Therapeutic Modalities and Injury Rehabilitation

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 athletes 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

Raynauds 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

Bodys 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 skins 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 providers 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, dont 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 athletes 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

The End
Any Questions???