ATC 101 - Exam 3

What are therapeutic modalities?

Physical agents - treatments that cause some change to the body

Origin - dating back to early Greek & Roman times

Interventions used to help heal someone

Methods used to promote, maintain, or restore the physical & physiological well being of an individual

Rehabilitation Processes

Focus on certain things

• Controlling Pain & Inflammation

• Regaining normal ROM, flexibility, muscular strength, endurance, coordination, & power

Therapeutic Modalities

• Help create environment for injury repair by limiting pain & the inflammatory response & breaking pain spasm cycle

Indication

Condition that could benefit from a specific modality

• Ice—> reduce swelling

Contraindication

Condition that could be adversely affected if a particular modality is used

• Ice for swelling could be bad if they have raynauds or bad circulation

Applications of Physical Agents

Need to understand scope of practice —> remember that if you haven’t been taught something, don’t attempt to do it on a patient/client

ALWAYS document treatment

Cryotherapy

Cold Application

Effects: Vasoconstriction, Decrease Inflammation, Decrease Tissue temperature, Decrease Tissue Metabolism, Decrease Tissue & capillary permeability, Decrease Pain, Decrease Spasm

Analgesic relief of pain

Cryotherapy - Indications

Pain, muscle spasm/guarding, inflammation, post surgically (pain & edema), minor burns

Cryotherapy - Contrindications

Cold sensitivity, cold allergy, circulatory/sensory impairment, Raynaud’s disease, Uncovered/open wounds

Cryotherapy - Methods

Commercial gel/chemical packs, Ice massage, Ice immersion, Ice bag, Cold whirlpool, cold compression unit (Game ready, Cyrocuff), Vapocoolant spray, Contrast bath

Thermotherapy

Heat application

Effects: Increase tissue temp, increase circulation, increase cellular metabolism, produce analgesic or sedative effect, decrease pain & spasm, vasodilation

Vasodilation:

• Increase oxygen concentration

• Promote healing

• Remove debris & waste

Thermotherapy - Indications

Subacute/Chronic

• Decrease swelling & edema

• Decrease muscle spasm& guarding

Increase Blood Flow

• Increase range of motion

• Resolve Hematoma

• Facilitate Tissue Healing

Relieve joint contractures

Thermotherapy - Contraindications

Acute inflammation or injury (first few days after injury), subacute/chronic pain, impaired circulation, impaired sensation, impaired thermal regulation

Thermotherapy - Methods

Moist heat pack, warm whirlpool, paraffin bath, warm immersion, contrast bath, fluidotherapy, jacuzzi & hot tub

Heat vs. Cold

Contraindications

Timing (acute vs. persistent pain)

Severity of pain & spasm

• Patient preference

Ultrasound

Using sound waves to encourage healing

“Conversion” - electrical energy “converted” to acoustic energy

Chronic injuries
Tissue healing sub-acutely

Effects: Increase tissue temp, increase blood flow, decrease edema

Ultrasound - Indications

Increase tissue temperature, Increase collagen extensibility, break up scar tissue/myositis ossificans, decrease inflammation, spasm, pain, & joint adhesion

Ultrasound - Contraindications

Acute inflammation, hemorrhage, infection, suspected malignancy, impair circulation/sensation, fractures, eyes heart, spine, genital

Ultrasound - Methods

Thermal (heating) - continuous 100%

Non-thermal (mechanical)

• Facilitate repair & healing

• Pulsed 10-50%

Application

• 1 MHz deeper 3-5 cm penetration

• 3 MHz superficial 1-2 cm tissue & tendon

Phonophoresis - ultrasounds w/ Meds 

• ANIT-INFLAMMATORIES 

• ANALGESICS 

Electrotherapy

Using electrical waves to treat injuries

Electrical stimulation of nerves ot achieve desired treatment effect

Effects: Decrease pain (pain control), decrease inflammation, increase muscle strength (re-education), promote wound healing

