Injury Mechanisms and Types of Injuries
Modalities
Sports Related Illnesses, Diseases, and Disorders
The Healing Process
The Injury Assessment Process
The Importance of Physicals
The Injury Process
The Rehabilitation Program
Medical Team |
MODALITIES
Introduction
Modalities are used to aid in the healing of tissues. One must always fit the modality to the tissue, not the tissue to the modality. The type of injured tissue must be taken into consideration and the surrounding tissues must be considered as well. Some modalities may be great for some tissues, but could harm other tissues. Injury depth is another issue when using modalities. Some injuries may be too deep for a modality to reach the injury site. Therefore, another alternative therapy must be used. It is important for clinicians to know the indications and contraindications for all the modalities. This will help the rehabilitation process go smoother.
What are the best Modalities and Therapies?
Modality use will depend on the injury, time allotted to recover, and the tissues affected. Know the contraindications for certain modalities and therapies. If a modality or therapy is contraindicated in the rehabilitation program, then it will further complicate, harm, and increase the amount of time it takes the athlete to recover. When using a modality while the athlete is still competing, the medical team must recognize if the modality will affect performance.
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Cold Modalities (Cryrotherapy)
Cold modalities can be very effective in treating injured tissues. A cold modality will range from 32 degrees F to approximately 65 degrees F. The main effects of cold application are decreasing cell metabolism (reduces the need for oxygen and nutrients), decrease in cellular waist products, decreasing pain sensations, vasoconstriction to retard swelling, decrease in inflammation, and decrease in muscle spasm. This can be accomplished by heat being transferred from the tissues to the cold modality. Deep muscles transfer heat to cooler superficial tissues, therefore it may take longer to decrease the temperature in deep muscle tissue, because the superficial tissues must become cool first. The affects of the cold modality will depend on the surface area covered, the temperature of the cold application, the duration of the treatment, the thickness of the adipose tissue, and the injured tissues metabolic activity (metabolic heat) and perfusion.
Note: Contraindications for cryrotherapy are cardiac or respiratory problems, an allergic reaction to the skin due to cold application, open wounds, circulation problems, and more.
• Dry Cold: Dry cold is usually considered to be crushed ice in an ice bag. It is probably one of the most widely used forms of cryrotherapy.
• Wet Ice: Wet cold is a terrycloth bag in which crushed ice is added. When the ice melts, the terrycloth soaks up the water. This forms a wet interface which allows for greater thermal conduction (water has a large thermal conductivity), than would be seen with a dry interface. This theory is still being researched. The thermodynamic theory is that the addition of the increased thermal conduction, and the potential of the additional evaporative cooling might produce lower intramuscular temperatures.3
• Gel Packs: Gel packs are synthetic gels that are housed in a casing. The advantages of gel packs are they can be washed and reused. However, the laws of thermodynamics say that even though gel packs can get colder than ice packs, the thermodynamics of ice melting actually has a greater influence on decreasing intramuscular temperatures. 4
• Ice Massage: Ice massage is the direct movement of ice over the injured area. Ice is usually frozen on a popsicle stick and rubbed on the injured area in a circular motion.
• Ice Immersion: Ice immersion is when the affected limb is immersed in a bucket of ice water. This not only encases the entire limb in cold water but it adds the advantages of hydrostatic pressure to the injured area. This will aid in decreasing edema. Wet suit booties should be placed over the toes to prevent freezing and thermal injuries to that region.
• Cold Whirlpool Bath: Whirlpool baths give you three advantages; cold, hydrostatic pressure, and when the jets are on, convection. Whirlpool baths are usually set around 60-65 F. When using whirlpool baths, allow the ice to melt in the water before turning the jets on. The jets slam the sharp pieces of melting ice into the skin and cause pain to an already sensitive injured area.
• Cryrocuffs: Cryrocuffs are cuffs that are fastened around joints. The cuffs are then filled with cold water. This has two advantages; the entire joint is encased in a cold compress, and the excess water in the fastened cuff adds pressure around the joint.
• Contrast Baths: Contrast baths consist of alternating emersion in warm and cold water. This action results in vasodilation and vasoconstriction. Thus, forming a pumping mechanism to stimulate peripheral blood flow and aids in venous and lymphatic return. This method is most commonly used in sub acute and chronic conditions. The best time ratio of cold to hot is still being debated.
