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Biomedical Engineering 1

THE APPRAISAL OF THE EFFECTS OF TREATMENT MODALITIES IN THE PROCESS

OF INJURY HEALING

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Professor’s Name

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City and State Where Institution is Located

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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

Introduction

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

Modality

Impact

Proliferative

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

maturation

Modulated high frequencies,

apply in surges at intensities of

275-300 (Manske and DeWitt

2015)

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

2014)

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

2014)

Causes vasodilation through

prolonged excitation and

depression of nerve activity

(Kolar 2014)

Analgesic action

None

Anesthetic action

None

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

Depth

Duration

Temperature in

1cm (0.39in)

15 min

101.84

2cm (0.78in)

20 min

102.38

3cm (1.17in)

15 min

104.72

Table 3: Temperature thresholds for subdermal heat treatments (Source: Manske and DeWitt

2015)

Conclusion

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

References

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.

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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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