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Mechanical Modalities
Therapeutic Modalities in
Athletic Rehabilitation
Mechanical Modailites
Intermittent Compression Devices
Continuous Passive Motion (CPM)
Biofeedback
Cervical and Lumbar Traction
Therapeutic Massage
Intermittent Compression Devices
Compression Principles
Constant compression
Focal compression
Intermittent compression
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
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
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
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)
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
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)
Continuous Passive Motion
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
Effects of CPM
“Motion that is never lost need never be regained” – most painful aspect of rehab often involves regaining motion
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
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
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
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
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
Contraindications
Must avoid unwanted joint translations (especially following surgical ligamentous repair)
Must avoid overstressing healing tissues with excessive motion
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
Biofeedback
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
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
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
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
Cervical and Lumbar Traction
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
Cervical Traction
Effectiveness linked to: Position of neck Force of applied traction Duration of applied traction Angle of pull Position of patient
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)
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)
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
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
Lumbar Traction
Effectiveness linked to:
Force of applied traction (tension)
Position of patient
Angle of pull
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
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
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
Indications
Muscle spasm Degenerative disc diseases Herniated/protruding intervertebral discs Nerve root compression Osteoarthritis Capsulitis of vertebral joints Anterior/posterior longitudinal ligament
injuries
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
Therapeutic Massage
Types of Massage
Effleurage
Petrissage
Friction massage
Tapotement
Myofascial release
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
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
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)
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
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
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
Contraindications
Acute injuries where pressure can cause further damage or irritation
Sites of active inflammation
Open wounds, skin infections
Phlebitis or thrombophlebitis