1
Q
Nervous System Viscoelasticity
A
Nervous tissue connective tissue
- Accepts tensile + compressive loads + transferring loads
- Adaptability through passive movement
–> elongate
–> longitudinal movment of nerve trunk
–> Level of relaxation of tissue at nerve trunk
- Can stretch up to 2cm or 10%
2
Q
What are the Tension sites?
A
- Tether points
- Stabilizes the spinal cord
C6
T6
L4 - Movement at tension sites depends upon the location of the stress and the order in which it is applied
3
Q
What are the peripherial tension sites?
A
Elbow
Shoulder
Knee
4
Q
Neurodynamic dysfunction
A
- compromise of nerve and microcirculation
- Adherent duram thethered unable to glide and stretch
- limited movement of body segment
- predispose nerve injury –> cascasde inflammatory process–> fibrosis tissue formation btw nerve and sheath
- motor, sensory, sympathetic
5
Q
Precautions to Neurodynamic
A
- recognize irratibility
- monitor response
- screen for active disease affecting nervous system
- Watch for signs of vascular compromise
6
Q
Contraindications for neurodynamic
A
- acute or ubstable neurological signs
- cauda equina symptoms related to the spine
- spinal cord injury or ysmptoms
- neoplasm
- infection
7
Q
Neurodynamic Tests
A
Upper limb tension test 1-4
Slump
Stright leg raise
Prone knee bend
8
Q
4 ULTTs
A
- ULTT 1- median nerve, anterior interosseous C5,C6,C7
- ULTT 2- Median nerve, musculocutaneous, axillary
- ULTT 3- radial nerve
- ULTT 4- Ulnar nerve C8 & T1 nerve roots
9
Q
Slump test is for diagnosising
A
Lumbar ridculopathy or disk herniation
- High false positive rates in asymptomatic individials
- Very high sensitivity
- CUtoff scores symptoms 22 degrees from terminal knee extnesion
10
Q
SLR neurodynamic assessments what are the different positions for each nerve
A
- DF + Eversion + great toe extension = tibial nerve
- DF + inversion = sural nerve
- PF + inversion = fibular nerve
11
Q
Positive Findings of SLR
A
- Stresses the sciatic nerve
- back pain alone is not a positive finding
- <70 degrees considered postivie reproducing sciatica symptoms pain radiates below knee neurological in nature
- 0-30 degree range may indicate serious pathology or malingering
- 30-70 degree range L4-S2 tissues are stretched 2-6mm
- > 70 degrees other structures become stretched
- Non-neural confounders: SIJ , hamstring length, lumbar facets, connecctive tissues, hip joint
- COrelate with other findings from evaluation
12
Q
Prone Knee Bend
A
- stretches the femoral nerve
- 80-100 degrees dura is stretched L2,L3,L4
13
Q
Prone Knee Bending Findings
A
Postive= reproduction of symptoms
- >100 degrees rectus femoris stretch and lumbar spine motion
- sensitivity 84%
14
Q
What is the goal of neurodyanmic interventions?
A
- restore normal mobillity and extensibility to nerve tissues- prevent adhesion formation after acute injury or surgery
Alleviate mechanical stimuli:
–> reduce mechnical stimuli
–> reduce traction/tension forces
–> reduce inflammation
–> modify enviornmental contributors
–> reduce intinsic pressures and improve nerve conduction velocity
15
Q
General principles of dosing for neurodynamic assessment
A
Intensity
–>irritability of the tissue
–> patient response
–> change in symptoms
- Greater irratibility –> gentler the technique
- graual approach : surrounding tissues–> neural tissues
- Neurological symptoms of tingling or increased numbness should not last when the stretch is released
- Once the patient has shown improvement–> the self-mobilization can be taught
16
Q
Neural Tension Technique
A
- Take limb to point of neural tension –> actively or passively move one joint in the pattern
- Hold 15 seconds then release and repeat (stretch)
- Oscillations into symptomatic range 15-30 seconds bouts (glides)
- Observe patients response
- reassess comparable sign repeat tension test, ROM
17
Q
Nerve Flossing Technique
A
- Take the limb to the point of tension
- moving two joints actively or passively
- ONe joint will move into position of increased tension the other into slack
- this maintains a constant tension on the nerve while it flosses back and forth through the surrounding tissues
- position can be held for 15 to 20 seconds released and repeated several times or performed with rhythmic oscillations of the movement
18
Q
Precautions to Tension/Flossing neurodynamic technique
A
- recognize irratibility
- monitor response
- screen for active disease affecting nervous system
- watch for sign sof vasuclar compromise
19
Q
What is the classic view of pain model?
