Biomedical Engineering

Biomedical Engineering 1
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Biomedical Engineering 2
Table of Contents
Introduction ..................................................................................................................................... 3
Review of Transcutaneous Nerve Stimulation ............................................................................... 5
Review of Game Ready .................................................................................................................. 8
Conclusion .................................................................................................................................... 12
References ..................................................................................................................................... 13
Biomedical Engineering 3
For the human body, experiencing an injury or trauma is the beginning of the healing
process, which is meant to return functionality to the damaged tissues. Overall, the process
involves sequential phases over which the body reacts to the immediate injury, initiates
inflammation to remove foreign material, restores blood flow as well as epithelial and fibrous
tissue, and undergoes granulation for wound contraction (Dougherty and Lister 2015). The case
under review involves a 23-year-old gymnast who suffered a Grade II partial rupture to his
anterior talofibular ligament (ATFL) between the landing and takeoff maneuvers of a floor
routine exercise. The patient is currently 48 hours into the recovery period, and is experiencing
significant swelling and bruising to the lateral ankle with considerable loss of function due to the
injury. The patient’s need for a full and effective recovery necessitate the development of a
therapeutic strategy that acknowledges the need for the restoration of full function and allows the
patient’s fitness to assure high flexibility after recovery.
The ATFL is a short connective ligament that links the talus to the fibula and a severe
tear in this ligament can necessitate surgical interventions to restore function and movement.
According to Ferkel (2016), this is dependent on the grade of the tear, with Grade II tears
involving increased damage to the ligament whereby partial structural damage results in
abnormal movement of the ankle joint, with moderate swelling and discomfort in the affected
ankle. The need for ice and compression as part of the rest, ice, compression, and elevation
(RICE) recommended therapy approach for such injuries can benefit from the use of a Game
Ready machine, which provides both the compression and ice components of the RICE strategy
(Grey and Rawlinson 2013). Game Ready will be essential for this case due to the reusability and
Biomedical Engineering 4
sustained temperature control aspects of the machine, which ensures maximum control over the
pressure and temperatures applied to the affected ankle.
The first three days of the post-injury period are referred to as the inflammatory/acute
phase, during which the injured tissues swell due to blood vessels leaking into the surrounding
tissue (Simons and Jordan 2016). During this 4-5-day period, cell death is experienced in the
affected region as a result of oxygen starvation, which also necessitates limited patient activity to
reduce demand for oxygen in injured tissues. Swelling from the leaking blood vessels also places
pressure on the nerves in the affected area and registers as pain, with white blood cells cleaning
out dead cells as a Fibrin layer is formed over affected tissues to entrap cellular debris
(Dougherty and Lister 2015). The proliferative/sub-acute stage marks the beginning of new
blood vessel formation in the damaged tissues, with the lymphatic system aiding in draining the
recovering tissues. During this stage, collagen is laid out by fibroblasts for the formation of new
scar tissue that increases the tensile strength of the recovering tissues.
Simons and Jordan (2016) note that the inclusion of controlled exercises in the
proliferative stage is essential due to the influence that it has on the tensile strength of recovering
muscles, with the collagen fibers laid out at this stage also following the direction of muscle
tension. Pain management becomes a critical issue due to the risk of either applying inadequate
tension to the affected tissues or over-exerting them, thereby necessitating the careful use of pain
management strategies such as analgesics and electrical stimulation therapies (Manske and
Dewitt 2015). However, controlled exercises are essential in maximizing the strength that the
affected muscle gains during the remodeling phase, which lasts between three weeks and a year
after the injury. During this stage, cell activity normalizes and the scar tissue strengthens along
the direction of mechanical tension, which also necessitates the inclusion of a strict exercise
Biomedical Engineering 5
regimen for increasing muscle strength (Grey and Rawlinson 2013). The lack of exercises during
this stage can also risk atrophying the injured tendon, thereby minimizing the capacity for the
patient to achieve optimal strength and flexibility as an athlete.
Review of Transcutaneous Nerve Stimulation
Transcutaneous nerve stimulation (TENS) involves the application of low-amperage
electrical currents to affected musculoskeletal regions with the intended purpose of alleviating
pain in the injured tissues. This approach can be utilized in the proliferative stage as a means for
reducing the amount of pain that the patient experiences while engaging in light exercises, which
Allatar and Kareem (2016) note are vital in turning type 3 collagen into type 1 and increasing the
tensile strength of recovering muscles. Considering that the patient is an athlete and would prefer
optimal performance from the recovered ATFL ligament, it is thereby essential to note the
potential that TENS has in increasing the patient’s capacity to load the affected joint and increase
the recovering ligament’s stress resistance in the future. Moreover, Frontera et al. (2014) also
note that TENS pain alleviation approach also means that patients can load affected joints more
safely, but highlight TENS as capable of increasing the risk of re-injury if utilized during the
inflammatory phase.
