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PHYSICAL THERAPIES IN MANAGEMENT OF SPORTS INJURIESDR SUSHMITA KUSHWAHAMD SPORTS MEDICINE SPORTS INJURY CENTRESAFDARJUNG HOSPITAL, NEW DELHI-110029

Different modalities:Physical energy can be applied to the body in various forms:Mechanical 1. Cryotherapy 2. Superficial heat 3. UltrasoundElectrical 1. Transcutaneous Electrical Nerve Stimulation(TENS) 2. Interferential Therapy 3. Galvanic stimulationRadiation 1. Laser 2. Magnetic Field Therapy 3.Extra corporeal shock wave therapy Other-Vaccusport

1.CRYOTHERAPY Cold therapy or cryotherapy refers to use of local or general body cooling for therapeutic purposes

Effects:Vasoconstriction--> (a) limits bleeding and (b) reduces the rate and extent of oedema formation and joint arthrosis.

Pain reduction: (a)reduces conduction of some pain nerves in skin (b)pain Gait control mechanism( d/t sensory stimulation) (c) release of endorphins and encephalins (d) reducing oedema formation

Reducing muscle spasm (a)by reducing pain component of pain spasm cycleDecreased local cellular metabolism- cells survived post injurydeprived of usual rate of O2 supply-->cold therapy---> reduced metabolic demand and necrotic enzyme release---> cell survival

Different Cold modalities available are:a)Cold paksb)Crushed ice packsc)Vapocoolant spraysd)Ice water immersione)Ice massagef)Contrast bathg)Cryotherapy machine. Using Cold therapy 1.Acute injuries- 1st 72 hrs ,ice for 10min every 2hrly. After that ice 15-20min 3 times a day. 2.After prolonged or vigrous activity--> ice for 15-20 mins. ( Do not apply ice for more than 20min)

CRYOTHERAPY

Clinical Indications: Contraindications1.Muscle spasm 1.Cold intolerance2.Trigger point pain 2. Cryoglobinemia3. Acute swelling/edema 3.Circulatory insufficiency4. Heat illness 5. Contusion Dangers 6. Pre and post massage 1.Ice burns7.Acute injuries 2.Superficial nerve damage 3.Anaesthesia

2.SUPERFICIAL HEAT THERAPYSuperficial heat modalities-->warms skin and immediatelyunderlying tissues via conduction--> dispersion of heatedblood spread of heat in deeper tissues.(protective fn.-heat dissipation from skin prevents skin damage)Effects:1.Pain relief2.Acceleration of healing3.Reduction of muscle spasm4.Facilitation of joint motion

Different therapeutic thermal conduction methods:1.Hot packs2.Wax bath3.Hot air4.Electrical heating pads5.Whirlpool bath6.Contrast bath

SUPERFICIAL HEAT THERAPY.Clinical Indications:1.Pain relief2.Muscle spasm3.Cervical pain4.Chronic pain and swelling5.Increases tissue extensibility( range of joint movement)How to use superficial heat:Temp- 45 -50 degree celsiusDuration- 15-20mins

SUPERFICIAL HEAT THERAPY.Contraindications:1.Sensory changes2.Circulatory problems3.Heat injuries4.Hypersenstivity or hyposenstivity to heat.Dangers:1.Increased bleeding and swelling(if used in first 48hours after acute injury)2.Burns

3.ULTRASOUND

3.ULTRASOUND Ultrasound refers to mechanical vibrations which are same as sound waves but of higher frequency.Mech of action: Ultrasound waves are generated by piezoelectric effect caused by vibration of crystals within the head of probe. these crystals are most commonly- Quartz other- Barium titanete and Lead zirconate titanete. Ultrasound waves ---->pass through the skin----> vibration of local soft tissues---->deep heating.

ULTRASOUND..Physiological effects of Ultrasonic therapy: 1.Thermal effect- local temp---> local blood flow2.Enhancing effect on each steps of tissue healing. Inflammatory stage- stimulates mast cell,platelets and wbcs. Proliferative stage-stimulatory effect on fibroblast, myofibroblast and endothelial cell. Remodelling phase- aids collagen orientation and improves tensile strength of scar tissue.

Different forms for delivering Ultrasonic waves1.Continuous mode : dose- 1 w/cm2Duration-< 5min,thrice a week indication- chronic cases2. Pulse mode : dose- 2.5w/cm2, 1MHz frequency , 20% duty cycle duration- thrice a week indication- acute injuries(analgesic effect)Pulsing---> reduces the rate of heating allowing same or more peak intensity to be used----> Mechanical effect >> thermal effect).(DUTY CYCLE=PULSE DURATION:TOTAL TIME OF PULSE + INTERVAL)Eg. 2o% duty cycle-- 1:5ratio of pulse to interval is 1:4. 50% duty cycle 1:2--- ratio of pulse to interval is 1:2.