A
Cartesian Model
- Bottom up view of pain
- That pain is a direct measure of tissue damage and the brain is a passive recipient of pain signal, stright through channel from the pain nerve to the pain center in the brain
20
Q
What is the specificity theory?
A
- Specific nerve to specific pathay to specific pain center within the brain
21
Q
Pattern Theory of pain
A
Generic nerves and the signal of pain is based on the coding of sensation or impulse
- How a frequency or intensity of the nerve signal is what actually creates the sensation of pain
22
Q
Affect theory of pain
A
- Pain is viewed as an emotion not a sensation
- Affective as a parallel process to or product of sensory process of pain
23
Q
Gate Control Theory of Pain
A
- Pain is the product of imbalnce of small and large fiber input
- INcludes central control system and process of descending control over sensory inputs
- Looking at a 2 way process going on through pain nerve impulses and that also the brain itself can controll/centrally control pain sensation
24
Q
Current Theories of Pain: Neuromatrix Theory of pain
A
- The brain and spinal cord are what produce pain, not tissue damage
- Various parts of the central nervous system work together to produce pain
25
Neuromatrix of Pain Theory
- Multiple inputs to different parts of the brain happening at once
- produces pain as an output in addition to other outputs
- genetically determined and enviornmentally shaped
26
Neuromatrix View of Pain
Nociception (noxious stimulus/tissue damage) + Threat ( perception of danger) = Pain (phenomena of the brain)
27
Biopsychosocial Perspective
Looking at the person as a whole
- pain is a component of the interplay between sensory info + emotion + context
28
Mature organism Model
- Views pain as a survival tool
- Humans as a mature organizm sample the enviornment/scrutinize the input and then respond
- pain perception = sensory dimension
- + altered thoughts= cognitive dimension
- + altered feelings= affective dimension
--> all of which alter outputs = behavior/physiology
- with pain there is either some negative noxious stimulus coming from the neviornment/tissue inputs the brain scrutinizes it
- Inputs are brought in and pain/nociception is just another input thats put in and procesed by the brain in order to improve our survival
29
Fear Avoiding Model
1. pain input - threat level- so if percieved as a low threat what will happen is they will give priority to their life goals over the perception of pain which is helped by positive affect and optimism they then cope and revoer from the pain
2. If the person percieves pain in the context of high threat then they are going to give priority to the pain ---> pain control over their life ---> feed into by negative affect/harm representation of pain and then end up doing the outward behavior will be ---> fear of pain/avoiding pain and interfere with recovery which leads to a negative affect ----> more ppor negative bad emotions which feeds back into pain/threat loop
30
Pain Catastrophizing
(FEAR)
- Tendency to explain pain experience in more exaggeration terms than average person
- Increases pain through altered attention, anticipation, and emotional response
31
Pain Catasrophizing Scale
Rumination: Attenion
Magnification: Exaggeration
Helplessness: Low self affect
32
What are the 4 stages of Stress
Stage 1 = Stimuli form one or more of the five senses are sent to the brain
Stage 2= The brain deciphers the stimulus as either a threat or non-threat
Stage 3= The body stays activated or aroused until the threat is over
Stage 4= The body returns to homeostasis, a stage of phsyciological calmness once the threat is gone
33
Stress and the HPA Axis
- Hypothalamus Pituitary Adrenal Axis
- Stress involves perception of threat and pain itself can be a stresso and stress can exacterbate the pain and there are broad long term effects with having chronic stress that are similar to some of the things we see in centralized pain
34
Stress Response
1. 1st stimulus and brings it through your senses and the info is then processsed by the amygadala and judged as stressful and does this with some consultation with the hippocampus (our memories)
2. If the amygadla decides it is a threat it sends that info to the hypothalamus
3. Hypothalamus is in charge of the stress response---> so the hypothalamus is goin got send a signal to the adrenal medulla
4. Adrenal medulla will then release epineprine / norepinephrine and this will work in cases of short term stress response, fight/flight/HR/RR and will also send a signal to the pituitary
5. Pituitary will respond to that signal from the hypothalamus by producing adrenal corticotrophic hormone that will stimulate the adrenal cortex
6. Adrenal cortex is going to produce cortisol which will enable our body to maintain blood sugar levels throughout the stress response
35
What is the long regulator of stress?
