Objec+ves. Modali+es and Rehabilita+on in the Training Room. Process of Rehabilita+on. Rehabilita+on Protocol. Stage I: Acute Inflammatory Phase

Transcription

1 Objec+ves Modali+es and Rehabilita+on in the Training Room Team Physician Course Feb 2013 Heather Gillespie, MD, MPH Assistant Professor, UCLA Team Physician, UCLA Athle+cs Enhance the learner s understanding of The general management and rehabilita+on of injuries at three stages of injury The role of therapeu+c exercise and modali+es in the training room A variety of training room therapeu+c modali+es and their indica+ons and evidence for use Process of Rehabilita+on Rehabilita+on Protocol Determine Phase of Injury Acute/Subacute/Chronic The restora+on of normal anatomical and physiological func+on Determine Desired Outcome/Goals Rule Out Precau+ons/Contraindica+ons Determine Therapeu+c Modality Develop Progression of Treatment Stages of Injury Stage I: Acute Inflammatory Phase Stage 2: Regenera+on and Repair Stage 3: Remodeling Phase Stage I: Acute Inflammatory Phase Lasts up to 72 hours Immobiliza+on? Avoid heat and massage Address psychological impact 1

2 Stage I: Goals Protect from further injury Control pain Limit swelling Promote normal healing Stage I: Management Pharmacological interven+ons Physical Modali+es PRICES +/- Immobiliza+on Therapeu+c Exercises Isometric ROM? Immobiliza+on?? + accelerates forma+on of granula+on +ssue + limits scar size + improved penetra+on of fibers through connec+ve +ssue - muscle atrophy - weakness Early mobiliza+on Increases tensile +ssue strength Improved orienta+on of regenera+ng muscle fibers S+mulates resorp+on of connec+ve scar +ssue Improved recapillariza+on Decreases muscle atrophy and weakness Stage 2: Regenera+on and Repair Fibro- elas+c/collagen- forming stage 48 hours 6 weeks Stage 2: Goals Allow normal healing Maintain func+on of uninjured parts Minimize decondi+oning Increases ROM Improve strength, endurance, power Increase aerobic capacity Improve propriocep+on 2

3 Stage 2: Management Modali+es Heat E- s+m Enhance motor unit ac+va+on/recruitment So^ Tissue Mobiliza+on Therapeu(c Exercises Stretching/flexibility Eccentric/concentric Isometric/isotonic/isokine+c Therapeu+c Exercises Prescribed outline of exercise with Type Intensity Dura+on Frequency Therapeu+c Exercises Early strength gains neurological factors Muscle hypertrophy occurs a^er several weeks of training Restora+on of strength can take 3-6 months Maintenance training at lower frequency should be permanent component of program Therapeu+c Exercises Aerobic Condi+oning Cycling, swimming, rowing Propriocep+on/coordina+on/balance Type Intensity Dura+on Frequency So^ Tissue Mobiliza+on Controlled stress on scar +ssue to influence final form and func+on Parallel fiber arrangement Elas+c More mobility without irrita+on and pain Stage 3: Remodeling Phase 3 weeks 12 months Remodeling of collagen to increase func+onal capabili+es of muscle, tendon, etc. 3

4 Stage 3: Goals Resolve: Residual strength deficits Imbalances Asymmetry Return to compe++on Absence of symptoms Normal flexibility Adequate strength (90%) Ability to perform Psychological aspect Stage 3: Management Con+nued condi+oning/exercises Development of sport specific skills Gradual RTP/training with team/coach Psychological prepara+on for play Preven+on of further injury (maintenance program) Rehabilita+on Protocol Determine Phase of Injury Acute/Subacute/Chronic Determine Desired Outcome/Goals Rule Out Precau+ons/Contraindica+ons Determine Therapeu+c Modality Develop Progression of Treatment Therapeu+c Modali+es no cookbook protocol Play a role at each stage of injury/healing Formulate a treatment protocol/plan Awareness of side effects Safety measures Beware of marke+ng!! Heat Ultrasound Phonophoresis Therapeu+c Modali+es Cryotherapy Electrical S+mula+on Laser Kinesio taping Superficial Conduc+on Hydrocollator packs Convec+on Whirlpool tanks Deep Conversion Ultrasound Diathermy Heat 4

