Transcript Basic Principles in Treating Athletic Injuries

Basic Principles in Treating
Athletic Injuries
1. Acute Phase
2. Healing Phase
3. Rehabilitation Phase
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• Acute Inflammation ( 24-48 hours )
• Chronic Inflammation ( 3-7 days )
• Healing ( 3-6 WEEKS )
• Rehabilitation ( up to a year ) Min 3
months
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Innate ?
• Tissues respond to injury through a set of
genetically programmed mechanisms to
replace the damaged components and
restore normal function
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Einstein on Insanity
“ Doing the same thing over and over
expecting a different result.”
Dog lady
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Evidence based Practice
• A method of integrating clinical expertise
with the best available evidence from
clinical research to make decisions about
the care of individual patients
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Process of EBP
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Defining the question
Searching the literature
Evaluating the evidence
Applying the results to the patient
Evaluating the outcome
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Levels of EBP
• Research report or original research with
systemic reviews
• Case-control studies or reports
• Expert opinions leads to clinical
commentary
• Application= Therapeutic Value
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Treating Athletic Injuries
Acute Phase
1. Control tissue injury complex
a. Enforce rest of injured area with protection
b. Maintain conditioning: anaerobic-aerobic
2. Treat Inflammation
a. Pain meds.
b. Nasaids
c. Modalities
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Treating Athletic Injuries
Acute Phase (Cont.)
3. If not overt signs of inflammation no meds or
modalities necessary
4. When healing allows :
a. Protected ROM
b. Isometric activity
c. Resisted short arc isotonic contractions
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Treating Athletic Injuries
Acute Phase (Cont.)
4. Goals:
a. Reduced Swelling
b. Decrease Pain
c. Tissue Healing
d. Improved ROM
When achieved - Proceed to healing phase.
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Treatment Protocols:
“Exercise is not an adjunctive
therapy, exercise is the therapy”
Ken Hutchins.
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Ardnt-Schultz Law
• Weak stimuli increases physiological
activity and very strong stimuli inhibits or
abolishes physiological activity.
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Law of Least Action
• Maupertius: The quantity of action
necessary to effect any change is the least
possible, the decisive amount is always
the minimal, the infintesimal.
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Treatment Protocols:
• Phase 1: Acute Inflammatory Phase:
– Question: Does inflammation cause pain or does pain cause
inflammation?
• For a long time pain has been summarily dismissed as the outcome of
direct stimulation of sensory nerve endings by injury and the pressure of
inflammation exudates. This opinion completely neglects the observation
that pain often initiates the inflammatory response and may become less
severe as that process gains speed. Robbins pg.44
• Goal is to control the pain and inflammation
– PRICE
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Protection
Rest
Ice
Compression
Elevation
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Treatment Protocols:
• Ice: 15-30 minutes of cryotherapy reduces
temperature 3-7 degrees C.
• Method of delivery:
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Ice Pack
Ice Massage
Versacooler: Adds compression to the TX.
Immersion
• Cryotherapy to the point of cold vasodilation is
counter productive. Hunter Reaction is the
bodies reaction to excessive cryotherapy
causing increase hemorrhage and inflammation.
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Treatment Protocols:
• ICE Suggested Protocol:
– 10 minutes: C-Spine, wrist, elbow, ankle shin
– 15 minutes T-Spine, knee, shoulder
– 20 minutes, L-Spine, pelvis, thigh.
Frequency: 2-4 times/day,
Maximum hourly: 15/45
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Treatment Protocols:
• ICE vs HEAT
Ice
Grade 2 Sprain-strain:
Grade 3
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Within 24 hours
6 days
13 days
Heat
After 24 hours
11 days
30 days
15 days
33 days
Sensory Fiber Analgesia: 4-5 minutes with cryotherapy
which lasts for 30 minutes.
Cryotherapy gives comparable relief
to local anaesthesia and morphine.
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Treatment Protocols:
• Electrotherapy: Used for edema reduction
and pain control:
– High Volt
– Low volt
– Interferential
– Faradic
– Galvanic: Iontophoresis
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Treatment Protocols:
• Ultrasound:
– Promotes healing of soft tissue.
• Continuous
• Pulsed
• Phonophoresis
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Physiological Effects of
Ultrasound
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Heat
Mechanical action
Micromassage
Tissue alterations
Chemical effects
Clearing agent
Microdestruction
Analgesia
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Heat
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Increase peripheral blood flow
Increase local metabolic rate
Increases membrane permeability
Blocks peripheral nerve impulses
Alters spinal reflexes
Relax muscle spasm
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Mechanical action
• Softens tissue
• Softens scar
• Breaks down collagen fibrils
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Chemical Action
• Increased gaseous exchange
• Liquifaction of cellular gels
• Increased oxygenation
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Clearing agent
• Causes exudates and precipitates to be
absorbed.
• Pulsed US especially effective in acute
stages of injury
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Microdestruction
• Disrupts tissue deposits
• Breaks down calcium deposits ( action not
conclusive)
• Calcified hematomos
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Analgesia
• Ultrasound triggers enkephalin formation
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Hands Free Ultra Sound
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Low intensity
Longer treatment time
Stationary
Results: Stress Fractures, Soft Tissue
Injuries
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Low Level Pulsed Ultrasound
• Reduced healing time in fracture repair by
30-38%
• When applied to non union fractures it
stimulated union in 86% of cases
• Potential for use in tendon, ligament,
muscle and cartilage injuries
• Conclusion: may have a beneficial effect in
treating sports injuries: accelerated
healing
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Treatment Protocols:
• Joint mobilization: Tissue must heal in the
presence of motion.
