or disease
|
|
|
Who is the primary patient for cryokinetics?
|
athletes in rehabilitiation
|
|
|
How is cryokinetics administered?
|
cold is applied to area for 20 minutes or until numb;
patient performs stretching and strengthening exercises for 3-5 minutes until sensation returns; area is recooled to numbness; and this is repeated about 5 times |
|
|
What is important to know prior to utilizing cryokinetics?
|
The exact nature of the injury to avoid further trauma and tissue damage
|
|
|
What is cryostretch?
|
the application of a cooling agent before stretching to reduce muscle spasm and improve range of motion
|
|
|
What are the contraindications for cryotherapy? ***
|
- hypersensitivity or intolerance (may develop urticaria, severe pain, numbness, tingling)
- cryoglobulinemia (proteins aggregate in distal extremity, impair circulation, cause ischemia--rare) - paroxysmal cold hemoglobinuria (blood in urine following exposure to cold--rare) - Raynaud’s disease/phenomenon (disease-symptoms bilateral no matter what's treated; phenomenon-affected extremity only) - over regenerating nerves (may delay regeneration) - peripheral vascular disease (vasoconstriction may aggravate--circulation already decreased) |
|
|
Contrast edema from inflammation with edema from poor circulation.
|
poor circulation - area is cool and pale (don't use cold)
inflammation - area is warm and red (can benefit from cold) |
|
|
What are the precautions for the use of cryotherapy? ***
|
over superficial main nerve branch (may cause conduction block)
over deep open wound (can delay healing) hypertension (can cause transient increases in BP--monitor during treatment) poor sensation poor mentation very old or very young (impaired thermal regulation and limited ability to communicate) |
|
|
What are some of the adverse effects of cryotherapy? ***
|
Frostbite; tissue death
Nerve damage (temporary or permanent) Unwanted vasodilation |
|
|
At what temperature can tissue damage occur? Frostbite?
|
15° C (59° F)
-4° to -10° C (39° to 14° F) |
|
|
What is the maximum cryotherapy treatment time and minimum temperature to avoid soft tissue or nerve damage?
|
under 45 minutes
keep temperature above 15° C (59° F) |
|
|
What is the maximum application time for cryotherapy to the distal extremities to produce vasoconstriction?
|
10 to 20 minutes
(we're using 10-15) |
|
|
Specifications for a cold pack:
|
Vinyl pack filled with silica
Stored in freezer -5° C (23° F) Rx: wrap cold pack with towel (wet with warm water) 10-15 min. usual time spasticity - about 30 min. (check every 10-15 minutes for adverse effects) |
|
|
Cryotherapy options:
|
cold pack/ice pack
ice cup/ice massage controlled cold compression vapocoolant spray frozen towels ice water cold whirlpool contrast bath |
|
|
Length of time to cool a cold pack:
|
2 hours before initial use,
30 minutes between uses |
|
|
In general, how deep is the cooling of frozen gel packs or ice packs after 20 minutes?
|
up to 2 cm
|
|
|
What is the sequence of sensations associated with cryotherapy? ***
|
1) intense cold
2) burning 3) aching 4) analgesia 5) numbness |
|
|
Ice pack specifications: ***
|
Plastic bag filled with water and ice - add a little alcohol
Or, use 4:1 ratio water:alcohol and place in freezer Stored in freezer -5° C (23° F) Rx: wrap cold pack with towel (wet with warm water) 10-15 min. usual time spasticity - about 30 min. (check every 10-15 minutes for adverse effects) |
|
|
Ice packs are more aggressive cooling agents than cold/gel packs because:
|
ice has a higher specific heat than most gels and ice absorbs a large amount of energy when it melts and changes from a solid to a liquid
|
|
|
Which requires more insulation, a cold/gel pack or ice pack?
|
ice pack, because it provides more aggressive cooling
|
|
|
When wrapping a cold/ice pack in a wet towel, what temperature water should be used to wet the towel? Why?
|
use warm water
to allow the patient to gradually become used to the cold |
|
|
What is a rule of thumb for use of wet/dry towel for cold or ice packs?
