1. the method of afferent nerve fiber stimulation designed to control pain through various mechanisms ?
  2. what type of current do TENS units use?
    pulsed current of asymmetrical, biphasic, square/rectangular or triangular/spike waveform
  3. nocioceptors receive noxious stimuli thru what kind of fibers?
    A delta (acute)

    C fibers (chronic)
  4. pain stimuli then go where after they are received?
    spinal cord
  5. after the pain stimuli reach the spinal cord what are the next progressions?
    spinal cord--substania gelinousa neurons in grey area--reticular formation--thalamus--somatosensory cortex
  6. pain is based on an imbalance of excitatory and inhibitory input to the T cells located within the spinal cord

    desribes what?
    gait control theory of pain
  7. excitatory input in gate controlled theory comes from what fibers?
    A delta, C-fiber afferent fibers
  8. inhibitory input in gate controlled theory comes from what fibers?
    A-beta non-nocioceptive afferents
  9. when the gate is open what happens?
    excitatory is greater than inhibitory

    = PAIN
  10. the gate is closed what happens?
    inhibitory is greater than excitatory

  11. morphine induced analgesia

    describes what type of pain control?
    endogenous opiate system
  12. opiate receptors ____release of substance P from _____ fiber terminals and ______pain transmission


  13. what does substance P do?
    excites pain transmitting neurons located in the spinal cord
  14. what do chemicals like Beta endorphine do to opiate receptors?
    inhibit pain
  15. Sensory pain management specifics
    mode of TENS:
    mechanism for action:
    what it does to fibers:
    conventional, modulation, SD


    gait theory

    stimulate A beta afferent to inhibit T cells
  16. Motor pain management specifics
    mode of TENS:
    mechanism for action:
    what it does to fibers:
    low frequency, burst


    endorphins for analgesia

    stimulates deeper afferent nerves which cause release of beat endorphine from hypothalamus and pituitary gland
  17. nerve block pain management specifics:
    mode of TENS:
    what it does to fibers:
    brief intense

    decrease conduction along A delta and C fibers durng stimulation which blocks AP of nocioceptors

    can produce an incrase of K which inhibits Na transport and conductance
  18. sensory stimulation:
    phase/pulse duration
    duration tx
    duration of analgesia after tx
    pins and needles/tingling

    50-125 microsecs

    50-110 pps

    20-60 mins

    short duration of analgesia
  19. motor stimulation:
    phase/pulse duration
    duration of tx
    analgesia after tx
    muscle twitch

    200-500 microsecs

    1-5 pps

    30-60 mins

    long last analgesia
  20. noxious level:
    phase/pulse duration
    duration of tx
    analgeisa after tx
    painful sensation

    less than 1 msec

    1-5 pps or less than 100 bps

    few seconds to minutes

    analgesia lasts long
  21. nerve block:
    phase/pulse duration
    duration of tx
    analgesia after tx
    maximum paresthesia

    250 microsecs

    110 pps

    15 mins

    short analgesia none to few mins
  22. Contraindications of TENS (4)


    over carotid sinus , laryngeal/pharyngeal muscles

    while operating heavy machinery
  23. advantages of conventional mode TENS

    fast acting

    used with acute and chronic

    can use it 24 hours
  24. disadvantages of conventional TENS
    short acting analgeisa affect

    based on chemical mechanism of action

    adaptation to stimulus is common therefore you need to increase amplitude or pulse duration
  25. advantages of modulation mode TENS

    fast acting

    used for acute and chronic

    can use 24 hours

    decreased nerve adaptation
  26. disadvantages of modulation mode of TENS
    analgesic effects are rarely felt after treatment has stopped

    constant changing stimulation can be annoying
  27. strength duration mode of TENS: mechanism
    amplitude will decrease % while the pulse duration increases % to main a certain strength of stimulation
  28. advantages of SD TENS