• Hunting Response: The hunting response has been found in humans. It is when there is a reflex vasodilatation of the blood vessels due to a cold application being applied over a long period of time. It is debatable to whether or not this is a survival mechanism. Some researchers believe this happens in order to restore blood flow and warm the cold tissue. The hunting response occurs only in various regions of the body.
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Heat Modalities
Heat can reduce muscle spasm and pain. Heat can also improve range of motion by increasing the elastic properties of collagen. Heat is contraindicated in acute situations and should be used in long term treatment of injuries.
Note: Heat modalities can cause physical harm if not monitored carefully. Close attention should be paid to the amount of time the modalities are used and the temperature of the modality.
- Wet Heat Packs: Wet heat packs are usually filled with a gel that absorbs water and is incased in a canvas bag. The bags or packs are usually kept in a heated water filled container (hydroculator) and are usually wrapped in a towel before applied. Application results in a vasodilatation and increased blood flow to the tissues and an increase temperature in intramuscular tissues which has many different affects.
- Short Wave Diathermy: SWD produces high frequency electromagnetic energy that is absorbed by the tissues and is converted to heat. The machine introduces a positive and negative pole which causes movement of ions. The free moving ions are attracted to these poles. The friction of the ions moving in this field, cause the tissue to heat.
- Heated Whirlpool: Heated whirlpools are excellent for heating tissues, compression of joints with hydrostatic pressure, and micro massaging muscles with water pressure from jets. However, athletes should not use heated whirlpools 48 hours prior to competition. These pools elevate body temperature which causes the body to sweat. Massive amounts of water can be lost and the athlete may become dehydrated. Dehydration can decrease performance levels and may induce a heat related illness or thermal injury during competition.
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Ultrasound
Ultrasound uses ultra high wave frequencies (1-3MHz) that produce thermal and non-thermal effects to the treated tissues. Ultrasound is commonly used to administer heat to deep tissues. The thermal effects of ultrasound can accelerate healing by increasing metabolism and blood flow to the injured area. In addition, ultrasound provides a micro massage to the tissues by pressing and stretching the cells. The other advantages of ultrasound are an increased rate of tissue repair, decrease in pain sensations, and relief of muscle spasms.
Note: Before using or selecting ultrasound as a modality one must know the physics of the machine and its effects on the body. Know the different wave forms, frequencies, intensities, power, effective radiating area (ERA), beam nonuniformity ratio (BNR), coupling agents, and the transfer and effects of ultrasound through (adipose tissue) and on (bone/periostitis) different tissues. Contraindications include acute conditions, ischemic areas, tendency to hemorrhage, around the eyes, heart, skull, or genitals, pregnancy (over fetus area), over nerve plexuses in high dosage, over fracture cites, active infection, and more.
- Coupled Mediums: Because ultrasound wave frequencies are so high (1-3 million Hz), ultrasound needs a dense medium such as gel, to travel through. A gels effectiveness is decreased when the body part is hairy or irregular. For hairy body parts, shaving might be an option. For irregular body parts immersing the area in distilled water, submerging the ultrasound head in the water, and running it over the irregularly shaped area may provide a better environment for treatment.
- Phonophoresis: Ultrasonic fields have the ability to deliver medications to tissues through the process of phonophoresis. The ultrasound waves produce mechanical pressure that drives medications such as pain meds and anti-inflammatory agents deep into tissues. The advantage of this is there is no invasiveness involved. A special coupling gel or cream containing the medication is used with this technique.
Note: Medication mixtures not specifically designed for phonophoresis should be avoided.
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Electrical Stimulation
Neuromuscular electrical stimulation comes in many forms. It has various effects on the body. Different tissues respond to electrical stimulation in a manor similar to how the body normally functions and grows. Sport therapist use electrical stimulation in many different ways such as; inducing muscle contractions, stimulating sensory nerves to help with pain modulation, stimulating and altering the healing process, decrease joint contractures, muscle re-education, minimizing disuse atrophy, muscle strengthening, and inducing medications into tissues.
Note: Contraindications include cardiac dysfunction, metal implants and external fixation devices (allows current to go in bone), throat region (carotid sinus, trachea), skin allergies to electrical stimulation products (gels, electrodes,etc...), and large amounts of adipose tissue.