|
thin, dry towel for slower, less intense cooling and to slow more intense cooling of ice pack
wet towel is more appropriate for a cold pack dry towel for ice pack |
|
|
Advantages of cold/ice packs:
|
- easy to use
- inexpensive materials and equipment - short use of clinician's time - low level of skill required for application - covers moderate to large areas - can be applied to elevated limb |
|
|
Disadvantages of cold/ice packs:
|
- pack must be removed to visualize treatment area during treatment
- patient may not tolerate weight of pack - pack may not be able to maintain good contact on small or contoured areas - long duration of treatment compared to massage with an ice cup |
|
|
Ice pack vs. cold pack:
|
- ice pack provides more intense cooling
- ice pack is less expensive - cold pack is quicker to apply |
|
|
Advantages of ice massage:
|
- treatment area can be observed during treatment
- can be used for small/irregular areas - short duration of treatment - inexpensive - can be applied to elevated limb |
|
|
Disadvantages of ice massage:
|
- too time-consuming for large areas
- requires active participation by clinician or patient throughout application |
|
|
Specifications for contrast bath: ***
|
Cold water at 10-18° C (50-64° F) (go with 60° F)
Warm water 38 – 44° C (100-111° F) (go with 110° F) Alternate baths 4 min. warm, then 1 min. cold. Continue sequence of warm-cold 1 min. each until 20-30 min. elapse end on warm, unless patient suffering from edema |
|
|
Sequelae of injury depend on:
|
- source and site of injury
- state of local homeostasis - whether injury is acute or chronic |
|
|
Ultimate goal of inflammation and repair is to restore function by:
|
- eliminating the pathological or physical insult
- replacing damaged tissue - promoting regeneration of tissue structure |
|
|
Three phases of inflammation and repair:
|
1) inflammation phase - prepares the wound for healing
2) proliferation phase - rebuilds the damaged structures and strengthens the wound 3) maturation phase - modifies the scar tissue into its mature form |
|
|
Can healing occur without inflammation?
|
No
|
|
|
Inflammation is an immediate ______
|
protective response
|
|
|
What are the five cardinal signs of inflammation? ***
(Cornelius Celsus - 4 Virchow - 1) |
heat (calor - increased vascularity)
redness (rubor - increased vascularity) swelling (tumor - blockage of lymphatic drainage) pain (dolor - physical pressure on or chemical irritation of pain-sensitive structures) Loss of function (Functio laesa - pain and swelling) |
|
|
What is hyperemia?
|
increase in blood in a given area
|
|
|
From what does local swelling originate at the site of acute inflammation?
|
increased permeability and vasodilation of local blood vessels and infiltration of fluid into the interstitial spaces of the injured area
|
|
|
Stages of tissue repair: ***
|
Inflammation Phase- (1-6 days) = Acute
Proliferation Phase- (3-20 days) = Sub-acute; Repair Maturation Phase- (9 days onward--could last a year or longer) = Chronic; Remodeling |
|
|
Causes of inflammation ***
|
- Foreign substances
- Allergens/Autoimmunity - Chemical agents (poisons, toxins, venoms) - Trauma - Pathogenic agents (bacteria, viruses, fungi, parasites) - Physical agents (radiation, temperature extremes) |
FACTPP
|
|
What characterizes the inflammation phase? ***
|
- vascular response - initial vasoconstriction, then vasodilation
- hemostatic response - clot formation - cellular response - WBCs (macrophage phagocytosis; sends signal to attract fibroblasts and alerts immune system); RBCs (minor role of oxygen), |
|
|
What characterizes the proliferation phase? ***
|
- epithelialization - re-establishment of epidermis, or serous and mucous membranes (a barrier is formed to protect the wound)
- collagen production [fibroblasts (precursors to collagen) migrate to area] - wound contracture - neovascularization - angiogenesis (new blood vessels) |
|
|
What is wound contraction? ***
|
pulling together the edges of the wound
|
|
|
What is healing by primary intention? ***
|
stitches
(healing without wound contraction) |
|
|
What is healing by secondary intention? ***
|
wound is left open to heal on its own (e.g., abscess)
|
|
|
What occurs during the maturation phase? ***
|
- balance of collagen synthesis and lysis
- too much synthesis can produce keloids (scars that invade surrounding tissue) or hypertrophic scars (raised, but within margin of original wound - collagen matures, vascularity decreases, scar whitens |
|
|
What is chronic inflammation? ***
|
- follows acute inflammation
- persists due to continued trauma or another inhibitor of healing (e.g., response to foreign material like an implant, or autoimmune disease) |
|
|
What two types of factors affect healing? ***
|
- local factors
- systemic factors |
|
|
What local factors affect healing? ***
|
- type, size, location of injury
- infection - vascular supply - external forces (temperature deviation, topical medications, electromagnetic energy) - movement/excessive pressure - retained foreign body |
|
|
What systemic factors affect healing? ***
|
- age
- disease - medications - metabolic status - nutrition - hormones - fever - oxygen |
|
|
What interventions are acceptable during the inflammation phase? ***
|
passive movement
protective phase--body is preparing wound for healing |
|
|
What interventions are acceptable during the repair/proliferation phase? ***
|
controlled motion
non-destructive active and some resistive movement |
|
|
What interventions are acceptable during the maturation phase? ***
|
return to normal function
|
|
|
How may heat be transferred with respect to the body?
