therapeutic modality: rehabilitation of the injured athletecondylar notch temperatures than the...
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Clin Sports Med 23 (2004) 299–313
Therapeutic modality: rehabilitation of the
injured athlete
John Nyland, Michael F. Nolan
This chapter reviews traditional and alternative therapeutic modalities for the
treatment of injuries commonly seen in an orthopaedic sports medicine practice.
The reader is reminded that active progressive functional exercises are considered
the ultimate modality and that other relatively ‘‘passive’’ modalities should be
incorporated in a manner that best serves patient advancement toward more
independent functional exercise participation.
Cryotherapy
Using an animal model, Dolan et al [1] reported that post-trauma limb
volumes following blunt injury were smaller for a group that received cold water
immersion (12.8�–15.5�C) compared with untreated control subjects. Myrer et al,
[2] in comparing the effects of 20 minutes of ice pack application with those of
cold whirlpool immersion (10�C) reported no differences in intra-calf muscle
temperature decreases; however, ice packs decreased subcutaneous tissue tem-
perature more than the cold whirlpool, and the cold whirlpool was superior for
prolonged temperature reduction. Zemke et al [3] reported that ice massage
provided more rapid deep muscular cooling than an ice pack following 15-minute
applications. Kuligowski et al [4] reported that cold whirlpool and contrast therapy
enabled earlier return to both baseline resting elbow flexion angle and perceived
pain level following exercise-induced delayed onset muscle soreness (DOMS)
than warm whirlpool or no treatment at all.
Speer et al [5] reported that shoulder surgery patients who received cryother-
apy had less pain, slept better, used less pain medication, and had greater overall
satisfaction than subjects in a non-cryotherapy control group. Lessard et al [6]
reported that knee arthroscopy patients who received a 1-week cryotherapy
0278-5919/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.csm.2004.04.004
This article is from: Nyland J, Nolan MF. Therapeutic modality: rehabilitation of the injured
athlete. In: Fitzgerald RH, Kaufer H, Malkani AL, editors. Orthopaedics. St. Louis: Mosby; 2002.
p. 537–44; with permission.
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313300
program in conjunction with exercises had increased exercise compliance,
improved weight-bearing status, and reduced pain medication consumption
compared with patients who received exercises alone. In comparing a combined
cold and compression cryotherapy system with conventional ice packs among
44 anterior cruciate ligament (ACL) reconstruction patients, Schroder and Passler
[7] reported less pain, less swelling, reduced pain medication comsumption,
increased active range of motion (AROM), and superior functional scores for the
cold-compression system group. In a study of post-unilateral total knee replace-
ment patients, Walker et al [8] reported that patients who used a continuous
cooling pad in addition to a continuous passive motion device had decreased pain
medication consumption compared with patients who received continuous
passive motion either with or without transcutaneous electrical nerve stimulation.
Ohkoshi et al, [9] in using implanted thermosensors, reported that ACL re-
construction patients who received cryotherapy had less pain, required less pain
medication, had less blood loss, and had lower suprapatellar pouch and inter-
condylar notch temperatures than the control group.
In contrast to reports supporting cryotherapy, Konrath et al, [10] in studying
103 consecutive ACL reconstruction patients, failed to find objective benefits
early in the postoperative course, suggesting that joint compression or a placebo
effect may be the more beneficial factors. Dervin et al, [11] in assessing 78 ACL
reconstruction patients, reported no differences in pain between those who
received either circulating ice water or room temperature water in a cold-com-
pression device. In assessing 131 ACL reconstruction patients for the effective-
ness of postoperative cooling at 4.4�, 7.2�, 12.8�, or 21�C, Daniel et al [12]reported that all of the cooling pads lowered skin temperature; however, differ-
ences were not found between groups for perceived pain, pain medication use,
swelling, or AROM.
