Pain, neuromuscular control, and biofeedback

Question 1

What are the categories of pain?

Answer 1

• Acute pain vs Chronic pain
– Don’t forget to look for the yellow flags
• Nociceptive
– Somatic or visceral
• Neuropathic
– Peripheral or Central
• Psychogenic
• Carcinogenic

Question 2

What is Kubler-Ross’s death and dying model?

Answer 2

– 5 stages of response to terminal illness
– Denial, anger, bargaining, depression,
acceptance

Question 3

T/F

Kuber-Ross’s death and dying model is applicable to athletic injury

Answer 3

False

Question 4

What are cognitive-appraisal models of injury

Answer 4

• Models state that response to injury
depends on understanding of the injury
• Response to injury is not neatly divided
into stages in particular order
• Response to injury can be influenced by
the actions and message of the doctor!!!

Question 5

T/F

When assessing a patient you need to be blunt with what you say to the patient, telling them exactly how it is regardless of what the patient might insinuate. Injuries are just physical anyways.

Answer 5

False

Patients often hear different things that what you say, must be aware of this.
Must also be aware of the psychological/emotional aspect to injuries.

Question 6

Examples of telling patients of their injuries the wrong way:

Answer 6

“Your meniscus is shot”
“You blew out your knee”
“Severe degeneration with disc disease”
“You have the bones of 60 year old man”`

Question 7

What is FAKTR?

Answer 7

Functional and kinetic treatment with rehab

Question 8

What are some of the primary characteristics of A-beta fibers?

Answer 8

Touch, pressure, hair deflection
Myelinated
Large diameter
Low threshold

Question 9

What are the basic characteristics of A-delta fibers

Answer 9

– Warm and cold receptors, hair follicles, free
nerve endings
• Touch, pressure, temperature and pain
• Free nerve endings respond to noxious stimuli
such as pricking, pinching and crushing
– Myelinated
– Smaller diameter than A-beta (1-6 micrometers)
» Slower conduction velocity

Question 10

What are the basic characteristics of C fibers?

Answer 10

– Pain, touch, pressure, temperature
• Include efferent postganglionic fibers of
sympathetic nervous system, mechanoreceptors,
nociceptors and thermoreceptors
• Smallest peripheral nerves associated with pain
– Unmeylinated
– Small diameter (less then one micrometer)
» Slow conduction velocit

Question 11

What are the most important parts of the thalamus for pain reception?

Answer 11

VPL (ascending fibers from the head synapse) and VPM (fibers from the head and face synapse)

Question 12

After VPL/VPM where does the pain signal go?

Answer 12

Somatosensory cortex then limbic system

Question 13

What is modulation phase?

Answer 13

• Any activity after the cortex has received input
• Have an excitatory or inhibitory role on new
impulses
• Hypothalamus

Question 14

In peripheral pain modulation what does ice do?

Answer 14

– Decrease the effects of chemical mediators

– Decrease speed of pain transmission

Question 15

What is gate theory?

Answer 15

– Non-painful stimulus can block the transmission of
noxious stimulus
– Substantia Gelatinosa in dorsal horn of spinal cord
acts as a “switch operator”.
– Interneuron that utilizes enkephalin is present in
substantia gelatinosa
– Inhibits pain transmission within the dorsal horn

Question 16

What is motor TENS?

Answer 16

– Low frequency, high intensity stimulation of
peripheral nerves

Causes activation of Reticular Formation and
pituitary gland

Question 17

DEOS

Answer 17

Descending endogenous opiate system

Question 18

What are the components of noxious pain modulation?

Answer 18

– Electrical stimulation of C fibers in the injury
area (Noxious TENS)
– Activates the Periaqueductal Gray (PAG) and
the Raphe nucleus
– Serotonin neurons in the dorsal horn inhibit
the second order neuron either directly or
through an interneuron
– Also with ice stimulation of C fibers during
burning and aching sensation

Question 19

What is nerve block pain modulation?

Answer 19

• When stimulation encroaches on the
refractory period of the sensory nerve and
causes inhibition

Question 20

What is nerve block pain modulation called and what are it’s results?

Answer 20

Called Wedenski’s inhibition or action
potential failure and results in anesthesia
between the electrodes

Question 21

What 2 EPA’s are best at achieving nerve block pain modulation?

Answer 21

Russian current, Interferential current

Question 22

What is EIH

Answer 22

Exercise induced hypalgesia. Decreased pain sensation during activity because of the activation of DEOS and catecholamines (must consider this if treating an athlete who just came off the field, may not feel the extent of the injury ‘cause all jacked up).

Question 23

Neuromuscular control consists of 3 components, all of which must be addressed in a rehabilitation plan, what are they?

Answer 23

– Consciously controlled muscle contraction (for loss of contraction ability due to injury)
– Reflex responses (e.g. ankle reflex to resist eversion)
– Complex movement patterns (injury leads to loss of these unconscious learned patterns)
• or complex functional movements

Question 24

What does a complex movement pattern refer to?

Answer 24

Unconscious movement patterns that are “second nature” after much practice.

Question 25

What are the three aspects of injury that disrupt complex movement patterns

Answer 25

– Swelling – Pain – Altered nervous system input (afference)

Question 26

T/F Pain can alter movement patterns (even in absence of swelling)

Answer 26

True

Question 27

How does pain effect motor control?

Answer 27

When active exercise is painful the motor patterns change which perpetuates abnormal motor control and slows recovery possibly leading to further injury

Question 28

What aspects of altered nervous system input have been shown to be affected with injury?

Answer 28

``` – Balance – Protective Reflexes – Force output – Joint stability – Position sense ```

Question 29

What are 4 clinical things you can do to restore neuromuscular control?

Answer 29

``` • Active Rehabilitation • EPAs to permit pain free exercises • Neuromuscular electrical stimulation for muscle activation • EMG biofeedback for retraining ```

Question 30

What is biofeedback?

Answer 30

• The use of information to bring physiological events to conscious awareness in the patient (e.g. mirror, video tape, clinicial, patient, electromyography). Measuring stress is one way to do this.

Question 31

What is electromyographic feedback?

Answer 31

``` • Teaching aid • Electrical activity in the muscles detected – Visual or auditory feedback • Relearning motor patterns and motor control • Relaxation of muscle spasm and muscle guarding ```

Question 32

Where are needle electrodes placed?

Answer 32

Over specific portion of muscle

Question 33

Where are surface electrodes placed?

Answer 33

Over whole muscles or muscle groups

Question 34

What are the clinical applications for electromyographic feedback?

Answer 34

* EMG provides positive feedback * Helps reduce trial and error * Helps reduce patient frustration

Question 35

If you are unable to generate any muscle contraction with EMG, what are 2 things you can do?

Answer 35

– Tap or stroke the muscle | – Neuromuscular stimulation (Russian stim)

Question 36

What is functional progression?

Answer 36

``` • Adjusting, EPAs, Active Care • Reduce pain and prevent/minimize adaptations • Early restoration of neuromuscular control starts with single muscles but must progress to specific activities – Rehab/Active Care ```