Download Therapeutic Modalities and Injury Rehabilitation

Therapeutic Modalities and
Injury Rehabilitation
Unit 7
Therapeutic Modalities
Create optimum environment for injury healing
Reducing pain and discomfort
Many different modalities to choose from
Selection of Specific
Treatment is dependant on:
Injury site, type and severity
Modality indication and contraindication
Physician prescription
Athlete willingness to accept treatment
More is not better
Misuse or overuse of a modality can:
Aggravate the condition
Delay the athlete’s return to play
Legal Concerns
Must be administered in accordance with local
regulations
Documentations of all treatments
Types of Modalities
Cryotherapy
Ice packs, ice massage, whirlpool, immersion, sprays
Thermotherapy
Moist heat packs, whirlpool, paraffin, ultrasound,
phonophoresis
Contrast
Electrotherapy
Iontophoresis
Mechanical
Massage, manipulation
Cryotherapy
Cold application
15-20 minutes every 11/2 waking hours- along with
rest, compression, and elevation
Reduces many adverse conditions related to
inflammatory phase
Physical and Physiological
Effects of Cold
PHYSICAL
Conduction- when a cold
object is applied to a
warmer object, heat is
abstracted
The longer cold exposure is
the deeper the cooling is.
Tissue that has previously
been cooled takes longer to
return to normal
temperature than tissue that
has been heated
Dept of cold penetration can
reach up to 5 cm
PHYSIOLOGICAL
Decrease in tissue temp
Decrease in blood flow
Vasoconstriction
Decrease in muscle spasms
Decrease in pain perception
Decrease muscle fatigue
Decrease metabolic rate
Decrease waste products
in area that act as muscle
irritant
Increase collagen
inelasticity and joint stiffness
Increase capillary
permeability
Special Considerations
Indications
Acute sprains, strains, contusions, spasms,
inflammation
Contraindications
Circulatory disturbances, hypersensitivity, prolonged
application over superficial nerves
Allergic
React with hives, joint pain and swelling
Continued on next slide…
Special Considerations
Cont…
Raynaud’s Phenomenon
Condition that causes vasospasm of digital arteries
lasting min-hours
Can lead to tissue death
Ice should never be applied for longer than 20-30
minutes
Hunting Response
Occurs when cold is applied for longer than 30 minutes
intermittently
Vasodilation occurs for 4-6 minutes
Reaction against tissue damage from too much cold
Stages of Cryotherapy
0-3 minutes after initiation feel cold sensation
2-7 minutes after initiation feel mild burning, aching
5-12 minutes after initiation feel numbness,
anesthesia
Cryotherapeutic Methods
Ice Packs
Flaked or crushed ice in a towel or plastic bag
Apply for 15-20 minutes combined with RICE
Ice Massage
Paper cup filled with frozen water to from an ice cylinder
Rub or massage directly over area until skin becomes bright pinkusually for 7-10 min
Cold Water Immersion
Whirlpool, bucket or container filled with mixture of water and icetemp- 55-65 degrees F
Immersion for 10-20 minutes- great for hands, feet and ankles
Vapocoolant Sprays
cold spray of chemicals sprayed of surface of skin to freeze it
Treat myofascial pain and trigger point, usually combined with
stretching. Effects are superficial and temporary
Thermotherapy
Used of sub-acute injuries
Used to increase blood flow
Promotes healing in the injured area
Vasodilation occurs to shunt cooler blood to
warmed area
Do not use until active inflammatory process is
over/ no signs of swelling
Conduction
Occurs when heat is transferred from a warmer
object to a cooler one
Heat should never exceed 116 degrees F
Examples are moist heat packs, paraffin baths, and
electric heating pads
Physical Principles of Heat
Conduction
Convection
Radiation
Conversion
Convection
Refers to the transference of heat through the
movement of fluids or gases
Factors that influence convection heating are
temperature, speed of movement and the
conductivity of the part
Example: whirlpool bath
Radiation
The process whereby heat energy is transmitted
through empty space
Heat is transferred from one object through space
to another object
Examples: Infrared heating and ultraviolet
therapies
Conversion
Refers to the generation of heat from another
energy form such as sound, electricity and
chemical agents
Examples: Ultrasound therapy, diathermy,
chemical agents- balms