|
into, away from, or within
|
|
|
How is heat transferred within the body by conduction?
|
one area of the body is heated by an external thermal agent, and the adjacent tissues increase in temperature
|
|
|
What is diathermy?
|
an electromagnetic form of energy that, when applied to the body, causes rotation of polar molecules, resulting in friction and increase in tissue temperature
|
|
|
What are some of the effects of heat application (thermotherapy) on the body? ***
|
- vasodilation (at the site and distally)
- increased nerve conduction velocity/firing rate - pain threshold increased - changes in muscle strength/endurance - increased metabolic rate - increased tissue extensibility |
|
|
Cutaneous vasodilation and the increase in blood flow that occurs in response to increased tissue temperature act to:
|
protect the body from excessive heating and tissue damage
|
|
|
How does vasodilation protect the cutaneous layers from tissue damage?
|
the increased blood flow increases cooling by convection; cooler blood is continuously pumped into the area where it takes heat away as it returns to the heart
|
|
|
Could you use fluidotherapy on a patient with an open wound?
|
you could treat if there was a way to cover the injury, such as using a glove
|
|
|
What is another contraindication specifically for fluidotherapy, over and above the contraindications for heat?
|
if the patient has a corn allergy
|
|
|
What are the advantages of fluidotherapy?
|
- patient can move during the intervention to work on gaining ROM
- minimal pressure is applied to the area being treated - temperature is well-controlled and constant throughout treatment - easy to administer - short use of clinician's time |
|
|
What are the disadvantages of fluidotherapy?
|
- expensive equipment
- limb must be in dependent position in some units, increasing risk of edema - constant heat source may result in overheating - if corn cob particles spill onto smooth floor, they make it very slippery |
|
|
How long can the analgesic effects of cryotherapy potentially last? Why?
|
1 hour or more after a 10-15 minute treatment
blocking of deep pain-transmitting A-delta fibers and gating of pain transmission is prolonged because the temperature of the treated area remains lower than normal for 1-2 hours after treatment; rewarming is slowed by cold-induced vasoconstriction preventing flow of warm blood into the area and subcutaneous fat slows rewarming by conduction from the ambient air |
|
|
With what afflictions may cryoglobulinemia be associated?
|
- multiple myeloma
- systemic lupus erythematosus - rheumatoid arthritis - other hyperglobulinemic states |
|
|
With what afflictions may Raynaud's disease or phenomenon be associated?
|
- thoracic outlet syndrome
- carpal tunnel syndrome |
|
|
Why does applying cryotherapy over an area of superficial skin damage result in less-pronounced responses?