5 Heat Hydrocollator/Hea+ng pack Indica+ons: Chronic pain, muscle spasm, inc blood flow Precau+ons: Thermal hypersensi+vity Contraindica+ons: Acute inflamma+on, malignancy, desensi+zed skin Treatment Dura+on: minutes or un+l heat has dissipated. Heat Hydrotherapy (Warm Whirlpool) F Indica+ons: Pain, muscular spasm, +ssue extensibility Precau+ons: Thermal hypersensi+vity Contraindica+ons: Malignancy, desensi+zed skin Treatment Dura+on: min Ultrasound Deep hea+ng agent Acous+c sound waves generate mechanical disrup+on of +ssues Possible effects: deep +ssue hea+ng, non- thermal +ssue manipula+on Ultrasound Frequency = number of wave cycles per second. Common: 1 MHz - 3 MHz Lower frequency deeper beam penetra+on 1 MHz deep hea+ng frequency (2 5 cm) 3 MHz superficial structures (1 2 cm) Ultrasound Indica+ons (Thermal effects): Tissue extensibility, chronic pain, muscular spasm, increasing blood flow, inducing inflammatory response to resolve chronic injury Indica+ons (Non- thermal Effects): Increase local metabolism, increase +ssue- healing factors, bone healing Precau+ons: thermal hypersensi+vity, allergy to gel Contraindica+ons: Acute inflamma+on (thermal), malignancy, desensi+zed skin, eyes, reproduc+ve organs and fluid filled cavity organs, epiphyseal plates, infec+on Phonophoresis An+- inflammatory medica+on added to u/s coupling medium (gel) Ultrasound waves promote transdermal +ssue absorp+on of medica+on 5

6 Phonophoresis vs. Ultrasound for Myofascial Pain RDBPCT 60 pa+ents Diclofenac phonophoresis and ultrasound therapy were effec+ve in the treatment of pa+ents with MPS. Phonophoresis was not found to be superior over ultrasound therapy. Ice bag Ice cups Frozen gel packs Cold whirlpool Cryotherapy Ay S, et al. Rheumatol Int Sep;31(9): Epub 2010 Mar 31. Cryotherapy Decrease blood flow (capillary constric+on) Reduce pain Decrease swelling Decreases inflammatory cytokine release Quicker healing +me? Cold whirlpool F Cryotherapy Indica+ons: Pain, muscular spasm, prevent or decrease swelling Precau+ons: Hypersensi+vity to cold Contraindica+ons: Infec+on, desensi+zed skin Treatment Dura+on: minutes Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols 20 min con+nuous vs. 10 on/10 off/10 on Both groups repeated every 2 hours over the first 72 hours of injury Intermipent protocol had significantly (p<0.05) less ankle pain on ac+vity than those using a standard 20 minute protocol One week a^er injury, NO significant differences between groups in terms of func+on, swelling, or pain at rest. Bleakley CM, et al. Br J Sports Med Aug;40(8):700-5; discussion 705. Effect of local cold- pack applica(on on systemic anabolic and inflammatory response to sprint- interval training: a prospec(ve compara(ve trial. 12 male handball players 4 x 250 m treadmill run, at 80% max Rest period with and without local cold- pack applica+on Pre, immediately post, and 60- min post- exercise blood samples drawn Local ice therapy immediately following sprint- interval training was associated with greater decreases in both pro- and an+- inflammatory cytokines and anabolic hormones suppor+ng some clinical evidence for possible nega+ve effects on athle+c performance Very small study! Nemet D, et al. Eur J Appl Physiol Nov;107(4): Epub 2009 Aug 4. 6

7 Electrical S+mula+on E- S+m Neuromuscular s+mula+on Electric current/skin electrodes Transcutaneous Electrical Nervous S+mula+on (TENS) TENS = non- specific term that refers to all forms of E- S+m, however, there are small, portable, bahery powered units referred to as TENS units Electrical S+mula+on Various Currents Used Interferen+al Current (IFC) Premodulated Current High Voltage Pulsed Current (HVPC) Russian Current Differ in: Intensity Pulse frequency Pulse dura+on Polarity Electrical S+mula+on Indica+ons: Pain modula+on, wound healing, muscle re- educa+on, edema reduc+on, muscle recruitment Contraindica+ons: Pacemakers, cancerous lesions, hemorrhage, pregnancy, metal implants in treatment area Therapeu+c Laser Light Amplifica+on by S+mulated Emission of Radia+on An+ inflammatory Vasodila+on S+mulates lympha+cs An+- pain Regulates Na- K pump in nerve fibers Speeds healing Inc capillaries S+mulates collagen Regenerates immune cells Addi(ve effects of low- level laser therapy with exercise on subacromial syndrome: a randomised, double- blind, controlled trial. 80 pa+ents with subacromial syndrome Group 1 : laser treatment (pulsed infrared laser) and exercise therapy for ten sessions for 2 weeks Group 2 : placebo laser and the same exercise therapy Conclusion: LLLT combined with exercise is more effec(ve than exercise therapy alone in relieving pain and in improving the shoulder ROM in pa+ents with subacromial syndrome Low- level laser therapy in ankle sprains: a randomized clinical trial 217 pa+ents: acute lateral ankle sprains 12 treatments of laser therapy in 4 weeks as an addi+on to standard rehab (bracing and HEP) 3 groups: high dose, low dose and placebo laser No sig difference in pain (primary outcome) CONCLUSIONS: Neither high- nor low- dose laser therapy is effec(ve in the treatment of lateral ankle sprains Abrisham SM, et al. Clin Rheumatol Oct;30(10): Epub 2011 May 4. de Bie RA, et al. Low- level laser therapy in ankle sprains: a randomized clinical trial. Archives of Physical Medicine and Rehabilita+on 1998 Nov;79(11):