HPA Axis
36
Chronic Stress
- Long tern stress- negative feedback loop
- Cortisol inhibits hypothalamus and pituitary
- Overtime the over used glands become less effective and then not able to function as well in actual stressful situations
- Lower cortisol levels impair ability to conrol inflammation (immunosuppression)
- Reduced growth factors in the brain (rpair and make new neurons will be reduced)
- Decreased function and size of hippocampus (needed for memory and mood and it can be negatively effected)
37
Health Effects of Chronic Stress
HTN
DM
Heart disease
Insomnia
Muscle Pain
Digestive Disorders
Excretory dysfucntion
Weak immun system
Reproductive dysfunction
Exisiting conditions get worse
Anxiety
Mood disorders
Overwhelm
Burnout
Maladaptive behaviors
38
Effects of Stress on The Brain
- The more stressed you feel the more susceptible you are to feeling stress
- Well worn path from the amygdala to the hypothalamus
- Amygdala calling the shots
- Put the prefrontal cortex back in charge to try and get rig of threat signals
39
Sleep
- Poor sleep and persisitant pain related
- sleep impairments stronger predictor of pain
40
Neuroplasticity
- Cortical map
- Sensory and motor cortices --> biologically coded/enviornmentally sculpted
- CHanges happen all the time--> learning
- Pain can cause maladaptive changes
41
Cortical Changes In Response to Pain
- Pain can quickly influence cortical maps
- Size changes: body representation grows
- Laterality recongition: Difficulty differentiating left from right
- Smudge: representation blurs
42
T/F Presentation of pain in acute phase can be the same in chronic phase
True
- pain is not phasic and not bound by phasic stages of healing
- Don't tie long term pain to some sort of phase of healing
43
Nociceptive
- Due to activation of nociceptors
- Inflammation
- Mechanical irritant
- Injury
Examples: OA, ankle sprain, RA
44
Nociplastic
- Due to disturbances in central pain processing
- increased excitability
- decreased inhibition
Examples: fibromyalgia, non specific lower back pain
45
Neuropathic
- Due to lesion or disease of the somatosensory system
- Examples: carpal tunnel , diabetic neuropathy, complex regional pain syndrome
46
Nocioceptive Pain Dominant
- Caused by stimulation of peripherial nociceptive fibers ---> some chemical/mechanical/ thermal noxious stimuli at play stimulating that nerve fiber
Presentation:
---> Pain localized and proportional to injury
---> Responds to aggravating and alleviating
---> Intermittened and sharp with movement/provication
---> Constant dull ache to throb at rest
Follows a predicatable pattern
47
Peripheral Neuropathic Pain dominant
--> Acutal injury to a nerve
--> Altered structure and function of peripheral nerves: no single mechanism
Presentation
--> referred in dermatomes or cutaneous distribution
--> history of nerve injury or disease
--> Proviation with test that load neural tissue
48
Nociplastic/Central Sensitization
- Amplification of neural signaling in the CNS that elicits pain hypersentivity
- Maintenance of persisiten pain state
- Nervous system " wind up" ---> wind up is inhibition of descending inhibitory pain pathways that then scews excitatory inhibitory inputs that contribute to the intensity of pain and changes the pain thresholds + contributes to spreading/radiating pain to uninjuried sites
- persistently highly reactive
- Imbalance of inhibitory and excitatory cells
49
Alodynia
Painful response to a normally non painful stimulus
50
Hyperalgesia
Amplification of sensation of pain
51
Irritability
Can be disproportionate to the stimulus so they could get aggervated easily and stay aggervated for a long time
52
Diffuse pain
Spreads out and remote to the area of injury + ill defined boarders + hard to localize + distribution of pain is altered
53
Symptoms associated with Central sensitization
Restless leg
Stress
Heachaches
Digestive
Energy
Sleep
54
2- Point Discrimination
It measures sensory thresholds in a receptive field
- in areas we have more density or receptive fibers/nerves we are going to have very fin small 2-point discrimination
- Has to do with density of receptors in the skin
- Contrextual influences: practice, fatigue, stress : its not 100% reliable due to outside conditions
- People who have cortical changes there may be a diminished ability to differentiate 2 points from 1 point and these 2 points discriminations thresholds any closer togehter than 1 cm ---> signals that there is a cortical change an that the receptors are not processing in put correctlu =cortical re-mapping
55
Sensation Localization and Graphesthesia
- Both are linked to cortical re-mapping
1. Graphesthesia= the ability to recognize a common symbol that is traced on the skin
