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Therapeutic Modalities and Injury Rehabilitation.

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Presentation on theme: "Therapeutic Modalities and Injury Rehabilitation."— Presentation transcript:

1 Therapeutic Modalities and Injury Rehabilitation

2 Therapeutic Modalities Create optimum environment for injury healing Reducing pain and discomfort Many different modalities to choose from

3 Selection of Specific Treatment is dependant on: Injury site, type and severity Modality indication and contraindication Physician prescription Athlete willingness to accept treatment

4 More is not better Misuse or overuse of a modality can: Aggravate the condition Delay the athletes return to play

5 Legal Concerns Must be administered in accordance with local regulations Documentations of all treatments

6 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

7 Cryotherapy Cold application minutes every 11/2 waking hours- along with rest, compression, and elevation Reduces many adverse conditions related to inflammatory phase

8 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

9 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…

10 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 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

11 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

12 Cryotherapeutic Methods Ice Packs Flaked or crushed ice in a towel or plastic bag Apply for 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 pink- usually for 7-10 min Cold Water Immersion Whirlpool, bucket or container filled with mixture of water and ice- temp degrees F Immersion for 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

13 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

14 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

15 Physical Principles of Heat Conduction Convection Radiation Conversion

16 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

17 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

18 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

19 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

20 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

21 Thermotherapy Methods Moist Heat Packs Whirlpool Bath Contrast Bath Paraffin Bath Ultrasound Therapy Phonophoresis

22 Moist Heat Packs Commercial Packs- Hydrocollator Packs Silicate gel in a cotton pad immersed in 170 degrees of hot water Apply 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

23 Whirlpool Bath Tank with a turbine motor which regulates the movement of water and air Cold- 55 degrees F, Neutral degrees F, Warm degree F and Hot degrees F Convection and Conduction are occurring Reduces swelling, muscle spasm and pain and active movement is also assisted

24 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

25 Contrast Baths One unit holding hot water at degrees F ( for example a whirlpool) One unit holding cold water at 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

26 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

27 Paraffin Baths Paraffin and mineral oil that is kept at 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

28 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

29 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

30 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

31 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

32 Indications for Ultrasound Post acute soft tissue trauma Bursitis Tendonitis Fascitis

33 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!!!)

34 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

35 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

36 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

37 Electrotherapy Purpose Control pain Exercise muscle tissue to decrease atrophy Encourage circulation Increase tissue temperature Encourage breakdown of adhesions Reeducate muscles

38 Physical Principles of Electrotherapy Electricity is a form of energy that displays the following factors on tissue: Magnetic Chemical Mechanical Thermal Effects

39 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

40 Special Considerations for Electrotherapy Contraindications Pacemakers Pregnancy When muscle contractions are not wanted Nonunited fractures Areas of active bleeding Near malignancies

41 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

42 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 minutes, once a day

43 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

44 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

45 Contraindications to Massage Acute injuries Hemorrhaging Infection Thromboses Nerve damage Skin Disease Possibility of Calcification

46 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

47 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

48 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

49 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

50 Rehabilitation Unit 7

51 Definition Restoration to a functional level for daily living Return to an appropriate level of competitive fitness

52 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

53 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

54 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

55 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

56 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

57 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

58 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

59 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

60 Types of Exercise Isometric Isotonic Isokinetic Plyometrics Manual Resistance Concentric/Eccentric Contraction Open / Closed Chain

61 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

62 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

63 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

64 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 stability- current injury is a contraindication

65 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

66 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

67 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

68 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

69 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

70 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

71 Phases of Rehabilitation There are three phases Phase 1- Acute First hours Phase 2- Sub-acute 72 hours to about 2 weeks after injury Phase 3- Intermediate Last up to 6 months

72 Phase 1- Acute First 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

73 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

74 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

75 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 pre- injury 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

76 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

77 The End Any Questions???

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