Therapeutic Modalities and Rehab

7/28/2019 Therapeutic Modalities and Rehab

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Therapeutic Modalities andInjury Rehabilitation


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Therapeutic ModalitiesCreate optimum environment for injury healing

Reducing pain and discomfort

Many different modalities to choose from


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Selection of Specific

Treatment is dependant on:Injury site, type and severity

Modality indication and contraindication

Physician prescriptionAthlete willingness to accept treatment


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More is not betterMisuse or overuse of a modality can:

Aggravate the condition

Delay the athletes return to play


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Legal ConcernsMust be administered in accordance with local

regulations

Documentations of all treatments


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Types of ModalitiesCryotherapy

Ice packs, ice massage, whirlpool, immersion, sprays

Thermotherapy

Moist heat packs, whirlpool, paraffin, ultrasound,phonophoresis

Contrast

Electrotherapy

IontophoresisMechanical

Massage, manipulation


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CryotherapyCold application

15-20 minutes every 11/2 waking hours- along with

rest, compression, and elevation

Reduces many adverse conditions related to

inflammatory phase


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Physical and Physiological

Effects of ColdPHYSICAL

Conduction- when a coldobject is applied to awarmer object, heat is

abstractedThe longer cold exposure isthe deeper the cooling is.

Tissue that has previouslybeen cooled takes longer toreturn to normal

temperature than tissue thathas been heated

Dept of cold penetration canreach up to 5 cm

PHYSIOLOGICALDecrease in tissue temp

Decrease in blood flow

Vasoconstriction

Decrease in muscle spasms

Decrease in pain perception

Decrease muscle fatigue

Decrease metabolic rate

Decrease waste productsin area that act as muscleirritant

Increase collageninelasticity and jointstiffness

Increase capillarypermeability


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Special ConsiderationsIndications

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


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Special Considerations

ContRaynauds 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


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Stages of Cryotherapy0-3 minutes after initiation feel cold sensation

2-7 minutes after initiation feel mild burning, aching

5-12 minutes after initiation feel numbness,

anesthesia


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Cryotherapeutic Methods

Ice PacksFlaked or crushed ice in a towel or plastic bag

Apply for 15-20 minutes combined with RICE

Ice MassagePaper cup filled with frozen water to from an ice cylinder

Rub or massage directly over area until skin becomes bright pink-usually for 7-10 min

Cold Water ImmersionWhirlpool, bucket or container filled with mixture of water and ice-

temp- 55-65 degrees FImmersion for 10-20 minutes- great for hands, feet and ankles

Vapocoolant Sprayscold 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


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ThermotherapyUsed 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


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ConductionOccurs 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


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Physical Principles of HeatConduction

Convection

Radiation

Conversion


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ConvectionRefers to the transference of heat through the

movement of fluids or gases

Factors that influence convection heating are

temperature, speed of movement and theconductivity of the part

Example: whirlpool bath


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RadiationThe 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


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ConversionRefers to the generation of heat from another

energy form such as sound, electricity and

chemical agents

Examples: Ultrasound therapy, diathermy,chemical agents- balms


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Physiological Effects of HeatBodys 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 stiffnessIncrease range of motion

Increasing the extensibility of collagen tissue

Increased general relaxation


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Special ConsiderationsReasonably safe- as long as heat is at safeintensity and application is not for too long

Contraindications:

An area of loss of loss of sensationImmediately after an injury

An area where there is decreased arterial circulation

Eyes and genitals

Abdomen during pregnancyTo a malignancy

Monitor heat when applied to elderly patients or infant


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Thermotherapy Methods

Moist Heat Packs

Whirlpool Bath

Contrast Bath

Paraffin Bath

Ultrasound Therapy

Phonophoresis


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Moist Heat Packs

Commercial Packs- Hydrocollator Packs

Silicate gel in a cotton pad immersed in 170 degrees ofhot water

Apply 15-20 minutesLayers of towels are used between packs and theskin to avoid burning. As packs cool removetowels

Deep tissues are not significantly heatedInhibited by subcutaneous fat acts as insulator

Patient should be in comfortable position

Patients should not lie on the hot pack becauseheat can not dissipate out


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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


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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


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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


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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


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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


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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


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Ultrasound Therapy

Ultrasound uses high frequency sound waves

Sound energy causes molecules in the tissues tovibrate, thus producing heat and mechanical

energy1mHz is the frequency used when heating isneeded for deep tissue

3mHz is the frequency used when heating is

needed for areas with minimal soft tissue coverageNerve tissue is twice as sensitive to ultrasoundthan muscles


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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


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Pulsed and Continuous

WavesPulsed

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

continuousIncrease circulation

Non thermal effects

At a low intensity

Acute injuries


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Indications for Ultrasound

Post acute soft tissue trauma

Bursitis

Tendonitis

Fascitis


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Contraindications for

UltrasoundAcute 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!!!)