    fast acting

    used for acute/chronic conditions

    can use for 24 hours

    decreased nerve adaptation
  29. disadvantages of SD TENS
    analgesia is limited to time of stimulation
  30. advantages of low frequency TENS
    longer lasting analgesia following treatment due to the 2-6 hour half life of beta endorphine

    adaptation to stimulus is slight, requiring only minimal adjustment of amplitude and pulse duration
  31. disadvantages of low frequency TENS
    motor response required to activate this mechanism--some patients may not get to this level

    not good for very acute conditions

    motor response may limit functional activities while undergoing stimulus

    stimulation is decreased to 1 hour

    onset of analgesia is delayed 20-30 mins
  32. advantages of burst mode TENS
    longer lasting analegisa due to the 2-6 hour half life of beta endorphine

    adaptation to stimulus is slight

    more comfortable than low frequency
  33. disadvantages of burst mode TENS
    motor response is required to activate this mechanism--some people can't get to that point

    not good for very acute conditions

    motor response may limit the functional activites of the pt during treatment

    stimulation is limited to 1 hour

    onset of analgesia is about 20-30 mins after treatments
  34. advantages of nerve block TENS

    very fast onset of analgesia

    can be used on extremely acute conditions
  35. disadvantages of TENS
    fast return to normal sensation when tx is done

    not effective for chronic pain because tx sessions are only 15 mins

    treatment best when placed over superficial peripheral nerves

    higher intensities can be annoying
  36. the use of ultrasound and electrical stimulating currents in combination to provide analgesia and reduce the effectiveness of the pain-spasm cycle.
    US and E-stim combo
  37. what is the most common condition that US and e stim combo is used for?
    myofascial trigger points
  38. US:
    1 MHz for deep structures

    3 MHz for superficial structures
  39. US:
    duty cycle
    20% pulsed for nonthermal effects

    100% continuous for thermal effects
  40. US:
    acute: less than .5 W/cm2

    subacute .5-1.3 W/cm2

    chronic 1.3-3.0 W/cm2
  41. US indications:
    soft tissue shortening

    subacute/chronic conditions

    can be used for muscle gaurding or trigger points

    can be used for wound healing
  42. Contraindications of US
    decreased arterial circulation


    do not use over eyes or abdomen if pregnant

    do not use if pt has cancer
  43. E stim for chronic condition:
    pulse width/duration-
    local visible muscle contraction

    1-4 Hz

    200-500ms, wide pulse width
  44. E stim for acute conditions:
    pulse width/duration
    comfortable sensation below motor stimulation level

    50-110 Hz

    50-125 ms, narrow pulse width
  45. advantages of US and E-stim combo
    increase efficacy of both

    US can provide a theraml effect in addition to the analgesia of the e stim

    can be used to treat a variety of conditions
  46. disadvantages of US and E stim combo
    not scientifically founded
  47. TENS like device used to deliver electrical stimuli to accomplish a variety of therapeutic purposes. Different from other methods delievering e-stim because of the waveform of the current and the voltage of the generator

    high voltage pulsed current
  48. waveform form shape characteristics
    twin spike monophasic pulsed current

    rise immediately, fall exponentially
  49. phase duration of HVPC
    50-100 microsecs
  50. pulse duration of HVPC
    up to 200 microsecs
  51. duration of A beta fibers
    20 microsecs
  52. duration of A delta fibers
    450 microsecs
  53. duration of C fibers
    1500 microsecs
  54. fixed characteristics of HVPC that cannot be changed

    0-500 V other e stim uses mA

    • skin resistance less than 100,000 (upside down horsehoe looking symbol)
    • when current goes thru resistance voltage decreases and energy decreases
  55. clinical uses of HVPC
    pain modulation

    tissue healing

    muscle re-ed

    edema control

    muscle strengthening
  56. HVPC frequency for:

    sensory vs motor
    sensory: 80-125 Hz

    motor-1-5 Hz
  57. HVPC intensity

    sensory vs motor
    0-500 V

    comfortable sensation below motor threshold (for sensory level)

    muscle twitch (motor)
  58. HVPC dosage:
    pulse duration
    treatment frequency
    comfortable sensation below motor response (sensory) and muscle twitch (motor)

