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Module 2: Therapeutic Modalities, commonly used modality for both acute…
Module 2: Therapeutic Modalities
Introduction
sources of Acute Soft Tissue Pain
pain can arise from:
Overstretch injury
Heavy eccentric loading
Muscle strains
DOMS
Direct insult to the tissue
How does muscle damage produce pain and weakness
The pathway from damage to pain
DOMS is still not entirely understood
The following is observed post-exercise
cellular osmolarity increases
capillary permeability increases, which increases the likelihood of edema
resulting edema can cause compression of the capillaries which can inhibit blood flow
results in reduced o2 delivery and impaired waste removal
inflammatory mediators are released
inorganic phosphate, H+ and lactic build up as a result of anaerobic metabolism
produces muscle fatigue
less force generation
Exercise can also induce oxidative stress from the increased energy turnover and elevated temperature
this oxidative stress can affect excitation-contraction coupling and modify Ca2+ levels
elevates calcium and inflammation can inhibit protein synthesis and impaire force generation
if there isn't proper post-exercise recovery, the inflammation can continue and cause secondary muscle damage
some heavy exercise types can cause direct damage to the muscle cell (sarcolemma and CT)
Rhabdomyolysis
breaks muscle tissue
Byproduct impair kidney function resulting in urine colour changes
can't give it to yourself since you can usually tell where your own threshold is
Acute and Chronic Pain
Acute pain not treated adequately can become chronic pain
Nerve cells start to remodel
Inhibitory interneurons are lost
Peripheral nociceptors become overactivated
This process leads to long-term sensitization of second-order spinal neurons: chronic pain
Acute pain management
Pharmacotherapies
Relaxants
Corticosteroids
for pain and inflammation
Acetaminophen
Opiods
use great deal of caution
NSAIDS
Nonpharmacological
Cold
Therapeutic ultrasound
Heat
TENS
Thermotherapy and Cryotherapy
Cryotherapy
used in managing:
DOMS
Inflammation
Muscle spasm
Edema
Chronic pain
Acute trauma
Effectiveness varies by the modality's ability to lower temperature - wetted ice is more effective than cubed at lower skin/muscle temp
Intended Effects
To reduce inflammation to an affected area by slowing the delivery of leukocytes and other inflammatory mediators
To reduce metabolic demand of an affected area in order to prevent secondary hypoxic damage
To reduce blood flow to an affected area via a sympathetic vasoconstrictive reflex
To produce an analgesic/anesthetic effect (cold-induced neuropraxia) by lowering activation threshold of nociceptors and the slowing the velocity of nerve signals carrying pain messages
To reduce muscle spasm via inhibition of the spinal cord reflex loop
Cold Sprays
Produces a cooling sensation superficially, which causes analgesia by activating ion channels in peripheral neurons
While it may have an analgesic effect, it does not actually lower tissue temperature or produce decreases in metabolism or blood flow
Do not act by lowering tissue temperature
Specific Uses
Ankle Sprain
High-quality studies examining the use of cryotherapy for ankle sprains are scarce
Many have small sample sizes and are of a structurally low quality
Some studies suggest a marginal benefit, some suggest improvements in pain, function and RTP; some are inconclusive or show no superior effect over compression alone
DOMS
Ice baths have demonstrated some ability to reduce post-exercise soreness
Not immediately, but within the DOMS time frame
The evidence is conflicting, however
Contraindications or Special Considerations
Should be used with caution or not used in individuals with:
cold hypersensitivity
Raynaud's disease
Decreased sensitization
Vascular compromise
hypertension
serious cognitive impairement
Thermotherapy
Superficial heat includes
wraps
hot stone therapy
heating pads
hot towels
hot water bottles
sauna, paraffin wax
Moist heat
Deep heat therapies
ultrasound
short wave and microwave diathermy
effectiveness is based on the modality's ability to raise tissue temperature
heat produces a therapeutic effect by:
Increasing blood flow (vasodilation), with the intention of increasing the supply of blood, oxygen and nutrients to the affected tissue, as well as tissue metabolism
Increasing elasticity of connective tissue, with the goal of improved ROM through increases in viscoelastic properties of collagen fibers
Relieving pain through mediation of neural transduction through descending
antinociceptive pathways
Specific use
LBP
Heat does demonstrate the ability to improve pain symptoms and ROM in pxs with low back pain
Heat can also serve as a successful adjunct to exercise therapy for LBP
DOMS
Heat demonstrated the ability to reduce symptoms of DOMS when used preventatively and post-exercise
special consideration
should be used with caution or not used in individuals with:
Spinal cord injury
diabetes mellitus
Poor Circulation
Rheumatoid arthritis
Multiple Sclerosis
Heat vs Cold
warm pool
decreased muscle stress markers including skeletal troponin I, CK, and myoglobin
Cold pool