- Iontophoresis: Iontophoresis is a method of delivering medications to injured tissues via a low voltage direct current. Pain meds and anti-inflammatory medications can be delivered using a low constant voltage output. There is an iontic reaction between the positive and negative poles. The medication molecules travel along the lines of force created by the current.
- Transcutaneous Electrical Nerve Stimulation: TENS is a biphasic current that stimulates sensory nerves to block pain signals and generate endorphins.
- Interferential Stimulation (IF): IF crosses two mediums with independent frequencies. Thus, working together to stimulate large impulse fibers. This helps interfere with pain message signals to the spinal cord, increase blood flow, and reduce edema.
- Pulsed Stimulation: Pulse currents can be either direct or alternating. However, they are characterized by the periods of no current flow.
- Galvanic Stimulation: Galvanic stimulation is a low voltage direct current. The current results in an increased circulation to body parts between the electrodes. It may help to fight infection, increase wound healing, decrease edema, and help remove inflammatory products.
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Aqua Therapy
- SwimEx: SwimEx pools are capable of circulating 30,000 gallons of counter current pool flow per minute to create a wall of water resistance that can be set at 40 different speeds up to 6-7-miles per hour. Built-in workout stations add versatility that allows an athlete to perform dozens of different exercises that work muscles and joints from every angle. In addition the pools are temperature controlled.
These pools offer a variety of advantages in the rehab program. Some of the advantages are the athlete can do an entire workout with hydrostatic pressure being applied to each joint. Athletes that cannot bare their body weight on a joint, can get in a SwimEx and actually walk without crutches. This not only adds a great physical application to the rehab program, but it provides a great psychological boost to the athlete. Patients in initial stages of rehab can begin therapy sooner due to the buoyancy of water. Utilizing the multi-depth capabilities of a SwimEx, the therapist can progress the patient from non-weight bearing activities and increasing to different levels of partial weight bearing. Results can be measured objectively as patient’s progress through the continuum of variable depths and increasing water resistance. Treatment can extend into a full range of training and conditioning.
- Aqua Bike: An Aqua Bike is a bike that sits down in a pool. It allows the athlete to rehab in an environment that offers low stress on injured joints and muscles, hydrostatic pressure to the joints, drag forces of water, and all while delivering an effective cardio workout. The warm therapeutic waters will help keep muscles warm and loose while riding. The aqua bike is a good way to keep up an athlete’s cardiovascular conditioning during the rehabilitation process.
- Under Water Treadmill: Underwater treadmills add a whole new dimension to any training or rehabilitative program by allowing patients to walk or run in a weight reduced environment against the natural smooth resistance of water.
- Hot/Cold Tubs: Cold/Hot Spa Pool units provide great cold and hot spa hydrotherapy. Athletes can utilize the powers of the cold plunge pool to cool muscles after a long workout or conveniently treat an acute injury. Water temperature is adjustable to 50 degrees. The hot spa pool provides soothing hot water adjustable to 104 degrees, allowing injured athletes the ability to treat specific injuries or their entire body. The pools come in varying depths this allows athletes to just soak a leg or the entire body. Jets can be directed to meet the needs of the athlete. A jet massage wand may also be added to enhance therapeutic effects.
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Exercise Equipment
- Therabands: Therabands are long stretching rubber bands that provide variable resistance. These giant rubber bands come in a tube form or thin band shape. They are color coded to represent different resistance levels. Therabands are excellent for rehabilitation or general strength and conditioning. These bands can be used anywhere. They can be tied to chairs, desk, tables, and more. Therefore, one could strengthen a muscle or group of muscles while talking on the phone at work or watching TV at home. The only limit of a therabands potential is the users or therapist imagination. These bands can be used anywhere and are great for athletes to use during rehab or general strengthening.
- Physioballs/Swiss Balls/Resistaballs: These balls are rubber and inflated with air. They provide an excellent means of variability in exercises. In addition, they provide an excellent unstable surface. The balls are ideal for injury rehabilitation and general strength and conditioning.
- Free Weights: Free weights are an excellent way to strengthen muscles during rehabilitation. No rehab program should be completed without free weights. Free weights provide variable resistance through many ranges of motions. In addition, athletes can execute bilateral and single limb motions with free weights. However, free weights do require the athlete to stabilize the weight in multiple planes of movement, when compared to weight machines. Therefore, athletes may want to use weight machines before they graduate to free weights during their rehab program. This will depend on the extent of the injury.