• Cyriax Cross Fiber:
• Laser :
• Exercise:
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Joint mobilization
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Activates mechanoreceptors
Breaks down adhesions
Decrease congestion in joint
Relieves compressive forces on articular
capsular and cartilagenous structures
• Relieves contracture of connective tissue
transversing joint
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Mobilization
• The strength of healed tendons is superior
to that of controls where mobilization was
delayed.
• An augmentation of extrasynovial tendon
healing by continuous passive motion has
been demonstrated in the rabbit model
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Mobilization
• Mobilization stimulates the intrinsic tendon
healing response, specifically the
fibroblasts, resulting in healing with
minimal scar formation.
• . Early passive mobilization reduces
adhesions
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Transverse FM
• Transverse friction massage of the injured
tendon in chronic tendonitis is thought to
be beneficial in breaking down adhesions,
• Tissue mobilizations maybe beneficial in
tendon healing by the transport of
nutrients to the area.
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Cyriax Crossfiber
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Mobilize scar tissue
Reduce adhesions
Activates phagocytes
Neurological component
Should be preceeded by ice massage
Followed by PNF stretches
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James Cyriax MD
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Muscle Energy
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Muscle energy
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Laser/Light
• Tissue heals relative to the reversal of
glycolytic damage.
• Oxygen utilization major key to healing
• Laser is directed at mitochondrial activity
• Increases cellular metabolism
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Laser v Light Therapy
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Light v Laser
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Physics
• UV light < 400nm < infrared
• 600-750 nm = Red
• 750 < Infra Red- not visible
• Depth of penetration = NM = Wave
Length
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Physics ( Cont )
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Depth of Penetration
400 nm = 2-3 mm
600-750 = 10 mm
880 nm = 30-40 mm
• Dose = sec x power/ area = JCm2
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LLLT Effect on Inflamation
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LLLT ( cont )
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LLLT ( cont )
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LLLT effect on pain
Cell membrane changes
Ca, Na, K ion changes
Endorphin increase
C-fiber depolar block
Nitric Oxide Production
Increased action potential
Decreased Bradykinin Levels
Increased acetylcholine
Pain reduction
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LLLT effect on healing time
Increased leukocytic activity
Increased macrophage activity
Increased vascular regeneration
Increased fibroblast proliferation
Early cell regeneration
Enhanced cell differentiation
Increased tensile strength
Accelerated wound healing
Reduced healing time
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Application
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Electrotherapy
• Low Frequency
• High Volt
• Interferential Current
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Low volt currents
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Galvanic current
Sine wave
Electrical muscle stimulation
Combination therapies
TENS
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Galvanic current
• Direct, unidirectional, waveless, low volt
current
• Various electrochemical effects
• Use today is almost totally limited to
iontophoresis
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Tens
• Transcutaneous electrical nerve
stimulation
• Based on the Melzack-Wall theory ( 1965)
• Sensory only
• Pad placement, dermatomal.
• Wave form widths 40-500ms
• Frequency: 70-150 pps
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Sine Wave
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Used primarily for muscle stimulation
Restricted joint motion
Adhesions
Muscle atrophy
Passive exercise
Trigger points
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High Volt Therapy
• High voltage monophasic pulsed
stimulation
• Advantage is primarily depth of
penetration
• No danger of burning patient
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General Settings for High Volt
Therapy
• 1-10 pps. Muscle stimulation or pain
modulation, small diameter electrode
• 10-15 pps, Muscle exercise, twitching
• 15 < Tetanize
• 20-80 pps muscle tetany without fatigue
• 70-110 enkephalin production for pain
control
• + polarity acute – polarity chronic
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Interferential
• Two or more oscillations applied
simultaneously
• 4000-4250 hz.
• Modulation
• 40-90 hz increases circulation
• 90-130 hz increased enkephalin
production
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Exercise
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Early transition from passive to active care
Key to restoration of function
Effects on the somatic system
Effects on nervous system
• Should be initiated as soon as pain free
motion is established.
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Kerri Welsh
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Kinesiotaping
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Theraband
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Theraband
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Treating Athletic Injuries
Recovery Phase : Rehabilitation
1. Begin tissue overload
a. Functional biomechanics
b. Deficit Complexes
2. Nsaids and modalities less appropriate
during recovery phase.
a. b. Focus on loading of bone, muscle, tendons.
b. c. Begin at the base of the kinetic chain.
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Treating Athletic Injuries
Maintenance Phase
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Absence of pain
Normal ROM
No residual tissue damage
Strength at 75% of normal
Smooth function of entire kinetic chain
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Treating Athletic Injuries
Maintenance Phase (Cont.)
Begin with return to play
Continues through athletes sport activity
Subclinical Adaptation Complex
a. Technique
b. Maintain Strength
c. Maintain ROM
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Treating Athletic Injuries
Nirschl mentions three concepts to initiate a
healing stimulus
1. Enhancement of peripheral aerobics.
(Oxygenation, nutrition, adequate peripheral
circulation)
2. Collagen induction, strengthening, and
alignment
3. Enhancement of biochemical changes
associated with endurance training.
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