Using Modalities in the Immediate First Aid Management of Injury
Table 2–2 summarizes the various modalities that may be used in the different phases of the healing process. Modality use in the initial treatment of injury should be directed toward limiting the amount of swelling and reducing pain that occurs acutely. The acute phase is marked by swelling, pain to touch or with pressure, and pain on both active and pas-sive motion. In general, the less initial swelling, the less the time required for rehabilitation. Tradition-ally, the modality of choice has been and still is RICE (rest, ice, compression, elevation).
Cryotherapy is known to produce vasocon-striction, at least superficially and perhaps indi-rectly in the deeper tissues, and thus limits the bleeding that always occurs with injury. Ice bags, cryocuffs, cold packs, and ice massage may all be used effectively. Cold baths should be avoided because the extremities must be placed in a gravity-dependent position. Cold whirlpools also place the extremities in the gravity-dependent position and produce a massaging action that is likely to retard clotting. The importance of applying ice immedi-ately following injury for limiting acute swelling through vasoconstriction has probably been over-emphasized. The initial use of ice is more important for decreasing the secondary hypoxic response asso-ciated with tissue injury (see Chapter 4). Analgesia, which occurs through stimulation of sensory cuta-neous nerves via the gating mechanism, blocks or reduces pain.
Immediate compression has been demon-strated to be an effective technique for limiting
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TABLE 2–2 Athletic Training Decision-Making on the Use of Various Therapeutic Modalities in Treatment of Acute Injury
PHASE CLINICAL PICTURE
(SIGNS AND SYMPTOMS)
POSSIBLE
MODALITIES USED
RATIONALE FOR USE APPROXIMATE TIME FRAME
Initial acute Swelling, pain to touch, pain on motion
CRYO ESC IC LPL ULTRA
↓ Swelling, ↓ pain
↓ Pain
↓ Swelling
↓ Pain
Nonthermal effects to ↑ healing
Injury– day 3
Inflammatory response
Swelling subsides, warm to touch, discoloration, pain to touch, pain on motion
Rest CRYO ESC IC LPL ULTRA
↓ Swelling, ↓ pain
↓ Pain
↓ Swelling
↓ Pain
Nonthermal effects to ↑ healing
Day 1– day 6
Fibroblastic-repair* Pain to touch, pain on motion, swollen
Range of motion THERMO ESC LPL IC ULTRA
Mildly ↑ circulation
↓ Pain—muscle pumping
↓ Pain
Facilitate lymphatic flow Nonthermal effects to ↑
healing
Day 4 – day 10
Maturation-remodeling*
Swollen, no more pain to touch, decreasing pain on motion
Range of motion Strengthening ULTRA ESC LPL SWD MWD
Range of motion Strenghtening Functional activities
Deep heating to ↑ circulation
↑ Range of motion, ↑ strength
↓ Pain
↓ Pain
Deep heating to ↑ circulation Deep heating to ↑
circulation
Day 7–recovery
CRYO, Cryotherapy; ESC, electrical stimulating currents; IC, intermittent compression; LPL, low-power laser; MWD, microwave diathermy; SWD, shortwave diathermy; THERMO, thermotherapy; ULTRA, ultrasound; ↓, decrease; ↑, increase.
*Anti-inflammatory medication prescribed by the physician is recommended.
swelling. An intermittent compression device may be used to provide even pressure around an injured extremity. The pressurized sleeve mechanically
reduces the amount of space available for swelling to accumulate. Units that combine both compres-sion and cold have been shown to be more effective
CHAPTER 2 Using Therapeutic Modalities to Effect the Healing Process 27 massages provide analgesic effects. The use of cold also reduces the likelihood of swelling, which may continue during this stage. Swelling does subside completely by the end of this phase.
It must be emphasized that heating an injury too soon is a bigger mistake than using ice on an injury for too long. Many athletic trainers elect to stay with cryotherapy for weeks following injury; in fact, some never switch to the superficial heating techniques. This procedure is simply a matter of per-sonal preference that should be dictated by experi-ence. Once swelling has stopped, the athletic trainer may elect to begin contrast baths with a longer cold-to-hot ratio.
An intermittent compression device may be used to decrease swelling by facilitating resorption of the by-products of inflammatory process by the lymphatic system. Electrical stimulating currents and low-power laser can be used to help reduce pain.
After the initial stage, the patient should begin to work on active and passive range of motion.
Decisions regarding how rapidly to progress exer-cise should be determined by the response of the injury to that exercise. If exercise produces addi-tional swelling and markedly exacerbates pain, then the level or intensity of the exercise is too great and should be reduced. Athletic trainers should be aggressive in their approach to rehabili-tation, but the healing process will always limit the approach.
Modality Use in the Fibroblastic-Repair Phase
Once the inflammatory response has subsided, the fibroblastic-repair phase begins. This stage may begin as early as 4 days after the injury and may last for several weeks. At this point, swelling has stopped completely. The injury is still tender to the touch but is not as painful as during the last stage. Pain is also less on active and passive motion.