Biomedical Engineering 6
Figure 1: Sample TENS electrode positioning for ankle injuries
The transcutaneous aspects of the TENS treatment make it a non-invasive strategy for the
patient considering the lack of a tear in the affected ligament. Moreover, TENS also stimulates
tendon healing as evidenced in pre-trial research by Folha et al. (2015), who found conclusive
evidence of analgesic action and reduced inflammation as well. These outcomes further highlight
the utility of TENS as a therapeutic option and compound the need for the application of TENS
in this patient’s case, owing to the mobility factor that it introduces for patients that would
otherwise be non-ambulatory without pain management strategies. However, the treatment
should also not be considered as a standalone solution for the patients’ recovery and should also
include movement and flexibility exercises as required in the proliferative phase (Gielen et al.
2015). As a result, TENS will be supplementary to the exercise regimen established as a means
for restoring motive function to the patient’s ATFL.
As highlighted, the patient suffered the ATFL injury about 48 hours ago, which places
him in the middle of the inflammatory/acute healing phase and means that he is experiencing
Biomedical Engineering 7
considerable discomfort and loss of function in the affected ankle. During this stage, it is
possible to utilize the TENS treatment for the pain alleviation elements of its electrical
interactions with cutaneous nociceptors (Folhar, et al., 2015). During this stage, it is essential to
minimize patient movement, which makes the use of TENS modalities a risky strategy for pain
alleviation. This is because there is an increased risk of the patient loading the joint due to the
reduced discomfort that he experiences, which risks damaging the newly-formed blood vessels
and exacerbating the injury (Dougherty and Lister 2015). This would have negative implications
for the patient’s healing, while also limiting the capacity for the recovered tissue to have the
strength necessary for a resumption of athletic activities.
Cooper et al. (2016) note that patients experiencing acute pain may require the use of
TENS treatments with higher voltages that have a more pronounced interaction with cutaneous
nociceptors, which can cause discomfort and requires continuous patient feedback to minimize
the risk of harm to the recipient. However, the use of the TENS therapeutic modality over the
course of the patient’s recovery will necessitate changes in the use of this treatment option to suit
the therapeutic needs of each recovery phase. The addition of an interferential current (IFC)
therapy in the late proliferative stage will also increase vasodilation and ease the removal of
toxins from the affected area by stimulating muscle relaxation, thereby improving healing time
while offering the pain relief that the TENS treatment provides (Sackheim 2013). Furthermore,
the use of a smaller range of high frequencies also makes IFC beneficial as an outpatient
treatment option, with specialists applying the TENS modalities during clinical visits.
Biomedical Engineering 8
Treatment Phase
Modulated high and low
frequencies, note the patient’s
comfort levels and adjust
intensity as needed (Manske and
DeWitt 2015)
Pain relief through activation
of subdermal nociceptors,
increased affinity for light
mobility exercises (Manske
and DeWitt 2015)
Late Proliferative
Modulated medium and low
frequencies, apply continuously
at intensities of around 250
(Manske and DeWitt 2015)
Stimulates healing through
removing toxins and reducing
inflammation, relieves pain
(Manske and DeWitt 2015)
Early remodeling
Modulated medium to low
frequencies, apply in surges and
at intensities of around 275
(Manske and DeWitt 2015)
Stimulates healing through
vasodilation, helps with
guided mobility recovery
(Manske and DeWitt 2015)
Late remodeling and
Modulated high frequencies,
apply in surges at intensities of
275-300 (Manske and DeWitt
Strengthens repaired ligament
fibers, improves capacity for
guided exercise (Manske and
DeWitt 2015)
Table 1: Review of TENS modalities over the course of the patient’s treatment (Source: Manske
and DeWitt 2015)
Review of Game Ready
While the TENS therapeutic modality will be vital in providing a non-analgesic
dependent treatment plan, it is also necessary to review modalities that will facilitate the healing
process and ensure rapid recovery. Thermal energy modalities provide one such alternative for
this particular case, with Denegar et al. (2015) noting that the use of heat therapy is beneficial for
reducing swelling and inflammation for superficial wounds. In this case, the patient’s ATFL
rupture is a subdermal tissue wound, and the application of heat in such cases has been found to
increase swelling and the associated recovery time. On the other hand, cryotherapy has the
opposite effect, with low temperatures having vasoconstrictor properties that provide an
analgesic numbing effect that also aids in pain management (Kolar 2014). For the patient, the
reduction of inflammation is a key component of the treatment plan since it increases the chances
Biomedical Engineering 9
of recovery through minimal interference with the natural healing process. Hawkins and
Hawkins (2016) highlight Game Ready technology as an effective means of applying the thermal
energy modalities while also preventing secondary tissue damage for improved healing
outcomes, making it a viable therapy for this patient’s case.