elevated levels of muscle stress reaction markers
must look at many different factors when choosing a modality
event
sport
age
training
Ultrasounds
Used with transition coupling gel
US is used for a huge array of MSK conditions
Sprained ligaments, inflamed tendons and tendon sheaths, lacerations and other soft tissue damage, scar tissue sensitivity and tension, strained and torn muscles, inflamed and damaged joint capsules, fasciitis, and delayed-onset muscle soreness
used therapeutically between 1-3 MHz
higher intensities are used for other clinical purposes like abortions
Non-thermal effects
US also provides non-thermal effects via acoustic streaming and cavitation
Cavitation
the physical forces of the sound waves on microenvironmental gases within fluid
Cavitation causes pulsations in tiny gas bubbles which can alter metabolism of the cell
Acoustic streaming
the physical forces of the sound waves that provide a driving force capable of displacing ions and small molecules
US is purported to modulate membrane potentials, alter cellular proliferation, increase collagen synthesis and increase proteins associated with inflammation and injury healing
Thermal effects
At certain frequencies, US can provide a thermal effect to target tissues
Any benefit here is derived through similar mechanisms of other modalities of thermotherapy
Effectiveness
In vivo studies using US are difficult
effectiveness in treating certain types of MSK conditions
some remaining mechanistic questions
Many rials have been performed in animal models
Mechanotransduction
“The process by which the body converts mechanical loading into cellular responses. These cellular responses, in turn, promote structural change.”
occurs in soft tissues and in bone tissue
Cell to cell communication (the integration)
The cell/s receiving the stimulus pass along the message to distal cells through
chemical mediators
Signaling proteins include calcium and inositol triphosphate
Effector response (the response)
So long as the load is within the beneficial range, effector cells will respond to the stimulus with growth, repair, or stimulation of the target tissue
Too heavy load can cause stress-induced degradation
Too little stimuli and tissues can atrophy or degrade
Mechanocoupling (the stimulus)
Can be shear forces, compressive forces, or tensile forces
Results in chemical signals being released
The physical load that disrupts a tissue's cells
Tissue Types
Articular Cartilage
Chondrocytes (cartilage cells) are mechanosensitive
Exact pathways seem comparable to muscle pathways, but are still under investigation
Muscle
Overload leads to immediate increase in mechanogrowth factor (MGF) – a relative of IGF-1
MGF leads to hyptertrophy via activation of satellite cells
when skeletal muscle is damaged:
Daughter cells differentiate into myoblasts (undifferentiated single-nucleus cells, that serve as a precursor to myocytes)
Satellite cell-mediated hypertrophy of damaged muscle
Satellite cells (undifferentiated stem cells) in the plasma membrane and basement membrane are activated and undergo mitotic proliferation
Tendon
Both mechanoresponsive and dynamic tissue
Tendon shows an upregulation of IGF-1 and other growth factors in response to exercise stimulus
Bone
Bone stimulation
Electrical Stimulation
Suggested to impact cellular pathways, including growth factor synthesis, proteoglycan and collagen regulation, and cytokine production
These pathways may stimulate the calcium-calmodulin pathway to stimulate bone
Non-invasive therapy meant to stimulate bone healing
Effectiveness
Ultimately, there is insufficient evidence to make a conclusion about bone stimulators
cost should be a major consideration
They detect tensile loads and transform that stress into a series of biochemical reactions
osteocytes are the mechanosensors in bone
Osteoclasts and osteoblasts are stimulated to cause bone formation
Nitric oxide (NO) and cAMP are secreted in response to mechanical stress in the
immediate early stage
The expression level of IGF-I is enhanced by other cellular mediators to respond to stress with growth
TENS (Transcutaneous Electrical Nerve Stimulation)
Tolerance to TENS can be developed
Can be avoided pharmacologically or non-pharmacologically
There is some evidence to suggest the effectiveness of TENS
Some studies are underpowered or not well-controlled
Functions to treat pain both peripherally and centrally
TENS can be used at different frequencies
Motor levels will help to initiate muscle contraction (Russian stimulation)
Sensory levels will assist with pain management
Typically used with either a small portable unit and attached electrodes or a larger stationary unit and electrodes
electrodes placed at the site of injury
Nonpharmacologica pain relief treatment for both acute and chronic pain
Central and Peripheral Functions
Centrally, sites in the spinal cord and brainstem that utilize opioid, serotonin, and muscarinic receptors are activated by TENS
GABA the primary inhibitor NT is also implicated
Peripherally, at the site of TENS application, opioid and α-2 noradrenergic receptors are involved in TENS-induced analgesia
commonly used modality for both acute and chronic pain
Both come in a wide array of types