Therapeutic Modalities and Rehab
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Transcript of Therapeutic Modalities and Rehab
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Therapeutic Modalities andInjury Rehabilitation
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Therapeutic ModalitiesCreate optimum environment for injury healing
Reducing pain and discomfort
Many different modalities to choose from
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Selection of Specific
Treatment is dependant on:Injury site, type and severity
Modality indication and contraindication
Physician prescriptionAthlete willingness to accept treatment
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More is not betterMisuse or overuse of a modality can:
Aggravate the condition
Delay the athletes return to play
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Legal ConcernsMust be administered in accordance with local
regulations
Documentations of all treatments
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Types of ModalitiesCryotherapy
Ice packs, ice massage, whirlpool, immersion, sprays
Thermotherapy
Moist heat packs, whirlpool, paraffin, ultrasound,phonophoresis
Contrast
Electrotherapy
IontophoresisMechanical
Massage, manipulation
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CryotherapyCold application
15-20 minutes every 11/2 waking hours- along with
rest, compression, and elevation
Reduces many adverse conditions related to
inflammatory phase
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Physical and Physiological
Effects of ColdPHYSICAL
Conduction- when a coldobject is applied to awarmer object, heat is
abstractedThe longer cold exposure isthe deeper the cooling is.
Tissue that has previouslybeen cooled takes longer toreturn to normal
temperature than tissue thathas been heated
Dept of cold penetration canreach up to 5 cm
PHYSIOLOGICALDecrease in tissue temp
Decrease in blood flow
Vasoconstriction
Decrease in muscle spasms
Decrease in pain perception
Decrease muscle fatigue
Decrease metabolic rate
Decrease waste productsin area that act as muscleirritant
Increase collageninelasticity and jointstiffness
Increase capillarypermeability
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Special ConsiderationsIndications
Acute sprains, strains, contusions, spasms,
inflammation
Contraindications
Circulatory disturbances, hypersensitivity, prolonged
application over superficial nerves
Allergic
React with hives, joint pain and swelling
Continued on next slide
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Special Considerations
ContRaynauds Phenomenon
Condition that causes vasospasm of digital arteries
lasting min-hours
Can lead to tissue death
Ice should never be applied for longer than 20-30
minutes
Hunting Response
Occurs when cold is applied for longer than 30 minutes
intermittently
Vasodilation occurs for 4-6 minutes
Reaction against tissue damage from too much cold
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Stages of Cryotherapy0-3 minutes after initiation feel cold sensation
2-7 minutes after initiation feel mild burning, aching
5-12 minutes after initiation feel numbness,
anesthesia
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Cryotherapeutic Methods
Ice PacksFlaked or crushed ice in a towel or plastic bag
Apply for 15-20 minutes combined with RICE
Ice MassagePaper cup filled with frozen water to from an ice cylinder
Rub or massage directly over area until skin becomes bright pink-usually for 7-10 min
Cold Water ImmersionWhirlpool, bucket or container filled with mixture of water and ice-
temp- 55-65 degrees FImmersion for 10-20 minutes- great for hands, feet and ankles
Vapocoolant Sprayscold spray of chemicals sprayed of surface of skin to freeze it
Treat myofascial pain and trigger point, usually combined with
stretching. Effects are superficial and temporary
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ThermotherapyUsed of sub-acute injuries
Used to increase blood flow
Promotes healing in the injured area
Vasodilation occurs to shunt cooler blood to
warmed area
Do not use until active inflammatory process is
over/ no signs of swelling
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ConductionOccurs when heat is transferred from a warmer
object to a cooler one
Heat should never exceed 116 degrees F
Examples are moist heat packs, paraffin baths, and
electric heating pads
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Physical Principles of HeatConduction
Convection
Radiation
Conversion
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ConvectionRefers to the transference of heat through the
movement of fluids or gases
Factors that influence convection heating are
temperature, speed of movement and theconductivity of the part
Example: whirlpool bath
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RadiationThe process whereby heat energy is transmitted
through empty space
Heat is transferred from one object through space
to another object
Examples: Infrared heating and ultraviolet
therapies
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ConversionRefers to the generation of heat from another
energy form such as sound, electricity and
