pain control

Card Set Information

pain control
2015-03-22 16:25:37

pain control, 2 lectures
Show Answers:

  1. pain receptors
    nocioceptors ("noxious" = harmful or undesirable)
  2. transduction
    when nocioceptors translate noxious stimulus into action potentials
  3. Transmission
    when action potentials (from transduction) are conducted along peripheral (afferent sensory) neurons into the dorsal root of spinal cord.
  4. Nocioception
    • unconsious perception of stimulus.  
    • when action potential from transduction/transmission enters dorsal horn of spinal cord until it reaches/processed by brain
    • OR
    • process of transduction, transmission, and modulation of neural signals generated in response to an external noxious stimulus.
    • OR 
    • physiologic component of pain consisting of processes of neural signals generated in response to noxious stimulus
  5. Pain
    • CONSCIOUSLY PERCIEVED nocioception
    • unpleasant EMOTIONAL and sensory experience associated with actual/potential tissue damage
    • causes stress response
  6. Fast pain
    • sharp/bright/pricking
    • felt in 0.1 seconds post-stimulus, first
    • Localized
    • mechanical or thermal
  7. Slow pain
    • burning/aching/throbbing
    • felt 2nd, takes 1 sec or more, increases
    • chemical, mechanical, thermal
    • hard to pinpoint
    • C fibers, nonmyelinated so slower
    • tissue destruction
  8. Aδ fibers
    • sensory nerve fibers associated with fast pain, 0.1 sec
    • sharp or pricking pain, feel first, LOCALIZE
    • A are smallest myelinated
    • skin, SQ tissue, periosteum, joints, muscles and viscera
  9. C fibers
    • sensory nerve fibers associated with slow pain, 1 sec, 2nd pain
    • dull, aching, throbbing.  Tissue damage and inflammation
    • unmyelinated
    • skin, SQ tissue, periosteum, joints, muscles and viscera
  10. modulation
    • nocioceptive pathway, altering or adaptation of nocioception according to circumstances
    • peripheral sensory nerve impulses are amplified or dimished in spinal cord
    • some direct synapse with projection neurons (sensory info to brain), but some synapse with excitatory or inhibitory before projection.
  11. Gate theory of pain
    • Aβ, Aδ and C fibers regulate activity of inhibitory interneurons in dorsal horn
    • Aδ, C activation opens gate and inhibits the inhibitory, so stimulates.
    • Aβ activates inhibitory to close gate, decrease stim (rub after pain)
  12. Aβ fibers
    • sensory afferent fibers, myelinated
    • Aα>Aβ>δ
    • skin, muscles, joints
    • NON-PAINFUL stimuli (pressure, touch, vibration, mvmt, position)
    • stimulation inhibitory to pain/nocio
    • large diameter, high velocity
  13. Can patients under general anesthesia feel pain?
    No, CONSCIOUS perception only.  Can feel nocioception.
  14. Aα fibers
    proprioception, large myelinated fibers
  15. How pain is determined from nocioception/fibers
    • BALANCE OF INPUT from Aδ/C vs Aα/Aβ
    • Aβ can't stop major injury pain, but rubbing a wound after sharp pain can be inhibitory to pain
  16. Stress response
    • activation of sympathetic NS and catecholamine release
    • increased secretion of glucocorticoids
    • hypermetabolism
    • Na and H2O retention
    • Activated by pain due to sx or trauma
    • self-sustaining neuroendocrine cascade, must be interrupted.  Immunosuppression, catabolism
  17. nocioception reflex - respiratory
    • nocioception can stimulate autonomic NS (doesn't have to be pain)
    • increased tidal volume and resp rate (tachypnea)
    • may not be seen due to anesthetic agents
  18. nocioception reflex - cardio
    • nocioception can stimulate autonomic NS (doesn't have to be pain)
    • increased sympathetic tone, increased cardiac workload
    • catecholamine release - increased HR and BP, arrhythmias
    • may not be seen due to anesthetics
  19. Hormonal/immunological response to nocioception
    • catecholamines, cortisol, etc
    • hyperglycemia, decreased GI blood flow, reduced wound healing, increased platelet aggregation, decreased cellular immunity.
