Transcript Other Mechanical Modalities Lecture

Mechanical Modalities
Therapeutic Modalities in
Athletic Rehabilitation
Mechanical Modailites

Intermittent Compression Devices
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Continuous Passive Motion (CPM)

Biofeedback
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Cervical and Lumbar Traction

Therapeutic Massage
Intermittent Compression
Devices
Compression Principles
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Constant compression
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Focal compression
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Intermittent compression
Intermittent Compression Units
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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)
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Cold water units ideal for use with acute
injuries
Types of Intermittent
Compression Devices
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Circumferential
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Applies equal pressure to involved area for set
time frame, diminishes and then repeats at set
time intervals
Sequential
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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
Effects of Mechanical
Compression
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Formation of pressure gradients
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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
Indications
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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”)
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Typically occur over bony prominences with
prolonged pressure (diabetes/circulatory
compromise)
Contraindications
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Acute conditions without R/O of fracture
Compartment syndromes not R/O
Peripheral vascular disease
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Atherosclerosis, congestive heart failure
Gangrene
Dermatitis
Deep vein thrombosis (DVT)
Thrombophlebitis
Treatment Parameters
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Must obtain patient’s diastolic blood pressure
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Treatment area covered with stockinette
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Cleanliness concerns (equipment and patient)
Select duty cycle (on/off time )
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Maximum pressure for treatment must not exceed diastolic
pressure
Typically preset by units – 3:1 is typical)
Select treatment time
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Ranges from 20 minutes to several hours
If using cold unit, must avoid prolonged exposure to
cryotherapy (increase temperature over time)
Continuous Passive Motion
Continuous Passive Motion (CPM)
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Utilized to counter negative effects of
immobilization
Salter (late 1980’s) proposed use of CPM to
assist healing in synovial joints
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Enhance nutrition and metabolic activity of
articular cartilage
Articular cartilage regrowth achieved by
stimulating tissue remodeling
Accelerated healing of articular cartilage, tendons
and ligaments
Effects of CPM
 “Motion
that is never lost need
never be regained” – most painful
aspect of rehab often involves
regaining motion
Effects of CPM
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Constant gentle stresses applied to tissues
encourages remodeling of collagen along
lines of stress and minimize negative effects
of immobilization
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Reduces capsular adhesions which allows for
maintenance of ROM
Enhances tensile strength of tendons and graft
tissues
Stimulates repair of articular cartilage
ROM Considerations
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Patients typically allowed to control own ROM
using pain as guide
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Early introduction of passive motion allows
for earlier introduction of active motion and
strengthening activities – may decrease
recovery time post-injury or post-operatively
Joint Nutrition Considerations
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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
Edema/Pain Reduction
Considerations
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Edema reduction theoretically enhanced via
improved venous/lymphatic return – “milking”
of joint and associated muscles
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Joint movement stimulates nerve fibers in
joint tissues, muscles and skin allowing for
pain relief via gate control theory
Indications
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Post-operative conditions
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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
Contraindications
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Must avoid unwanted joint translations
(especially following surgical ligamentous
repair)
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Must avoid overstressing healing tissues with
excessive motion
Treatment Parameters
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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
Biofeedback
Biofeedback
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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
Biofeedback
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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
Neuromuscular Effects
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After injury/surgery, edema, pain and
decreased joint movement make
active/voluntary muscle contraction difficult
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Biofeedback assists central nervous system
in re-establishment of the “forgotten” neural
pathways that cause the desired muscular
contraction
Indications/Contraindications
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Indications
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Contraindications
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To facilitate muscular contractions
To regain neuromuscular control
Any condition where muscular contraction may
cause tissue damage or pain
Treatment duration
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May be performed daily as needed
Cervical and Lumbar Traction
Traction Principles
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Application of a longitudinal force to the spine
Continuous/sustained
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Intermittent
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Maintains spine in elongated position for
extended period of time utilizing small force
Alternates periods of traction force with periods of
relaxation
May be mechanical or manual
Cervical Traction
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Effectiveness linked to:
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Position of neck
Force of applied traction
Duration of applied traction
Angle of pull
Position of patient
Position of Neck/Angle of Pull
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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)
Force of Traction
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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)
Duration of Traction
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Treatments may last for several hours, but
mechanical benefits are realized in first few
minutes of treatment
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Most common applications are in 10-20
minute treatment sessions
Patient Positioning
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Supine position is most common
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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
Lumbar Traction
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Effectiveness linked to:
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Force of applied traction (tension)
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Position of patient
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Angle of pull
Force Application
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Significantly more tension necessary to
achieve similar effects for lumbar vs. cervical
spine segments
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Approximately one half of force applied is
necessary to overcome weight of body part
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Range of tension varies considerably from
10% to 300% of total body weight
Position of Patient/Angle of Pull
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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
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Anterior pull increases lordosis, posterior pull
increases kyphosis
Effects of Traction
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Pain reduction
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Decreases mechanical pressure on nerve roots
Continuous traction allows reabsorption of
nucleus pulposis of disc lesions
Muscle spasm reduction
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Breaks pain-spasm-pain cycle by lengthening
affected muscles
Indications
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Muscle spasm
Degenerative disc diseases
Herniated/protruding intervertebral discs
Nerve root compression
Osteoarthritis
Capsulitis of vertebral joints
Anterior/posterior longitudinal ligament
injuries
Contraindications
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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
Therapeutic Massage
Types of Massage
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Effleurage
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Petrissage
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Friction massage
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Tapotement
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Myofascial release
Effleurage
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“Stroking” of the skin
Slow, light strokes
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Deep strokes
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Promotes relaxation, introduces modality
Performed at start and end of treatment
Encourages circulatory and lymphatic flow
Generally done from distal to proximal
Fast strokes
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Encourages circulation and stimulates (“wakes up”) the
affected tissues
Petrissage
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Lifting, kneading and rolling
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Deeper target tissue than with effleurage
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Emphasis on stretching and separating
muscle fibers, fascia and scar tissue
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Generally preceded and followed by
effleurage
Friction Massage
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Intent is to mobilize muscle fibers and separate
adhesions in muscles, tendons and/or scar tissue
which causes pain and inhibits ROM
Circular
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Typically applied in circular motion with thumbs
Especially good for treating spasm/trigger points
Transverse
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Use of thumbs/fingers in opposite directions
Especially good for post-op scars (incision sites, etc. and
tendonitis)
Tapotement
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“Tapping” or “pounding” of skin
Generally used to promote relaxation,
especially after vigorous techniques
Hacking
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Cupping
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Use of 5th metacarpal, “karate chop”
Hands are cupped, multiple contact points
Pincement
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Skin lightly pinched between fingers
Myofascial Release
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Combines typical massage techniques with
stretching of muscles and fascia to obtain relaxation
of tense/adhered tissues and restore tissue mobility
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Fascia only deforms with application of long,
moderate intensity forces – “creep”
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Specified training required for proficiency to be
acquired
Indications/Effects of Massage
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Edema reduction
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Neuromuscular effects
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Promotes relaxation of spasm/trigger points
Increases ROM and mobility of muscles/skin
Pain control
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Promotes vascular and lymphatic uptake
“Traffic jam” principle
Gate control theory vs endogenous opiate theory
Psychological benefits
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No direct evidence supporting, but hard to debate
anecdotal responses
Contraindications
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Acute injuries where pressure can cause
further damage or irritation
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Sites of active inflammation
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Open wounds, skin infections
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Phlebitis or thrombophlebitis