chemical agents
Examples: Ultrasound therapy, diathermy,chemical agents- balms
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Physiological Effects of HeatBodys response to heat depends on
Type of heat energy, duration, intensity, tissue type
Decrease muscle spasm
Decrease pain perception
Increased blood flow
Increase metabolic rate
Decreased joint stiffnessIncrease range of motion
Increasing the extensibility of collagen tissue
Increased general relaxation
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Special ConsiderationsReasonably safe- as long as heat is at safeintensity and application is not for too long
Contraindications:
An area of loss of loss of sensationImmediately after an injury
An area where there is decreased arterial circulation
Eyes and genitals
Abdomen during pregnancyTo a malignancy
Monitor heat when applied to elderly patients or infant
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Thermotherapy Methods
Moist Heat Packs
Whirlpool Bath
Contrast Bath
Paraffin Bath
Ultrasound Therapy
Phonophoresis
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Moist Heat Packs
Commercial Packs- Hydrocollator Packs
Silicate gel in a cotton pad immersed in 170 degrees ofhot water
Apply 15-20 minutesLayers of towels are used between packs and theskin to avoid burning. As packs cool removetowels
Deep tissues are not significantly heatedInhibited by subcutaneous fat acts as insulator
Patient should be in comfortable position
Patients should not lie on the hot pack becauseheat can not dissipate out
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Whirlpool Bath
Tank with a turbine motor which regulates the
movement of water and air
Cold- 55 degrees F, Neutral- 92-96 degrees F,
Warm- 96-98 degree F and Hot 98-104 degrees F
Convection and Conduction are occurring
Reduces swelling, muscle spasm and pain and
active movement is also assisted
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Whirlpool Continued
Treatment time should not exceed 20 minutes
Whirlpool unit/tank must be kept clean
Frequent water changes and daily cleaning
essential
Open wounds and abrasions should be handled
cautiously so that contamination or spreading of
the infection is prevented
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Contrast Baths
One unit holding hot water at 105-110 degrees F
( for example a whirlpool)
One unit holding cold water at 50-65 degrees F
( for example a bucket can be used)
The goal to alternating hot and cold is to increase
local circulation to the treated limb
Vasodilation from hot water and Vasoconstriction from
the cold water accomplishes this
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Contrast Baths Continued
The limb is first placed in the warm water for 5
minutes
Then is alternated to the cold water for 1 minute
Hot to cold is 1 cycle, after first cycle use 4 minutes
in hot and 1 minute in cold
Repeat 4/1 cycle for up to 30 minutes
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Paraffin Baths
Paraffin and mineral oil that is kept at 125-130
degrees F in a controlled unit
Provide superficial heat to angular, bony areas of
the body (hands, feet, wrists)
Allows the part to remain elevated
Sustains heat which increases circulation and
decreases pain in affected area
Before treatment clean and dry area to be treated
thoroughly
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Paraffin Bath Continued
Dip the affected part into the paraffin bath and
quickly pull it out
Allow the accumulated wax to dry and form a solid
covering
This process of dipping and withdrawing is
repeated until the wax coating is 1/4 to 1/2 inch
thick
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Ultrasound Therapy
Ultrasound uses high frequency sound waves
Sound energy causes molecules in the tissues tovibrate, thus producing heat and mechanical
energy1mHz is the frequency used when heating isneeded for deep tissue
3mHz is the frequency used when heating is
needed for areas with minimal soft tissue coverageNerve tissue is twice as sensitive to ultrasoundthan muscles
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Ultrasound Therapy
Thermal and mechanical effects of ultrasound
increase circulation and promote healing
Ultrasound raises tissue temperature 7-8 degrees
F up to 2 inches below the skins surface
Little or no change in skin temperature
Also provides a micro massaging action on cells
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Pulsed and Continuous
WavesPulsed
Non thermal effect
The flow of sound
waves are interrupted,thus less energy is
produced
Best used on
Sub acute injuries
Wound healing
Over bony areas
Continuous
Thermal effects
Sound waves are
continuousIncrease circulation
Non thermal effects
At a low intensity
Acute injuries
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Indications for Ultrasound
Post acute soft tissue trauma
Bursitis
Tendonitis
Fascitis
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Contraindications for
UltrasoundAcute inflammatory conditions with continuous
mode
Over areas with limited vascularity or sensation
Over eyes, ear, heart, reproductive organs,
endocrine glands, CNS or open epiphysis (growth
plates!!!)