LIPUS( Low Intensity Pulsed Ultrasound ) High intensity ultrasound and conventional ultrasound macines(continuous mode) shown to have detrimental effects on bone healing. Low intensity( stimulate various enzyme pathway--->COX-2 and prostaglandin release--->bone mineralisation and endochondral ossification fracure healing.

Effects:1.Accelerate healing of an acute fracture A recent review reports that LIPUS at 1.5mHz pulsed at 1kHz with 30mW/cm2 for 20 minutes per day can accelerate bone healing in Tibial, Radial and Scaphoid fractures by upto 40%.2.Stimulate healing process in non-union.3.Minimise delayed healingDose :Intensity- 38 c Over pregnant uterus.In case of malignancies

5.INTERFERENTIAL THERAPYDef : it is a form of electrotherapy in which 2 alternating medium freq. currents are used to produce low freq effect. Principle- to pass two medium freq alternating current slightly out of phase through the tissue and where the current intersect produces a low frequency current , equal to the difference of both the frequencies(beat freq.).

Physiological effects:

1. Pain relief (80 100 Hz): local of the circulation.Gate control mechanism(by 80 100 Hz) stimulation of small fiber which will cause the release of enkephalin and endorphin (15Hz)2. Motor stimulation: muscle Contraction (1 100Hz )both voluntary and involuntary musclescontraction of deeply placed muscles(abdominals, pelvis floor, thigh). 3. Absorption of exudate ( 1 10 Hz) 4. Tissue healing & resolution of inflammation(up to 100 Hz)

Factors affecting physiological effect of I.F.TCurrent intensityLow sensory response (fine tingling), used in acute pain, swelling and circulation.Medium strong tingling + mucles contraction. Used in muscle Strengthing & Reeducation.High painful stimulation(tingling + contraction + pain), used in chronic. Pain. Beat of frequency: 1 10 Hz swelling.5 20 Hz motor stimulation.80 100 Hz pain relief.

Technique of application: Positioning the electrodes so that the crossing points of the 2 current is over or within the lesion. Appropriate freq. to the indicated condition. current intensity is adjusted until the pt. feels mild tingling sensation if accommodation occurs intensity may be increased. Duration - 15mins

Indication of IFT :Acute soft tissue injuries swelling/edema muscle spasmPain esp. deep(acute knee ,ankle or shoulder )

Dangers: Electrical burns due to increased skin resistanceElectrodes on the skin are too close allowing the short circuit.Contra-indications:Acute inflammation or TBMalignancy.Metal implants.Pace makersSkin lesions.IntolerancePregnancyOver thrombo-phelibitis (release of thrombi)Febrile conditions.

6.Galvanic current

It is a direct current used to stimulate muscle directly, without activation of the peripheral nerve. painful to overcome this, regular pause can be given between stimulation.

Two types of current -Intermittent galvanic current (for muscle stimulation) -Constant direct current ( for iontophoresis)

EffectsAppropriate electrical stimulation can cause a denervated muscle to contractContraction of a denervated muscle limit edema and venous stasis within the muscle delay muscle fiber degeneration and fibrosisRecovery time following denervation appears to be shortened .Maintain the extensibility of the muscles.Improves local circulation.Prevents contracture.

Iontophoresis Method of treatment which uses direct current to push drugs or therapeutically active ions through the skin

Compounds applied using iontophoresis:1)Dexamethasone(anti inflammatory)2)Lidocaine(anaesthetic)3)Hyaluronidase(facilitate breakdown of brusing/ bleeding into the tissues)4)Salicylic acid( analgesics & anti inflammatory)5)Acetic acid/acetates(breakdown calcifications)

MechanismCompound being used placed under electrode(drugs releasing +ve charge placed under anode & -ve charge under cathode)

Like charges repel each other, facilitating entry of drug through skin primarily via hair follicles/sweat glandsRecommended current density: Cathode- 0.5mA/cm2 Anode-1.0mA/cm2DangerChemical burns

Galvanic current indications:

Electro diagnostic Rehabilitation of paralyzed muscles Peripheral nerve injury. Bells palsy. IontophoresisContraindications1)Pace maker2)Malignancy3)Over heart4) Pregnancy

7.LASER (Light amplification by the Stimulated emission of Radiation)Therapeutic laser is also known as Soft laser, Cold laser, Low intensity laser. CLASSIFICATION1. Hot laserHILSurgical LaserCauses tissue heatingPower > 60mW2. Cold laserLILTherapeutic LaserNo Tissue heating Power < 60mW

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LASEREffect of Laser therapy 1.Pain reliefGait control theoryEndorphin release 2.Tissue healingAccelerates collagen synthesisAccelerates inflammation phase of wound healingEnhances immune cells to combat pathogensIncreases vascularity of healing tissueFibroblast productionCartilage stimulation

More than 130 double-blind positive studies confirming clinical effect of LLLT.