Therapists should be educated in biomechanics so that they know the effects of free weights and stabilization of those weights, in certain motions, with certain joints. This can help in reducing further injury to the athlete. If free weights are used too early in a rehab program, they can sometimes injure the athlete. The same exercise may be able to be executed on a weight machine. For instance, a free weight bench press could be replaced with a machine weight bench press. The machine weight bench press will be stabilized and the athlete can simply push the weight in a linear motion without overloading the injured stabilizing muscles of the shoulder. Again these options will greatly depend on the injury and tissues involved.
- Weight Machines: Weight machines are excellent to use in a rehab program. They provide variable resistances, however they offer different stabilization parameters. Weight machines can allow athletes to rehab muscle groups without having to worry about stabilizing the weight. When an athlete uses free weights he/she has to stabilize the weights in different planes. Weight machines allow athletes to push and pull weights in linear and non-linear motions. In addition, athletes can execute bilateral and single limb motions with machine weights. Therapists should be educated in biomechanics so that they know how to use weight machine stabilizations to their advantage.
- Balancing Aids (BAPS Boards, ProFitter, Wobble Boards, and Teeter Boards): Balancing aids are an excellent way for the medical team to administer closed kinetic chain activities, which restore proprioception and improve coordination. Balancing aids can be used to improve sensory cues and balance during a rehabilitation program.
- Isokinetic Machines: Isokinetic machines (KinCom, Biodex, and Cybex) use the principle of accommodating resistance, which allows an athlete to provide muscular overload through a ROM to move a lever arm at a controlled velocity or fixed speed. Isokinetic training will allow the medical team to evaluate force outputs and more throughout a range of motion. In addition, the machines use a software package that allows the medical team to examine torque-motion curves, total work, average power and more.
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Magnetic Therapy
Magnetic therapy is still very controversial. It claims to increase blood flow to the injured tissue. It does this by drawing the iron from hemoglobin to the site where the magnet is. Some say the distance is too great from the magnet to the hemoglobin, for the magnetic field to have an affect on the blood. Some of the success stories to the effectiveness of magnetic therapy devices can be attributed to placebo effects and to other effects accompanying their use. The injured tissue may heal faster and reduce pain because the magnet and casing providing mechanical support, and localized warming. These effects are helpful with or without magnets. However, much more research needs to be done to draw a conclusion out of the science of magnetic therapy.
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Massage Therapy
Massage is the use of soft tissue manipulation techniques to the body. Massage is intended to reduce stress, fatigue, improve circulation, help break down scar tissue, reduce spasms and cramping, increasing joint flexibility, pain relief, and many more. Massage therapy has many different variations which account for many different techniques. There are currently over 200 different massage techniques. Each technique has its own physiological, mental, and physical application. Below are a few techniques found in sports therapy.
Note: In some acute injury situations and the presence of vascular disease, any type of massage is contraindicated.
- Reflexology: Reflexology is a holistic healing method. Therapist use their hands and fingers to manipulate and apply pressure to the ears, feet, and hands. The majority of practitioners favor using the feet when practicing reflexology because the feet are considered to have a greater quantity of sensitive nerve endings. Pressure and tissue manipulation is applied to reflex areas in order to decrease stress and bring the body into balance. This is done to bring the body's systems into optimal functioning and promote self-healing. Although some practitioners include the hands and ears in their treatment, the foot is the most widely used.
Reflexology is based on the principle that the foot holds reflex areas that connect to all parts of the body. Practitioners use a system of zones and charts to pinpoint these areas. The technique promotes overall relaxation and facilitates improvement in circulation and elimination systems. Reflexology can be used in almost any environment and does not require any equipment. Therefore it is great for rehabilitation, and can be done by the athlete at home. This may help calm the athlete and promote the healing process.
- Friction Massage: Friction massage is generally used around joints and areas where certain tissues are superficial. It is used on muscle spasms, scars, adhesions and more. The purpose is to stretch and manipulate the superficial tissue, develop friction in the area, and increase circulation around the area being massaged.
- Lymph System Massage: The lymph system is designed to remove bacteria and toxins from the body, massaging the lymph system can improve the flow of lymph and benefit the patient. Practitioners use light rhythmic strokes to manipulate the lymph system. Lymph system massage strokes are always with the muscle fiber, rather than cross-fiber, because the lymph system runs in the direction of the muscle fiber.