    100-200 microsecs

    30-60 mins

    1-2x day
  59. advantages of HVPC
    short pulse duration-no electrochemical effects

    high voltage-bypasses skin impedence
  60. disadvantages of HVPC
    short pulse duration

    cannot stimulate denervated muscle

    cannot perform iontophoresis
  61. acupuncture, motor or trigger points, many of these points are located at the same anatomical site
    specific points
  62. most utilized, though not always placed at the appropriate source of pain, effective post surgery, placing electrodes close to incisions
    painful region
  63. placing electrodes according to _______can be a useful method of focusing on specific spinal levels
  64. by placing electrodes beside specific vertebrae or between the spinous processes, localized vertebral column pain can be alleviated
    spinal cord segment
  65. some ______nerves such as ulnar nerve have superficial points that are readily accessible for stimulation (not to be confused with dermatomes)
    peripheral nerves
  66. directly stimulating the nerve plexus itself can be beneficial although the brachial plexus is the only one which can be stimulated superficially. other can be stimulated by percutaneous methods
    nerve plexus
  67. described as lines which have anatomical counterparts through which pain is transmitted. pathways may be useful when pain is diffuse and extensive
    linear pathways
  68. these methods use all the other guidelines but often employ multiple electrodes. examples include dual-channel placement, bilateral placement, contralateral placement etc
    alternative methods
  69. treatment technique that uses medium frequency currents
    interferential current
  70. 2 channel stimulators producing a sinusoidal, symmetrical, alternating current at frequencies of several thousand cycles per second on each channel
    interferential current
  71. what are the common frequencies of 2 unmodulated sine waves? (IFC)
    200-500 Hz
  72. frequency of resultant amplitude IFC can be _____ or _____
    constant or variable
  73. modulation/beat frequency of IFC
    varies from 0-1000bps
  74. sensory nerve stimulation for IFC (frequency and phase duration)
    frequency 4000 Hz

    125msec phase duration
  75. motor nerve stimulation for IFC (frequency and phase duration)
    frequency 2000 HZ

    250msec phase duration
  76. Purposes of IFC
    pain relief

    deep tissue currents

    increased blood flow to deeper tissues

    reduces edema

    decreases muscle spasm
  77. How does IFC work?
    2 currents cross

    nerve fibers receive max stimulation

    each beat is amplitude modulated

    stimulated fibers do not accommodate
  78. at greater than 50 bps and low amplitudes, pain relief is achieved in 2 ways
    -stimulating large afferent fibers

    -interfering with ascending transmission of pain impulses
  79. with stimuli of constant amplitude and frequencies greater than 1000 Hz, successive stimuli prevent the nerve from repolarizing.. This temporary nerve member depolarization is known as _________.
    Wedensky inhibition
  80. What ist he effect of the Wedensky inhibition?
    responsibile for the decreased sensation under the electrodes---only occurs with unmodulated current
  81. reciprocal scanning of IFC through an arc of 45d. This allows the current to perfuse through a greater volume of tissue then if this option was not selected
  82. frequency modulation that prevents adaptation
  83. a mode in which the 2 currents are mixed within the machine to produce an amplitude-modulated frequency output. mode only uses 2 electrode
  84. 0-10 bps is good for...?
    amplitude enough to produce small pulsating muscle contractions, may relieve pain
  85. 30-50 bps is good for...?
    results in tetany of the muscle, may be able to modulate the contractions, but may not be effective for muscle strengthening
  86. greater than 50 bps is good for...?
    low amplitudes, pain relief
  87. advantages of IFC
    low impedence when crossing the skin

    targets deeper sites

    more comfy low amplitude current delivered thru skin with higher amplitude delievered to deeper structures
  88. disadvantages of IFC
    current is highest directly under electrodes so patient may not be able to perceive the stimulation at the targest site