Physiological Effects of Heat
Body’s response to heat depends on
Type of heat energy, duration, intensity, tissue type
Decrease muscle spasm
Decrease pain perception
Increased blood flow
Increase metabolic rate
Decreased joint stiffness
Increase range of motion
Increasing the extensibility of collagen tissue
Increased general relaxation
Special Considerations
Reasonably safe- as long as heat is at safe
intensity and application is not for too long
Contraindications:
An area of loss of loss of sensation
Immediately after an injury
An area where there is decreased arterial circulation
Eyes and genitals
Abdomen during pregnancy
To a malignancy
Monitor heat when applied to elderly patients or infant
Thermotherapy Methods
Moist Heat Packs
Whirlpool Bath
Contrast Bath
Paraffin Bath
Ultrasound Therapy
Phonophoresis
Moist Heat Packs
Commercial Packs- Hydrocollator Packs
Silicate gel in a cotton pad immersed in 170 degrees of
hot water
Apply 15-20 minutes
Layers of towels are used between packs and the
skin to avoid burning. As packs cool remove
towels
Deep tissues are not significantly heated
Inhibited by subcutaneous fat acts as insulator
Patient should be in comfortable position
Patients should not lie on the hot pack because
heat can not dissipate out
Whirlpool Bath
Tank with a turbine motor which regulates the
movement of water and air
Cold- 55 degrees F, Neutral- 92-96 degrees F,
Warm- 96-98 degree F and Hot 98-104 degrees F
Convection and Conduction are occurring
Reduces swelling, muscle spasm and pain and
active movement is also assisted
Whirlpool Continued
Treatment time should not exceed 20 minutes
Whirlpool unit/tank must be kept clean
Frequent water changes and daily cleaning
essential
Open wounds and abrasions should be handled
cautiously so that contamination or spreading of
the infection is prevented
Contrast Baths
One unit holding hot water at 105-110 degrees F
( for example a whirlpool)
One unit holding cold water at 50-65 degrees F
( for example a bucket can be used)
The goal to alternating hot and cold is to increase
local circulation to the treated limb
Vasodilation from hot water and Vasoconstriction from
the cold water accomplishes this
Contrast Baths Continued
The limb is first placed in the warm water for 5
minutes
Then is alternated to the cold water for 1 minute
Hot to cold is 1 cycle, after first cycle use 4 minutes
in hot and 1 minute in cold
Repeat 4/1 cycle for up to 30 minutes
Paraffin Baths
Paraffin and mineral oil that is kept at 125-130
degrees F in a controlled unit
Provide superficial heat to angular, bony areas of
the body (hands, feet, wrists)
Allows the part to remain elevated
Sustains heat which increases circulation and
decreases pain in affected area
Before treatment clean and dry area to be treated
thoroughly
Paraffin Bath Continued
Dip the affected part into the paraffin bath and
quickly pull it out
Allow the accumulated wax to dry and form a solid
covering
This process of dipping and withdrawing is
repeated until the wax coating is 1/4 to 1/2 inch
thick
Ultrasound Therapy
Ultrasound uses high frequency sound waves
Sound energy causes molecules in the tissues to
vibrate, thus producing heat and mechanical
energy
1mHz is the frequency used when heating is
needed for deep tissue
3mHz is the frequency used when heating is
needed for areas with minimal soft tissue coverage
Nerve tissue is twice as sensitive to ultrasound
than muscles
Ultrasound Therapy
Thermal and mechanical effects of ultrasound
increase circulation and promote healing
Ultrasound raises tissue temperature 7-8 degrees
F up to 2 inches below the skin’s surface
Little or no change in skin temperature
Also provides a micro massaging action on cells
Pulsed and Continuous
Waves
Pulsed
Non thermal effect
The flow of sound
waves are interrupted,
thus less energy is
produced
Best used on
Sub acute injuries
Wound healing
Over bony areas
Continuous
Thermal effects
Sound waves are
continuous
Increase circulation
Non thermal effects
At a low intensity
Acute injuries
Indications for Ultrasound
Post acute soft tissue trauma
Bursitis
Tendonitis
Fascitis
Contraindications for
Ultrasound
Acute inflammatory conditions with continuous
mode
Over areas with limited vascularity or sensation
Over eyes, ear, heart, reproductive organs,
endocrine glands, CNS or open epiphysis (growth
plates!!!)
