dr. jack dolbin dc session 3 basic principles in treating athletic injuries 1. acute phase 2....
TRANSCRIPT
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
Dr. Jack Dolbin DC Session 3
Einstein on Insanity
“ Doing the same thing over and over expecting a different result.”
Dog lady
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Treating Athletic Injuries
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
Dr. Jack Dolbin DC Session 3
Treating Athletic Injuries
Acute Phase (Cont.)
4. Goals:a. Reduced Swellingb. Decrease Painc. Tissue Healingd. Improved ROM
When achieved - Proceed to healing phase.
Dr. Jack Dolbin DC Session 3
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.
Dr. Jack Dolbin DC Session 3
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.
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
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.
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Treatment Protocols:
• 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
Dr. Jack Dolbin DC Session 3
Treatment Protocols:
• 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.
Dr. Jack Dolbin DC Session 3
Treatment Protocols:
• Electrotherapy: Used for edema reduction and pain control: – High Volt– Low volt– Interferential– Faradic – Galvanic: Iontophoresis
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Treatment Protocols:
• 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
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Mobilization
• Mobilization stimulates the intrinsic tendon healing response, specifically the fibroblasts, resulting in healing with minimal scar formation.
• . Early passive mobilization reduces adhesions
Dr. Jack Dolbin DC Session 3
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.
Dr. Jack Dolbin DC Session 3
Cyriax Crossfiber
• Mobilize scar tissue
• Reduce adhesions
• Activates phagocytes
• Neurological component
• Should be preceeded by ice massage
• Followed by isometric stretches
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Muscle Energy
Dr. Jack Dolbin DC Session 3
Muscle energy
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Laser v Light Therapy
Dr. Jack Dolbin DC Session 3
Light v Laser
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Multiradiance
Dr. Jack Dolbin DC Session 3
Light with Stim
Dr. Jack Dolbin DC Session 3
Interferential Light Therapy
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Physics
• UV light < 400nm < infrared
• 600-750 nm = Red
• 750 < Infra Red- not visible
• Depth of penetration = NM = Wave Length
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
LLLT Effect on Inflamation
Dr. Jack Dolbin DC Session 3
LLLT ( cont )
Dr. Jack Dolbin DC Session 3
LLLT ( cont )
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Application
Dr. Jack Dolbin DC Session 3
Electrotherapy
• Low Frequency
• High Volt
• Interferential Current
Dr. Jack Dolbin DC Session 3
Low volt currents
• Galvanic current
• Sine wave
• Electrical muscle stimulation
• Combination therapies
• TENS
Dr. Jack Dolbin DC Session 3
Galvanic current
• Direct, unidirectional, waveless, low volt current
• Various electrochemical effects
• Use today is almost totally limited to iontophoresis
Dr. Jack Dolbin DC Session 3
Tens
• 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
Dr. Jack Dolbin DC Session 3
Sine Wave
• Used primarily for muscle stimulation
• Restricted joint motion
• Adhesions
• Muscle atrophy
• Passive exercise
• Trigger points
Dr. Jack Dolbin DC Session 3
High Volt Therapy
• High voltage monophasic pulsed stimulation
• Advantage is primarily depth of penetration
• No danger of burning patient
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
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.
Dr. Jack Dolbin DC Session 3
Kerri Welsh
Dr. Jack Dolbin DC Session 3
Kinesiotaping
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
KT
• 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
Dr. Jack Dolbin DC Session 3
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
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Dr. Jack Dolbin DC Session 3
Treating Athletic Injuries
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.
Dr. Jack Dolbin DC Session 3
Treating Athletic Injuries
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
Dr. Jack Dolbin DC Session 3
Treating Athletic Injuries
Maintenance Phase (Cont.)
Begin with return to playContinues through athletes sport activity
Subclinical Adaptation Complexa. Techniqueb. Maintain Strengthc. Maintain ROM
Dr. Jack Dolbin DC Session 3
Treating Athletic Injuries
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.