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What is pain?

Subjective sensation: “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

Photobiomodulation absorption wavelengths

UV-B, UV-A, Blue (400-470) —— skin
Red (600-650) —— subcutaneous

infrared (>1350) HEAT

Universal contraindications

pregnancy

pacemakers

areas of sensitivity (eyes)

sites of infection or accute inflammation

tumors or cancerous lesions

metal implants

pain or diminish sensation

open wounds

ABCs of Pain perceptions (3)

Affective - one’s emotional factors affect pain experience

Behavioral - how one expresses or controls pain

Cognitive - one’s beliefs (attitude) about pain

BIOWAVE EXPLANATION

BioWave is a non-invasive, high-frequency electrical stimulation device used in pain management and tissue healing. It delivers high-frequency pulsed current (HFPC) to target tissues, which modulates pain signals and promotes healing at the cellular level.

How It Works:

• High-Frequency Stimulation: BioWave emits electrical pulses at frequencies (typically 10,000 Hz or higher) that penetrate deep into tissues without causing muscle contractions.

• Pain Gate Mechanism: The electrical impulses interfere with pain signal transmission by activating non-painful nerve fibers (A-beta fibers), effectively "closing the gate" to pain signals in the spinal cord.

• Enhanced Circulation & Healing: The stimulation increases local blood flow, reduces inflammation, and promotes the release of endorphins and other healing factors.

• Cellular Effects: The electrical currents may enhance ATP production, reduce edema, and accelerate tissue repair by influencing ion channels and cellular metabolism.

Influence on Tissue Healing:

• Reduces Inflammation: Modulates pro-inflammatory cytokines.

• Accelerates Repair: Stimulates fibroblast activity and collagen synthesis.

• Decreases Pain: Allows for improved mobility and faster recovery.

Pain vs. Nociception

nociception is the neurophysiological process that may be interpreted as pain

pain is the unpleasant sensation

Where does pain come from (4 major categories)

Nociceptive (somatic, visceral, cutaneous)

Neuropathic (peripheral, central)

Psychogenic

Carcinogenic

Cutaneous pain

sharp, bright, burning; can have fast or slow onset

Deep Somatic pain

stems from tendons, muscles, joints, periosteum, and blood vessels

Visceral pain

originates from internal organs; diffuse at first then may be localized

Psychogenic pain

individual feels pain but cause is emotional rather than physical

Pain Sources

Fast - localized through A-Delta axons in skin

Slow - aching throbbing burning carried by C Fibers

What is referred pain?

occurs away from pain site

Noxious means…

harmful, injurious

Nociceptor

nerve receptor that transmits pain impulsesP

Pain Threshold

level of noxious stimulus required to alert an individual of a potential threat to tissue

Pain Tolerance

amount of pain a person is willing or able to tolerate over the threshold

Accommodation phenomenon

adaptation by the sensory receptors to various stimuli over an extended period of time (less sensitive over time)

Hyperesthesia

abnormal acuteness of sensitivity to touch, pain, or other sensory stimuli

Paresthesia

abnormal sensation such as burning, pricking, tingling

Inhibition

depression or arrest of a function

Analgesic

a neurologic or pharmacologic state in which painful stimuli are no longer painful

Types of Nerves

Afferent (Ascending) transmitting from periphery to brain

• first second and third order neurons

Efferent (Descending) transmitting from brain to periphery

First Order Neurons

Stimulated by sensory receptors, end in dorsal horn of spinal cord

• A-Alpha: non pain

• A-Beta: non pain

• A-Delta: pain due to mechanical pressure (SHORT/FAST)

• C Fibers: pain due to chemical or mechanical (SLOW)

Second Order Neurons

Lamina II, Substantia Gelatinosa (SG) determine the imput sent to T Cells from peripheral nerve

T Cells organize and transmit to CNS (brain)

ENDS IN THALAMUS

Third Order Neurons

Begin in Thalamus

ends in specific brain centers

• perceive location, quality, intensity

• integration of past experiences and emotions to determine reaction to stimulus

Neurotransmitters

Chemical substances that allow nerve impulses to move from one neuron to another

Substance P Neurotransmitter

responsible for transmission of pain producing impulses

Acetylcholine Neurotransmitter

transmits motor nerve impulses

Enkephalins Neurotransmitter

reduces pain perception by bonding to pain receptor sites

Norepinephrine Neurotransmitter

causes vasoconstriction

2 types of chemical neurotransmitters that mediate pain

Endorphins (morphine like, incr. pain threshold)

