Duke Sports Medicine- Tracy Ray MD MODALITIES: APPLICATIONS FOR THE TRAINING ROOM

Transcription

1 Duke Sports Medicine- Tracy Ray MD MODALITIES: APPLICATIONS FOR THE TRAINING ROOM

2 Objectives Define modality Discuss appropriate use of modalities Examine 3 primary modalities used in training room and associated evidence

3 What is a modality? The method of application of a therapeutic agent or regimen in order to promote, maintain, or restore the physical and physiologic well-being of an individual These include the therapeutic use of heat, cold, ultrasound, massage, and electrical stimulation to induce a healing effect.

4 What is a modality? Physical agents/modalities should be utilized only as a component of patient/client management. Without documentation which justifies the necessity of the exclusive use of physical agents/modalities, the use of physical agents/modalities in the absence of other skilled therapeutic or educational interventions should not be considered physical therapy.

5 Back to the basics Modalities: should not be the sole focus of treatment intervention Are most effective when used in conjunction with other treatment interventions (i.e. manual therapy, active movement/exercise) Parameters for use vary Most have limited research evidence to support use

6 What is a modality? Heat modalities: increasing blood flow to propagate healing factors at injured area Cold modalities: decreasing blood flow to inhibit influx of chemical byproducts and inflammatory mediators which impede healing process Electrotherapy: altering neuromuscular excitability and increasing electrical current to improve muscle activation and strength

7 Contraindications The following are applicable to most modalities: Cancer Pregnancy Vascular disease or those areas with impaired circulation Impaired sensation Thrombophlebitis Hemorrhage Heat or cold intolerance (for cold/heat modalities)

8 Types of Modalities Cryotherapy Ice packs, ice massage, whirlpool, immersion, sprays Thermotherapy Moist heat packs, whirlpool, paraffin, ultrasound, phonophoresis Contrast baths (hot and cold alternating) Electrotherapy Electrical stim, interex, biowave Iontophoresis Massage

9 Heat Superficial heating(hot pack, paraffin) penetrates skin 1-2 cm Deep heating modalities (ultrasound, diathermy) heat 2-5 cm below skin Heating effect occurs with transfer of energy via conduction Increases local or systemic circulation Promotes vasodilation

10 Heat Physiology A localized increase in temperature causes increased metabolic rate, capillary pressure and flow, clearance of metabolites, and oxygenation of tissue Increases extensibility of soft tissue structures In most cases should not replace active warm-up As a movement based profession, active motion should be encouraged to increase tissue temperatures and oxygen to healing tissue via increased blood flow

11 Clinical Application for Heat Promote relaxation and blood flow before stretching, prepares for other treatments Decrease muscle guarding following whiplash type injuries in contact sports Improve local circulation to an area Used in sub-acute and chronic situations Often used after dry needling or other manual techniques to decrease soreness and promote flexibility/blood flow Petrofsky, J. S., Laymon, M., & Lee, H. (2013). Effect of heat and cold on tendon flexibility and force to flex the human knee. Medical science monitor: international medical journal of experimental and clinical research, 19, 661.

12 Cryotherapy Most commonly applied modality in sports medicine Examples: Cold pack, ice cup massage, whirlpool

13 Cryotherapy Physiology Reduced blood flow due to vasoconstriction Reduction in inflammatory response due to reduced metabolic rate/enzyme levels Reduced pain through gate-control theory and inhibition of nocioceptors Altered nerve conduction velocity Tissue temp needs to be reduced degrees for therapeutic effect to occur

14 Cryotherapy Physiology Used to intervene in presence of arthrogenic muscle inhibition (AMI) which is a protective reflex mechanism following joint injury External stimulus of cold application or lowlevel sensory input alters inhibitory signaling Increased excitatory efferent signaling to muscle results in increased activation

15 Cryotherapy Cryotherapy and TENS shown to increase vastus medialis motor neuron pool following artificial knee joint effusion Hopkins et. al Cryotherapy and Transcutaneous Electric Neuromuscular Stimulation Decrease Arthrogenic Muscle Inhibition of the Vastus Medialis After Knee Joint Effusion JAthl Training 20 minutes of ice bag application/45 minutes of TENS shown to increase quadriceps activation in subjects with diagnosed tibial osteoarthritis Pietrosimone et. al Immediate Effects of Transcutaneous Electrical Nerve Stimulation and Focal Knee Joint Cooling on Quadriceps Activation Med Sci Sports Exerc 2009