Treatments may change during this stage from cold to heat, once again using increased swell-ing as a precautionary indicator. Thermotherapy in reducing swelling than using compression alone.
Regardless of the specific techniques selected (see Chapter 13), cold and compression should always be combined with elevation to avoid any additional pooling of blood in the injured area due to the effects of gravity.
Electrical stimulating currents may also be used in the initial phase for pain reduction. Parameters should be adjusted to maximally stimulate sensory cutaneous nerve fibers, again to take advantage of the gate control mechanism of pain modulation.
Intensities that produce muscle contractions should be avoided because they may increase clotting time (see Chapter 5).
Low-intensity ultrasound has been demon-strated to be effective in facilitating the healing pro-cess when used immediately following injury and certainly within the first 48 hours. Low intensities produce nonthermal physiologic effects that alter the permeability of cell membranes to sodium and calcium ions important in healing (see Chapter 8).
The low-power laser has also been shown to be effective in pain modulation through the stimula-tion of trigger points and may be used acutely (see Chapter 10).
The injured part should be rested and protected for at least the first 48 to 72 hours to allow the inflammatory phase of the healing process to do what it is supposed to.
Modality Use in the
Inflammatory-Response Phase
The inflammatory-response phase begins immedi-ately with injury and may last as long as day 6 fol-lowing injury. With appropriate care, swelling be-gins to subside and eventually stops altogether. The injured area may feel warm to the touch, and some discoloration is usually apparent. The injury is still painful to the touch, and pain is elicited on move-ment of the injured part.
As in the initial injury management stage, modalities should be used to control pain and reduce swelling. Cryotherapy should still be used during the inflammatory stage. Ice bags, cold packs, or ice
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techniques including hydrocollator packs, paraffin, or eventually warm whirlpool may be safely employed. The purpose of thermotherapy is to increase circulation to the injured area to promote healing. These modalities can also produce some degree of analgesia.
Intermittent compression can once again be used to facilitate removal of injury by-products from the area. Electrical stimulating currents can be used to assist this process by eliciting a muscle contrac-tion and thus inducing a muscle pumping accontrac-tion.
This aids in facilitating lymphatic flow. Electrical currents can once again be used for modulation of pain, as can stimulation of trigger points with the low-powered laser.
The athletic trainer must continue to stress the importance of range-of-motion and strengthening exercises and progress them appropriately during this phase.
Modality Use in the
Maturation-Remodeling Phase
The maturation-remodeling phase is the longest of the four phases and may last for several years, depending on the severity of the injury. The ul-timate goal during this maturation stage of the healing process is return to activity. The injury is no longer painful to the touch, although some progressively decreasing pain may still be felt on motion. The collagen fibers must be realigned ac-cording to tensile stresses and strains placed upon them. Virtually all modalities may be safely used during this stage; thus, decisions should be based on what seems to work most effectively in a given situation.
At this point some type of heating modality is beneficial to the healing process. The deep-heating modalities, ultrasound, or short-wave and micro-wave diathermy should be used to increase circula-tion to the deeper tissues. Ultrasound is particu-larly useful during this period since collagen absorbs a high percentage of the available acoustic energy. Increased blood flow delivers the essential nutrients to the injured area to promote healing, and increased lymphatic flow assists in breakdown and removal of waste products. The superficial heating modalities are certainly less effective at this point.
Electrical stimulating currents can be used for a number of purposes. As before, they may be used in pain modulation. They may also be used to stim-ulate muscle contractions for the purpose of increasing both range of motion and muscular strength. 12
Low-power laser can also assist in modulating pain. If pain is reduced, therapeutic exercises may be progressed more quickly.
The Role of Progressive Controlled Mobil-ity in the Maturation Phase. Wolff’s Law states that bone will respond to the physical demands placed upon it, causing it to remodel or realign along lines of tensile force. 36 Although not specified in Wolff’s Law, the same response occurs in soft tissue. Therefore, it is critical that injured structures be exposed to progressively increasing loads, particularly during the remodeling phase.
Controlled mobilization has been shown to be supe-rior to immobilization for scar formation, revascu-larization, muscle regeneration, and reorientation of muscle fibers and tensile properties in animal models. 2 However, immobilization of the injured tissue during the inflammatory-response phase will likely facilitate the process of healing by controlling inflammation, thus reducing athletic training symptoms. As healing progresses to the repair phase, controlled activity directed toward return-to-normal flexibility and strength should be combined with protective support or bracing. Gen-erally, clinical signs and symptoms disappear at the end of this phase.
Clinical Decision-Making Exercise 2–1 A female soccer player sprains her ankle, and the team physician diagnoses it as a grade 1 sprain.
The coach wants to know how long the athlete will be out. On what information should the athletic trainer base his or her response?
CHAPTER 2 Using Therapeutic Modalities to Effect the Healing Process 29
great for the level of tissue repair or remodeling.
The athletic trainer must be aware of the timelines required for the process of healing and realize that being overly aggressive can interfere with that process.