Serotonin (local vasodilation, incr. permeability of capillaries)

4 types of Sensory Receptors

Mechanoreceptors - touch, light or deep pressure

Thermoreceptors - hot/cold

Proprioceptors - change in length or tension

Nociceptors - painful stimuli

Nerve endings are

termination of a nerve fiber in a peripheral structure

endings may be sensory or motor

nociceptors and sensitivity

sensitive to repeated or prolonged stimulation

mechanosensitive - excited by stress & tissue damage

chemosensitive - excited by the release of chemical mediators

Neuroanatomy: synapse

“Lock and Key”

unique receptor shape for neurotransmitters allows for competitive inhibition (morphine)

Gate Control Theory of Pain

Operates @ Spinal Level, proposing single gate mechanism located in the Second Order Neurons

Both large and small fibers stimulate T Cells which pass information to the action system, but they stimulate differently— Large fiber = + on SG, Small fiber = - on SG

Inhibitory mechanism located in the SG (inhibiting T Cell)

Central Control (brain) inhibits or facilitates the T cell directly. Central control integrates information from multiple sources.

Neuromatrix Theory of Pain

“multidimensional experience"

produced by characteristic neurosignature patterns of nerve impulses

patterns may be triggered by or independent of sensory inputs

Acute pain is evoked by brief noxious inputs transmitted to and processed by the CNS as described by the gate control theory

Neuromatrix: unique to each individual, initially determined by genetics, heavily modified throughout life/experiences

Questions to ask about pain

Pattern (onset & duration), Area, Intensity, Nature (description)

Pain assessment scales

Visual & Numeric analog scales, locate area of pain on picture scales

5 distinct and successive physiologic phases of experiencing pain

Transduction (converting energy)

Peripheral Transmission Phase

Modulation Phase (suppression/amplification)

Central Transmission Phase

Perception Phase

Variability of pain tolerance

varies from person to person and episode to episode

Learned pain

conditioned response which develops from pain memories of physiological and emotional elements of either nociceptive or neuropathic pain experience

Goals in managing pain

reduce & control

protect from further injury while encouraging progressive exercise

Drugs and Pain relief

Morphine blocks pain (fills NT binding site)

Bradykinin

directly stimulates nociceptors

Prostaglandins

sensitization of the nerve fibers so that other mediators can enhance nociception

Substance P

NT released centrally to produce the pain response and peripherally producing hyperalgesia and inflammatory responses

Histamine

released by mast cells to directly stimulate nociceptors

Pathology of pain

Referred pain - pain is felt some distance away from actual site

Phantom pain - following amputation pain in missing limb (neuroma, ectopic activation)

Problem Solving Approach (PSA) incorporates

Clinical exam findings, long term goals, available evidence

Treatment and Rehab program planning integrates

Clinical exam skills, knowledge of pathology, goal settings, patient motivation and education, knowledge of physiological effects of therapeutic techniques, id of the patient’s level of function

Internal Classification of Function (ICF)

Disease oriented approach

interventions focused on resolving pathology

Patient oriented approach

interventions focused on factors that are meaningful to the patient

Minimum detectable change (MDC)

smallest clinically significant difference in the scores of 2 administrations of the instrument; useful in determining the efficacy of an intervention

Minimally clinically important change (MCID)

measure of responsiveness, smallest change that is important or beneficial to patient

the goal of evidence based practice is to

provide most efficient effective treatment, maximizing outcomes and making effective use of time

Factors to consider when choosing modality

can energy produced by modality directly or indirectly affect target tissues?

can modality produce the physiological response required to promote healing?

does this device improve patient outcomes better than a placebo treatment or no treatment at all?

PICO meaning?

