As Physical therapists, an apprehension of hurting and its influence on a patients ability to follow with intervention is indispensable for easing a good, effectual pattern.
Osteoarthritis ( OA ) is the most common status impacting synovial articulations. Osteoarthritis has a world-wide distribution though there is a fluctuation in the prevalence among different cultural groups and genders. However, Osteoarthritis chiefly affects the aged population. The prevalence of Osteoarthritis in populations older than 60 old ages of age is more than 50 % ( Soloman, 1997 ) , the agony and socioeconomic effects are significant. Treatment schemes for OA include pharmacological, non-pharmacological and surgical intercessions. ( Jamtvedt, et al. , 2007 )
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2.0 Anatomy, Physiology and Pathology
2.1 Anatomy of the lumbar spinal column and the hurting tract
The lumbar vertebrae ( L1-5 ) are the largest and strongest of the unfused castanetss in the vertebral column ( Tortora & A ; Derrickson, 2009 )
The roots ( anterior rami ) of the spinal nervousnesss L1-L4 form the lumbar rete. On either side of the first four lumbar vertebrae, the lumbar rete passes sidelong outward between the superficial and deep caputs of the Psoas Major musculus and front tooth to the Quadratus Lumborum. It so gives rise to the peripheral nervousnesss. The lumbar rete supplies parts of the lower limb ( Tortora & A ; Derrickson, 2009 )
Figure: The Lumbar Plexus ( Tortora & A ; Derrickson, 2009 )
Peripheral nervousnesss relay urges via the dorsal horn of the spinal cord. From here they are transferred to the rise fibers for transmittal to the encephalon and other countries in the CNS via interneurones ( Sofaer, 1998 )
OA is the most common signifier of arthritis and one of the most of import causes of long disablement in grownups ( Soloman, 1997 ) . OA has a world-wide distribution though there is a fluctuation in the prevalence among different cultural groups and genders. However, OA chiefly affects the aged population. The prevalence of OA in populations older than 60 old ages of age is more than 50 % ( Soloman, 1997 ) . OA of the articulatio genus is an of import factor in wellness attention cost in most states. In Germany, fiscal costs straight attributable to osteoarthritis were estimated at around ?4.6 billion in 1995 ( Scharf, et al. , 2006 )
The common sites of articulations to develop OA include the articulatio genus, manus, hip, spinal column and pes. Of these, OA of the articulatio genus is most normally found. In add-on to increasing age, OA of the articulatio genus is associated with fleshiness, injury, history of inflammatory arthritis and certain metabolic diseases ( Fife 1997 ) . Common ailments in people with articulatio genus OA are pain exacerbated by motion or weight bearing, stiffness, swelling and malformation, and restricted walking distance. The chief symptom of OA is hurting, which occurs with joint usage and is relieved by remainder ( Sarzi-Puttini, et al. , 2005 ) . The first alterations seen in OA are devolution and fissuring of the articular gristle. This progresses to loss of gristle and exposure of subchondral bone ( Tidswell, 1998 ) limited motion develops as the disease progresses due to joint surface incongruousness, musculus cramp and contracture, capsular contracture, and mechanical block due to osteophytes and loose organic structures. Crepitus, a greaves or scranching sound produced as the articulation in moved, may be identified in some instances of OA ( Felson, 2000 )
2.3 Pain Physiology
Pain has sensory and emotional dimensions and is associated with both existent and possible tissue harm ( Walsh, 1997 ) . It is a complex and multifaceted response to a noxious stimulation or to possible or existent tissue harm ( Robertson, et al. , 2006 ) . Three of import mechanisms have been described: segmental suppression, the endogenous opioid system, and the falling inhibitory nervus system ( Patel, 2010 )
Besides the gating of transmittal of noxious stimulations, other systems regulate pain response ( Sofaer, 1998 ) . Opioids and their derived functions are powerful anodynes and remain the pillar of hurting alleviation. ( Patel, 2010 ) receptors were found in the for opioid derived functions were found in the nervus cells of the periaquiductal grey affair and the vertebral myelin, every bit good as the spinal cord. This determination implied that chemicals need to be produced by the nervous system. ////// ( Patel, 2010 )