Electrotherapy - Indications

Decrease pain, inflammation, spasm

Increase muscle function, muscle strength, healing

Electrotherapy - Contraindications

Pacemaker, pregnancy, compromised sensation/circulation, skin lesion/infection

Electrotherapy - Methods

Many different wave forms

• Alternating current, direct current, mono-phasic, biphasic

Many different types of units

• TENS unit

• High voltage pulsed simulation

• Neuromuscular education (russian)

• Interferential (4 pads)

Iontophoresis - E stim w/ meds

Combo of ultrasound & e-stim

Cupping Therapy

Form of acupuncture

Cup is put on the skin of individual to create negative pressure

Effects: opens up skin pores, stimulates blood flow, reduces pain, balances & re-aligns the flow of qi, toxins are drawn out of the body

Cupping Therapy - Indications

Headache, lower back/neck pain, hypertension, Rheumatoid arthritis, diabetes, heart disease, infections, skin disorders

Cupping Therapy - Contraindications

Cancer, organ failure, pace maker, blood disorders, DVT, open wounds, fractures

Cupping Therapy - Methods

Glass cups, silicone cups, dry cupping, wet cupping

Manual Therapy (Massage)

Manipulation of soft tissue structures

Effects: relaxation, increase blood flow, promotes venous/lymphatic return, reduce swelling, reduce pain

Manual Therapy (Massage) - Indications

Chronic injuries, trigger points, increase blood flow, venous/lymphatic flow, & tissue elasticity, decrease swelling, pain, & spasm

Manual Therapy (Massage) - Contraindications

Acute Injuries, fractures, open lesions, infections, venous conditions, cancerous regions

Manual Therapy (Massage) - Methods

• Effleurage (stroking) 

• Petrissage (kneading) 

• Tapotement (percussion) 

• Vibration 

• Friction (rubbing) 

• Myofascial release 

• Injury massage should not be comfortable 

Traction

Drawing or pulling tension on a body part

Most often on the spine

Effects: Distraction of vertebral bodies, widening of vertebral foramen, distraction/gliding of facets, stretching & relaxation of muscle & ligaments

Traction - Indications

Herniated disc protrusion, spinal nerve impingement or inflammation, joint hypo-mobility, degenerative joint disease, muscle spasm, joint/spinal pain

Traction - Contraindications

Unstable vertebrae, acute injury/pain, patient discomfort, fracture

Traction - Methods

Mechanical 

• Use of a machine 

Manual 

• Done by a person 

Cervical, Lumbar, & Limbs 

Therapeutic Modalities Summarized

• Cold - decrease pain, decrease blood flow

• Heat - decrease pain, increase blood flow 

• Ultrasound - increased tissue temp & blood flow 

• Electrotherapy - decrease pain, muscle contractions 

• Cupping - decrease pain, increase blood flow 

• Massage - relaxation, increase blood flow 

• Traction - decrease pain, neurologic symptoms

Rehabilitation Plan

• Therapeutic exercise/rehabilitation 

• To create a full plan you must understand: 

  • Complete Injury 

    • Knowledge of how injury was sustained 

    • Major anatomical structures affected 

    • Grade of trauma 

  • Stage or phase of injury’s healing 

  • Psychological response 

  • Stay within scope of practice 

    • Controlling initial swelling & managing pain is first aid

5 Signs of Inflammation

Pain, Swelling, Redness, Heat, & Loss of Function

Psychological Response to Injury

Kubler-Ross

• Denial, Anger, Bargaining, Depression, Acceptance

Not always applicable to injuries unless season or career ending then will be variable

Biopsychosocial Model

Nagi Model

• Musculoskeletal Injury —> impairment —> Functional Limitation —> Disability

• Considers impact of injury on patient’s life, NOT only pathology

Important for treatment to focus on BOTH the patient & the injury

Effective Communication

• Presentation of information

  • Too much vs. too little

  • Dependent on patient

Ultimate Goal of Rehabilitation

Return patient to full activity as safely as possible

Thin line between being overly aggressive & not pushing hard enough

Major Components of a Rehabilitation Plan

Control Pain, Minimize Swelling, Regain or Improve ROM, Restore or Increase muscular strength, endurance, & power, re-establish core stability, re-establish neuromuscular control, regain balance & postural control, maintain cardiorespiratory endurance, incorporate functional progressions

Swelling & Pain Control

Use of therapeutic modalities

PRICE

Unless you control pain, patient will NOT progress

Progression through rehab should help as well

Increasing Range of Motion

What is normal?