|
while cryotherapy can be used over areas of superficial (not deep) tissue damage, the thermal receptors which play a large part in activating the vasoconstriction, pain control, and spasticity reduction may be damaged or absent, resulting in a less-desirable outcome
also, absence of skin could result in excessive cooling of these tissues; use less-intense cooling |
|
|
What is the Game Ready used for? ***
|
controlled cold compression
|
|
|
What are the types of vapocoolant sprays? ***
|
- ethyl chloride (which is volatile and flammable)
- fluori-methane (which was volatile and a CFC/ozone layer depleter--now discontinued) - Gebauer's ethyl chloride (not flammable or ozone-depleting) sold as: -Spray and Stretch - Instant Ice, and - Pain Ease |
|
|
Who devised the spray and stretch treatment for trigger points?
|
Janet Travell
|
|
|
How is pain defined? ***
|
unpleasant sensory AND EMOTIONAL experience
associated with actual or potential tissue damage, or described in terms of such damage |
|
|
What are some factors that influence pain? ***
|
- focus of attention (you're thinking about it)
- level of anxiety - degree of suggestibility - level of arousal/cognitive awareness - degree of fatigue - previous emotional and psychological experience - cultural mores |
|
|
List three different pain theories. ***
|
- Specificity Theory
- Pattern Theory - Gate Control Theory |
|
|
What does the Specificity Theory of pain state? ***
|
pain is the response to stimulation of "specific" pain receptors
sensory impulses travel along specific sensory fibers pain impulses travel along specific pain fibers (uses separate sensors for pain and heat) |
|
|
What does the Pattern Theory of pain state? ***
|
quality of sensation depends on intensity or frequency of impulses
|
|
|
How does the Gate Control Theory describe pain? ***
|
a control mechanism (gate) exists in the spinal cord
- greater input from A-beta fibers closes the gate and reduces or eliminates pain - greater input from A-delta or C fibers opens the gate and increases pain |
|
|
What are the components of the Neurochemical Theory of Pain Control? ***
|
neurochemicals - endogenous opiates produced in brain and glands, released to counter pain
- enkephalins - 2-minute half life - endorphins - (opiopeptins) 4-hour half life dynorphins, serotonin, dopamine |
|
|
Name three types of pain. ***
|
- acute
- chronic - referred |
|
|
How is acute pain characterized? ***
|
pain of recent and sudden onset
with demonstrable etiology and limited course |
|
|
How is chronic pain characterized? ***
|
pain that no longer signals real or impending tissue damage
- does not resolve in the usual time it takes for the disorder to heal, or - continues beyond the duration of noxious (harmful) stimulation often has a psychological component (depression, attention-seeking, hypochondria) |
|
|
How is referred pain characterized? ***
|
pain felt at a location distant from its source
(e.g., pain in jaw during a heart attack) |
|
|
What is a trigger point? ***
|
a small, hypersensitive area in the muscle or fascia
when pressure is applied to it, it can produce pain at the site, or at a referred site |
|
|
What is analgesia? ***
|
absence of pain on noxious stimulation
|
|
|
What is causalgia? ***
|
intense, burning pain accompanied by trophic skin changes due to injury of nerve fiber
|
|
|
What is neuralgia? ***
|
pain occurring along the course of a nerve
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What is hyperalgesia? ***
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increased sensitivity to noxious (harmful) stimulation
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What is hypoalgesia? ***
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decreased sensitivity to noxious (harmful) stimulation
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What is allodynia? ***
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painful response to a normally non-painful stimulus
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What is the pain perception threshold? ***
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the least intensity of noxious (harmful) stimulation at which a person perceives pain
fairly constant from person to person |
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What is pain tolerance? ***
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the greatest intensity of noxious (harmful) stimulation an individual can bear
varies greatly from person to person |
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Which is fairly constant from person to person: ***
pain perception threshold pain tolerance level |
pain perception threshold
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Which varies greatly from person to person: ***
pain perception threshold pain tolerance level |
pain tolerance level
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What is the pain pathway? ***
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from the
- nociceptor to the - A-delta and C fibers, to the - dorsal horn of the spinal column, to the - spinothalamic tracts, to the - thalamus, to the - cortex |
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What is a nociceptor? ***
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a sensory receptor (from the L. nocere--to injure)
in most tissue (except nucleus pulposus and inner part of annulus fibrosus) activated by intense thermal, chemical, and/or mechanical stimuli |
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What are C fibers? ***
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small, unmyelinated fibers
transmit signal slowly (1-4 m/sec); long-lasting pain (emotionally difficult, diffuse) dull, throbbing, aching--noxious (may also be reported as tingling, tapping, etc.) (see p. 54) |
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What are A-delta fibers? ***
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small, myelinated nerves
transmit signals quickly (5-30 m/sec); localized sensation sharp, stabbing, pricking quick onset, short lasting, not generally emotionally involved |
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What is the dorsal horn? ***
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gray matter of the spinal cord
lateral spinothalamic tract - transmits sharp pain, localized (A-delta fiber) anterospinothalamic tract - transmission of more prolonged, aching pain, involve disturbing emotions (C fiber) |