The falling inhibitory nervus system///nerve activity in falling nervousnesss from certain brain-stem countries ( periaquiductal grey affair, rostral myelin ) can command the acclivity of nociceptive information to the encephalon. Serotonin and norepinephrine are the chief senders of the tracts, which can hence be modulated pharmacologically. Selective 5-hydroxytryptamine re-uptake inhibitors ( SSRIs ) and tricyclic antidepressants ( e.g. Elavil ) may hence hold analgetic belongingss
2.4 TENS and how it affects hurting
TENS is anything that delivers electricity across the integral surface of the tegument to trip implicit in nervousnesss ( Watson, 2008 ) the physiological purpose of TENS when used for hurting is alleviation is to selectively trip different groups of nervus fibers to trip anti-nociceptive mechanisms that produce important hurting alleviation. When increasing the amplitude of TENS, nociceptive nervus fibers are activated and the user experiences a painful prickling under the electrodes. The development and application of TENS were based on the gate theory of Melzack and Wall ( 1965 ) ( Brosseau, et al. , 2002 ) . The gate control theory describes the stimulation of the big sensory nerve fibres ( AI? ) the suppression of the little nociceptive fibres ( AI? and C ) by the activation of repressive interneurones in the substantia gelatinosa of the spinal cord dorsal horn. The antalgic consequence is local, taking topographic point in the dermatomes of the spinal section recruited by the stimulation ( Melzack & A ; Wall, 1965 ) . Several types of TENS applications, differing in strength and electrical features, are used in clinical pattern. There are two chief parametric quantities used in mundane pattern: High frequence 150 Hz, 50-80I?s pulsation breadth at a low strength, arousing a pins and acerate leafs esthesis. Low frequence 1-4 Hz, 200I?s pulsation breadth, high strength, arousing a crisp pricking esthesis with musculus vellication ( Fox & A ; Sharp, 2007 ) .
2.5 TENS – documents on TENS and Pain ( critical reappraisal of the literature ) There may be a figure of ways of mensurating hurting – e.g. VAS etc.
Since the 1970s, transdermal electrical nervus stimulation ( TENS ) has been used to handle assorted ague and chronic hurting conditions ( Johnson, 2000 ; Thompson, 1998 ) . It is more effectual than any placebo intervention in cut downing hurting in OA articulatio genuss, irrespective of the TENS parametric quantities used ( Aubin and Marks, 1995 ; Roche and Wright, 1990 ) .
TENS as a intervention mode has been used widely as a intervention for hurting
Aim ( s )
Hypothesis ( hypotheses )
Chapter 3: Methodology
The survey was an experimental perennial steps design. The independent variable being assessed was whether the TENS machine was on or off. The dependent variable was pain force per unit area threshold ( PPT ) . This was recorded utilizing an algometer before and after the disposal of TENS.
3.2 Sample/ topics
Twenty topics ( 10 male, 10 female ) go toing Cardiff University volunteered to take part in the survey. Mean age of the topics was /// ( Full anthropometric topic inside informations in Appendix 3 ) and ranged from /// . To be included topics had to be free from hurt on their dominant leg at the clip of informations aggregation and have no history of surgery or serious pathology to that lower limb. Participants used were non physical therapy as this decreased the likeliness of them holding experienced TENS in the past and would therefore are less likely to show demand features.
Both males and females are being used as there are reported differences in PPT between the genders with healthy females holding a lower PPT than that of healthy males ( Chesterton, et al. , 2002 ) . By utilizing both males and females within the survey the survey has greater external cogency ///
The battery operated TPN 200 plus double channel TENS machine was administered via 50mm2 Verity Medical adhesive electrodes
Pain force per unit area threshold was recorded with a Jtech Commander-algometer
3.4 Ethical motives
Ethical blessing for the survey was granted by the University Ethics Committee ( Cardiff University, 2007 ) .
3.5 Pilot survey
A pilot survey was performed on 3 topics non take parting as theoretical accounts in the chief survey. This was done in order to guarantee the methodological analysis was sound and to set up an effectual protocol. Second, it allowed pattern with equipment such as utilizing the algometer accurately and application of facets of the TENS machine such as electrode application and scenes. Third, make up one’s minding on the location of application of the algometer to the L3 dermatomal country and standardizing this measuring of 2.5cm proximally of the supra-patellar as this was good within the L3 dermatome on all participants within the pilot.