More info on Ultrasound
There must be a coupling medium
Acoustic energy can not travel through air, is reflected
by skin
Lotion, gel, water applied to the skin
Transducer (sound head) should be kept moving at
all times
Small circles or longitudinal strokes at speed 1-2 inches
per second
More info on Ultrasound
Treatment is 5 minutes for an area 3-4 times of the
sound head
Intensity
Determined by the stage of injury and depth of target
tissue
Underwater application
Good for bony areas like hand, wrist and feet
Hold sound head 1 inch from body part and move in
circular or longitudinal patterns
Phonophoresis
Method of driving molecules through the skin by ion
transfer – by the mechanical vibration of the
ultrasound
Designed to move an entire molecule of medication
into injured tissues
Hydrocortisone and and anesthetic are used with
success
Massage medication into the skin over area, then
spread the coupling agent, then ultrasound
Lower intensity for a longer duration
Tendonitis, bursitis and painful trigger points
Electrotherapy
Purpose
Control pain
Exercise muscle tissue to decrease atrophy
Encourage circulation
Increase tissue temperature
Encourage breakdown of adhesions
Reeducate muscles
Physical Principles of
Electrotherapy
Electricity is a form of energy that displays the
following factors on tissue:
Magnetic
Chemical
Mechanical
Thermal Effects
Electrotherapy Currents
Produce waveforms
Waveforms refer to the shape, direction, amplitude and
duration of electric current
Direct Current
Flows in one direction
Electrons move from a negative to a positive pole
Feel tingling, followed by a feeling of warmth
Chemical reactions, increase blood flow, muscle
reeducation, decrease swelling, spasm and pain
Alternating current
AC
The flow of electrons reverse in direction once each cycle
Special Considerations for
Electrotherapy
Contraindications
Pacemakers
Pregnancy
When muscle contractions are not wanted
Nonunited fractures
Areas of active bleeding
Near malignancies
Electrotherapy Methods
Moist electrode pads are placed on the skin
Small pad is the active pad which brings the
current to the body
Larger pad is where the electrons leave the body
Closer the pads are the shallower and more
isolated the muscle contraction
The farther apart the pads are, the deeper and
more generalized the contraction
Active exercise can be used at same time
Ice packs, cold water immersion and ultrasound
can all be combined with electrotherapy
Iontophoresis
Process which chemical ions are transported
through the intact skin by an electrical current
Polarity of the electrode used depends on the
polarity of the ion introduced
The most common used medication for
iontophoresis are hydrocortisone and salicylates
The patient should not experience discomfort or a
burning sensation
Treatment times are 10-20 minutes, once a day
Mechanical/Manual Therapy
Therapy where the direct use of the provider’s
hands are being used
Used in conjunction with or as supplement to to
other methods
Massage
One of the oldest modalities used
Manipulation
Joint mobilization
Massage
Therapeutic and Physiological Effects
Stimulating Cell metabolism
Increasing venous flow and lymphatic drainage
Increase circulation and nutrition
Stretches superficial scar tissue
Relaxes muscle Tissue
Contraindications to Massage
Acute injuries
Hemorrhaging
Infection
Thromboses
Nerve damage
Skin Disease
Possibility of Calcification
Massage Methods
Effleurage
Superficial or deep stroking with the heels and palms of
the hand
Petrissage
Kneading, hold soft tissue between the thumb and
forefinger and alternately roll, lift, twist to loosen tissue
Tapotement
Cupping, hacking, pincing and percussive movements
Massage Methods
Vibration
Trembling, forward and backward movement, rapid
shaking of tissue by hand or machine
Friction
Pressure across muscle or tendons. Fingers and