Passive Range of Motion (PROM)

• Clinician moves them through the ROM

Active Assisted Range of Motion (AAROM)

• Clinician helps but there is an active contraction

Active Range of Motion (AROM)

Resisted Range of Motion (RROM)

Joint Mobilization

Isometric Exercise

Muscle with isometric contraction —> contracts but doesn’t lengthen or shorten

Activate muscle without movement —> engage muscle

ROM limitations

Isokinetic Exercise

Muscle Contraction at a FIXED VELOCITY

Machine needed to control speed

Plyometric Exercise

How the muscle is working

Explosive Activity —> functional pieces of rehab

Open Chain vs. Closed Chain

Closed chain = feet on floor (weight-bearing)

Open chain = feet not on ground

Have certain restrictions on whether or not you can do open or closed chain

Re-establish Neuromuscular Control

Proprioceptive neuromuscular facilitation (use isometric exercises)

Kinesthesia/Joint Positioning

Rhythmic Stabilization

Strengthening through functional movement

Maintaining Cardiorespiratory Endurance

Initiate as soon as possible (often neglected)

What are the demands of the patient’s primary activity?

Things to Consider

• Impact vs. Non-impact

• Lower Extremity vs. Upper Extremity

• Movements created that may affect injury

Functional Progression

Prepare for return to activity

• Must be ready physically & psychologically

Symptom Free

Sport Specific Drills are essential

Series of gradually progressing activities to prepare for return to activity

Activity must be accomplished before next step is added

Functional Testing

Uses Functional progressive drills to assess ability to return to activity

Performance of single maximal effort

Includes agility runs, hopping, vertical jumps, shuttle runs, etc.

Can be compared with pre-season base line testing

Rehabilitation Key Points

• Understand what is happening in healing process - will help determine treatment

• Signs & symptoms will dictate limitations 

  • Modalities can be helpful 

• Maintain Activity levels in some way 

• Progression Back to normal function 

  • Protocols exist for surgical repairs

Primary Goals of Comprehensive Strength & Conditioning Program

• Reduce Risk of Injury

• Enhance Performance

Three Variables Manipulated to Improve Performance

Exercise, Nutrition, & Rest

When one variable changes, they all need to change

F.I.T.T

(program design variable to maximize results)

Frequency - number of workouts per time period (week, month, cycle, etc.)

Intensity - load/level of exercise
Time - time interval of the workout (duration)
Type - mode or method of exercise

Scientific Principles to Maximize Results

Progression: the systematic manipulation of the intensity and or volume of exercise

• Proportionate to the individual’s ability to adapt

Specificity: (S.A.I.D) specific adaptation of a muscle, muscle group, or physiological system to an imposed demand

• Energy/metabolic system

• Biomechanics

• Neuromuscular System

• Emulate movements on the court, field, ice, pool, track. etc.