  20. Behavioral indicator of stress/pain
    CHANGES: activity, aggression, appearance, appetite, attitude, facial expression, locomotion, posture, response to handling, vocalization
  21. Physiological pain
    • acts as a protective mechanism, causing animal to withdraw from stimulus or avoid movement during reparative phase
    • Helpful/protective
  22. pathologic pain
    • exaggerated response that exceeds protective usefulness.  Associated with tissue injury during surgery or trauma.  
    • NOT serving protective function
  23. somatic pain
    • 2 types (deep and superficial)
    • pain originating from periphery
    • usually Aδ/fast pain, easier to localize.
  24. superficial somatic pain
    • pain originating from skin, SQ tissues or mucous membranes
    • usually Aδ/fast pain, easier to localize.
  25. deep somatic pain
    • originating from muscles, tendons, joints or bones
    • usually Aδ/fast pain, easier to localize.
  26. visceral pain
    • pain originating from abdominal viscera or pleura, thoracic viscera or pleura, internal organs or blood vessels
    • usually C fibers, slow pain, hard to localize
  27. acute pain
    pain with predictable duration, usually from injury or surgery
  28. chronic pain
    • ongoing, often intermittant pain that persists from months to years.  
  29. Referred pain
    • pain perceived at uninjured intact tissues a distance away from the presumed causative lesion
    • generally produced by deep somatic or visceral injury (vs superficial).  Toothache
  30. neuropathic pain
    • pain arising directly from nerves (nerve damage, injury or dysfunction)
    • may be persistent stabbing, shooting or burning
    • may be numbness or tingling
    • (diabetic neuropathy)
  31. analgesia
    • relief or absence of pain in response to normally-painful stimulus
    • includes diminished sensory perception of pain AND alleviation of emotional components
  32. pre-emptive analgesia
    • prevention or minimization of pain prior to patient consciously experiencing (give drugs before pain)
    • more effective, decrease dose and frequency
    • standard of care, stops from entering CNS
  33. nocioceptive adaptive pain
    • transient pain in response to a noxious stimulus
    • normal protective response, protects body from environment
  34. inflammatory adaptive pain
    • pain in response to tissue damage and inflammation
    • ongoing leads to maladaptive pain
  35. maladaptive pain
    • chronic adaptive pain leads to physiological changes in brain and spinal cord = chronic pain
    • retain hyperexcitable state even when stimulus is removed.
    • 3 types: neuropathic, central neuropathic, functional
  36. spinal wind-up pain/central sensitization
    • Stimulation of afferent C-fibers at critical rate causing neurons in dorsal horn of spinal cord to be hypersensitized/over-exciteable
    • 2 phases: 1 = hyperalgesia  2= allodynia
  37. glutamate
    neurotransmitter released by C fibers in spinal wind-up pain.  Received by NMDA receptor
  38. NMDA receptor
    • type of glutamate receptor, only open after prolonged depolarization fo post-synaptic membrane at critical rate
    • excites post-synaptic neuron
  39. spinal wind-up mechanism
    • C fibers in dorsal horn release glutamate and other neurotransmitters
    • receptors (NMDA) in ligand-gated ion channels, opens and depolarizes post-synaptic membrane
  40. hyperalgesia
    • phase 1 of spinal wind-up pain
    • increased response to stimulus that is normally painful
    • less stimulation causes more pain, oversensitivity
    • heightened sense of pain at site of tissue damage or in surrounding undamaged tissue
  41. allodynia
    • phase 2 of spinal wind-up pain
    • normally non-painful stimuli are felt as painful
  42. multimodal anesthesia
    • use of more than one drug with different actions to produce optimal analgesia. additive/synergistic effect
