儀器治療學
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[編輯] Using Therapeutic Modalities to effect the Healing Process
[編輯] How should the athletic trainer incorporate therapeutic modalities into a rehabilitation program for various sports-related injures?
在
比賽現場的臨時AT:
一般
有發生受傷情形，一定都會準備冰塊(製成ice pack)或冷噴做為急性發炎期的緊急處理。
專業的隨隊防護員:
可能本身球隊或訓練中心就備有專業治療配備(ex:水療、超音波儀器、短波微波儀器.........)，防護員只需幫助運動員使用治療儀器和指導運動員各種儀器帶來的治療效果，督導運動員持續復健治療，促進運動員的傷害復原，使運動員能以最快的復原速度回到練習或賽場。專業防護員如果隨隊出國，也有一些儀器可以隨身攜帶(ex:超音波儀器)，使運動員在國外也可馬上進行復健治療。
1.發炎反應期：
可進行冷療(每次冰敷約15~20分鐘，休息20分鐘，反覆2個小時)
2.纖維修復期：
熱療，深層熱療有止痛效果，或進行電療及後期配合運動
3.成熟重塑期：
熱療再配合運動
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[編輯] What specific modalities may be incorporated into treatment during the inflammatory-response phase and fibroblastic-repair phase?
Inflammatory - response phase : We can use cryotherapy , electrical stimulating and low - power laser to modulate pain .
And we also use low intensity ultrasound to facilitate the healing .
Fibroblastic - repair phase : We will chang treatment from coid to heat . Superficial heat can be used ex : hot pack , paraffin , warm whirlpool , infrared , fluidotherapy ...these modalities can reduce pain . And we may use electrical stimulation and low - power laser to modulation pain , as can stimulation of trigger points with low - power laser .
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在Inflammatory - response phase需要先止痛以及控制腫脹
止痛：冷療（ice bags, cold packs, ice massages等） 電刺激 低功率雷射可以用來止痛
控制腫脹： 冷療（降低傷部循環）
間歇性按壓（促進淋巴系統再吸收發炎反應的by-products來減少腫脹）
可以配合passive ROM exercise
fibroblastic-repair phase要增加局部循環來促進癒合
熱療（hot pack, paraffin, warm whirlpool, infrared, fluidotherapy等）可以增加傷部循環
間歇性的按壓也可以促進by-products的再吸收
電刺激 低功率雷射也可以再這個時期用來止痛
在此時期建議要增加ROM以及作strengthening exercises
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Inflammatory - response phase:
Cryotherapy should still be used to reduce likelihood of swelling;
Ice bage,cold packs,or ice massages
provide analgesic effects.
Fibroblastic - repair phase :
Intermittent compression can failitate removal of injury by-products.
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[編輯] What are the physiological events associated with the inflammatory-response phase of the healing process? How can you differentiate between acute and chronic inflammation?
一,
The physiological event in healing process :
(1) Immediate vasoconstriction (2)Vasodilation (3)Clot formation (platelet plug)
(4)纖維組織的生長
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二,Inflammatory-response phase physiological events:
Vascular reaction:
Injury → immediate vasoconstriction of vascular walls → vasodilation with hyperemia → stasis
Cellular reaction:
1. Histamine → vasodilation
2. Leukotaxin → forming exudate
3. Necrosin → phagocytes
Chronic inflammation:
