1. Mechanical Modalities
Therapeutic Modalities in
Athletic Rehabilitation

2. Mechanical Modailites
Intermittent Compression Devices
Continuous Passive Motion (CPM)
Biofeedback
Cervical and Lumbar Traction
Therapeutic Massage

3. Intermittent Compression Devices

4. Compression Principles
Constant compression
Focal compression
Intermittent compression

5. 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

6. 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

7. 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

8. 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)

9. 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

10. 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)

11. Continuous Passive Motion

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Contraindications
Must avoid unwanted joint translations (especially following surgical ligamentous repair)
Must avoid overstressing healing tissues with excessive motion

20. 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

21. Biofeedback

22. 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

23. 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

24. 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

25. Indications/Contraindications
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

26. Cervical and Lumbar Traction

27. 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

28. Cervical Traction Effectiveness linked to: Position of neck
Force of applied traction
Duration of applied traction
Angle of pull
Position of patient

29. 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)

30. 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)

31. 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 minute treatment sessions

32. 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

33. Lumbar Traction Effectiveness linked to:
Force of applied traction (tension)
Position of patient
Angle of pull

34. 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

35. 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

36. Effects of Traction Pain reduction Muscle spasm 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

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

38. 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

39. Therapeutic Massage

40. Types of Massage Effleurage Petrissage Friction massage Tapotement
Myofascial release

41. Effleurage “Stroking” of the skin Slow, light strokes Deep 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

42. 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

43. 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)

44. 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

45. 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

46. 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

47. Contraindications
Acute injuries where pressure can cause further damage or irritation
Sites of active inflammation
Open wounds, skin infections
Phlebitis or thrombophlebitis