    • better/longer lasting analgesia than 1 drug alone
    • keep reassessing and recalculating
  43. TPRP
    temp, pulse, respiration, PAIN
  44. How often to assess pain?
    • depends
    • qh for first 6h after sx
    • don't wake to assess but do give scheduled meds
  45. physiological signs of pain in d/c
    • ↑ HR,↑ BP, Δ in RR, lacrimation, salivation, mydriasis, hyperglycemia, elevated serum cortisol levels
    • may have other causes, animal may show all or none, or show and have no pain
  46. abnormal behavior seen with acute pain
    anxiousness/fear, restlessness, trembling, guarding, lameness, reluctance to move, attempts to escape upon palpation, altered posture, immobalization, aggression, anorexia, lethargy, depression, insomnia, stop caring for self
  47. guarding
    tension in muscles to prevent palpation
  48. splinting
    • prayer position
    • tensing of muscles esp ventral abdominal muscles as a response to pain
  49. pain response in dogs
    also includes  glazed/worried expression, licking, hiding painful area, agitation, plegia, u/d inside
  50. pain response in cats
    also includes hiding, crouching at back of cage, purring, squinting eyes, flattened ears, whiskers pulled back/grimace, inappropriate elimination, frenzy, self-mutilation, lack of grooming or over-grooming, hunched posture, not seeking attention, don't want to be handled, head-down position, eye-lids half closed, eyes in slanted position
  51. horse pain signs
    • head lowering or turning, teeth grinding, nostril flaring, sweating, rigid posture, kicking at abdomen, pawing, rolling, skin twitching, looking at body part, lameness
    • stiffly backward ears, orbital tightening, tension above eye, strained chewing muscles, strained muscles, pronounced chin
  52. ruminant pain signs
    hunched, lying down, head pressing, teeth grinding, foot stamping, tail flicking, isolation from herd, falling and rolling, expiratory grunting or when ruminating, vocalization (goats)
  53. Pain assessment: SDS
    • simple descriptive scale
    • qualitative assessment by observer
    • none, mild, moderate, severe, very severe
  54. pain assessment: NRS
    • numerical rating system
    • qualitative assessment by observer
    • numerical value assigned to pain description
  55. pain assessment: visual analog scale
    • Continuous line going from 0 (no pain) to max (100)
    • Colorado State
  56. If you are not sure if the patient is in pain
    • treat them for pain
    • if they resume normal behavior they were
  57. adaptive pain - inflammatory
    spontaneous pain and hypersensitivity to pain in response to tissue damage and inflammation
  58. adaptive pain - nocioceptive
    transient pain in response to a noxious stimulus
  59. anesthesia
    medically induced insensitivity to pain
  60. analgesia
    absense of pain in response to stimuli that would normally be painful
  61. distress
    acute anxiety or pain
  62. dysphoria
    a state of anxiety or restlessness
  63. maladaptive pain - neuropathic
    spontaneous pain or hypersensitivity to pain in association with nervous system damage or lesion
  64. maladaptive pain - functional
    hypersensitivity to pain resulting from abnormal processing of normal input
  65. maladaptive pain - central neuropathic pain
    pain initiated or caused by primary lesion or dysfunction in the CNS
  66. neurogenic pain
    general term, pain from lesion in PNS or CNS - pain initiated by a PNS or CNS primary lesion or dysfunction
  67. palliative care
    care that relieves or alleviates a problem without dealing with the cause (like hospice)
  68. peripheral neuropathic pain
    pain initiated or caused by primary lesion or dysfunction in the PNS
  69. preemptive analgesia
    administration of an analgesic before the painful stimulation
  70. wind-up pain
    central sensitization - heightened sensitivity that results in altered pain thresholds.  Can happen in chronic pain, not just anesthesia.
  71. sickness syndrome
    • produced by severe pain
    • dysfunction, disability, systemic inflammatory response (SIRS), distress, suffering, MODS (organ dysfunction), leads to/hastens death
  72. SIRS
    systemic inflammation response syndrome, leads to organ dysfunction
  73. MODS
    multiple organ dysfunction syndrome, from sickness syndrome and systemic inflammatory response syndrome, death.
  74. The Five Freedoms
    • Freedom from thirst, hunger and malnutrition
    • Freedom from discomfort
    • Freedom from pain, injury and disease
    • Freedom to express normal behavior
    • Freedom from fear and distress
  75. Goals of analgesic therapy
    • suppression or elimination of pain
    • suppression or elimination of pain behavior and the promotion of normal behavior
    • improve comfort
    • return to max function despite residual pain
    • removal of stress or distress
  76. Drugs at transduction
    • (where stimulus turns into impulse)
    • local block, opioids, NSAIDs
  77. Drugs at transmission
    • stop pain at the first-order neuron in the dorsal horn (A-delta, C fibers)
    • Local anesthetics, Alpha-2 antagonists
  78. drugs at modulation
    • drugs that stop excitatory neuropeptides which amplify (glutamate, substance P), where body released endogenous opioids to decrease signal
    • Local anesthetics, NMDA blockers, alpha-2 antagonists, opioids, SSRI (selective seratonin reuptake inhibitors), TCAs (tricyclic antidepressants)
  79. neuroplasticity
    • chagnes in CNS and PNS associated with nocioception, change in NS response.  Leads to peripheral sensitization and central sensitization.  Peripheral usu from inflammation (chem mediators, reduced threshold), central due to NMDA/increased excitability/reduced threshold.  