8 Low level laser therapy for nonspecific low- back pain Cochrane Database Syst Rev insufficient data to draw firm conclusions on the clinical effect of LLLT for low- back pain. need for further methodologically rigorous RCTs to evaluate the effects of LLLT compared to other treatments, different lengths of treatment, wavelengths and dosages. Kinesio taping Elas+c therapeu+c tape with a texture and elas+city very close to living human +ssue Designed in 1970s by Kenzo Kase, a Japanese chiropractor and acupuncturist Claim: li^s the skin and allows improved blood and lymph flow Yousefi- Nooraie R, et al. Cochrane Database Syst Rev Apr 16;(2):CD Kinesio taping Indica+ons: support injured muscles, increase range of mo+on, decrease muscle pain Most common: shoulder, forearm and quadriceps adjunct to PT rehabilita+on Some benefit in 40-60% of users Placebo? More studies needed! Minimal harm Cost Kinesio Taping in Treatment and Preven(on of Sports Injuries: A Meta- Analysis of the Evidence for its Effec(veness 10 ar+cle Meta- analysis Only 2 studies inves+gated sports- related injuries (shoulder impingement) only one involved injured athletes Efficacy of KT in pain relief was trivial no clinically important results Inconsistent range- of- mo+on and strength outcome results Conclusion: liple quality evidence to support the use of KT over other types of elas+c taping in the management or preven+on of sports injuries Further studies needed Williams, S, et al. Sports Medicine, Volume 42, Number 2, 1 February 2012, pp (12) Rehabilita+on Protocol Summary Determine Phase of Injury Acute/Subacute/Chronic Determine Desired Outcome/Goals Rule Out Precau+ons/Contraindica+ons Determine Therapeu+c Modality Develop Progression of Treatment Effec+ve training room rehabilita+on is pa+ent specific and may involve medica+ons, exercises, procedures and modali+es Develop a treatment protocol More research needed on the effec+veness of various modali+es Psychological benefits of rehab 8

9 References Abrisham SM, et al. Addi(ve effects of low- level laser therapy with exercise on subacromial syndrome: a randomised, double- blind, controlled trial. Clin Rheumatol Oct;30(10): Epub 2011 May 4. Ay S, et al. Comparison the efficacy of phonophoresis and ultrasound therapy in myofascial pain syndrome. Rheumatol Int Sep;31(9): Epub 2010 Mar 31. Bleakley CM et al. Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. Br J Sports Med Aug;40(8):700-5; discussion 705. Epub 2006 Apr 12. Bleakley CM et al. The PRICE study (Protec(on Rest Ice Compression Eleva(on): design of a randomised controlled trial comparing standard versus cryokine(c ice applica(ons in the management of acute ankle sprain [ISRCTN ]. BMC Musculoskelet Disord Dec 19;8:125. de Bie RA, et al. Low- level laser therapy in ankle sprains: a randomized clinical trial. Archives of Physical Medicine and Rehabilita+on 1998 Nov;79(11): Hubbard TJ, Denegar CR, Does Cryotherapy Improve Outcomes With So_ Tissue Injury? J Athl Train Sep;39(3): Nemet D, et al. Effect of local cold- pack applica(on on systemic anabolic and inflammatory response to sprint- interval training: a prospec(ve compara(ve trial. Eur J Appl Physiol Nov;107(4): Epub 2009 Aug 4. Senbursa G, et al. Comparison of conserva(ve treatment with and without manual physical therapy for pa(ents with shoulder impingement syndrome: a prospec(ve, randomized clinical trial. Knee Surg Sports Traumatol Arthrosc Jul; 15(7): Epub 2007 Feb 28. Swenson C. et al. Cryotherapy in sports medicine. Scand J Med Sci Sports Aug;6(4): Williams S, et al. Kinesio Taping in Treatment and Preven(on of Sports Injuries: A Meta- Analysis of the Evidence for its Effec(veness Sports Medicine, Volume 42, Number 2, 1 February 2012, pp (12) Yousefi- Nooraie R, et al. Low level laser therapy for nonspecific low- back pain. Cochrane Database Syst Rev Apr 16; (2):CD Physiotherapy Evidence Database PEDro; hpp:// Easy access to randomized controlled trials and systema+c reviews of physiotherapy interven+ons. Method Score: 10/10 Random alloca+on; Concealed alloca+on; Baseline comparability; Blind subjects; Blind therapists; Blind assessors; Adequate follow- up; Inten+on- to- treat analysis; Between- group comparisons; Point es+mates and variability 9