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What are the first-order neurons? ***
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C fibers
A-delta fibers to dorsal horn |
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What are the second-order neurons? ***
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dorsal horn to thalamus
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To where do the C fibers and A-delta fibers transmit pain signals? ***
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to the dorsal horn
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To where does the dorsal horn direct pain signals received from the C fibers and A-delta fibers? ***
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to the thalamus
(where the second-order neurons terminate) |
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What does the thalamus do with the pain signals it receives? ***
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interprets the information and redirects it to the cortex
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Where do third-order neurons terminate? ***
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in the cortex
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What happens to pain signals in the cortex? ***
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they reach into the consciousness
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What is substance P? ***
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a neurotransmitter thought to be involved in transmission of pain
released from nociceptors, triggering action potential also found in CNS (persons with elevated levels of substance P often have signs of depression as well) |
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List some methods of measuring pain: ***
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- Keele's Scale
- Visual Analog Scale (VAS) - McGill Pain Questionnaire |
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How does Keele's Scale measure pain? ***
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mild, moderate, severe
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How does the Visual Analog Scale measure pain? ***
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on a line or on a scale of 1-10
(faces for children) ("no pain" to "worst pain possible") good for quick estimate of pain severity |
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How does the McGill Pain Questionnaire measure pain? ***
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uses adjectives in columns to collectively describe the pain sensation
a.k.a. semantic differential scale |
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How are body diagrams used to describe pain? ***
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various markings are made on a drawing of the body to describe the pain type and location
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What are some pharmacological approaches to pain control? ***
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NSAIDs
Acetaminophen opiates antidepressants spinal analgesia local injection |
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What are some available NSAIDs and their side effects? ***
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- aspirin
- ibuprofen - naproxen sodium - piroxicam (Feldene) - Celebrex (1999) - Vioxx (1999-2004, withdrawn) side effects include: GI irritation, prolonged bleeding, kidney damage |
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What is the primary side effect of acetaminophen (Tylenol)? ***
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liver damage
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Name some opiates available for pain control and list their side effects. ***
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- morphine
- codeine - hydrocodone - fentanyl - methadone side effects include: nausea, vomiting, sedation, cough suppression, slowed respiration, possible addiction |
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How are antidepressants used in pain management? ***
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chiefly for chronic pain
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What injection methods are available for inducing spinal analgesia? ***
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- anesthetics,
- corticosteroids, or - opiates injected into the epidural or subarachnoid space |
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What injection methods are available for localized pain control? ***
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- anesthetics,
- corticosteroids, or - opiates injected into joints, bursae, trigger points |
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Who is involved in a multidisciplinary approach to pain treatment? ***
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- physical therapy
- physician - psychologist |
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Steps in the inflammation phase, according to the chart on page 26:
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- vasoconstriction (caused by norepinephrine; lasts for the first 5-10 minutes post injury)
- vasodilation (caused mainly by histamine; of non-injured vessels for up to 1 hour post injury) - clot formation (platelets bind to exposed collagen, release fibrin, create fibrin lattice to confine area; chemotactic signaling of fibroblasts) - phagocytosis (neutrophils first for 24 hours; monocytes 24-48 hrs, convert into macrophages, remove damaged tissue & release chemotactic chemicals esp. to signal fibroblasts) |
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Steps in the proliferation phase, according to the chart on page 26:
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- epithelialization (uninjured epithelial cells from the margins reproduce and migrate over the surface of area)
- fibroplasia/collagen production (concurrent reduction of fibrin clot; initially immature, weak type III collagen; by day 12 replacement with stronger type I collagen starts; 6 weeks to 80% strength) - wound contracture (pulls edges together; myofibroblasts = fibroblasts contractile like smooth muscle) - neovascularization (by angiogenesis; new vascular network, anasomosis to preexisting vessels, or coupling; then retract to give mature scar more whitish appearance |
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What is healing by delayed primary intention?