2. Sensation Localization= The back is mapped as a grid and you see if the person can identify where they are being touched: someone in persistent pain state its common to find they don't know /lack the ability to localize light touches to the skin or any touch to the skin
56
Laterality recognition
The ability to identify L and R and found to be impaired in people with persitant pain/cortical changes can happen super fast and this can come on very quickly after an injury occurs
- To test someon you show them a series of imgaes and they look at the hand and have to try and identify if its L or R
57
Fibromyalgia
- Complex polysymptomatic
- Chronic widespread pain
- fatigue and sleep alterations
- autonomic disurbances
- cognitive dysfunction
- hypersentivity to external stimuli
- somatic syptoms
- psychiatric disorders
58
4 pillars of treatment fo Fibromyalgia
1. Patient education
2. fitness
3. pharmacology
4. Psychotherapy
59
Exercise/Fitness for Fibromyalgia
1. monitor BP/HR
2. low moderate aerobic exercise
3. Flexability exercises
4. Strength training
5. promote safety/reduce threat
6. aquatic therapy
7. low impact; swimming, biking, yoga, tai chi, pilates
Parameters
- short sessions initially 3-5 minutes
- RPE scale to measure tolerance
- Increased duration in small increments
- No pain nor gain DOES NOT apply here
WEAK evidence for manual therapy
WEAK TO NO evidence support modalities
60
Education vs. Graded Exposure
Education= pain/neuroscience education
Graded exposure= exposing the pt. in a step by step graded manner to what exaacterbtes the pain or scares them about pain
61
T/F without a threat/perception of dnager there is no pain
True
62
Neurophysiology-Neuroplasticity:
Top Down=
Brain down
Cognitive Based Interventions
- education about pain neuroscience
- graded motor imagery
- Cognitive behavior therapy
- mindfulness meditation
Work in the brain to help influence + make neuroplastic changes and influence how pain is percieved
63
Neurophysiology-Neuroplasticity:
Bottom Up
Using somatosensory input around thr body throuhg things like :
- physical interventions
- manual therapy
- motor learning
- peripheral discimination training
Also can help influence neuroplasticity as well
64
Biopsychosocial Approach
- recognizes we are talking to a person NOT just a piece of broken anatomy- person has to percieve the sensation as a threat fro it be percieved as pain
Recognize Threats:
- Injury
-Surgery
- Accident
- Disease
- Aging
- Brain map
- Fear
- Catastrophizing
- Social
Pain is activated whenever there is percieved threat
65
Pscyhologically Informed PT practice
- Understanind and being informed by psychological principles not avoiding/ down playing psychosocial influences in our pts. lives
4 Themes Central to Success from Patient Perspective
1. Working with the whole of me
2. more than just a professional
3. awareness
4. working throuhg challenges in the therapeutic relationship (therapeutic alliance)
66
Therapeutic Alliance
You and the patient are working together in a team collaberative partnership
67
Cognitive Behavioral Therapy
- Thoughts/feelings/behaviors
- Principle assumptions: thoughts,emotional responses, physiological and behavioral responses interact and influence one another
- Was made to improve coping with depression, anxiety, chronic illness, pain---> to help the pts. have strategeies to solve problems, change patterns of thought, behavior, and emotional regulation
- Cna be used to correct maladaptive thinking about pain
68
Mechanism- Based Approach to Pain Management: Nociceptive
- exercise
- massage
- TENS
69
Mechanism- Based Approach to Pain Management: Nociplastic
- Education
- Exercise
- massage
-Manipulation
-TENS
70
Mechanism- Based Approach to Pain Management: Neuropathic
- exercise
71
Mechanism- Based Approach to Pain Management: Pyschosocial
- Education
-Exercise
- Massage
72
Mechanism- Based Approach to Pain Management: Motor
-Education
- Exercise
- Manipulation
73
T/F when a patient is educated on actual pain science it reduces pain, disability, catastrophizing and improves movement
True
74
Pain/Neuroscience Education: Advice to Patients
- Aerobic exercise (brisk walk for 10-20 minutes, raise HR 20 BPM)
- Sleep hygiene (8 hours)
- Activity Logging
- medicine- antidepressants can help refer to MD
- Goals & pacing: task oriented goals broken into manageable chunks
75
Mindful Meditation
- "non-elaborative, non-judgemental awareness" of present moment experience
- movement by moment attention to cognitive, emotional, senosry events
- Recognition that the moment is temporary and subject to change
- Lack of cognitive/emotional apprasial or judgement about events