    • Combination results in increased magnitude and duration of pain
  80. drugs for perception of pain
    general anesthesia, sedatives, opioids, alpha-2 antagonists
  81. Opioids
    • peripheral, spinal and paraspinal activity. Initial v/d, then constipation.  Feel warm/pant (thalamus), HISTAMINE RESPONSE. Vasodilation. Glucuronidation, bad for cats
    • Mu receptor is best analgesia, worst side effects.  Little cardio effect, most respiratory depression, euphoria, bradycardia, addictive.  Schedule II.  
    • Delta receptor is a modified mu receptor.  
    • Kappa less pain, more sedation.  causes miosis and dysphoria
  82. Mu agonist
    • best analgesia, most side effects
    • bradycardia, hypotension (histamine = vasodilation), sedation, respiratory depression, urinary retention, vomiting (first time only), defection then constipation, panting (thalamus)
    • Morphine, oxymorphone, hydromorphone, fentanyl, methadone.  Buprinorphine, torb partial
  83. Morphine
    • protoypical opioid, pure mu agonist
    • control II
    • no ceiling on analgesia/resp depression
    • histamine release (vasodilation) and vomiting
    • no cats (glucuronidation to become active)
  84. oxymorphone (numorphan)
    • 10x more potent pure mu agonist opioid than morphine
    • schedule II
    • no ceiling on analgesia/resp depression
    • no histamine release (vasodilation) and less vomiting/nausea
    • Bradycardia common
    • no cats (glucuronidation to become active)
  85. hydromorphone
    • 8x more potent pure mu agonist opioid than morphine
    • schedule II
    • no ceiling on analgesia/resp depression
    • no histamine release (vasodilation) and less vomiting/nausea (but still common)
    • increased noise sensitivity
    • Bradycardia common
    • no cats (glucuronidation to become active), hyperthermia and agitation in cats
  86. fentanyl
    • 80-100x more potent than morphine, pure mu agonist opioid
    • schedule II
    • short-acting so good as CRI (lots of control, less with ketamine): minimal CV depression and hypotension, decreases MAC by up to 63% (less windup, less pain/nocio)
    • injectible vs transdermal
  87. fentanyl transdermal patch
    • systemic effects with topical application, for post-sx.  Absorption and bioavailability variable, 75-100mg patches the worst so use 2 50's for a larger pet.  Can't cut patch, just use half backing.  
    • Put on a flat spot - lumbosacral for dogs, chest/ribs near axillary for cat.  Shave, vacuum, don't scrub (needs oils).  Patch warm to stick best, date/time/inital
    • 72h in dogs, 5 days in cats.  Bring in to have removed
  88. Recuvrya
    Fentanyl liquid, apply like flea/tick.  last 72h, released under risk-management.  Keep kids/adults away from pet for 72h.
  89. methadone
    • pure mu agonist opioid, delta agonist and NMDA antagonist, so helps with spinal windup, prevents opioid tolerance
    • least likely to cause vomiting
    • bradycardia and respiratory depression at high doses
    • synergistic with ace (prevents brady and resp. depression)
  90. Buprenorphine
    • partial mu agonist, VERY HIGH AFFINITY, can't get back off (antagonist for other mu drugs, possibly kappa antagonist).  May antagonize endogenous opioids, decreases sedation
    • few adverse effects, analgesic ceiling, delayed onset (30-60min)
    • Simbadol SQ for cats, otherwise IV, IM, transmucosal
  91. butorphanol
    • weak mu antagonist, kappa agonist.  NOT FOR PAIN, may reverse some pure mu.  Causes release of GABA due to kappa, some minor short-lived visceral analgesia (D 30m-1h, C 1-3h), sedation.  No resp depression  
    • in Kitty Magic
  92. Kitty Magic
    • butorphanol, dexmedetomidine, ketamine
    • ket vs dex to keep HR steady
    • watch for vomiting in cats due to dex
  93. doggy magic
    butorphanol, dexmedetomidine, midazolam
  94. Nalbuphine
    • kappa agonist, partial mu antagonist
    • not controlled
    • very little pain control (mild and short) (non-controlled torb)
    • visceral rather than somatic pain
    • minimal sedation, resp depression or cardio effects
    • best when combined with alpha-2 agonist
  95. naloxone
    • mu receptor antagonist, reversal for opioids (but not total buprenorphine), short duration so may have to dose again.  Torb not reversed very well
    • not controlled
  96. tramadol
    • mu receptor agonist (minimal in dogs, good in cats but bitter), serotonin and norepinephrine reuptake inhibitor
    • DON'T combine with SSRI or MAO inhibitor, causes serotonin syndrome (watch with prozac, destabilizes autonomic NS)
    • commonly sedation, occasional restlessness, some GI upset.  Oral.
