Therapeutic Modalities and Injury Rehabilitation

1. Therapeutic Modalities and Injury Rehabilitation Unit 7

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 athlete’s 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 • 15-20 minutes every 11/2 waking hours- along with rest, compression, and elevation • Reduces many adverse conditions related to inflammatory phase

8. 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 Physical and Physiological Effects of Cold

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… • Raynaud’s 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

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 15-20 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- 55-65 degrees F • Immersion for 10-20 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 • Body’s 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 15-20 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- 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

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 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

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 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

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 skin’s surface • Little or no change in skin temperature • Also provides a micro massaging action on cells

31. 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 Pulsed and Continuous Waves

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 10-20 minutes, once a day

43. Mechanical/Manual Therapy • Therapy where the direct use of the provider’s 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