2 basic forms
1. Focused attention: uses an attentional focus example-breahting control
2. Open monitoring: non-focused, open and non-judgemental monitoring of awareness itself
76
Mechanism of Mindfulness Mediation
- enahnced cognitive and emotional control
- Altered contextual evaluation fo senosry events ---> Apprasial of senosry events at your feet touching the floor/sensations that you are perciveing and evaluation of those sensory events can change and modulate the pain response
Attenuates the Subject Experience:
- Expectations
- Attention toward experience
- Emotional response
- enhanced acceptance and coping
*********- Experienced: effects seen even when not in meditative state ---> pain intensity, same, unpleaasantness decreased*********
Very little training needed for results
77
Attenuate definition
Reduce effect/value
78
Breath Control
- Breahting in a link between our voluntary and involuntary NS
- Our breathing automatically responds to stress (sympathetic NS)
- We can control our breathing levels and tap into parasympathetic NS
-
79
Graded Motor Imagery Definition
- Brain exercise that works at the synaptic level to restore the map of the body and brain
Reorganize:
- body schema
- self awareness
- Ownership
- Slef-perceptions
80
Progression Low to High Threat
1. observation
2.L/R judgements
3. Imaging movements
4. Mirrors
5.Physical movements and activities
81
Implicit Imagery Task=
Person doesn't notice that they are mentally moving---> working from low to high threat and relaxed images to higher threat images the body part positions/engaging activitues that are painful/ threat for that pt. is typical progression
82
Motor Imagery
- Imaging body part
- Start imagery of resting/neutral/comfortable position---> move to comfortable movement---> imagening a painful static position---> painful movement ---> painful activity/task
- Activates the same areas in the brian as actual movemnt and has a broader effect in just a movment
- Low threat approach
- Frequent reps 2x a day
- Activates the same motor areas of the brain as actual movement
83
Mirror Therapy
- Using a mirror to trick the brain
- Improvements in motor, sneosry, and attention
84
Sensory Discrimination
- Aims to reverese cortical reorganization
- Bottom up approach ---> tactile discrimination: sensorimotor training
- recognize location of stimulus
- recognize type of stimulus
- requires active perception by the patient
- treatment variability, no set standards
85
Ideal transition of care from hospital to community
1. discharge planning
2. complete communication and information
3. availibility, timelines, clarity and organization of information
4. medication safety
5. educating patients to promote self-management
6. Advance care planning
7. coordinatingg care among team members
8. monitoring and managing symptoms after discharge
9. outpaitnet follow up
86
Re-Assessment Vs. Re-eval
1. Re-assessment = at every intervention , the patients status should be constantly reassessed and documented
2. Re-eval= Repetition of the initial eval - done for formal reporting to payers/physcian ---> shows the status of goals /makes case to continue or discontinue care, make changes to goals or plan of care
87
Outcome Definition
- end result of PT management
- personal level measure
- record changes over time
- can be observation/measures made by clinician from the examinationT
88
T/F Patient Reported Outcomes are tested and vaild tools
True
- evidence based
- collect information from the patients perspective
- Standardized way of evaluating the effects/outcome of any intervention
89
Types of outcome measures (PROs)
- condition or impairment specific
- region specific
- broad functional scales
- quality of life
90
Evidence based
methodological research- non-experimental design
- describe development
- describe validation study
91
Minimal Detectable Change
MDC - the amount of change that has to occur so that I know it is not by accidnet/error
92
MCID
the amount of change that need to occur to have meaingful clinical change : minimally clinically
93
Steps of Recovery
1. Acute/inpatient rehab
2. Subacute inpatient PT
3. Home PT
4. Outpatient
5. Recovery
94
Daily note
Reports on the individual visit and response that day
95
Progress note
reports on responses across time
96
Re-examination
process of performing, tests, measures and outcome measures like intial exam in order to evaluate progress to update POC
- if patient is having issues /symptoms you may want to re-evaluate
- new status made by MD
- 3rd party payers might have certain time frames
97
T/F a re-examination cannot be performed by a PTA
True
Winter 2024 MSK 1
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