Mechanical Modalities

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Mechanical Modalities

• HuP 195
• Therapeutic Modalities in
• Athletic Rehabilitation

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Mechanical Modailites

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

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Intermittent Compression Devices
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Compression Principles

• Constant compression
• Focal compression
• Intermittent compression

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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

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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

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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

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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)

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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

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Treatment Parameters

• Must obtain patients 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 31 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)

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Continuous Passive Motion
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Continuous Passive Motion (CPM)

• Utilized to counter negative effects of
  immobilization
• Salter (late 1980s) 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

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Effects of CPM

• Motion that is never lost need never be
  regained most painful aspect of rehab often
  involves regaining motion

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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

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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

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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

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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

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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

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Contraindications

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

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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

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Biofeedback
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Biofeedback

• Most prevalent use in orthopedics/sports medicine
  is for muscle re-education or muscle relaxation
• Conversion of bodys electrical activity into
  auditory and/or visual signals by biofeedback
  unit
• Biofeedback doesnt monitor actual response, but
  measures conditions associated with the desired
  response

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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 whats being
  measured into meaningful and helpful feedback to
  get desired response

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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

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Indications/Contraindications

• Indications
• 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

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Cervical and Lumbar Traction
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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

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Cervical Traction

• Effectiveness linked to
• Position of neck
• Force of applied traction
• Duration of applied traction
• Angle of pull
• Position of patient

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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)

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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
  patients body weight (more if patient in seated
  position)

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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

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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

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Lumbar Traction

• Effectiveness linked to
• Force of applied traction (tension)
• Position of patient
• Angle of pull

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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

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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

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Effects of Traction

• Pain 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

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Indications

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

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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

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Therapeutic Massage
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Types of Massage

• Effleurage
• Petrissage
• Friction massage
• Tapotement
• Myofascial release

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Effleurage

• Stroking of the skin
• Slow, light 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

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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

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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)

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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

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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

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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

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Contraindications

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