  97. What's good for dysphoria from opioids
    alpha-2 agonists
  98. alpha-2 agonists
    • analgesia and profound sedation, biphasic CV (pre-synaptic = vasoconstriction/hypertension/bradicardia, then post = block Ca/norepi, vasodilation, hypotension WITHOUT TACHYCARDIA, atropine doesn't help).  Decrease O2 delivery.  V in cats, respiratory depression and increased urine production 
    • CRI, synergistic with opioids, good for opioid dysphoria
    • reversed with atipamezole
    • xylazine, medetomidine, dexmededomidine
  99. alpha-2 agonist uses
    • Reversible sedation in healthy pets
    • periop IV bolus or CRI (reduce MAC, synergistic with opiods, post-op sedation and analgesia (short))
    • IM with ketamine and opioid for short procedures (magic)
    • decrease opioid in dysphoric pets
  100. Atipamazole
    • Alpha-2 antagonist
    • reversal agent, given IM.  Best if given in thigh muscle, less fat so absorbs faster
  101. constituative prostaglandins
    "good" prostaglandins, COX1, physiologic functions like GI mucus health, possibly platelet function inhibition.
  102. Inducible prostaglandins
    COX2, inflammatory.  Some still important for physiologic function, like normal nerve transmission, support of renal perfusion by causing renal vasodilation in low-flow states so NO NSAIDS IN HYPOVOLEMIA OR HYPOTENSION
  103. NSAIDS mechanism and side effects
    • inhibit cyclooxygenase pathway of arachadonic acid metabolism to block prostaglandin production. COX 2 selective option, still some COX1 inhibition. Reduce inflammation and peripheral nocioceptor sensitization. Minimize intra-op bleeding.
    • side effects are mechanism-based (GI ulcers, renal toxicity) or idiosyncratic (hepatotoxicity with carprofin).  GI ulcerations and hemorrhage most common
  104. NSAID restrictions
    • glucuronidation so careful in cats (meloxicam or onsior only).
    • avoid hypovolemic, hypotensive or renal/hepatic/GI dz
  105. Onsior / Robenacoxib
    • feline-specific 3-day targeted Cox-2 NSAID for cats 
    • causes hepatotoxicity in dogs
  106. local anesthesthic
    • sodium channel blockers, so COMPLETE ANESTHESIA, stops transduction, transmission, modulation, etc. decreased dorsal horn = decreased wind-up.  Can produce mild sedation to decrease MAC and other drugs
    • Can be local (line block over incision) or regional (dental block, over an area)
  107. adverse effects of local blocks
    • local tissue swelling, bleeding, inflammation
    • CNS (muscle tremors, seizures, coma)
    • CV collapse
    • decreases EVERYTHING that requires depolarization
    • NO bupivicaine IV, causes CV collapse.  ONLY LIDOCAINE IV, ONLY IN DOGS.
  108. Why we don't use lidocaine in 2 or 3 heart blocks (though it treats v-tach)
    kills escape beats so no cardiac output
  109. drugs for local blocks
    • lidocaine (rapid onset, short duration, stings)
    • bupivicaine (later onset, longer duration)
    • increased volume helps, add sterile water.  Can add low-dose opioids (bup or morphine) to increase duration to 20h
  110. indwelling wound catheters
    • "soaker catheter" locoregional block.  
    • catheter with holes, sewn into deep wound, CRI for 48-96h.  Extends duration of local.
  111. Dental block
    • infraorbital foramen block, 107/207 forward
    • mandibular block, inside back of jaw, whole mandible
    • mental foramen block, 305/306 forward
  112. Ring block
    • three point locoregional block for onchyectomy
    • medial to accessory carpal pad
    • lateral and proximal to accessory carpal pad
    • dorsal medial carpus
  113. epidural
    • locoregional block for surgeries affecting caudal aspect of P.  Usually opioid (don't block motor so legs can be used) but can include local (minor motor block).  