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More info on Ultrasound
There must be a coupling medium
Acoustic energy can not travel through air, is reflected
by skin
Lotion, gel, water applied to the skin
Transducer (sound head) should be kept moving at
all times
Small circles or longitudinal strokes at speed 1-2 inches
per second
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More info on Ultrasound
Treatment is 5 minutes for an area 3-4 times of the
sound head
Intensity
Determined by the stage of injury and depth of target
tissue
Underwater application
Good for bony areas like hand, wrist and feet
Hold sound head 1 inch from body part and move in
circular or longitudinal patterns
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Phonophoresis
Method of driving molecules through the skin by iontransfer by the mechanical vibration of theultrasound
Designed to move an entire molecule of medicationinto injured tissues
Hydrocortisone and and anesthetic are used withsuccess
Massage medication into the skin over area, thenspread the coupling agent, then ultrasound
Lower intensity for a longer duration
Tendonitis, bursitis and painful trigger points
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Electrotherapy
Purpose
Control pain
Exercise muscle tissue to decrease atrophy
Encourage circulation
Increase tissue temperature
Encourage breakdown of adhesions
Reeducate muscles
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Physical Principles of
ElectrotherapyElectricity is a form of energy that displays thefollowing factors on tissue:
Magnetic
Chemical
Mechanical
Thermal Effects
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Electrotherapy Currents
Produce waveforms
Waveforms refer to the shape, direction, amplitude andduration of electric current
Direct CurrentFlows in one direction
Electrons move from a negative to a positive pole
Feel tingling, followed by a feeling of warmth
Chemical reactions, increase blood flow, musclereeducation, decrease swelling, spasm and pain
Alternating current
AC
The flow of electrons reverse in direction once each cycle
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Special Considerations for
ElectrotherapyContraindicationsPacemakers
Pregnancy
When muscle contractions are not wanted
Nonunited fractures
Areas of active bleeding
Near malignancies
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Electrotherapy Methods
Moist electrode pads are placed on the skin
Small pad is the active pad which brings thecurrent to the body
Larger pad is where the electrons leave the bodyCloser the pads are the shallower and moreisolated the muscle contraction
The farther apart the pads are, the deeper and
more generalized the contractionActive exercise can be used at same time
Ice packs, cold water immersion and ultrasoundcan all be combined with electrotherapy
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Iontophoresis
Process which chemical ions are transported
through the intact skin by an electrical current
Polarity of the electrode used depends on the
polarity of the ion introduced
The most common used medication for
iontophoresis are hydrocortisone and salicylates
The patient should not experience discomfort or a
burning sensation
Treatment times are 10-20 minutes, once a day
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Mechanical/Manual Therapy
Therapy where the direct use of the providers
hands are being used
Used in conjunction with or as supplement to to
other methods
Massage
One of the oldest modalities used
Manipulation
Joint mobilization
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Massage
Therapeutic and Physiological Effects
Stimulating Cell metabolism
Increasing venous flow and lymphatic drainage
Increase circulation and nutrition
Stretches superficial scar tissue
Relaxes muscle Tissue
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Contraindications to Massage
Acute injuries
Hemorrhaging
Infection
Thromboses
Nerve damage
Skin Disease
Possibility of Calcification
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Massage Methods
Effleurage
Superficial or deep stroking with the heels and palms of
the hand
PetrissageKneading, hold soft tissue between the thumb and
forefinger and alternately roll, lift, twist to loosen tissue
Tapotement
Cupping, hacking, pincing and percussive movements
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Massage Methods
Vibration
Trembling, forward and backward movement, rapid
shaking of tissue by hand or machine
FrictionPressure across muscle or tendons. Fingers and
thumbs move in circular patterns, stretching underlying