Patient, intervention, comparison, outcome - provides a structure for developing clinical questions

PSA approach steps

1. Obtain medical history

2. Identify patient activity limitations

3. Prioritize the problems

4. Set treatment

5. Review evidence

6. Plan interventions

7. Re-examine patient and assess outcomes

Medical History

review existing records

identify contraindications to specific interventions

problem recognition

conduct formal patient examinations & re-examinations regularly

Long term goals

indentify and quantify the final outcomes of the program

focus on restoring participation rather than addressing the individual pathologies afflicting the person

Short Term goals

2 weeks or less

describe patient’s projected progress in a specific time and focus on the specific problems identified during the examination (and if they will achieve long term goals)

Treatment planning

application of knowledge of the physiological effects of the therapeutic modalities and exercise to resolve the problems required to achieve the patient’s goals

Considerations of the healing stage

Active inflammatory stage (decrease inflammation, reduce secondary hypoxic injury and control edema)

Proliferation phase (increase blood flow to and from injured tissue while trying to control edema)

Maturation phase (increase tissue extensibility and control post-exercise inflammation)

patient self treatment

instructions should be given to the patient in writing, and illustrations that depict the exercises to be performed are also helpful

Reexamination

if short term goals are met, create new ones

if not met, identify why

develop new treatment plan

re-administer outcome measures

influences on patient care

treatment setting, experience and expertise of staff, type of equipment available, time and financial constraints

why keep records?

communication and quality control

legal considerations

research

injury history

traffic patterns

Legal considerations in patient care

professional ethics and responsibility mandate the care provided be in the best interest of the patient, be safe and effective, and progress toward meeting the patient’s goals.

Scope of Practice

legal boundaries that define the manner in which clinicians may practice

Medical prescription

therapeutic modalities that require prescription medications necessitate that each patient have a prescription

informed consent

except in cases of emergency care, patients must grant their consent to be treated

seeking treatment implies consent

patient confidentiality

Health Insurance Portability and Accountability Act (HIPAA) affects past present and future medical records and seeks to ensure confidentiality by controlling protected health information (PHI)

Family Education Rights Privacy Act (FERPA) protects education records, including medical files, from unauthorized release

Negligence

providing care that falls below the minimally accepted standard

omission occurs when an individual fails to response to a given situation

commission occurs when an individual acts on a situation but does not perform at the level that a reasonable and prudent person would

negligent care of facilities

food and drug administration oversight

major regulator of over the counter and prescription medications

occupational safety and health administration regulations (OSHA)

prevent work related injuries and illnesses and through enforcement branch fines or prosecutes employers who do not comply with these standards

medical documentation

if it wasnt documented it wasnt done

each state’s statute of limitations determines the length of time that medical records should be kept after the patient is no longer receiving care

treatment rendered and patient progress

documentation of the day’s treatments should describe the date, time, individual or individuals providing the care, the pathology treated, the modalities and exercises used and parameters used

legal record

well-documented records assist in proving that staff exercised reasonable patient care if a liability were to come to trial

reimbursement documentation

therapeutic services billed for this purpose wil be reimbursed only if they meet the patient’s treatment goals

legal considerations

most lawsuits occur years after the event usually after the memory of specific details are gone

records supply proof

facilities

physical facility where care is given must be free of potential hazards and be conducive to patient care, including access by disabled patients or clinicians

hydrotherapy area, treatment area, plumbing and electrical are of special concern

product maintenance

requires regular inspection for defects/hazards, periodic cleaning, and professional calibration according to manufacturer recommendations

SAID principle

Specific Adaptation to Imposed Demands

body responds to a given demand with a specific and predictable adaptation

Atrophy vs. Hypertrophy

Atrophy

• protein synthesis ↓

• protein degradation ↑↑

Hypertrophy

• protein synthesis ↑↑

• protein degradation ↓

Principle of Specificity

exercise adaptations specific to mode and intensity of training

must stress most relevant physiological systems for given sport

training adaptations highly specific to type of activity, training volume, and intensity

Muscle Overload

muscles must be loaded beyond normal loading for improvement

strength training

high resistance 2-10 RM training

• gains in strength

Primary signals of resistance training in muscle fiber

Muscle stretch increase = microtears → igf-1 , Akt, mTOR → protein synthesis

Signal timing for protein synthesis

hours post exercise incr. protein synthesis

muscular hypertrophy most important aspect

the load

mechanisms of muscle strength gain: fiber type alterations

type IIx → type IIa transition common

muscular endurance is the ability to

make repeated contractions against a submax load

endurance training involves

low resistance training 20+ RM

Primary signals for resistance training

increase in Ca2+, AMP/ATP, Free Radicals

post exercise endurance training

days post exercise = increase in PGC-1 and mitochondrial biogenesis

endurance training induced changes in fiber type

fast to slow shift in muscle fiber type

increased # of capillaries