Module 6 Treating Pain with Modalities, Manual Therapy and Graded Motor Imagery

Why is therapeutic modalities for pain valuable tools?

-Reduces nociception
-Calms down the nervous system
-Improves the pain experience

What are some considerations for therapeutic modalities for pain/

-Passive treatment
-Patient beliefs
-Improved self-efficacy
-Utilized with symptom-provoking activities

What are the 2 mechanisms behind therapeutic modalities for pain?

-Altering of nociceptive info from the periphery
-Increased production of endogenous opioids

What is TENS for pain?

Application of low-voltage electrical current for pain relief

What is IFC for pain?

Application of 2 medium frequency currents to produce amplitude-modulated low frequency for pain relief

What are the 2 mechanisms of TENS and IFC?

-Increases central inhibition (gate control theory)
-Reduces central excitability (endogenous opioid theory)

What 2 endogenous opioids does high-frequency TENS for analgesia activate?

Beta-Endorphin and Enkephalin

What 2 things does high-frequency tens for analgesia release?

GABA and acetylcholine

High-frequency TENS for analgesia decreases the release of what excitatory neurotransmitters?

-Glutamate
-Cytokines
-Substance P

High Frequency TENS increases activity peripheral alpha-2a-adrenergic receptors, such as ____

Norepinephrine

Low-Frequency TENS activates endogenous opioids beta-endorphins, enkephalin, and ____

seratonin

Strong non-painful TENS’ stimulation ____ is critical to therapeutic success

intensity

What is the clinical utility of TENS?

-Low risk
-Non-addictive
-Cost-effective
-Over the counter
-Self efficacy

True or False: TENS should be used at the highest tolerable intensity

True

TENS is used to restore _____ and to reduce central excitability

central inhibition

For the greatest effects, where should the electrodes be placed

At the site of injury

What is the proposed mechanism behind thermal agents?

Change in tissue temperatures alters cellular and physiological function

Thermal agents have what type of pain modulation effect for the following:
-pain thresholds in healthy controls
-peripheral nociceptor activation
-nerve conduction

-Increase
-Decrease
-Decrease

What is the proposed mechanism behind ultrasound?

Acoustic energy for tissue healing, anti-inflammatory effects

How does ultrasound affect pain modulation for the following:
Peripheral nociceptor activation
Nerve conduction

Decreases both

True or False: Ultrasound has limited and inconclusive evidence for pain management

True

What pain modulation effects does low-intensity laser have for the following:
Release of substance P
Release of B-Endorphins

Decrease
Increase

What are some considerations for manual therapy?

-Pain mechanisms
-Models
-Locus of control
-Language
-Patient expectations
-PNE + manual therapy

What are the central mechanisms of massage therapy?

-Descending inhibitory pathways
-Stress reduction
-Potentially lower cortisol levels

What are the peripheral mechanisms of massage therapy?

-Increase expression of tissue healing genes
-Decrease expression of inflammatory genes

How does high thrust joint manipulation help pain?

Increases pain threshold
Decreases motor neuron excitability

What is the “physical movement of the nervous system”?

Neurodynamics

What are the three elements of neurodynamics?

Space
Movement
Blood

What are the three bottom lines with manual therapy

-Decreases mechanical/chemical irritants that activate nociceptors
-Non-nociceptive input to proprioceptors
-Activate central descending mechanisms to decrease pain

True or False: Manual therapy has no negative evidence

True

What are some contextual factors to the delivery of manual therapy?

-Treatment factors
-Patient/therapist characteristics
-Patient-provider relationship
-Healthcare setting

How does an impaired “body map” affect patients with chronic pain

-creates a “smudging” of the homunculus
-Disrupted body image
-Decreased tactile acuity in area of usual pain

What is graded motor imagery?

Various synaptic exercises aimed at restoring altered body maps

What are some techniques behind graded motor imagery?

-Normalize laterality
-Motor imagery
-Mirror therapy
-Sensory discrimination

What is the goal of laterality retraining?

Cortical reorganization in the homunculus

What is the goal of motor imagery?

Solidifying brain maps and run those maps with minimal pain, without actual movement

What are some strategies behind motor imagery?

-Think about the movement
-Visualize the activity
-Progress when can do with little to no pain

What is the goal of sensory discrimination?

Sharpen the body map on or close to the affected area
-Potential linkage of sensory & proprioceptive neural circuits to refresh body maps

What is the goal of mirror therapy?

Provide a visual cue that movement is occurring with little to no pain

What are some strategies of mirror therapy?

-Use mirrors to trick the brain
-Uninvolved extremity does movement and the mirror projects movement of involved extremity
-All about exposure
-Progress to active, graded exposure