16 Clinical Applications Cold pack: Suggested application varies in the literature from minute treatments 2-4x/day up to minutes every 2 hours Recent research promotes intermittent sessions of 10 minutes, followed by 10 minutes off, then 10 minutes on every 2 hours Training room application: post-practice/surgery/injury Recent study has shown decrease in temp at intercondylar notch following cryotherapy performed after ACLR Post-op application: Ice bag DIRECTLY applied to injured area, encourage quad strengthening exercise during application Pietrosimone et. al Immediate Effects of Transcutaneous Electrical Nerve Stimulation and Focal Knee Joint Cooling on Quadriceps Activation Med Sci Sports Exerc 2009 Rashkovska, A., Trobec, R., Avbelj, V., & Veselko, M. (2013). Knee temperatures measured in vivo after arthroscopic ACL reconstruction followed by cryotherapy with gel-packs or computer controlled heat extraction. Knee Surgery, Sports Traumatology, Arthroscopy, 1-9

17 Compression Devices Often used in conjunction with cryotherapy and elevation Most popular device is the Game Ready Also seeing more use of pneumatic compression devices such as Normatec

18 Electrical Stimulation Used for acute/sub acute/chronic injuries Settings vary depending on acuity of pain and effects desired Most often used in combination with heat or ice An athlete modality of choice

19 Electrical Stimulation Based on the gate control theory in the dorsal horn of the spinal cord Pain travels through small diameter afferent nerve fibers (A-delta and C fibers) By activating the larger diameter afferent fibers (A-beta) through touch, pressure, or electrical currents, the gate is closed on pain fibers Training room application: used during exercise in post-op period, everyday use

20 Electrical Stimulation Clinical Applications Russian wave form for post op quad activation Low pulsatile current for longer acting pain control High pusatile current for immediate pain control, but short term benefits Should be an adjunct to exercise, not a stand alone treatment Gondin, J., Cozzone, P. J., & Bendahan, D. (2011). Is high-frequency neuromuscular electrical stimulation a suitable tool for muscle performance improvement in both healthy humans and athletes?. European journal of applied physiology, 111(10),

21 Biowave Latest technology in electrotherapy Similar to TENS/Interferential that uses surface electrodes to reduce pain Claims to use Deep tissue signal technology Provides deeper delivery of stimulation while also being more comfortable for pt Research very limited so far

22 Summary Modality application most effective when used with other treatment measures Modalities should not be the sole focus of treatment Implementation of modalities promote the healing and recovery of injured tissues More research is needed to support parameters and effectiveness of modalities in treating a variety of musculoskeletal conditions

23 References Axman, T., Esfeld, S., Jackson, C., Moore, A., & Quillin, D. (2013). The effects of cryotherapy and hot-pack treatments on quadriceps femoris strength measured by an isokinetic machine. Bleakley CM Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Med; 40: Doucet, B. M., Lam, A., & Griffin, L. (2012). Neuromuscular electrical stimulation for skeletal muscle function. The Yale journal of biology and medicine, 85(2), 201. Gondin, J., Cozzone, P. J., & Bendahan, D. (2011). Is high-frequency neuromuscular electrical stimulation a suitable tool for muscle performance improvement in both healthy humans and athletes?. European journal of applied physiology, 111(10), Hopkins et. al Cryotherapy and Transcutaneous Electric Neuromuscular Stimulation Decrease Arthrogenic Muscle Inhibition of the Vastus Medialis After Knee Joint Effusion JAthl Training Johnson, M. I., Ashton, C. H., & Thompson, J. W. (1991). An in-depth study of longterm users of transcutaneous electrical nerve stimulation (TENS). Implications for clinical use of TENS. Pain, 44(3),

24 References Lake, D. A., & Wofford, N. H. (2011). Effect of Therapeutic Modalities on Patients With Patellofemoral Pain Syndrome A Systematic Review. Sports Health: A Multidisciplinary Approach, 3(2), Lamba, D., Verma, S., Basera, K., Taragi, M., & Biswas, A. (2012). A study to compare the effects of moist heat therapy with ultrasonic therapy and ultrasonic therapy alone in lateral epicondylitis. Indian Journal of, 6(2), 41. Nyland, J. Nolan, M. (2004). Therapeutic Modality: Rehabilitation of the Injured Athlete. Clin Journ of Sports Med; 23 ( ) Petrofsky, J. S., Laymon, M., & Lee, H. (2013). Effect of heat and cold on tendon flexibility and force to flex the human knee. Medical science monitor: international medical journal of experimental and clinical research, 19, 661. Pietrosimone et. al Immediate Effects of Transcutaneous Electrical Nerve Stimulation and Focal Knee Joint Cooling on Quadriceps Activation Med Sci Sports Exerc 2009 Prentice, William E. Therapeutic Modalities: for Sports Medicine and Athletic Training. 5 th ed. New York: McGraw-Hill 2003 Rashkovska, A., Trobec, R., Avbelj, V., & Veselko, M. (2013). Knee temperatures measured in vivo after arthroscopic ACL reconstruction followed by cryotherapy with gel-packs or computer controlled heat extraction. Knee Surgery, Sports Traumatology, Arthroscopy, 1-9