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first letting the wound heal by contraction, then approximating the wound's edges with sutures or skin grafts
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During proliferation phase, how does the scar appear, and why?
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red and swollen
from increase in vascularity and fluid, innervation of healing site, relative immaturity of the tissue that is weak and can bleed easily and is tender to tension or pressure) |
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Steps in the maturation phase, according to the chart on page 26:
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- collagen synthesis/lysis balance (remodeling via collagen turnover; may last 12-24 months post injury)
- collagen fiber orientation (collagen in scar less organized than surrounding tissue; elastin not present) - healed injury |
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What is the longest phase in the healing process?
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maturation
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What is a contracture?
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uncontrolled wound contraction
highly resistive to passive stretch may result from: - fibrosis of tissues surrounding a joint - adhesions - muscle shortening - tissue damage |
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What is type I collagen?
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the primary collagen in bone, skin, and tendon; also the predominant collagen in mature scars
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What is type II collagen?
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the predominant collagen in cartilage
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What is type III collagen?
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collagen found in the gastrointestinal tract, uterus, and blood vessels
also the first type of collagen to be deposited during the healing process |
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What are the four potential outcomes from an acute inflammatory process?
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- complete resolution and replacement of injured tissue with like tissue
- healing by scar formation - formation of an abscess - progression to chronic inflammation |
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What is chronic inflammation?
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the simultaneous progression of active inflammation, tissue destruction, and healing
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How does chronic inflammation arise?
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one of two ways:
- after acute inflammation and can be result of persistence of injurious agent or another interference with healing process - result of immune response to either an altered host tissue or a foreign material (such as an implant or suture) or the result of an autoimmune disease |
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How long does acute inflammation last?
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no more than 2 weeks
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What is inflammation lasting more than 4 weeks called?
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subacute inflammation
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How long does chronic inflammation last?
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months or years
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What are the primary cells involved in chronic inflammation?
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mononuclear cells, including:
- lymphocytes, - macrophages/monocytes - eosinophils (occasionally) |
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What are the primary determinants of the outcome of any injury?
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- type and extent of injury
- regenerative capacity of involved tissues - vascular supply of injured site - extent of damage to extracellular framework |
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Why does cartilage have a limited ability to heal?
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it lacks lymphatics, blood vessels, and nerves
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Is it more helpful to the healing process to have a cartilage injury alone, or in conjunction with the subchondral bone?
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in conjunction with the bone
cartilage alone is avascular and has difficulty healing if subchondral bone is involved, the cartilage can gain access to inflammatory cells and produce granulation tissue, although this cartilage will still be weaker and predisposed to degeneration and erosion |
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How well do tendons heal?
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under the right circumstances, they can achieve a state of repair close to regeneration, especially if the synovial sheath is undamaged
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How well do ligaments repair?
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depends on type of ligament, size of defect, and amount of loading used
some are more avascular and don't heal as well mature ligamentous repair tissue is still 30-50% weaker than uninjured ligament |
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What is myositits ossificans?
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a calcified hematoma in muscle tissue after severe contusion
they are rare after surgery if hemostatis is controlled |
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What are the stages of fracture healing?
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- impaction
- induction - inflammation - soft callus - hard callus - remodeling |
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What are nociceptors?
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receptors of noxious (harmful) stimuli (e.g., pain)
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Pain comprises:
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- activation of nociceptors
- sensory experiences - suffering - alterations in behavior associated with such activation |
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What are the goals of pain management?
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- resolving the underlying condition
- modifying the patient's perception of the discomfort - maximizing function within the limitations |
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What is acute pain?
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pain of less than 6 months duration for which an underlying pathology can be identified
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What is chronic pain?