Comprehensive Strength & Conditioning Program

Strength Training (olympic & traditional), Speed + Agility, Plyometrics, Functional Training, Core Conditioning, Cardiorespiratory Conditioning, Flexibility

Olympic Weight Lifting (full body conditioning)

Training Full Body vs. Body Parts

• Synchronicity - multiple muscle groups contracting in sequence (together) to accomplish a task

Strong Body vs. Body Parts

• The utilization of the kinetic chain to generate & transfer energy/momentum through the:

  • Legs —> Hip —> Torso (out to the) Chest/Shoulder —> Arm —> Hand

Power Clean

• Training for power/explosiveness (Strength X Speed)

Traditional Weight Lifting

Training Body Parts - muscle isolation

• Less emphasis on kinetic chain

• Often utilize external stabilizers

  • Bench - sitting, lying, kneeling

  • Padded Anchor

Muscular Fitness

Describes the integrated status of:

1) Muscular Strength

2) Muscular Endurance

3) Muscular Power

4) Hypertrophy

Strength (low speed strength)

The amount of force that a muscle or muscle group can exert or absorb in one maximal effort

• One repetition maximum/ 1 RM

• Speed not a factor

Muscular Endurance

The ability of a muscle or muscle group to perform repeated contraction agaisnt a sub-maximal resistance, resisting fatigue

Power (high speed strength)

The ability of a muscle or muscle group to exert high force while contracting at a high speed (strength x speed)

Hypertrophy

Enhancement of muscular size by increasing cross sectional are

Speed

Ability to achieve high velocity (stride length x stride frequency)

Metabolic Conditioning

• Increase the storage & delivery of energy for physical activity

• Ability to optimize energy system utilization & recovery

Agility

• Ability to start, stop, & change direction while maintaining an upright equilibrium

Plyometric

Plio = more/increase

Metric = measurement

Increase measurement

• Power - strength x speed

• Height (vertical)

• Distance (horizontal)

• Displacement of body weight

Quick power movement using a pre-stretch or counter movement that involves the stretch shortening cycle

• Characterized by: rapid deceleration followed by rapid acceleration of mass in opposite direction

Functional Fitness

Train movement patterns vs. isolating muscles (integrate, not isolate)

Integrated multi-joint & multi-planar movement that incorporates:

• Stabilization, Balance, Coordination, Proprioception (with the intent of improving movement ability, core strength, & neuromuscular efficiency)

• Facilitates smooth, integrated, & efficient movement

• Multi joint & multi-planar movements

• Recruit stabilizers & proprioceptors

• Balance & coordination

• Synergism

Core Conditioning

Role of Core:

• Connects the upper & lower extremities

• Transmission of force

• Stabilize & coordinate movement between the upper & lower extremities

• Support/stabilize the spine from all sides

Cardiorespiratory Conditioning (S&C)

• The ability of the heart & lungs to deliver oxygen ot the working muscles & the muscles ability to generate energy with the oxygen resulting in increased performance 

• Improvement is measured by assessing the change in maximal oxygen uptake (VO2 max) 

• Training induced increases in VO2 max generally range between 5-30%

• Modes of Cardiorespiratory Conditioning 

  • The greatest improvement in VO2 max occur when exercises involve: 

    • Large muscle groups over prolonged periods 

    • Rhythmic & aerobic in nature 

      • Walking, Jogging, Cycling, Rowing, Stair climbing, Elliptical, Cross Country Skiing, Swimming, Group aerobic/fitness classes

Flexibility

Elongating a muscle beyond its resting length

Types of Stretching

• Static

• Dynamic

• Foam Roll

Tissue Quality

Range of Motion: the amount of movement of a particular joint/bony interface

Flexibility: the elasticity, pliability, or elongation ability of soft tissue

Mobility: the range of motion of a joining & flexibility of surrounding soft tissue

Static Stretching

• Static = stationary 

• Slow, controlled stretch with the end position being held

Dynamic Stretching

• Dynamic = motion/movement 

• Functionally based stretching that uses sport/activity specific movements to prepare the body for activity 

• Utilize muscle(s) in “stretched” positions that facilitate: strength & coordination in new ranges of motion

Foam Rolling

• Self myofascial release (SMR)

  • Myo = muscle 

  • Fascia = tissue that surrounds the muscle 

• By putting pressure on and rolling over knots/tender areas along the muscle tissue: 

  • Releasing the knots/tight area 

  • Increasing blood flow 

  • Increasing movement ability 

  • Promoting recovery