Figure 2: Sample Game Ready machine usage for ankle injuries
The use of Game Ready is highlighted by Simons and Jordan (2016) as a foundational
element of the RICE (rest, ice, compression, exercise) approach to injury management, making it
a widely supported strategy for treating a wide range of surface and internal tissue damage. As a
Grade II partial tear, the patient’s clinical signs include inflammation and swelling, which limit
the applicability of the RICE strategy in its entirety. Rather, the current acute stage calls for
minimal use of compression and exercise with more extensive application of the thermal and
rest-oriented elements of the therapeutic approach to ensure minimal risk of complicating the
Biomedical Engineering 10
recovery process. By lowering the temperature around the patient’s affected ankle using Game
Ready, Kolar (2014) notes that the resultant vasoconstriction will be essential in reducing the
amount of swelling that the patient is currently experiencing while also controlling effusion from
the damaged tissue.
Over the course of the patient’s treatment, it will be essential to balance out the pain
management approaches to complement the healing process and minimize both discomfort and
complications resulting from the injury. The need for minimal movement during the acute phase
will necessitate considerations for the damage to the ligament tissue, for which Game Ready will
be essential in restricting movement around the patient’s ankle region (Rigby and Dye 2017). By
decreasing the inflammation to the underlying tissue, it will be possible to limit the chances of
damaging the new growth that marks the beginning of the sub-acute phase (Grey and Rawlinson
2013). Concerns for the patient’s gymnastic performance make it essential to expedite the motion
exercises, which further makes the case for the use of thermal therapeutic modalities to allow for
stretching and other low-intensity exercises to begin. Consequently, the proprioceptive needs of
this patient’s case necessitate the use of Game Ready for reducing the inflammation and swelling
that he is currently experiencing, while also increasing the range of exercises that he can
undertake during the sub-acute healing stage.
Biomedical Engineering 11
Bodily Response
Initial Effects
Prolonged Effects
Heart rate
Raises patient’s heart rate as
blood is pumped away from
the application area (Kolar
Reduces patient’s heart rate as
the body tries to conserve heat
(Kolar 2014)
Vascular system
Causes vasoconstriction in the
chilled area by activating
nerve cell activity (Kolar
Causes vasodilation through
prolonged excitation and
depression of nerve activity
(Kolar 2014)
Analgesic action
Anesthetic action
Numbs the affected area by
depressing nerve activity and
reducing conductivity of pain
receptors (Kolar 2014)
General action
Excitation of cell action,
reduces rate of cell death by
reducing metabolism rate and
increasing metabolite removal
rates (Kolar 2014)
Relaxation of cell action,
reduces inflammation by
restricting blood flow to
injuries (Kolar 2014)
Table 2: General physiological effects of cryotherapy treatments (Source: Kolar 2014)
Even as low-temperature Game Ready therapy proves instrumental in this acute phase of
recovery, the use of heated Game Ready therapy in the sub-acute stages is also highlighted as a
possible solution that will ease the healing process without adversely affecting the patient’s
recovery goals. Manske and DeWitt (2015) note that in the sub-acute stages, the need for
effective blood and oxygen flow benefits from heat since it causes a shift in the dissociation
curve and enhances both nutrient and oxygen transport in the damaged regions. In this case, this
will be essential in enhancing stimulation of fibroblast proliferation, thereby increasing the rate
at which endothelial cells proliferate and reducing inflammation in the ATFL area. However, it is
essential to note that the use of heated Game Ready therapy is limited to the sub-acute recovery
stage since it can cause increased inflammation if applied during the critical acute stage (Starkey
2013). Nonetheless, the associated vasodilation and enhancements in blood flow will provide an
opportunity to capitalize on the increased mobility associated with the use of the TENS
treatment, thereby enhancing the utility of the mobility exercises included in the treatment plan.