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pain that persists beyond the normal time for tissue healing
usually the result of activation of dysfunctional neurological or psychological responses that cause the individual to continue to experience the sensation of pain even when no damaging or threatening stimulus is present |
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What is referred pain?
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experience of pain in one area when the actual or potential tissue damage is in another area
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How can knowing if the patient's pain is acute, chronic, or referred help the therapist?
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it can help determine the mechanisms and processes that may be contributing to the sensation and facilitate selection of the most appropriate intervention to control or relieve this system
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How does acute pain serve a protective function after injury?
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by limiting activity to prevent further trauma and promote healing and recovery
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How is chronic pain classified?
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by pathophysiology:
- nociceptive pain - neuropathic pain - mixed pain syndrome - psychological pain |
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Chronic nociceptive pain causes and examples:
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caused by stimulation of pain receptors by noxious mechanical, chemical, or thermal stimuli and associate with ongoing tissue damage
e.g., arthritis, ischemia, cancer, chronic pancreatitis |
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Chronic neuropathic pain causes and examples:
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result of peripheral or central nervous system dysfunction without ongoing tissue damage
e.g., diabetic neuropathy, postherpetic neuralgia, and phantom limb pain |
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Chronic mixed pain syndrome causes and examples:
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those with multiple or uncertain pathophysiology
e.g., recurrent headache and some vasculitic syndromes |
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Chronic psychological pain syndromes causes and examples:
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syndromes in which psychological processes play a large role
may be seen in somataform disorders and conversion reactions |
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What are the three ways it is thought that pain is referred?
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- from a nerve to its area of innervation
- from one area to another derived from the same dermatome - from one area to another derived from the same embryonic segment |
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Describe the current thought on pain transmission:
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specific nerve endings (nociceptors) respond to all painful stimuli
specific nerve types (small, myelinated A-delta fibers and unmyelinated C fibers) transmit the sensation of pain from these nociceptors to the spinal cord from the spinal cord, within specific tracts, to the brain |
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Quality of pain depends upon:
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type of tissue from which the stimulus originates
which of the two nerve types transmits the pain (A-delta or C fibers) |
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Intensity of the pain is related to:
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the firing rate of the nerves
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Pain from cutaneous noxious stimulation is usually perceived as:
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sharp, pricking, tingling
easy to localize |
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Pain from musculoskeletal structures is usually:
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dull, heavy, or aching
harder to localize |
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Pain from viscera:
|
has an aching quality similar to musculoskeletal pain, but tends to refer superficially rather than deeply
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Pain transmitted by C fibers is usually:
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dull, long-lasting and aching
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Pain transmitted by A-delta fibers is generally:
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sharp
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Nociceptors can be activated by intense:
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thermal, mechanical or chemical stimuli from exogenous or endogenous sources
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Examples of:
exogenous chemical stimuli endogenous chemical stimuli |
- acid or bleach
- bradykinin, histamine, arachidonic acid (these chemicals are part of the normal inflammatory response, but can also activate nociceptors; since they remain after the initial physical stimulus has passed, they can also prolong pain) |
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Which fiber action is generally not blocked by opiates, A-delta or C?
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A-delta
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What is the ratio of A-delta to C fibers?
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20% are A-delta
80% are C fibers |
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A-beta fibers, or wide dynamic-range neurons, have relatively large myelinated axons that conduct impulses ____ ____ than A-delta and C fibers.
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more quickly
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Where are the receptors for A-beta fibers located?
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- skin
- bones - joints |
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What types of sensations do A-beta fibers transmit?
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- vibration
- stretching of skin - mechanoreception - do not transmit pain |
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While A-beta fibers don't normally transmit pain, what happens in cases of neuropathy and central sensitization?
|
these A-beta neurons alter their transduction so that normal stimuli result in pain
this alteration in nerve function is key in prolonged pain |
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How does pain gating work?
|
nociceptors receive an excitatory pain signal and send it off via A-delta and/or C fibers, which relay the signal to the dorsal horn
transmission cells (interneurons in the dorsal horn) are either excited by the A-delta/C fibers or inhibited by nonnociceptive A-beta fibers (thus opening or closing the gate) |
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Describe A-beta fibers:
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nonnociceptive
large-diameter myelinated release norepinephrine, serotonin, and enkephalins to modulate flow of afferent pain pathways |
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Balance of the excitatory A-delta/C fiber impulses and the inhibitory A-beta fiber impulses determines:
|
whether the individual feels pain
how severe the pain sensation is |
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What is pain gating?