    research is sparse

    TENS is just effective
  89. indications for IFC
    pain relief

    • muscle exercise for
    • increased blood flow
    • muscle relaxation
    • edema reduction
    • relief of urinary stress incontinence
  90. contraindications of IFC


    stimulation over eyes, mucousal membranes

    cardiac diseases
  91. IFC for chronic pain:
    frequency; 3-5 Hz

    sweep: on

    time: 20-30 mins

    intensity: mild twitching
  92. IFC for subacute pain
    frequency: 1-150 Hz

    sweep: on

    time: 20-30 mins

    intensity: sub contraction/pt comfort zone
  93. IFC for acute pain-
    frequency: 80-120 Hz

    sweep: on

    time: 20-30mins

    intensity: sub contraction/pt comfort zone
  94. IFC for hyper acute pain
    frequency: greater than 1000 Hz (nerve block)

    sweep: N/A

    time: 8-10 mins

    intensity: patient comfort zone
  95. responses to IFC
    tingling under electrodes

    skin should show no change in color and in integrity

    tx ineffective :rearrange electrodes or use scanning feature for change in amplitude
  96. form of neuromodulation that uses noxious input to control pain
  97. noxious level stiumlation for pain improvement is the application of electrotherapeutic currents to produce a painful stimulus in or remote from the pain sit
  98. what mechanism of action does hyperstimulation use?
  99. do endogenous opiates increase/decrease patients pain threshold with hyperstim?
  100. what is a noxious level stimulation that causes a quick onset of pain modulation called?
    hyperstimulation analgesia
  101. T/F hyperstim is used as a first approach? explain
    FALSE--used after adaptation to sensory stimulation
  102. T/F Hyperstimulation is MOTOR stimulation? explain
    FALSE! hyperstim is noxious stimulation
  103. mechanism of hyperstim
    relieves pain thru proposed brainstem neurochemical mechanism that exerts descending inhibitory control at spinal cord level
  104. what do small pain fibers excite when a noxious stimuli hits them?
    reticular formation
  105. information from the reticular formationt then excites what?
    PAG with high opioid concentration
  106. the raphe nucleus is high in what NT
  107. ultimately, what is the overall mechanism of hyperstim?
    intense stimulation activates small diameter nerve fibers to block pain
  108. where is noxious level stimulation applied?
    areas with no motor nerve fibers
  109. how is hyperstim different from other analgesia mechanisms?
    patient is required to perceive stimulus as painful
  110. what are other methods of hyperstim?
    acupuncture, intense cold, dry needling, intense heat, mechanical pressure
  111. advantages of hyperstim
    fast onset of analgesia

    effectiveness can be felt after a few mins or a few points

    small little points are more effective than large electrodes
  112. disadvantages of hyperstim
    unpleasant noxious stim--patients may not be able to tolerate it
  113. indications for hyperstim
    pain control

    headaches, RSD, trigger point syndromes

    scar tissue

    chronic intractable pain

    joint pain

    phantom pain
  114. contraindications of hyperstim

    cardiac disease



    skin irritation
  115. precautions of hyperstim
    muscular stiffness treatment often not effective until 10mins or later
  116. low frequency of hyperstim
    1-5 pps
  117. high frequency of hyperstim
    80-100 pps
  118. frequency of hyperstim
    1-2 times a day for initial pain then progressing to 3-5 times a week
  119. phase/pulse duration for hyperstim
    250 microsec to 10 milisecs
  120. pulse rate of hyperstim
    1-4 pps
  121. amplitude of hyperstim
    maximum tolerable level of noxious input
  122. intensity of hyperstim
    noxious sensation
  123. duration of treatment of hyperstim
    each point is 30-60secs
  124. duration of analgesia of hyperstim
    very long, lasts for hours
  125. how many points at a time can you treat for a hyperstim patient?
    20 points
  126. where are electrodes placed in hyperstim?
    right over pain sight to generate the best response
  127. measure the distance between the 2 creases of the IP joints of the patients flexed middle finger = ?

