47
Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Embed Size (px)

Citation preview

Page 1: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Mechanical Modalities

Therapeutic Modalities in

Athletic Rehabilitation

Page 2: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Mechanical Modailites

Intermittent Compression Devices

Continuous Passive Motion (CPM)

Biofeedback

Cervical and Lumbar Traction

Therapeutic Massage

Page 3: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Intermittent Compression Devices

Page 4: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Compression Principles

Constant compression

Focal compression

Intermittent compression

Page 5: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Intermittent Compression Units

Utilizes flow of air or cold water to provide compression (mechanical pressure) to enhance venous and lymphatic return – typical appliances designed for LE (full leg, foot/ankle)

Cold water units ideal for use with acute injuries

Page 6: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Types of Intermittent Compression Devices

Circumferential Applies equal pressure to involved area for set

time frame, diminishes and then repeats at set time intervals

Sequential Applies pressure to involved area through

sequential (distal to proximal) filling of separate chambers until whole unit is pressurized, diminishes and then repeats at set intervals

Page 7: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Effects of Mechanical Compression

Formation of pressure gradients With application of external compression, gradient

between tissue hydrostatic pressure and capillary filtration pressure reduces – improves reabsorption of interstitial fluids (edema)

External compression also forms pressure gradient between distal (high) and proximal (low) aspect of extremity – fluids flow from high pressure to low pressure area

Elevation enhances benefits of both situations

Page 8: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Indications

Post-trauma edema Post-operative edema Primary and secondary lymphedema

(swelling of lymph nodes due to blockage of lymphatic channels)

Venous stasis/decubitus ulcers (“bedsores”) Typically occur over bony prominences with

prolonged pressure (diabetes/circulatory compromise)

Page 9: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Contraindications

Acute conditions without R/O of fracture Compartment syndromes not R/O Peripheral vascular disease

Atherosclerosis, congestive heart failure Gangrene Dermatitis Deep vein thrombosis (DVT) Thrombophlebitis

Page 10: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Treatment Parameters

Must obtain patient’s diastolic blood pressure Maximum pressure for treatment must not exceed diastolic

pressure Treatment area covered with stockinette

Cleanliness concerns (equipment and patient) Select duty cycle (on/off time )

Typically preset by units – 3:1 is typical) Select treatment time

Ranges from 20 minutes to several hours If using cold unit, must avoid prolonged exposure to

cryotherapy (increase temperature over time)

Page 11: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Continuous Passive Motion

Page 12: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Continuous Passive Motion (CPM)

Utilized to counter negative effects of immobilization

Salter (late 1980’s) proposed use of CPM to assist healing in synovial joints Enhance nutrition and metabolic activity of

articular cartilage Articular cartilage regrowth achieved by

stimulating tissue remodeling Accelerated healing of articular cartilage, tendons

and ligaments

Page 13: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Effects of CPM

“Motion that is never lost need never be regained” – most painful aspect of rehab often involves regaining motion

Page 14: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Effects of CPM

Constant gentle stresses applied to tissues encourages remodeling of collagen along lines of stress and minimize negative effects of immobilization Reduces capsular adhesions which allows for

maintenance of ROM Enhances tensile strength of tendons and graft

tissues Stimulates repair of articular cartilage

Page 15: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

ROM Considerations

Patients typically allowed to control own ROM using pain as guide

Early introduction of passive motion allows for earlier introduction of active motion and strengthening activities – may decrease recovery time post-injury or post-operatively

Page 16: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Joint Nutrition Considerations

Articular cartilage and menisci are essentially avascular and get nutritional elements from synovial fluid

Movement of joint stimulates circulation of synovial fluid, thereby enhances nutrition delivered to articular cartilage and menisci

Obviously, this is beneficial to healing of these structures

Page 17: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Edema/Pain Reduction Considerations

Edema reduction theoretically enhanced via improved venous/lymphatic return – “milking” of joint and associated muscles

Joint movement stimulates nerve fibers in joint tissues, muscles and skin allowing for pain relief via gate control theory

Page 18: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Indications

Post-operative conditions Repair of joint fractures Repair of joint ligamentous injuries (ACL) Knee arthroplasty (joint replacement) Menisectomy Repair of extensor mechanism disorders/tendon

lacerations Repair of osteochondral injuries Joint contractures/manipulation Joint debridement

Page 19: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Contraindications

Must avoid unwanted joint translations (especially following surgical ligamentous repair)

Must avoid overstressing healing tissues with excessive motion

Page 20: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Treatment Parameters

ROM – allows clinician/patient to adjust flexion and extension limits

Speed – adjusts rate of movement per second

Pause – stops unit at end ranges to allow for temporary passive stretching of tissues

Duration – varies from 1 hour multiple times daily to constant/continuous application

Page 21: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Biofeedback

Page 22: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Biofeedback

Most prevalent use in orthopedics/sports medicine is for muscle re-education or muscle relaxation

Conversion of body’s electrical activity into auditory and/or visual signals by biofeedback unit

Biofeedback doesn’t monitor actual response, but measures conditions associated with the desired response

Page 23: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Biofeedback

Most common application utilizes surface electrodes to allow for EMG measurement of skeletal muscle activity

Allows for monitoring of physiological process (is neuromuscular activity present?) and objective measurement of that process (provides scale for reference) to convert what’s being measured into meaningful and helpful feedback to get desired response

Page 24: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Neuromuscular Effects

