Dr. Jack Dolbin DC Session 3 Basic Principles in Treating Athletic Injuries 1. Acute Phase 2....

Dr. Jack Dolbin DC Session 3

Basic Principles in Treating Athletic Injuries

1. Acute Phase

2. Healing Phase

3. Rehabilitation Phase

• Acute Inflammation ( 24-48 hours )

• Chronic Inflammation ( 3-7 days )

• Healing ( 3-6 WEEKS )

• Rehabilitation ( up to a year ) Min 3 months

Einstein on Insanity

“ Doing the same thing over and over expecting a different result.”

Dog lady

Evidence based Practice

• A method of integrating clinical expertise with the best available evidence from clinical research to make decisions about the care of individual patients

Levels of EBP

• Research report or original research with systemic reviews

• Case-control studies or reports

• Expert opinions leads to clinical commentary

• Application= Therapeutic Value

Treating Athletic Injuries

Acute Phase1. Control tissue injury complex

a. Enforce rest of injured area with protection

b. Maintain conditioning: anaerobic-aerobic

2. Treat Inflammationa. Pain meds.

b. Bromelain: Studies

c. Modalities

Acute Phase (Cont.)

3. If not overt signs of inflammation no meds or modalities necessary

4. When healing allows :a. Protected ROM

b. Isometric activity

c. Resisted short arc isotonic contractions

Acute Phase (Cont.)

4. Goals:a. Reduced Swellingb. Decrease Painc. Tissue Healingd. Improved ROM

When achieved - Proceed to healing phase.

Treatment Protocols:

“Exercise is not an adjunctive therapy, exercise is the therapy”

Ken Hutchins.

Ardnt-Schultz Law

• Weak stimuli increases physiological activity and very strong stimuli inhibits or abolishes physiological activity.

Law of Least Action

• Maupertius: The quantity of action necessary to effect any change is the least possible, the decisive amount is always the minimal, the infintesimal.

Treatment Protocols:• Phase 1: Acute Inflammatory Phase:

– Question: Does inflammation cause pain or does pain cause inflammation?

• For a long time pain has been summarily dismissed as the outcome of direct stimulation of sensory nerve endings by injury and the pressure of inflammation exudates. This opinion completely neglects the observation that pain often initiates the inflammatory response and may become less severe as that process gains speed. Robbins pg.44

• Goal is to control the pain and inflammation

– PRICE• Protection• Rest• Ice• Compression• Elevation

Treatment Protocols:• Ice: 15-30 minutes of cryotherapy reduces

temperature 3-7 degrees C.• Method of delivery:

– Ice Pack– Ice Massage– Versacooler: Adds compression to the TX.– Immersion

• Cryotherapy to the point of cold vasodilation is counter productive. Hunter Reaction is the bodies reaction to excessive cryotherapy causing increase hemorrhage and inflammation.

• ICE Suggested Protocol:– 10 minutes: C-Spine, wrist, elbow, ankle shin– 15 minutes T-Spine, knee, shoulder– 20 minutes, L-Spine, pelvis, thigh.

Frequency: 2-4 times/day,

Maximum hourly: 15-20 /45

• ICE vs HEAT Ice Heat Grade 2 Sprain-strain: Within 24 hours After 24 hours

6 days 11 days 15 days

Grade 3 13 days 30 days 33 days

• Sensory Fiber Analgesia: 4-5 minutes with cryotherapy which lasts for 30 minutes.

Cryotherapy gives comparable relief

to local anaesthesia and morphine.

• Electrotherapy: Used for edema reduction and pain control: – High Volt– Low volt– Interferential– Faradic – Galvanic: Iontophoresis

Treatment Protocols:• Ultrasound:

– Promotes healing of soft tissue.• Continuous

• Pulsed

• Phonophoresis LLLT vs Ultrasound.mht

Hands Free Ultra Sound

• Low intensity

• Longer treatment time

• Stationary

• Results: Stress Fractures, Soft Tissue Injuries

Low Level Pulsed Ultrasound• Reduced healing time in fracture repair by

30-38%

• When applied to non union fractures it stimulated union in 86% of cases

• Potential for use in tendon, ligament, muscle and cartilage injuries

• Conclusion: may have a beneficial effect in treating sports injuries: accelerated healing

• Joint mobilization: Tissue must heal in the presence of motion.

• Cyriax Cross Fiber: • Laser :

• Exercise:

Joint mobilization

• Activates mechanoreceptors

• Breaks down adhesions

• Decrease congestion in joint

• Relieves compressive forces on articular capsular and cartilagenous structures

• Relieves contracture of connective tissue transversing joint

Mobilization

• The strength of healed tendons is superior to that of controls where mobilization was delayed.

• An augmentation of extrasynovial tendon healing by continuous passive motion has been demonstrated in the rabbit model

Mobilization

• Mobilization stimulates the intrinsic tendon healing response, specifically the fibroblasts, resulting in healing with minimal scar formation.