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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


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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


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Phonophoresis

Method of driving molecules through the skin by iontransfer by the mechanical vibration of theultrasound

Designed to move an entire molecule of medicationinto injured tissues

Hydrocortisone and and anesthetic are used withsuccess

Massage medication into the skin over area, thenspread the coupling agent, then ultrasound

Lower intensity for a longer duration

Tendonitis, bursitis and painful trigger points


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Electrotherapy

Purpose

Control pain

Exercise muscle tissue to decrease atrophy

Encourage circulation

Increase tissue temperature

Encourage breakdown of adhesions

Reeducate muscles


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Physical Principles of

ElectrotherapyElectricity is a form of energy that displays thefollowing factors on tissue:

Magnetic

Chemical

Mechanical

Thermal Effects


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Electrotherapy Currents

Produce waveforms

Waveforms refer to the shape, direction, amplitude andduration of electric current

Direct CurrentFlows 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, musclereeducation, decrease swelling, spasm and pain

Alternating current

AC

The flow of electrons reverse in direction once each cycle


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Special Considerations for

ElectrotherapyContraindicationsPacemakers

Pregnancy

When muscle contractions are not wanted

Nonunited fractures

Areas of active bleeding

Near malignancies


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Electrotherapy Methods

Moist electrode pads are placed on the skin

Small pad is the active pad which brings thecurrent to the body

Larger pad is where the electrons leave the bodyCloser the pads are the shallower and moreisolated the muscle contraction

The farther apart the pads are, the deeper and

more generalized the contractionActive exercise can be used at same time

Ice packs, cold water immersion and ultrasoundcan all be combined with electrotherapy


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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


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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


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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


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Contraindications to Massage

Acute injuries

Hemorrhaging

Infection

Thromboses

Nerve damage

Skin Disease

Possibility of Calcification


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Massage Methods

Effleurage

Superficial or deep stroking with the heels and palms of

the hand

PetrissageKneading, hold soft tissue between the thumb and

forefinger and alternately roll, lift, twist to loosen tissue

Tapotement

Cupping, hacking, pincing and percussive movements


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Massage Methods

Vibration

Trembling, forward and backward movement, rapid

shaking of tissue by hand or machine

FrictionPressure across muscle or tendons. Fingers and

thumbs move in circular patterns, stretching underlying

tissue


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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


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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


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Rehabilitation

Unit 7


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Definition

Restoration to a functional level for daily living

Return to an appropriate level of competitive fitness


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Individualized and Influenced

by:Severity of injuryStage 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


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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


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Goals of Rehabilitation

Vigorous, intense BUT controlled exercise allowing

return to competition

Ensuring injured part is as optimally conditioned as

possibleRestoration of function to the greatest possible

degree in the shortest possible time

Goals must be realistic and reachable


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Realistic and Reachable

GoalsIncrease range ofmotion

Increase strength

Increase joint mobilityIncrease endurance

Encourage relaxation

Enhance coordination

and skillImprove 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


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Equipment

Specialized equipment is very useful

This will not guarantee results if program is

inadequate, if athlete is not motivated or there is poor

supervisionPossible 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


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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, self-doubt, 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


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Components of a rehab

programProgram must be progressive increase amount ofwork performed at each session

Use correct form to maximize results and prevent

injuryStrength

Speed

Endurance

FlexibilityProprioception

Sport Specific Skills- functional


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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 orsuperior to the uninjured side

Proprioception is often forgotten

Postural defects, anatomical malalignment and

biomechanical imbalances are neglectedSports specific skills are not incorporated

SAID principle not incorporated


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Types of Exercise

Isometric

Isotonic

Isokinetic

Plyometrics

Manual Resistance

Concentric/Eccentric Contraction

Open / Closed Chain


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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


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ISOTONIC EXERCISE

The joint is moved through a range of motionagainst the resistance of a fixed weight

The resistance is fixed and the speed is variable

Dynamic movement since movement takes placeGreatest strength gain takes place in the initialmovement as the muscle attempts to overcomeresistance / Least strength gain is at the mid point

Examples: Bench press, arm curls, squat, heelraises


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ISOKINETIC EXERCISE

Exercise where there is variable resistance andwhere the speed of the motion is set

Resistance accommodates to match the force

appliedDynamic contraction since there is maintenanceof a constant velocity

Advantage- visual readouts are possible whichhelps evaluate progress and acts as a powerfulpsychological stimulus for the athlete

Disadvantage- Cost of isokinetic machines


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PLYOMETRICS

A variety of exercises that utilize explosive

movements to increase athletic POWER

Maximize the stretch reflex

Examples: Power jumps, leaps, bounds, throwinga 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 stability-

current injury is a contraindication


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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 canlift or overcome

Rate is more important than magnitude


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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


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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


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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


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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


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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


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Phases of Rehabilitation

There are three phases

Phase 1- Acute

First 48-72 hours

Phase 2- Sub-acute72 hours to about 2 weeks after injury

Phase 3- Intermediate

Last up to 6 months


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Phase 1- Acute

First 48-72 hours

Symptoms- redness, heat, swelling, pain,

inflammation, loss of function

Short Term GoalsDecrease pain, swelling and inflammation

Increase Range of Motion and Control Pain

Maintain Cardiovascular conditioning


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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


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Phase 2- Sub acute

72 hours to about 2 weeks

Inflammation is decreasing and tissue is beingrepaired

Begins as soon as pain and swelling are controlledand complete immobilization is no longernecessary

Warm up the area prior to attempt exercise andROM will allow tissue to respond more effectively

Ice injured area after working it to preventsecondary swelling and effusion


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Phase 2- Sub Acute continued

Short Term Goals

Reach full range ofmotion

Increase musclestrength, power andendurance to allmuscle groups

Maintaincardiovascular

endurance to pre-injury strength

Begin proprioceptiontraining

Amount of time neededfor tissue repair isbased on severalfactors:

Degree of injury

Location of injury

Age

Nutritional status

Medical problemsMedications

Use of corticosteroids


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Phase 3- Intermediate

Lasts up to 6 months

Tissue is repairing, changing and remodeling to

restore function

Prepare for Specific Functional ExercisesIncluding open and closed chain exercises


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The End

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Therapeutic Modalities and Rehab