    • Inject into lumbosacral or sacrococcygeal (blocked cats) space, between dura and ligamentum flavum.  
    • Too far will go intra-thecal and will migrate higher, into C5-C6 and paralyze diaphragm
    • 24h analgesia with little/no side effects.  Get CSF, subdural, TOO FAR
  114. perineural
    placing drug around nerve to be absorbed
  115. Peripheral nerve block
    pain mgmt for limb surgeries, use peripheral nerve locator and inject perineural
  116. balanced anesthesia/analgesia
    • multimodal to minimize risk and maximize safety and comfort.  
    • Keep calm to minimize stress/anxiety/sympathetic tone/catecholamine release
    • minimize pain by stopping before starts, hit from many directions
    • chemical anesthesia to reduce MAC where possible
  117. Constant-rate infusions
    precisely calculated drug delivered continuously.  Start with loading dose or CRI takes 3-5 half-lives, then steady state.
  118. lidocaine
    • Good for CRI in dogs, analgesic and sedative.  Can prevent ileus
    • glucuronidation in cats, NEVER IV
    • rapid onset, short duration, stings
  119. ketamine
    • dissociative anesthetic and NMDA antagonist, prevents wind-up
    • improves opioid sensitivity, reduces tolerance, minimizes hyperalgesia
    • good for CRI
  120. Tramadol
    • oral mu opioid, oral for humans and cats.  Also inhibits serotonin and norepinephrine uptake to increase inhibition of neurons.  Only the last pertains to dogs.
    • short half-life
    • not with SSRIs MAO inhibitors, TCAs (no fluoxitine), leads to seratonin syndrome
  121. Amantadine
    flu drug with NMDA antagonist abilities.  Combines with NSAIDs, causes diarrhea but short-lived.
  122. gabapentin
    oral anticonvulsant, not sure how it works, LIKE gaba (inhibitory neurotransmitter). Neuropathic and chronic pain. Causes sedation
  123. Amitriptyline
    • tri-cyclic anti-depressant. Increases inhibition of pain signal
    • neuropathic pain in humans, good for chronic feline interstitial cystitis in cats
    • not with SSRI or MAO inhibitors
  124. adequan
    • injectable polysulfated glycosaminoglycan (PSGAG) for pain managment for joint disease or injury
    • only supplement approved by the FDA. Anti-inflammatory that inhibits degradory enzymes and stimulates chondrocytes. From hyaluronic acid (gives synovial fluid its viscosity), restores viscosity to retain nutrition and health of cartilage, reduces prostaglandins (anti-inflammatory) and reduces free-radicals from joint degredation.  IM, no adverse effects, possible platelet inhibition
  125. Rehab
    • prevents stiffness and muscle atrophy
    • movement causes cartilage to be bathed in synovial fluid, gives it nutrition, very important
  126. orthodics
    support the limb
  127. prosthetics
    replace the limb
  128. Passive range of motion
    • moving of a joint through its range of motion without exertion by the patient
    • returns to normal range of motion
    • stimulates cartilage regeneration and increase nutrition
    • prevent loss of motion in neuro disorders
    • Should hurt
  129. cryotherapy and heat therapy
    • removes heat when applied to the body
    • causes vasoconstriction to reduce postop bleeding and bruising
    • slows nerve conduction to decrease pain
    • decreased enzyme activity reduces inflammation
    • cryo for first 72h, then alternate.  10-15m, not over metal or directly on skin
  130. therapeutic laser
    • low energy laser for accelerated cell division, increased WBC phagocytosis, stimulation of fibroblasts and collagen formation, mast cell degranulation (vasodilation)
    • Caution, retinal damage (bouncing too), not over metal implants or cancer
  131. massage therapy
    • increases blood flow and lymphatic drainage
    • never pain, calm and quiet, different techniques to stretch and decrease potential for injury
  132. hydrotherapy
    resistance through entire range of motion to build strength, improve lung capacity, increase blood flow, reduce concussive force on joints, and adjust heat and depth as necessary
  133. acupuncture
    needles over neurovascular bundles, constant noxious stimulus, gate closes.  Increases blood flow to area, some endogenous opioids, enkephalins and serotonin release
  134. nervi vasorum
    small nerve bundles near major blood vessels