Sonotherapy
In a comparison of the tissue heating effects of 1 MHz and 45 kHz frequency
continuous ultrasound using a non-living animal model, Ward and Robertson [13]
reported that the heating provided by the 45 kHz ultrasound was very superficial,
whereas 1 MHz ultrasound heated both superficial and deep tissues. In using an
animal model to assess deep tissue heating differences between ultrasound with
coupling gel and underwater ultrasound at 2 cm from the skin surface, Forrest and
Rosen [14] reported that only the direct method using coupling gel produced
therapeutic temperature increases. In using an animal model to study Achilles
tendon healing, Jackson et al [15] reported that the continuous ultrasound group
(1.5 W/cm2, 4 min) had improved collagen synthesis and greater mechanical
strength than a control group.
In assessing the effect of continuous ultrasound to the volar forearm (1.5W/cm2,
5 min) on human skeletal muscle blood flow, Robinson and Buono [16]
reported no differences for up to 30 minutes post-treatment, concluding that
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313 301
muscle hyperemia was probably not the primary mechanism responsible for the
clinical benefits seen following ultrasound therapy. In contrast to this study,
Fabrizio et al [17] reported that ultrasound (1.0 MHz, 1.0 and 1.5 W/cm2)
increased triceps surae blood flow velocity. Ward and Robertson, [18] in
assessing continuous 1 MHz ultrasound at three intensity levels (0.5, 1.0, and
2.0 W/cm2) when delivered underwater reported that increasing the applicator–
skin surface distance resulted in progressive and significantly lower tissue
temperature increases. From these data, they designed dosage correction factors
to provide equivalencies for ultrasound provided away from the skin surface.
Stay et al [19] reported no differences in upper arm swelling, relaxed-elbow
extension angle, strength, or soreness between female subjects with exercise-
induced DOMS who were treated with pulsed ultrasound (20% duty cycle,
1 MHz, 1.5 W/cm2, 7 min) and untreated control subjects. Rose et al [20]
reported that 1 MHz continuous ultrasound at 1.5 W/cm2 to the human calf (4�Ctissue temperature increase) produced a slower thermal decay and slower deep
tissue cooling than 3 MHz ultrasound. From these data they concluded that the
effective stretching window following ultrasound therapy was greater for deeper
tissues. Draper et al [21] reported that 3 MHz ultrasound heated tissues at 0.8 cm
and 1.6 cm depths faster than 1 MHz ultrasound (2.5 and 5 cm2 sound head
sizes). Chan et al [22] reported that continuous ultrasound (3 MHz, 1 W/cm2,
4 min) increased human patellar tendon temperature at both two times and four
times the effective radiating area of a 4.5 cm2 sound head, but two times the
effective radiating area provided greater heating of longer duration. Draper et al,
[23] in comparing the deep heating effect of ultrasound (1 MHz, 1.5 W/cm2,
10 min) on human calf muscle that had been treated with either a real or sham
hot pack (75�C) reported that greater temperature increases (> 4�C) could be
attained with 2 to 3 minutes less total ultrasound time when preheating with a hot
pack. Rimington et al [24] reported that ultrasound alone (1 MHz, 1.5 W/cm2)
provided a greater heating effect at a depth of 3 cm in human calf muscle than
ultrasound preceded by cryotherapy.