After injury/surgery, edema, pain and decreased joint movement make active/voluntary muscle contraction difficult

Biofeedback assists central nervous system in re-establishment of the “forgotten” neural pathways that cause the desired muscular contraction

Page 25: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Indications/Contraindications

Indications To facilitate muscular contractions To regain neuromuscular control

Contraindications Any condition where muscular contraction may

cause tissue damage or pain Treatment duration

May be performed daily as needed

Page 26: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Cervical and Lumbar Traction

Page 27: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Traction Principles

Application of a longitudinal force to the spine Continuous/sustained

Maintains spine in elongated position for extended period of time utilizing small force

Intermittent Alternates periods of traction force with periods of

relaxation May be mechanical or manual

Page 28: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Cervical Traction

Effectiveness linked to: Position of neck Force of applied traction Duration of applied traction Angle of pull Position of patient

Page 29: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Position of Neck/Angle of Pull

When neck is placed in flexion, anterior elements are compressed and posterior elements are elongated and vice versa

For opening of posterior articulations and intervertebral foramen and stretching of posterior soft tissue, utilize flexion (25-30 degrees)

For facet joint separation, utilize extension (15+ degrees)

Page 30: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Force of Traction

Can be expressed as pounds or percentage of body weight (utilized for settings on mechanical units – inexact science for manual techniques)

Separation of cervical spine segments requires application of force equal to about 20 percent of patient’s body weight (more if patient in seated position)

Page 31: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Duration of Traction

Treatments may last for several hours, but mechanical benefits are realized in first few minutes of treatment

Most common applications are in 10-20 minute treatment sessions

Page 32: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Patient Positioning

Supine position is most common Allows for relaxation of cervical musculature Less tension required to obtain effects

For seated position, traction force must first overcome gravity before actually mechanically affecting cervical spine

Page 33: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Lumbar Traction

Effectiveness linked to:

Force of applied traction (tension)

Position of patient

Angle of pull

Page 34: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Force Application

Significantly more tension necessary to achieve similar effects for lumbar vs. cervical spine segments

Approximately one half of force applied is necessary to overcome weight of body part

Range of tension varies considerably from 10% to 300% of total body weight

Page 35: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Position of Patient/Angle of Pull

More influence with lumbar traction than with cervical traction

Greatest flexibility of lumbar spine achieved with patient supine and with hips and knees flexed

Positioning and angle of pull should maximize tension on target tissue – often results from trial and error Anterior pull increases lordosis, posterior pull

increases kyphosis

Page 36: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Effects of Traction

Pain reduction Decreases mechanical pressure on nerve roots Continuous traction allows reabsorption of

nucleus pulposis of disc lesions

Muscle spasm reduction Breaks pain-spasm-pain cycle by lengthening

affected muscles

Page 37: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Indications

Muscle spasm Degenerative disc diseases Herniated/protruding intervertebral discs Nerve root compression Osteoarthritis Capsulitis of vertebral joints Anterior/posterior longitudinal ligament

injuries

Page 38: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Contraindications

Acute injuries/conditions Unstable spine/spinal segments Cancer/meningitis Vertebral fractures Spinal cord compression Intervertebral disc fragmentation Osteoporosis Conditions where spinal flexion/extension are

contraindicated

Page 39: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Therapeutic Massage

Page 40: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Types of Massage

Effleurage

Petrissage

Friction massage

Tapotement

Myofascial release

Page 41: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Effleurage

“Stroking” of the skin Slow, light strokes

Promotes relaxation, introduces modality Performed at start and end of treatment

Deep strokes Encourages circulatory and lymphatic flow Generally done from distal to proximal

Fast strokes Encourages circulation and stimulates (“wakes up”) the

affected tissues

Page 42: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Petrissage

Lifting, kneading and rolling

Deeper target tissue than with effleurage

Emphasis on stretching and separating muscle fibers, fascia and scar tissue

Generally preceded and followed by effleurage

Page 43: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Friction Massage

Intent is to mobilize muscle fibers and separate adhesions in muscles, tendons and/or scar tissue which causes pain and inhibits ROM

Circular Typically applied in circular motion with thumbs Especially good for treating spasm/trigger points

Transverse Use of thumbs/fingers in opposite directions Especially good for post-op scars (incision sites, etc. and

tendonitis)

Page 44: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Tapotement

“Tapping” or “pounding” of skin Generally used to promote relaxation,

especially after vigorous techniques Hacking

Use of 5th metacarpal, “karate chop” Cupping

Hands are cupped, multiple contact points Pincement

Skin lightly pinched between fingers

Page 45: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Myofascial Release

Combines typical massage techniques with stretching of muscles and fascia to obtain relaxation of tense/adhered tissues and restore tissue mobility

Fascia only deforms with application of long, moderate intensity forces – “creep”

Specified training required for proficiency to be acquired

Page 46: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Indications/Effects of Massage

Edema reduction Promotes vascular and lymphatic uptake “Traffic jam” principle

Neuromuscular effects Promotes relaxation of spasm/trigger points Increases ROM and mobility of muscles/skin

Pain control Gate control theory vs endogenous opiate theory

Psychological benefits No direct evidence supporting, but hard to debate

anecdotal responses

Page 47: Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

Contraindications

Acute injuries where pressure can cause further damage or irritation

Sites of active inflammation

Open wounds, skin infections

Phlebitis or thrombophlebitis