1. Occurs when acute response does not eliminate injuring agent.
2. Leukocytes replaced by macrophages, lymphocytes, and plasma cells.
3. Specific mechanism which causes conversion is unknown.
4. Overuse or overload with cumulative repetitive microtrauma.
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三,Inflammatory-response phase physiological events:
紅.腫.熱.痛
血管反應:
受傷 → 血管會收縮避免出血的持續→收縮過久血液無法流通,所以血管會充血 →
於是就會淤塞和瘀血
細胞反應:
Histamine→vasodilation&cell permeability增加
Leukotaxin → forming exudate
Necrosin → phagocytes
另外發炎反應也會出現血塊的現象
Chronic inflammation:
受傷的組織得不到休息,一再受傷造成
過度使用or overloading 重複累積的微小傷害
白血球被巨噬細胞和淋巴球及血將細胞所取代
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四,
Ans1; phagocytic cells and leukocytes are delivered to the injuryed tissue. Phagocytosis protect and repair the injury tissue.vascular reaction involves vascular spasm,formation of a platelet plug, blood coagulation, and growth of fibrous tissue. initial injury 5-10 min is vasoconstriction, but replace rapid by hyperemia of the vascular dilation. This is transitory and gives way to slowing of the flow.blood and plasma effuselasts for 24-36 hours. Histamine can dilate the vascular. Therefore, it’s important for exudate formation and supply leukocytes.clot formation ,thromboplastion->prothrombin->thrombin->fibrinogen->fibrin clot (complete by 48 hours)
Ans2;
Acute inflammation appear leukocytes, but chronic not .
In the acute, phagocytic cells protect , repair, and migration of leukocutes from the blood to the tissue occur.
I th chronic, phagocytic cells repair and heal.
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[編輯] Infrared Modalities
[編輯] What are the definition and basic therapeutic clinical of an infrared modality and how are these modalities classified within the electromagnetic spectrum?
Definition and basic therapeutic clinical of infrared modality:
Near infrared:
Also called luminous.
Wavelength: 800-1500 nanometers
Far infrared:
Also called nonluminous.
Wavelength: 1500-150,000 nanometers
Definition:
1.Dry hot
2. Infrared ray are a portion of the electromagnetic spectrum and are just beyond the red portion of visible light.
3. Intensity is controlled by varying the wattage and the distance of the lamp from the surface to be heated.
4.Place the lamp parallel with the body part being treated so that the rays hit the body surface as close to a 90° angle as possible for maximum absorption.
5. All jewelry in the area must be removed.
6. If an area near the face is being treated, covering the eyes with cotton ball, gauze or goggles may be advisable.
[[<span class=|Image:file.jpg">Image:file.jpg]]
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Infrared 在electromagnetic spectrum中位在可見光上(即wavelength較長,frequency較低)
大多數heat(淺層) and cold modatities 的波長及頻率都落在電磁譜中的Infrafed portion,
include:ice massage, commercial cold packs, cold spray, cryo-cuff, hot pack, paraffin, fluidotherapy, infrared lamps...等等
此時的heat transmission 是由以下四種mechanisms達成: conduction, convection, radiation, evaporation
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the basic therapeutic clinical of infrared modality:分為cryotherapy和thermotherapy(為淺層
熱療儀器)
clinical application: 可以穿透大於1cm，主要直接影響表淺的皮膚血管和神經受器，可以止痛和降低對痛的敏感度
infrared mpdality主要落於電磁譜中紅外線部分，偏高頻率、短波長
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[編輯] What are the physiological effects of both therapeutic heat and cold?
(1)熱對於生理效應的影響可大致分為代謝反應與血管反應,甚至會影響反射與化學物質的釋放等
(2)冷對於生理效應的影響包含血管反應,代謝反應,週邊神經反應,深層組織反應等
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(1)冷療的生理效應: 一開始皮膚表層的血管收縮
皮膚顏色改變成藍紫色
血液黏滯度上升 使血流降低
快速的肌肉收縮(發抖)
寒毛豎起
非彈性的組織延展性降低
周邊神經活性降低
關節的溫度降低 使關節變得僵直
(2)熱療的生理效應:有助於肌肉與關節放鬆
減低疼痛與鬆弛軟組織
加速血液循環以降低溫度，加速血液循環，提高組織修復能力
增進排除代謝廢物的速度，催化化學反應。
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此外
冷療對於也會產生感覺麻痺
新陳代謝速率的下降
組織二氧化碳的堆積
上升神經衝動的閾值
熱療也有新陳代謝速率上升(上升10度可增加2~3倍的新陳代謝速率)
下降神經衝動的閾值
而兩者皆達到止痛的效果(Gate Control Theory)，但冷療的效果比較好。
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[編輯] What are the various thermotherapy techniques that can be used by the athletic trainer?