tissue
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Massage
Use lubricants
Oil, lanolin, lotion, powder
Stroke toward the heart
Increases venous return to reduce swelling
Proper positioning
Injured part made easily accessible, comfortable and
relaxed
Be confident
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Manipulation/Manual Therapy
Mobilization of joints and soft tissue to allow proper
functioning of a body part
All movement is passive on part of the athlete
Based on the concepts of joint play
Gliding and rolling of one joint surface on another
At no time should a provider attempt manipulation
without education and practice
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Rehabilitation
Unit 7
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Definition
Restoration to a functional level for daily living
Return to an appropriate level of competitive fitness
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Individualized and Influenced
by:Severity of injuryStage of tissue healing
Type of Treatment (surgery, protocol)
Strength of the muscles of the limb
Pain on motion of the joint
Joint swelling
Sport specific demands
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Rules of Rehabilitation
Create an environment for optimal healing
Do no harm
Be as aggressive as you can without doing harm
If it hurts, dont do it
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Goals of Rehabilitation
Vigorous, intense BUT controlled exercise allowing
return to competition
Ensuring injured part is as optimally conditioned as
possibleRestoration of function to the greatest possible
degree in the shortest possible time
Goals must be realistic and reachable
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Realistic and Reachable
GoalsIncrease range ofmotion
Increase strength
Increase joint mobilityIncrease endurance
Encourage relaxation
Enhance coordination
and skillImprove joint stability
Prevent re-injury
Decrease pain
Improve function
Minimize atrophy and
deconditioning
Improve technique,
posture and mechanics
Decrease inflammation
and swelling
Improve motor control
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Equipment
Specialized equipment is very useful
This will not guarantee results if program is
inadequate, if athlete is not motivated or there is poor
supervisionPossible to use little or no equipment
As long as the program is carefully and knowledgeably
designed for athletes needs and if athlete is adequately
motivated and supervised
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Psychology of Rehabilitation
Rehab is 75% psychological and 25% physical
Rapport with athlete is critical (motivation and
communication)
Help athlete deal with fear, anger, depression, self-doubt, and motivation
Use a variety of exercise to achieve the same
results and avoid boredom
Involve injured athlete with the team as much as
possible- meetings, functions and practice
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Components of a rehab
programProgram must be progressive increase amount ofwork performed at each session
Use correct form to maximize results and prevent
injuryStrength
Speed
Endurance
FlexibilityProprioception
Sport Specific Skills- functional
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Common Mistakes in Rehab
Look for the culprit not the victim
Focusing on one single muscle group
Not moving on until injured limb is equal orsuperior to the uninjured side
Proprioception is often forgotten
Postural defects, anatomical malalignment and
biomechanical imbalances are neglectedSports specific skills are not incorporated
SAID principle not incorporated
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Types of Exercise
Isometric
Isotonic
Isokinetic
Plyometrics
Manual Resistance
Concentric/Eccentric Contraction
Open / Closed Chain
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ISOMETRIC EXERCISE
Does not result in any movement of the joint
Often performed against a fixed resistance
Least effective form of strength improvement
Static exercise since there is no movement
Examples; Wall press, stationary press
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ISOTONIC EXERCISE
The joint is moved through a range of motionagainst the resistance of a fixed weight
The resistance is fixed and the speed is variable
Dynamic movement since movement takes placeGreatest strength gain takes place in the initialmovement as the muscle attempts to overcomeresistance / Least strength gain is at the mid point
Examples: Bench press, arm curls, squat, heelraises
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ISOKINETIC EXERCISE