- Myofascial Release Therapy: Myofascial Release works by the manipulation of the fascia that connects and surrounds muscles. The fascia is throughout the body. Any tension or trauma in one part of the body can affect another part. Therapists use this technique to release the adverse effects of inflammation, tensions, and trauma.
- Myotherapy: Myotherapy is the technique of relaxing muscle spasm, improving blood flow, and alleviating pain. The therapy defuses trigger points, which are small knots of muscle tension that often refer pain to other areas of the body. When trigger points experience excessive emotional or physical stress they often respond by causing a muscle spasm. The spasm, in turn, causes pain. This can throw off body mechanics. Sports therapist erase muscle spasms by pressing on the appropriate trigger points for several seconds. This is done with the fingers, knuckles, and elbows and then re-educates the affected muscle to its normal resting relaxed condition.
- Swedish Massage: Swedish massage employs long gliding strokes, kneading, friction, tapping, and shaking motions. It is effective for most ailments, because massaging the skin, sets up a series of reactions that produces a positive effect on the nerves, glands, muscles, and blood flow.
- Acupressure Massage: Acupuncture points lie within meridians. When the body becomes injured or ill, these points become tender. Acupressure releases these tender points by pressing on them. This will give the athlete temporary relief from the pain associated with these points.
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Chiropractics
Chiropractors restore normal alignment of the spine and body segments by manipulating certain joints that may be causing the misalignment. Athletes often get “adjusted” by chiropractors to reposition points in the musculoskeletal system. Any misalignment in an athlete’s skeletal structure can affect his/her performance.
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Wound Care
Wound care is very important in the rehabilitation program. If an athlete suffers a wound during play, then the athlete will be prone to infection. Therefore, cleaning and dressing a wound is crucial to the rehabilitation process. Bandaging can determine the out come of wound healing. If a bandage is not applied properly, it can cause discomfort, lack of blood flow, and or contamination. This will impede healing. Wounds should be properly cleansed with a sterile saline solution or other sterile medically used substance. In some cases the wound should be medicated or the athlete may need to start an oral dosage of medication to help fight infection and heal the wound.
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Drug Therapies
Pharmacological treatments are commonly found in athletic rehabilitation. An injury will cause pain and inflammation. Drugs can be prescribed to decrease pain, inflammation, and more. Drug prescription should be taken with caution, and all contraindications should be noted. Drug therapy can be very effective and beneficial to the athlete. Drugs come in all shapes and sizes. Athletes may take injections, pills, IV’s, creams, gels, and more. There are too many drugs to list and the drugs constantly change.
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Nutritional Therapies
Nutritional therapy will greatly depend on the injury involved and the design of the rehabilitation program. Athletes can eat to provide adequate nutrition for a variety of illness and injury conditions. For instance, athletes who suffer large amounts of muscle atrophy may need to supplement their rehabilitation diet with protein. While nutritional aids can help athletes in their rehabilitation programs, the affects of some nutritional aids are still being debated.
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Orthotics and Braces
Once an athlete has been injured he/she may need to have the injured structure supported. This support may need to be continued for the remainder of the athlete’s career. Orthotics are generally referred to as an insert that goes in an athlete's shoe. These inserts support structures of the foot and distribute forces away from tissues. Braces may be used by athletes to support structures or to distribute forces away from an injured tissue. Doctors will return athletes to play with the restriction, that the athlete has to wear the brace or orthotic. The positive thing is athletes can return to play faster with employment of a brace or orthotic. However, braces and orthotics should be chosen carefully because they can decrease performance. Safety should always be chosen over a decrease in performance therefore, athletes should wear braces when needed.
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References
- Prentice , William. Rehabilitation Techniques in Sports Medicine. Mosby:
2nd Ed. Missouri; 1995.
- Starkey, Chad. Therapeutic Modalities for Athletic Trainers. F.A. Davis
Company; 1993
- Merrick, M. A., Jutte, L.S., Smith, M. E. Cold modalities with different
thermodynamic properties produce different surface and intramuscular temperatures.
J of Athletic Training Research. 2003, 38: 28-33
- Knight, K.L. Cryrotherapy in Sport Injury Management. Champaign, IL: Human
Kinetics; 1995.
- Arnhiem, D. D., Prentice, W. E., Principles of Athletic Training. McGraw-Hill:
9th Ed. Boston; 1997
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