Hydrocollator Packs, Paraffin Bath, Infrared Lamps, Fluidotherapy
Ultrasound, shortwave, microwave,
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Hydrocollator Packs：建議水溫於攝氏71~76度並且建議放入Hydrocollator Packs後將毛巾摺六層，治療的時間約為15~20分鐘。
Paraffin Bath：治療用的蠟皆會混合礦物油，因為可下降其溫度從54.5度至47.8度。將欲治療的肢體放入蠟中數秒後拿出凝固，重覆此循環六次，之後套上塑膠袋，接著裹上毛巾15~20分鐘。
Infrared Lamps：將乾毛巾覆蓋在欲治療的部位，燈離的距離等於需要治療的時間，例如燈距患者20英吋及需治療20分鐘。
Fluidotherapy：治療的溫度隨著治療的部位及患者的忍受度而調整，大致範圍約在38.8~47.8度，治療時間約為20分鐘。
Ultrasound'：使用的平均強度應每平方公分大於0.2瓦，強度可隨著病人的忍受度而改變。在推動transducer的時候建議速度為每秒4公分。治療時間約5至10分鐘。
Shortwave diathermy：剛開始強度為30~40%之後調至max，再調到患者忍受範圍約為50%，治療時間約為20~30分鐘。
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[編輯] Therapeutic Ultrasound
[編輯] What is therapeutic ultrasound, and what are its two primary physiologic effects?
●治療型超音波主要是一種音波能，
治療型超音波頻率介於0.75-3MHz，故人耳聽不見，
其又分為低頻治療超音波與高頻治療超音波，
低頻的超音波衰退率較慢（穿透力較高），可達較深層的組織，
高頻的超音波主要針對表淺治療。
●治療型超音波的生理效應主要是熱效應和非熱效應
熱效應方面主要是讓組織受熱，增加組織溫度使產生熱反應
（增加膠原組織彈性、增加皮下血流、止痛、紓緩肌肉、增加關節活動度、修復慢性發炎等）
非熱效應方面主要是產生空泡效應使空泡周圍的液體流動可減少水腫疼痛、藉由直接改變細胞活性達治療目的為主。
Thermal effects:
Mild: increase 1℃, increase metabolic rate.
Moderate : increase 2-3℃, reduce muscle spasm, reduce pain, and increase blood flow.
Vigorous: increase 3-4℃, increase soft tissue extensibility.
Nonthermal effects:
Acoustical streaming: refer to the movement of fluids along the boundaries of cell membranes as a result of mechanical pressure wave.
Cavitation: is the vibration effect on gas bubbles by an ultrasound beam.
參考文獻：Therapeutic Modalities-For Sports Medicine and Athletic training,5th （Prentice）
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[編輯] How does an ultrasound wave travel through biologic tissues, and what happens to the acoustic energy within those tissues?
●超音波是透過探頭(applicator)發出音波，
而探頭主要的結構是壓電晶體(piezoelectric crystal)
當被交流電刺激時壓電晶體產生的形狀上凹凸的變化，而產生出高頻率（Hz）的音波。
●在軟組織(soft tisue)傳遞是以縱波(longitudinal waves)的方式傳遞，
而傳遞到骨頭時以橫波(transverse waves )的方式傳遞。
在波的能量傳遞過程中，
會因為介質性質的不同或是波傳遞方向和介質之間的夾角而產生被穿透、被吸收、折射和反射。
音波穿透身體會經過皮膚、脂肪組織、肌肉和一些結締組織最後到骨頭，
而每一層都對音波的都有不同的吸收能力。
除此之外在不同的介質之間也會因為傳到速率發生改變而造成能量的被吸收
(ex：骨頭和肌肉之間，因組織(介質)不同，而造成音波的反射，熱點(hot spots)的產生)。
參考文獻：Therapeutic Modalities-For Sports Medicine and Athletic training,5th
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●Attenuation(弱化):energy contained within a sound beam is decreased as it travels through tissue.
Attenuation is due to scattering and absorption.
The attenuation is greater in tendon, cartilage, and bone.
參考文獻：Therapeutic Modalities-For Sports Medicine and Athletic training,5th（Prentice）
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[編輯] What are the potential thermal effects and nonthermal effects of ultrasound facilitate the healing process?