In assessing the effect of phonophoresis (1.5 W/cm2, 1.0 MHz, 8 min) with
0.33% dexamethasone on adrenal function, Franklin et al [25] reported no
evidence of systemic effects. Bare et al [26] failed to find elevated levels of
serum cortisol following phonophoresis (1.0 MHz, 1.0 W/cm2, 5 min) of a 10%
hydrocortisone solution to the volar forearm of 16 subjects. Klaiman et al [27]
failed to distinguish differences in pain level or pressure tolerance between
49 patients with soft-tissue injuries who were treated with fluocinonide phonopho-
resis or ultrasound. Ciccone et al [28] reported that phonophoresis with trolamine
salicylate was more effective than ultrasound alone in decreasing the effects of
DOMS. In an excellent review of phonophoresis, Byl [29] reported that maximal
treatment effectiveness requires topical agents that transmit ultrasound, moist
skin that is pretreated with ultrasound, heating or shaving, patient positioning that
maximizes circulation to the treated area, continuous ultrasound within the
thermal ranges (� 1.5 W/cm2) unless there are contraindications for heating
based on patient condition (acute injury, open wound), and leaving the drug on
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313302
the skin with an occlusive dressing after treatment. For acute injury or open
wound treatment, pulsed ultrasound (0.5 to 1.0 W/cm2) should be used. All
patients should be monitored for systemic drug side effects, especially when a
large area is treated or when there is a loss of continuity of the stratum corneum
(higher diffusion rate for open wounds).
Pulsed electrical stimulation (motor response)
In exploring the effect of various combinations of burst and carrier frequencies
of neuromuscular electrical stimulation (NMES) pain perception during 50%
maximal voluntary isometric quadriceps femoris muscle contractions, Rooney
et al [30] reported that burst frequencies of 50, 70, and 90 bps at carrier freq-
uencies of 2500 and 5000 Hz did not differ in perceived pain intensity and that
greater pain was reported at 10,000 Hz regardless of burst frequency. They
recommended that different burst and carrier frequency combinations be tried on
a client-by-client basis (to determine the most comfortable, yet greatest torque-
producing stimulus). In a comparison of console and portable battery-powered
NMES units for the treatment of the quadriceps femoris of 52 ACL reconstruction
patients, Snyder-Mackler et al [31] reported that subjects who trained with console-
style clinical stimulators (Fig. 1) had greater training intensities and quadriceps
torque than subjects who used battery-powered units. Draper and Ballard [32]
compared electromyographic biofeedback and portable NMES used in conjunc-
tion with quadriceps setting and straight-leg raises (3 times/day, 30-min sessions,
for 4 weeks). They reported that the biofeedback group recovered to 46% of the
Fig. 1. Console electrical neuromuscular stimulation of the quadriceps femoris.
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313 303
contralateral quadriceps maximal voluntary isometric contraction, whereas the
portable NMES group recovered to 38%.
Transcutaneous electrical nerve stimulation
Fundamentally, transcutaneous electrical nerve stimulation (TENS) alters the
pattern and frequency of nerve action potentials transmitted toward the central
nervous system along the stimulated nerve fibers. [33–35] Animal studies using
intracellular neurophysiological recording techniques have led to theories related
to the ability of TENS to close a theoretical ‘‘gate’’ to nociceptive impulses
associated with tissue injury. [36] TENS is also associated with theories of pain
relief linked to the activation of a primitive endogenous pain relief system housed
in the reticular core of the brain stem. Some investigators have reported that
TENS increases endorphin levels, [37] whereas others found no change in
circulating endorphins [38] following TENS application. TENS can be viewed
as altering the perceptual pain component and being of little value in managing
problems related to the other four components (physiological, affective, cogni-
tive, and behavioral). [39] Patients with acute pain that produces frequent no-
ciceptive impulses are likely to benefit more from TENS than patients with
chronic pain in whom some tissue repair has occurred. TENS is likely to be more
helpful for patients with localized tissue damage and pain than for patients with
diffuse pain that is difficult to localize and characterize.
Jensen et al, [40] in studying the effects of TENS, placebo TENS, and no
TENS on 90 patients following arthroscopic knee surgery reported that the TENS
group had less pain, required less pain medication, and re-attained preoperative
knee muscle strength earlier than the other two groups. Meyler, [41] in evaluating
TENS use among 211 patients with differing pain syndromes, reported that TENS
was associated with a favorable response in the majority of patients with pain
caused by peripheral nerve damage (53%) and musculoskeletal pain due to
mechanical causes (69%). Hidderley and Weinel [42] reported that TENS applied
to true acupuncture points remote from the pain site of 14 patients under-
going herniorrhaphy reduced their pain level and morphine use compared with
patients who received TENS at non-true acupuncture points. Lein et al [43]
reported equal increases in wrist pain threshold for auricular, somatic, and
combined TENS treatment groups of nonimpaired subjects compared with a
control group.