thumbs move in circular patterns, stretching underlying
tissue
Massage
Use lubricants
Oil, lanolin, lotion, powder
Stroke toward the heart
Increases venous return to reduce swelling
Proper positioning
Injured part made easily accessible, comfortable and
relaxed
Be confident
Manipulation/Manual Therapy
Mobilization of joints and soft tissue to allow proper
functioning of a body part
All movement is passive on part of the athlete
Based on the concepts of joint play
Gliding and rolling of one joint surface on another
At no time should a provider attempt manipulation
without education and practice
Rehabilitation
Unit 7
Definition
Restoration to a functional level for daily living
Return to an appropriate level of competitive fitness
Individualized and Influenced
by:
Severity of injury
Stage of tissue healing
Type of Treatment (surgery, protocol)
Strength of the muscles of the limb
Pain on motion of the joint
Joint swelling
Sport specific demands
Rules of Rehabilitation
Create an environment for optimal healing
Do no harm
Be as aggressive as you can without doing harm
If it hurts, don’t do it
Goals of Rehabilitation
Vigorous, intense BUT controlled exercise allowing
return to competition
Ensuring injured part is as optimally conditioned as
possible
Restoration of function to the greatest possible
degree in the shortest possible time
Goals must be realistic and reachable
Realistic and Reachable
Goals
Increase range of
motion
Increase strength
Increase joint mobility
Increase endurance
Encourage relaxation
Enhance coordination
and skill
Improve joint stability
Prevent re-injury
Decrease pain
Improve function
Minimize atrophy and
deconditioning
Improve technique,
posture and mechanics
Decrease inflammation
and swelling
Improve motor control
Equipment
Specialized equipment is very useful
This will not guarantee results if program is
inadequate, if athlete is not motivated or there is poor
supervision
Possible to use little or no equipment
As long as the program is carefully and knowledgeably
designed for athletes needs and if athlete is adequately
motivated and supervised
Psychology of Rehabilitation
Rehab is 75% psychological and 25% physical
Rapport with athlete is critical (motivation and
communication)
Help athlete deal with fear, anger, depression, selfdoubt, and motivation
Use a variety of exercise to achieve the same
results and avoid boredom
Involve injured athlete with the team as much as
possible- meetings, functions and practice
Components of a rehab
program
Program must be progressive increase amount of
work performed at each session
Use correct form to maximize results and prevent
injury
Strength
Speed
Endurance
Flexibility
Proprioception
Sport Specific Skills- functional
Common Mistakes in Rehab
Look for the “culprit” not the “victim”
Focusing on one single muscle group
Not moving on until injured limb is equal or
superior to the uninjured side
Proprioception is often forgotten
Postural defects, anatomical malalignment and
biomechanical imbalances are neglected
Sports specific skills are not incorporated
SAID principle not incorporated
Types of Exercise
Isometric
Isotonic
Isokinetic
Plyometrics
Manual Resistance
Concentric/Eccentric Contraction
Open / Closed Chain
ISOMETRIC EXERCISE
Does not result in any movement of the joint
Often performed against a fixed resistance
Least effective form of strength improvement
Static exercise since there is no movement
Examples; Wall press, stationary press
ISOTONIC EXERCISE
The joint is moved through a range of motion
against the resistance of a fixed weight
The resistance is fixed and the speed is variable
Dynamic movement since movement takes place
Greatest strength gain takes place in the initial
movement as the muscle attempts to overcome
resistance / Least strength gain is at the mid point
Examples: Bench press, arm curls, squat, heel
raises
ISOKINETIC EXERCISE