熱效應可以使組織血液灌流增加，促使細胞釋放Histamine使細胞通透上升，接著Histamine會刺激白血球活性上升清潔組織。
血液的灌流可以使組織得到的養分增加，使組織修復增快。
非熱效應則是形成空泡作用，使周圍組織液體流動減少水腫和使細胞通透性改變，增加組織Healing速度。
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[ Thermal Effects of Ultrasound ]
- 增加 collagen extensibility
- 增加血流
- 減少疼痛
- Reducyion of muscle spasm
- 減少 Joint stiffness
- Reduction of chronic inflammation
肌肉組織一般溫度為36°C-37°C
在Mild Heating中,利用超音波的熱療使溫度增加1°C可使新陳代謝速率加速
在Moderate Heating中,溫度增加2-3°C可減少肌肉spasm,疼痛,chronic inflammation,與血流
在Vigorous Heating中,增加3-4°C可減少viscoelastic properties of collagen
[ Non-Thermal Effects of Ultrasound ]
- 增加纖維母細胞活性
- 增加蛋白質合成
- 組織再生
- 減少腫脹與疼痛
- Bone healing
- Pain modulation
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Non-Thermal Effects of Ultrasound
音波流(Microstreaming)：改變納離子和鈣離子的通透性幫助細胞復原。
空洞效應(Cavitation)或稱細胞按摩：透過音波(縱波)使介質密度的改變，造成細胞周圍壓力的變化來增加細胞內液體流動。
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[編輯] Shortwave and Microwave Diathermy
[編輯] What is diathermy, and what are the different types of diathermy? What are the potential physiological effects of using continuous shortwave, pulsed shortwave, or microwave diathermy?
Diathermy is the application of high-frequency electromagnetic energy that is primarily used to generate heat in body tissues. It may also be used to produce nonthermal effects.
Diathermy may be classified as two distinct modalities: shortwave diathermy and microwave diathermy. Shortwave diathermy may be continuous or pulsed.
The physiologic effects of continuous shortwave and microwave diathermy are primarily thermal, resulting from high-frequency vibration of molecules. Pulsed shortwave diathermy has been used for its nonthermal effects in the treatment of soft-tissue injuries and wounds.
Resource: Therapeutic Modalities-For Sports Medicine and Athletic Training, 5th edition, McGraw-Hill.
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1.Diathermy是一種深層熱,可以透到人體深層肌肉組織,並對此產生作用。它運用到電磁光譜中無線電的非離子部份。因為高頻波長太短,不會產生去極化,所以對神經肌肉不產生刺激。
2.Diathermy有短波、微波
3.(1)Continuous shortwave diathermy& microwave diathermy:主要是運用在非急性期。使血管通透性好,組織溫度升高,代謝提高,靜脈和淋巴回流循環增高。也能使肌肉放鬆,消除水腫。
(2)Pulsed shortwave diathermy:非熱效應,主要運用在急性期。用來治療軟組織的傷害和傷口。它可以讓受傷的細胞再極化,使恢復繁殖和再生能力。
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[編輯] What are the various clinical applications、precautions, and indications for using continuous shortwave, pulsed shortwave, and microwave diathermy?
Diathermy治療能夠促進血管擴張，增加血流及代謝速率、下降疼痛閾值、加速神經細胞的修復等功能。Continous shortwave, pulsed shortwave, and microwave diathermy在臨床上常用於治療muscle strain, contusions, osteoarthritis, tendinitis, bursitis, tenosynovitis, ligament sprain, myofascial trigger point, joint contractures等傷害，其中Continous shortwave和microwave diathermy大部分是利用" Thermal effect (熱效應)" 來減少肌肉的疼痛、改善關節的ROM、以及改善受傷部位的循環功能，減少水腫的情形出現。
而在使用diathermy儀器時應特別注意避免任何電子儀器靠近，包含像是配有助聽器及心律調節器的人都不宜使用，另外懷孕的人過於肥胖的人也應避免diathermy的治療。
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Precautions:
1. Instruct the patient not to move after the unit is positioned for treatment, because movement can change the tuning.
2. To avoid possible shock, instruct the patient not to touch any part of the device and object that may be grounded,
3. Instruct the patient to notify you in case of any discomfort or if it gets too hot. If the patient complains of any pain or discomfort during treatment, immediately reduce the output to zero. Make the necessary corrections before treatment is re-initiated.
4. Ordinary prudent practice makes it unlikely that therapists would be exposed to harmful levels of radiation.
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