High-volt pulsed current (EDEMA CONTROL)
Whereas evidence for the efficacy of using motor level electrical stimulation
(‘‘muscle pumping’’) for edema reduction is considerable, evidence for edema
reduction using sensory level stimulation is less abundant. Michlovitz et al [44]
reported no differences in edema control when high-volt pulsed current (HVPC)
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313304
was added to the ice, compression, elevation treatment of acute ankle sprain
patients. Cosgrove et al, [45] using an animal model, reported no differences in
edema reduction following blunt trauma between HVPC, symmetrical, biphasic
pulsed current, and sham electrical stimulation for edema control.
Using an animal model, Taylor et al [46] reported that cathodal and anodal
HVPC, but not alternating current, decreased macromolecular leakage from
microvessels following histamine treatment. Based on the results of several
experiments using animal models, Mendel and Fish [47] proposed a tentative
edema management protocol using cathode HVPC at 120 pps and 90% of
visible motor threshold using a water immersion technique. They recommended
30-minute treatments every 4 hours beginning as soon after the injury as possible,
or as long as edema is still likely to be forming. They speculated that whatever
HVPC was doing to curb edema formation was induced by non-neurological
factors, such as affecting microvacular permeability. These studies suggest
that the effects of muscle pumping (motor response) may resolve edema once it
is formed and that sensory-level cathodal stimulation with HVPC may retard
edema formation.
Iontophoresis
Li et al [48] reported that patients with rheumatoid arthritis of the knee who
were treated with iontophoresis-delivered dexamethasone had less pain at rest and
greater AROM than patients who received placebo treatments. Pellecchia et al
[49] reported that patients with infrapatellar tendinitis who were treated with
iontophoresis-delivered dexamethasone and lidocaine had less pain, less tender-
ness with palpation, and better functional scores than patients who received
traditional treatment modalities. Gudeman et al [50] reported greater symptom
relief and function for plantar fasciitis patients who received iontophoresis with
dexamethasone in conjunction with standard modalities than patients who
received standard modalities alone. Wieder [51] reported increased knee AROM
and a 98.9% decrease in the myositis ossificans mass of a 16-year-old male using
iontophoresis-delivered 2% acetic acid solution followed by pulsed ultrasound
(three treatments for 3 weeks). Perron and Malouin, [52] in assessing the efficacy
of using acetic acid iontophoresis and ultrasound (0.8 W/cm2, 1 MHz, 5 min) in
the treatment of patients with calcifying shoulder tendinitis failed to report
differences between treatment and control groups. Lark [53] advised using the
pain-relieving effects of iontophoresis-delivered lidocaine to assess whether the
target painful sites are reachable by iontophoresis.
Acupuncture
Repetitive acupoint stimulation by ‘‘needling’’ is believed to cause repetitive
neuronal firing, thereby altering the anatomic, physiological, and chemical
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313 305
components of the synaptic junctions and creating neuronal memory circuits. [54]
ANational Institutes of Health sponsored panel reported that acupuncture produces
equivocal results because of poor study designs, small sample sizes, and inherent
difficulties in the use of placebo or sham controls. [55] Currently, there is a wide
variation in the practice of acupuncture, with the number of points represented on
various training charts ranging from 365 to more than 2000. [56] Based on reports
of promising results among large and diverse patient populations, the panel
concluded that acupuncture may be useful as a component of a comprehensive
patient management program but strongly recommended further research.