    equivalent to 1 inch
  128. width of patients 4 fingers =?
    3 CUN
  129. what type of fibers does hyperstim affect?
    unmyelinated C fibers
  130. what type of duty cycle does hyperstim have?
  131. what type of current does hyperstim have?
    monopolar pulsed DC
  132. parameters for neuroprobe system 4
    pulse rate
    stim time
    output intensity
    treatment area
    pulse rate- 4 Hz monopolar

    stim time-15-45 secs

    output intensity-maximal patient tolerance

    treatment area-trigger points
  133. tender points will become ____ during prepared to reduce the current intensity
  134. non-pathological point or points which respond immediately to treatment generally ______during stimulation. be prepared to increase intensity to maintain hyperstim
  135. these points have very low pain thresholds and should be used for follow up TENS application
  136. about 5% of patients treated in this mode will experience more pain following stimulation. you should still continue future treatments
    increased pain
  137. where should the patient experience tingling?
    under electrodes and in problem area
  138. what is the ultimate goal for all modes of TENS?
    pain relief
  139. ______occupy the position of an acupuncture site
  140. what are the different techniques of acupuncture?
    manual needling and twisting

    electrical acupuncture

    heavy needling
  141. what types of substances are released by acupuncture?


  142. what effects do low intensity, high frequency electroacupuncture produce?
    endorphin mechanism

    slow onset analgesia

    long lasting results

    cumulative effect
  143. acupuncture for pain control
    2 Hz of stim and 100 Hz of stim plus the release of enkephalin, dynoprhin and beta endorphin allow for powerful analgesic effect
  144. deficiency of energy or decrease in response; treatment should be tonifying (warming, weak stimulation) moxibustion etc
  145. abundance of energy or increase in response; treatment should be dispersing (microbleeding, strong stimulation) acupuncture etc
  146. channel/pathway through which energy flows=
  147. how many meridians are there?
  148. what are meridians commonly used for?
    GI issues and myocarditis
  149. pt has organ dysfunction and corresponding distal meridian points are found to have increase pain threshold and differ in heat sensitivity and EP ===?
    Akabane Phenomenon
  150. Ryodoraku literally translates into?
  151. one point along each Ryodoraku provides average electroconductive value for all points on the same Ryodoraku (so just have to measure 1 point instead of 12) ===?
    representative measuring point (RMP)
  152. tonification points excite in ____% of cases but sedate in ___% not perfect
    80% excite

    20% sedate
  153. the point that has a higher electro-permeability (EP) than the surrounding area
    reactive electro permeability points (REPP)
  154. REPP is measured at how many volts?
    12 V
  155. conductivity at REPP is related to _____ activity/excitability
  156. depolarization is by ________ (sympathetic/parasympathetic)
  157. polarization is by ______(sympathetic/parasympathetic)
  158. Pts with higher lower REPP averages have _______(hyperstate/hypostate) ANS
  159. Pts with lower REPP averages tend to have _____(hyperstate/hypostate) ANS
  160. hyperstate ANS includes what?
    hot weather, youth, acute disease
  161. hypostate ANS includes what?
    cold weather, eldery, chronic
  162. readings of electrical acupuncture are affected by?




    recent treatments

  163. electroacupuncture uses what type of current?______changes peripheral polarization in tissues and therefore has a strong analgesic effect
  164. describe the mirror image of electroacupuncture
    peripheral afferent stimuation travels to spinal cord and is sent back out bilaterally
  165. detecting electrode is....? (anode/cathode)
  166. dispersion electrode is.....? (anode/cathode)
  167. neurometer current reading
    200 microA
  168. intensity of neurometer
    12 V
  169. duration of neurometer
    7 sec, continue until muscles relax to stimulation
  170. depth of neurometer
    .5 mm
  171. acute conditions and neurometer
    mod/high finger pressure pain response

    use short and strong stimulation
  172. chronic conditions and neurometer
    pleasurable sensation from finger pressure

    use long and mild stimulation
  173. for strong stimulation use what type of technique
    sparrow's pecking @ 1 stroke/sec
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