DosageDuration--> 15-20 mins, repeated doses at regular intervals of 1-3 days.Energy density = Power (W) Time (sec) Treatment Area ( cm) 1-6 j/cm(2) acute pain 2-4 j/cm(2) muscle pain 4-6 j/cm(2) neurological indications 4-8 j/cm(2) joint pain 5-6 j/cm(2) wounds 8-12 j/cm(2) chronic pain and OA Wavelength may vary from 400nm -1064 nmAcute :ContinuousChronic: Pulsed

LASERIndications ContraindicationsArthritis over eyes Tendonitis on cancerous lesionWounds Pregnant abdomenEdema Unclosed fontanelsContractures/scar tissue Cardiac region of heart patients Trigger finger Over endocrine glandMuscle spasms Areas with recent cortisone inj.Bicipital tendinitis

8.MAGNETIC FIELD THERAPY It is a therapeutic technique that consists of applying artificial magnetic fields on an affected part of the human body, controlling intensity and frequency.Two ways of delivering magnetotherapy1.Non Stationary, Pulsed electromagnetic field(PEMF) : work only when connected to electricity. Pulsed generator connected to a coil magnetic field current flows in tissue Duration:20-30mins;6-10 sessions

MAGNETIC FIELD THERAPY......2. Stationary (Permanent magnets): are fully charged with electric current and remain permanently magnetized.(Earings, bracelets, necklace or pellets)

MAGNETIC FIELD THERAPY......Mech of action: research is limited and inconsistent. Two main theories proposed:1. Magnetic therapy---> vasodilation --->increase blood flow at site of injury--->increase oxygen delivery to the tissues---> analgesia and accelerate tissue healing.2. Magnetic therapy---> changes cell membrane potentials--->reduces output of nociceptors---> reduces pain.

Indications Contraindications1.Spondylosis. 1.Acute infections2.Muscle spasm 2.Haemorrhagic focus3.Osteoporosis 3.Cardiac pacemaker 4.Osteomylitis 4.Pregnancy5.Dysmenorrhae 5.Tumors6.Depression & Migranes 6.Diabetes7.Epicondylitis 7.Patient on hydrocortisone trt8.Sciatica9.Trigeminal neuralgia.10.Gout, Rheumatoid and osteo arthritis12.Recent trauma and fractures14.Trophic ulcers

9.EXTRACORPOREAL SHOCK WAVE THERAPY(ESWT)ESWT is a non invasive, safe and promising treatment for variety of tendinopathies. Mechanism of Action: still unclear; Two theories proposed are1. Repeated shock wave--->local microtrauma---> neovascularisation---> promote tissue healing.2. Stimulation of acute inflammatory response in a chronic inflammatory environment---> promote healing.

(As new inflammatory reaction is considered beneficial after ESWT---> anti-inflammatory med not to be used after trt.)

Types of ESWTHigh Energy ESWT Energy level >0.6mJ/m2 single dose painful used in conjunction with local anaestheticLow Energy ESWT Energy level arterial perfusion is stimulated-->flow of oxygenated blood to extremities. Phase of normal pressure-the backflow of venous blood and lymph within the large vessels is facilitated.

VACUSPORT..........Effects :Passive vascular training Reduction of oedema Advances wound healing Enhancement of peripheral blood flow Enhances lymphatic drainage Analgesia Increases capillarizationSignificant acceleration of regeneration and rehabilitation. Dosage: 4 10 session each session- 30-45mins.

Indications: numerous indications; still great need for research Vascular diseases of leg To accelerate rehabilitation oedema in lower extremities contusion and ligament injuries.

Contraindications Negative effects could not be detected until now. Nevertheless, should not be conducted in case of acute injuries such as Phlebothrombosis, Thrombophlebitis, infection, pregnancy

Safety during pregnancy 1.Ultrasound-C/I 2.Electrical current- Uncertain. 3.LASER therapy- C/I 4.Short wave theray-C/I 5.Superficial heat- distant site safe, but should be avoidedelevated maternal tempfetal malformations 6.Sensory level TENS- safe in LBA in preg. 7.Superficial ice- safe

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