Using animal dissections, Egerbacher and Layroutz [57] reported that acu-
puncture points resembled either neurovascular bundles or cutaneous spinal nerve
branches penetrating fascia or dermis, respectively. Tillu and Gupta, [58] in
treating 18 patients with a 25-month mean duration of recalcitrant plantar fasciitis
symptoms, reported significant pain reduction following acupuncture. Based on a
multicenter study of seven practitioners and 58 patients, Macpherson and Fitter
[59] reported that acupuncture effectiveness started to plateau after the first seven
treatments and that patients with more severe initial conditions (particularly
bodily pain) tended to make more rapid improvements. They also reported that
patients with ‘‘less chronic’’ symptoms displayed more rapid recoveries. Gaw et al
[60] reported similar improvements between patients with osteoarthritis who
were treated with either ‘‘real’’ or sham acupuncture. Johnson et al [61] reported
no differences in sensation or pain threshold between nonimpaired subjects who
received acupuncture at sites that were either related or unrelated to sites of
electrically induced finger pain. Takeda and Wessel [62] reported that ‘‘real’’ and
sham acupuncture produced similar pain relief for patients with osteoarthritic
knee pain.
Magnetic field therapy
Introducing efficacious electrical changes into the cellular microenvironment
may have a beneficial effect on tissue growth and repair. The anti-inflammatory
effect and enhanced microcirculation of pulsed magnetic fields (PMF) and pulsed
electromagnetic fields (PEMF) are believed to be due to their magnetic or
electromagnetic field action, independent of any heat produced by the fields
themselves, probably via the alterations they induce in cell membrane potentials
and ionic fluxes. [63] Using an animal model, Lee et al [63] studied the effects of
PMF (17 or 50 Hz) and PEMF (15 or 45 Hz) compared with control in treating
Achilles tendon inflammation. They reported that the group treated with a 17 Hz
PMF had better collagen alignment and less inflammation than groups treated
with other PMF or PEMF frequencies or control by 30 days postinjury. In a
study using PEMF for treating 29 patients with persistent rotator cuff tendinitis
(� 3 months), Binder et al [64] reported that the treated group had less pain and
greater AROM following 4 weeks of treatment. In a comparison of 34 patients
with heel pain, Caselli et al [65] reported no differences between patients treated
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313306
for 4 weeks with either molded insoles with continuous magnetic field foil heel
inserts or standard insoles. Foley-Nolan et al [66] in a study of 40 patients with
acute whiplash reported less pain and greater AROM among patients who
received active PEMF therapy via their soft cervical collars than patients who
received collars without an active PEMF. Borsa and Liggett [67] reported no pre-
or post-treatment differences between subjects who received ‘‘real’’ CMF,
placebo CMF, or no CMF among 45 nonimpaired subjects following an exer-
cise-induced DOMS.
Biofeedback
Biofeedback provides a method of bioelectrical monitoring and amplifying the
physiological processes that are ordinarily not within a patient’s awareness or
control. Biofeedback can be provided by console (Fig. 2) and portable devices
(Fig. 3), in single and multichannel configuations. Using radiographic techniques,
Ingersoll and Knight [68] reported that nonimpaired subjects who used electro-
myographic biofeedback in combination with vastus medialis exercises improved
their patellofemoral congruence angle compared with patients who used standard
exercise and with control subjects. Draper and Ballard, [32] in studying 30 ACL
reconstruction patients, reported that biofeedback was superior to portable NMES
for improving knee extensor torque. Levitt et al, [69] in studying 51 patients
following knee arthroscopy, reported that patients treated with exercise and
biofeedback had greater knee extensor torque than those treated with exercise
alone. In treating three patients with volitional posterior glenohumeral joint
instability who were treated with exercise and biofeedback at the posterior head
of the deltoid muscle, Beall et al [70] reported decreased pain, decreased
Fig. 2. Console biofeedback device.
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Fig. 3. Portable biofeedback device.