Biomedical Engineering 12
Temperature in
15 min
20 min
15 min
Table 3: Temperature thresholds for subdermal heat treatments (Source: Manske and DeWitt
The review of therapeutic modalities for application in the case of a patient with a Grade
II partial rupture to his anterior talofibular ligament (ATFL) reveals that transcutaneous nerve
stimulation (TENS) alongside Game Ready and heated wrap treatment modalities can maximize
the treatment plan’s efficacy. The Game Ready machine will be essential in the inflammatory
and proliferative stages as a means for providing compression to the affected ankle while also
applying cryotherapy to reduce swelling around the injured ankle. This will be essential in
minimizing cell death during these vital healing stages and improve recovery time as well. On
the other hand, the TENS treatment will be vital in the proliferative and remodeling stages as a
means for reducing the patient’s discomfort and increasing his capacity to safely load the
affected ankle. Through its interactions with subcutaneous nociceptors and muscle fibers, the
TENS modalities will prove essential in relaxing the muscles around the injured tendon and
removing toxins from the injury site during the proliferative stage. Additionally, TENS will also
be essential in pain management, with an additional IFC therapy allowing the patient to achieve
comparable pain management outcomes in the outpatient setting during the proliferative and
remodeling phases. While this will be essential in ensuring that the patient can engage in strength
exercises during this period, the addition of a heated wrap treatment modality will also help in
increasing blood flow in the injured region during the proliferative and remodeling stages.
Biomedical Engineering 13
Alattar, A. and Kareem, S., 2016. Rehabilitation, Back to Sports and Competition. In Foot and
Ankle Sports Orthopaedics (pp. 127-144). Springer International Publishing.
Cooper, B., Follett, R.J. and Chiverton, N., 2016. Back Pain. ABC of Common Soft Tissue
Disorders, p.19.
Denegar, C.R., Saliba, E. and Saliba, S., 2015. Therapeutic Modalities for Musculoskeletal
Injuries, 4E. Human Kinetics.
Dougherty, L. and Lister, S. eds., 2015. The Royal Marsden manual of clinical nursing
procedures. John Wiley & Sons.
Ferkel, R.D., 2016. Foot & Ankle Arthroscopy. Lippincott Williams & Wilkins.
Frontera, W.R., Silver, J.K. and Rizzo, T.D., 2014. Essentials of Physical Medicine and
Rehabilitation E-Book. Elsevier Health Sciences.
Gielen, J., Dyck, P. and Veryser, J., 2015. Proceedings of the Foot and Ankle meeting, Leiden,
25.03. 2011. Journal of the Belgian Society of Radiology, 95(2).
Grey, J. and Rawlinson, G., 2013. The physiotherapy management of inflammation, healing and
repair. Tidy’s Physiotherapy. Elsevier Health Sciences, pp.253-271.
Hawkins, J.R. and Hawkins, S.W., 2016. Clinical Applications of Therapeutic Modalities
Among Collegiate Athletic Trainers, Part I: Cryotherapy. International Journal of
Athletic Therapy and Training, 21(1), pp.62-67.
Jankovic, D. and Peng, P., 2015. Regional Nerve Blocks in Anesthesia and Pain Therapy:
Traditional and Ultrasound-Guided Techniques. Springer.
Kolar, P., 2014. Clinical rehabilitation. Alena Kobesová.
Biomedical Engineering 14
Manske, R. C., & DeWitt, J., 2015. Ligament Healing. Fundamental Orthopedic Management
for the Physical Therapist Assistant-E-Book, 32, 155.
Rigby, J.H. and Dye, S.B., 2017. Effectiveness of Various Cryotherapy Systems at Decreasing
Ankle Skin Temperatures and Applying Compression. International Journal of Athletic
Therapy and Training, pp.1-19.
Sackheim, K. A. (Ed.)., 2013. Rehab Clinical Pocket Guide: Rehabilitation Medicine. Springer
Science & Business Media.
Simons, S. M., & Jordan, C. C., 2016. Sub-acute and Chronic Injuries in the Posterior Leg. In
Muscular Injuries in the Posterior Leg (pp. 99-110). Springer US.
Starkey, C., 2013. Therapeutic modalities. FA Davis.
Waldman, S. D., 2016. Pain Review E-Book. Elsevier Health Sciences.

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