|
inhibition of pain by inputs from nonnociceptor afferents
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How does the pain-spasm-pain cycle work?
|
- nociceptor is activated
- impulse via A-delta/C fiber to dorsal horn - transmission cell (T cell) activates and stimulates anterior horn cell to cause a muscle fiber to contract - contraction results in fluid accumulation,increase in tissue irritants, and mechanical compression of nociceptor - nociceptor activation increases (repeat!) |
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Lateral spinothalmic tract projects:
|
directly to the medial area of the thalamus
lateral spinothalamic tract - transmits sharp pain, localized (A-delta fiber) |
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Anterospinothalamic tract separates:
|
from the lateral spinothalamic tract in the brain stem to synapse with neurons in the reticular formation and the hypothalamic and limbic systems, to then project to lateral, ventral, and caudal areas of the thalamus
anterospinothalamic tract - transmission of more prolonged, aching pain, involve disturbing emotions (C fiber) |
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Anterospinothalamic tract also relays information to
|
the periaqueductal grey matter
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|
What is in the periaqueductal grey matter?
|
thought to contain a large concentration of opiate receptors for pain modulation
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First-order neurons synapse in the dorsal horn with second-order neurons to project to:
|
the thalamus
(via the lateral spinothalamic tract - sharp, or via the anterospinothalamic tract - aching) |
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Second-order neurons synapse in the thalamus with third-order neurons to project to the _____.
Why? |
cortex
so the sensation of pain can reach consciousness |
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Examples of inhibition or modification of pain transmission or perception:
|
- rubbing or shaking an injured area
- stress can cause pain not to be felt at time of injury |
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|
What device was developed based on the gate control theory of pain modulation?
|
the transcutaneous electrical nerve stimulation (TENS) unit
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Who first proposed the gate control theory of pain modulation, and when?
|
Melzack and Wall
1965 |
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What types of treatments are thought to work based on activating nonnociceptive nerves (A-beta fibers) and causing gating of pain?
|
- transcutaneous electrical nerve stimulation (TENS)
- electrical stimulation (ES) - traction - compression - massage |
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|
What are opiopeptins?
|
(previously known as endorphins)
endogenous opiate-like peptides control pain by binding to specific opiate receptors in the nervous system |
|
|
What endogenous peptides function similar to morphine?
|
methionine-enkephalin (met-enkephalin)
leucine-enkephalin (leu-enkephalin) beta-endorphin dynorphin A and B |
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How is pain suppression by stress suspected to work?
|
it is most likely caused by increased opiopeptin (endorphin) levels at the spinal cord and higher CNS centers
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|
The endogenous opiate theory also explains:
|
why there is a paradoxical pain-relieving effect of painful stimulation and acupuncture
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|
What things are important to consider when assessing a patient's pain?
|
- source
- intensity - duration - how it affects function, activity, and participation |
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|
What are the basic categories of pain management approaches?
|
- controlling inflammation
- altering nociceptor sensitivity - increasing binding to opiate receptors - modifying nerve conduction - modulating pain transmission at the spinal cord level - altering higher-level aspects of pain perception |
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|
What is the primary intervention used to alleviate pain?
|
administration of pharmacological agents
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|
Why may physical agents be more appropriate than pharmacological agents for pain control?
|
they may be able to effectively control pain with fewer adverse effects
|
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|
How do phamacological analgesic agents control pain?
|
- by modifying inflammatory mediators at the periphery
- altering pain transmission from the periphery to the cortex - altering the central perception of pain |
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Upon what does selection of a particular pharmacological analgesic agent depend?
|
- cause of pain
- length of time patient is expected to need the agent - side effects of the agent |
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|
What is the primary method of pain management?
|
administration of a systemic analgesic
|
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|
Which requires higher doses of NSAIDs, reducing pain or reducing inflammation?
|
reducing inflammation
|
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