Exercise where there is variable resistance and
where the speed of the motion is set
Resistance accommodates to match the force
applied
Dynamic contraction since there is maintenance
of a constant velocity
Advantage- visual readouts are possible which
helps evaluate progress and acts as a powerful
psychological stimulus for the athlete
Disadvantage- Cost of isokinetic machines
PLYOMETRICS
A variety of exercises that utilize explosive
movements to increase athletic POWER
Maximize the stretch reflex
Examples: Power jumps, leaps, bounds, throwing
a weighted object- medicine ball
Should be performed 2-3 days a week to allow full
recovery from fatigue
Strength should first be attained to provide stabilitycurrent injury is a contraindication
Stretch Reflex
The muscle is fully stretched immediately
preceding the shortening of it
An eccentric contraction occurs immediately
before the concentric contraction
The greater the stretch put on the muscle from
its resting length immediately before the
contraction the greater the load the muscle can
lift or overcome
Rate is more important than magnitude
MANUAL RESISTANCE
A provider adjusts the speed of movement and
resistance to that best suited to the athlete’s needs
Will vary according to the stage of rehabilitation
and the state of fatigue
Concentric Exercise
Concentric exercises are related to positive work
The muscle shortens as the weight is lifted
Example:
The up phase of a biceps curl
The biceps is the muscle working concentrically
ECCENTRIC EXERCISE
Eccentric exercise is related to negative work
Muscle lengthens or is forcibly stretched while the
weight is lowered
Greater strength gains
More stressful work for muscles resulting in muscle
soreness
Example:
Lowering a dumb bell during a biceps curl
The biceps is the muscle that is working eccentrically
Open Chain Exercise
Exercise when distal segment is not fixed and is
freely moving in space
Functional for upper extremity
Examples:
Leg extension
Leg flexion
Abduction/Adduction exercise machines
Functional activities such as throwing, jumping
Closed Chain Exercise
Exercise where distal segment is fixed
Functional for lower extremity
Examples:
Standing leg press with sport cord
Lunges
Baps board
Slide board
Therapy Balls
Phases of Rehabilitation
There are three phases
Phase 1- Acute
First 48-72 hours
Phase 2- Sub-acute
72 hours to about 2 weeks after injury
Phase 3- Intermediate
Last up to 6 months
Phase 1- Acute
First 48-72 hours
Symptoms- redness, heat, swelling, pain,
inflammation, loss of function
Short Term Goals
Decrease pain, swelling and inflammation
Increase Range of Motion and Control Pain
Maintain Cardiovascular conditioning
Phase 1-Acute continued
Emphasis of cardiovascular fitness
Isometric contractions if immobilized
Exercise the opposite unaffected limb may provide
cross over reaction
Muscle stimulation
RICE used to control swelling
Phase 2- Sub acute
72 hours to about 2 weeks
Inflammation is decreasing and tissue is being
repaired
Begins as soon as pain and swelling are controlled
and complete immobilization is no longer
necessary
Warm up the area prior to attempt exercise and
ROM will allow tissue to respond more effectively
Ice injured area after working it to prevent
secondary swelling and effusion
Phase 2- Sub Acute continued
Short Term Goals
Reach full range of
motion
Increase muscle
strength, power and
endurance to all
muscle groups
Maintain
cardiovascular
endurance to preinjury strength
Begin proprioception
training
Amount of time needed
for tissue repair is
based on several
factors:
Degree of injury
Location of injury
Age
Nutritional status
Medical problems
Medications
Use of corticosteroids
Phase 3- Intermediate
Lasts up to 6 months
Tissue is repairing, changing and remodeling to
restore function
Prepare for Specific Functional Exercises
Including open and closed chain exercises