When working out patients positioning throughout the survey, sitting side on a chair was found to be a good place as articulatio genus and lower dorsum were both accessible without compromising participants comfort
3.6 PPT and Algometer – dependability and cogency. This is your mensurating tool.
Secondary to reading the information sheet ( Appendix 1 ) and giving full written consent ( Appendix 2 ) , subjects removed their places, socks and changed into trunkss. Their tallness, weight and day of the month of birth were recorded and BMI calculated ( Appendix 3 ) . The topics filled in a tick sheet ( Appendix 4 ) and if they passed the inclusion standards began a five minute warm up on a inactive exercising motorcycle at a self-selected gait to cut down the likeliness of hurt.
Test all equipment prior to subject come ining the lab. The TENS machine is set to the right parametric quantities ; Pulse rate of 4 Hz and pulse breadth of 200Aµs
Subjects will come in Research Laboratory for Clinical Kinaesiology, located on the land floor of Ty Dewi Sant edifice in Cardiff University.
Subject will hold about 15 proceedingss to be briefed, reminded of contraindications and asked to read through the information sheet and consent signifier.
They will so be given a presentation of how the Algometer works as the research worker will mensurate their one Pain Pressure Threshold ( PPT ) .
Patient is offered the chance to inquire any inquiries prior to subscribing the consent signifier.
Subject will subscribe the consent signifier, holding to the footings and conditions of the survey.
Subject is asked to remove/lift shirt to uncover their lumbar spinal column. Modesty will be ensured throughout the survey, as towels will be provided. And to set trunkss on to expose articulatio genuss
The patient ‘s lumbar spinal column will be wiped utilizing an alco-wipe to guarantee that the electrodes adhere to the tegument decently
Subject will so sit on a chair to put the surface marker of the electrodes at the spinal degree of L3 and look into skin esthesis in this country with a pin-prick trial. Surface markers will be made utilizing a cat line drive pen.
Subject is so seated on a chair and surface marker of L3 dermatomal country standardised by taging 2.5cm proximally of the supra patellar and once more skin esthesis is checked with a pin-prick trial. Once once more, surface markers will be made utilizing a cat line drive pen.
A tally through of the algometer will be carried out so that the patient is cognizant of the esthesis of hurting force per unit area threshold prior to entering. This pattern will be taken on the non dominant leg so non to impact the result of the consequences. This will be done at the L3 dermatome country of the non-dominant Leg. All PPT readings will be taken by the same experimenter. Care will ever be taken to guarantee that the algometer investigation is applied perpendicular to the topic ‘s skin Degree centigrade: UsersMikeDocumentsDocuments3rd twelvemonth assignmentDissertationPilotstudyWP_000134.jpgC: UsersMikeDocumentsDocuments3rd twelvemonth assignmentDissertationPilotstudyWP_000106.jpg
Place electrodes 50mm2 either side of the spiny procedure of the Lumbar spinal column at the degree of L3.
The pre-intervention PPT will be taken utilizing the algometer at the L3 dermatome country on the patient ‘s dominant side
Bend on TENS machine and increase strength until tolerated by the topic, without sing hurting ( Chesterton, 2003 ) . Capable ensured that it must be comfy and non doing them any hurting ( Fox and Sharp, 2007 ) . Subject are told that they will see a crisp buzzing or prickling esthesis under some or all of the electrodes, but that this is wholly normal.
Once the topic is satisfied with the strength the timer on the stop watch will be started for 30 proceedingss. One experimenter will be in charge of the stop watch, while another will set the strength of TENS, as the participant accommodates to the esthesis.
Once the 30 minute period is completed, the post-intervention PPT will be instantly taken with the algometer at the standardized surface taging at the L3 dermatome country
Remove the TENS electrodes from the topic ‘s Lumbar spinal column.
Wipe down the surface markers at the Lumbar spinal column and L3 dermatomal country utilizing alcowipes.
Check for any inauspicious reactions such as erythema
Once the experimenter and topic are satisfied with the survey consequences the topic may go forth the lab.
Subject is to return at least 48 hours after the first status for the 2nd portion of the cross-over survey.