• . Early passive mobilization reduces adhesions

Transverse FM

• Transverse friction massage of the injured tendon in chronic tendonitis is thought to be beneficial in breaking down adhesions,

• Tissue mobilizations maybe beneficial in tendon healing by the transport of nutrients to the area.

Cyriax Crossfiber

• Mobilize scar tissue

• Reduce adhesions

• Activates phagocytes

• Neurological component

• Should be preceeded by ice massage

• Followed by isometric stretches

Muscle Energy

Muscle energy

Laser/Light

• Tissue heals relative to the reversal of glycolytic damage.

• Oxygen utilization major key to healing

• Laser is directed at mitochondrial activity

• Increases cellular metabolism

Laser v Light Therapy

Light v Laser

Multiradiance

Light with Stim

Interferential Light Therapy

Physics

• UV light < 400nm < infrared

• 600-750 nm = Red

• 750 < Infra Red- not visible

• Depth of penetration = NM = Wave Length

Physics ( Cont )

• Depth of Penetration

• 400 nm = 2-3 mm

• 600-750 = 10 mm

• 880 nm = 30-40 mm

• Multiradiance: 5-6 inches

• Dose = sec x power/ area = JCm2

LLLT Effect on Inflamation

LLLT ( cont )

LLLT effect on pain

Cell membrane changes Ca, Na, K ion changes

Endorphin increase C-fiber depolar block

Nitric Oxide Production. Produced by fibroblasts.

Increased action potential

Decreased Bradykinin Levels Increased acetylcholine

Pain reduction

LLLT effect on healing time

Increased leukocytic activity Increased macrophage activity

Increased vascular regeneration Increased fibroblast proliferation

Early cell regeneration Enhanced cell differentiation

Increased tensile strength Accelerated wound healing

Reduced healing time

Application

Electrotherapy

• Low Frequency

• High Volt

• Interferential Current

Low volt currents

• Galvanic current

• Sine wave

• Electrical muscle stimulation

• Combination therapies

• TENS

Galvanic current

• Direct, unidirectional, waveless, low volt current

• Various electrochemical effects

• Use today is almost totally limited to iontophoresis

• Transcutaneous electrical nerve stimulation

• Based on the Melzack-Wall theory ( 1965)

• Sensory only

• Pad placement, dermatomal.

• Wave form widths 40-500ms

• Frequency: 70-150 pps

Sine Wave

• Used primarily for muscle stimulation

• Restricted joint motion

• Adhesions

• Muscle atrophy

• Passive exercise

• Trigger points

High Volt Therapy

• High voltage monophasic pulsed stimulation

• Advantage is primarily depth of penetration

• No danger of burning patient

General Settings for High Volt Therapy

• 1-10 pps. Muscle stimulation or pain modulation, small diameter electrode

• 10-15 pps, Muscle exercise, twitching

• 15 < Tetanize

• 20-80 pps muscle tetany without fatigue

• 70-110 enkephalin production for pain control

• + polarity acute – polarity chronicDr. Jack Dolbin DC Session 3

Interferential

• Two or more oscillations applied simultaneously

• 4000-4250 hz.

• Modulation

• 40-90 hz increases circulation

• 90-130 hz increased enkephalin production

Exercise

• Early transition from passive to active care

• Key to restoration of function

• Effects on the somatic system

• Effects on nervous system

• Should be initiated as soon as pain free motion is established.

Kerri Welsh

Kinesiotaping

• KT resulted in positive changes in scapular motion and muscle performance.

• Results supported its use as a treatment aid in managing impingement problems.

• Journal of Electromyography and Kinesiology. 29 May 2007

• KT may assist clinicians to obtain immediate improvement in pain-free shoulder abduction.

• Long term no more efficacious then sham taping at decreasing shoulder pain intensity and disability.

• JOSPT: July 2008 volume 38, number 7

KT compared to PT• Disability of arm, shoulder, hand scale

scores in the KT group were significantly better at the second week than the control group and the PT group.

• KT more effective than local modalities at the first and second week.

• Clinical Rheumatology 2011, Feb 30:201-7Dr. Jack Dolbin DC Session 3

Recovery Phase : Rehabilitation

1. Begin tissue overloada. Functional biomechanicsb. Deficit Complexes

2. Modalities less appropriate during recovery phase.a. Focus on loading of bone, muscle, tendons.b. Begin at the base of the kinetic chain.

Maintenance Phase

1. Absence of pain

2. Normal ROM

3. No residual tissue damage

4. Strength at 75% of normal

5. Smooth function of entire kinetic chain

Maintenance Phase (Cont.)

Begin with return to playContinues through athletes sport activity

Subclinical Adaptation Complexa. Techniqueb. Maintain Strengthc. Maintain ROM

Nirschl mentions three concepts to initiate a healing stimulus

1.Enhancement of peripheral aerobics. (Oxygenation, nutrition, adequate peripheral circulation)

2.Collagen induction, strengthening, and alignment

3. Enhancement of biochemical changes associated with endurance training.

Dr. Jack Dolbin DC Session 3 Basic Principles in Treating Athletic Injuries 1. Acute Phase 2....

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