Exercise where there is variable resistance andwhere the speed of the motion is set
Resistance accommodates to match the force
appliedDynamic contraction since there is maintenanceof a constant velocity
Advantage- visual readouts are possible whichhelps evaluate progress and acts as a powerfulpsychological stimulus for the athlete
Disadvantage- Cost of isokinetic machines
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PLYOMETRICS
A variety of exercises that utilize explosive
movements to increase athletic POWER
Maximize the stretch reflex
Examples: Power jumps, leaps, bounds, throwinga weighted object- medicine ball
Should be performed 2-3 days a week to allow full
recovery from fatigue
Strength should first be attained to provide stability-
current injury is a contraindication
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Stretch Reflex
The muscle is fully stretched immediately
preceding the shortening of it
An eccentric contraction occurs immediately
before the concentric contraction
The greater the stretch put on the muscle from
its resting length immediately before the
contraction the greater the load the muscle canlift or overcome
Rate is more important than magnitude
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MANUAL RESISTANCE
A provider adjusts the speed of movement and
resistance to that best suited to the athletes needs
Will vary according to the stage of rehabilitation
and the state of fatigue
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Concentric Exercise
Concentric exercises are related to positive work
The muscle shortens as the weight is lifted
Example:
The up phase of a biceps curl
The biceps is the muscle working concentrically
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ECCENTRIC EXERCISE
Eccentric exercise is related to negative work
Muscle lengthens or is forcibly stretched while the
weight is lowered
Greater strength gains
More stressful work for muscles resulting in muscle
soreness
Example:
Lowering a dumb bell during a biceps curl
The biceps is the muscle that is working eccentrically
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Open Chain Exercise
Exercise when distal segment is not fixed and is
freely moving in space
Functional for upper extremity
Examples:Leg extension
Leg flexion
Abduction/Adduction exercise machines
Functional activities such as throwing, jumping
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Closed Chain Exercise
Exercise where distal segment is fixed
Functional for lower extremity
Examples:
Standing leg press with sport cord
Lunges
Baps board
Slide board
Therapy Balls
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Phases of Rehabilitation
There are three phases
Phase 1- Acute
First 48-72 hours
Phase 2- Sub-acute72 hours to about 2 weeks after injury
Phase 3- Intermediate
Last up to 6 months
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Phase 1- Acute
First 48-72 hours
Symptoms- redness, heat, swelling, pain,
inflammation, loss of function
Short Term GoalsDecrease pain, swelling and inflammation
Increase Range of Motion and Control Pain
Maintain Cardiovascular conditioning
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Phase 1-Acute continued
Emphasis of cardiovascular fitness
Isometric contractions if immobilized
Exercise the opposite unaffected limb may provide
cross over reaction
Muscle stimulation
RICE used to control swelling
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Phase 2- Sub acute
72 hours to about 2 weeks
Inflammation is decreasing and tissue is beingrepaired
Begins as soon as pain and swelling are controlledand complete immobilization is no longernecessary
Warm up the area prior to attempt exercise andROM will allow tissue to respond more effectively
Ice injured area after working it to preventsecondary swelling and effusion
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Phase 2- Sub Acute continued
Short Term Goals
Reach full range ofmotion
Increase musclestrength, power andendurance to allmuscle groups
Maintaincardiovascular
endurance to pre-injury strength
Begin proprioceptiontraining
Amount of time neededfor tissue repair isbased on severalfactors:
Degree of injury
Location of injury
Age
Nutritional status
Medical problemsMedications
Use of corticosteroids
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Phase 3- Intermediate
Lasts up to 6 months
Tissue is repairing, changing and remodeling to
restore function
Prepare for Specific Functional ExercisesIncluding open and closed chain exercises
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The End
Any Questions???