Mechanical Modalities Therapeutic Modalities in Athletic Rehabilitation

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

Intermittent Compression Devices

Compression Principles Constant compression Focal compression Intermittent compression

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

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

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

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)

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

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)

Continuous Passive Motion

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

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

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

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

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

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

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

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

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

Biofeedback

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

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

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

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

Cervical and Lumbar Traction

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

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

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)

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)

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 10-20 minute treatment sessions

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

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

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

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

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

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

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

Therapeutic Massage

Types of Massage Effleurage Petrissage Friction massage Tapotement Myofascial release

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

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

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)

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

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

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

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