J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313 307
dislocation episodes, and a successful return to athletic activities following
4 weeks of therapy. In a case study involving a 15-year-old female with volitional
posterior glenohumeral joint dislocation, Young [71] reported good results using
a dual-channel biofeedback unit (anterior, posterior deltoid heads) for clinical
sessions, and a single-channel unit during home program exercises, which pro-
gressed from isometric to AROM to retrain voluntary glenohumeral joint control.
Reid et al [72] reported that patients with symptomatic subluxing shoulders who
used biofeedback and motor control–based exercises showed greater improve-
ment in work and sport function and had less pain over time than patients who
performed an isokinetic exercise strength program. Farmer [73] reviewed the
use of biofeedback in combination with visualization to enhance athletic and
exercise performance.
Massage
Martin et al, [74] in comparing the effect of a single 20-minute lower
extremity massage, active recovery (stationary cycling for 20 minutes at
80 RPM and at 40% VO2 peak) or rest in supine (20 minutes) on blood lactate
clearance following maximal anaerobic leg exercise among 10 cyclists, reported
that only the active recovery group had significant decreases in blood lactate
measurements. Tiidus [75] reported that there is little evidence that massage has
any significant effect on the physiological factors associated with the exercise
recovery process, deeming light exercise of the affected muscles preferable to
improve muscle blood flow (thereby enhancing healing). Shoemaker et al [76]
compared the effects of forearm and thigh effleurage, petrissage, and tapotement
with mild active exercise among 10 nonimpaired subjects. Active exercise in-
creased mean blood flow velocity and vessel diameter, and massage did not.
Sullivan et al [77] reported reduced triceps surae H-reflex amplitudes among
subjects who received ipsilateral calf petrissage compared with control subjects.
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J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313308
In a comparison between massage (2 hours postexercise) and control groups
following exercise-induced elbow flexor/extensor DOMS, Smith et al [78]
reported reduced serum creatine kinase levels, prolonged neutrophil elevation,
and diminished diurnal cortisol reduction for the massage group. Goldberg et al,
[79] in assessing the effect of manual massage pressure levels on triceps surae
H-reflex amplitude reported decreased amplitudes during deeper massage com-
pared with control conditions, suggesting that inhibitory responses were pres-
sure sensitive.
Exercise
Functionally relevant movements (or components thereof) should be included
in the exercise prescription as early as possible with consideration for patient
safety and tissue healing status. Within any exercise prescription, the clinician
needs to decide what percentage of the program will concentrate on isolated
deficiencies (Fig. 4) and what percentage will concentrate on integrated multiple
joint and multiple neuromuscular component activities (functional tasks) (Fig 5).
Clinicians also must weigh the relative client needs regarding the primary energy
system demands of the task (adenosine triphosphate–creatine phosphate, anero-
bic glycolysis, aerobic) by manipulating training variables (e.g., sets, repetitions,
recovery time, frequency, exercise choice, exercise order). Similarly, exercise
programs should combine the positive attributes of both closed kinetic chain and
open kinetic chain function (particularly as they relate to position-specific joint
stresses), with progressions toward performance at neuromuscular contraction
Fig. 4. Conventional isokinetic rehabilitation.
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Fig. 5. Views. (A) Adapted assistive device ‘‘3D Foot.’’ (B) Protected closed kinetic chain func-
tional exercise.
J. Nyland, M.F. Nolan / Clin Sports Med 23 (2004) 299–313 309
velocities and modes that simulate performance demands). Client needs regarding
the restoration of normal coordination, proprioception, and kinesthesia are of
particular importance among the athletic community. Modalities other than
exercise should be incorporated in a manner that is considered to be most
efficacious for catalyzing specific tissue responses (e.g., control of pain, inflam-
mation, edema, torque increases). To achieve this, clinicians must continually
evaluate the effect of their interventions and manipulate all treatment modalities
to effect the desired changes, facilitate patient progress, and avoid the likelihood
of the patient’s ‘‘plateauing’’ at a point far short of the desired outcome.
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