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Therapeutic Modalities

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THERAPEUTIC MODALITIES

Terminology

• Modalities: methods of treating injuries, using heat, cold, ultrasound or electric stimulation

• Therapeutic: referring to treatment• Indications: reasons to use a modality• Contraindications: reasons not to use a

modality

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Types of Modalities

1. Thermal Modalities: transfer heat into or out of the body

2. Mechanical Modalities: use mechanical energy to produce effects

3. Electrical Modalities: stimulate nerve tissues

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General Purposes of Modalities

• Alter blood flow (vasoconstriction or vasodilation)

• Decrease pain• Decrease muscle spasm• Decrease swelling• Alter metabolism

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Indications for Using Modalities

• Acute injuries• Acute or chronic pain• Swelling• Chronic inflammation• Muscle spasm• Joint tightness

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Contraindications for Using Modalities

• Open wounds• Infections• Cold-related allergies• Areas of sensory or circulatory deficits• Open growth plates• Over organs (heart, eyes, etc.)• Possible fractures

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THERMAL MODALITIES

Terminology

• Conduction: heat transfer that occurs when objects are in direct contact

• Convection: heat transfer that occurs through the movement of fluids or gases

• Conversion: heat transfer that occurs as energy is changed from one form to another

• Radiation: heat transfer that occurs through space from one object to another

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Heat Transfer Principle

• Heat is always transferred from the warmer object to the colder object

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Conduction

• Heat transfer that occurs when objects are in direct contact with each other

• Example = hydrocollator (moist heat) pack on shoulder

• How is heat transferred in this example?

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Convection

• Convection is a method of heat transfer that occurs through the movement of fluids or gases

• Example: an athlete’s ankle in a cold whirlpool• How is heat transferred in the example?

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Conversion

• Conversion is a form of energy transfer that occurs when heat is generated from sound, electricity or chemical means and transferred into heat energy

• Example: ultrasound application over an athlete’s quadriceps

• How is heat transferred in the example?

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Radiation

• Radiation occurs as heat is transferred from one object through space to another object

• Example: diathermy treatment for an athlete’s back

• How is heat transferred in the example?

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Factors influencing heat transfer

1. The temperature difference between the two tissues– (Bigger differential leads to higher transfer of

energy)

2. The length of treatment time– (The longer the exposure, the greater the transfer)

3. The conductive properties of the area– (Fat is an insulator and takes longer to heat/cool;

muscle has a high water content and is a good conductor of heat/cold)

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CRYOTHERAPY

Terminology

• cryotherapy: using a source of cold for treatment

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Physiological Effects of Cold

• Decreased muscle spasm• Decreased pain• Decreased blood flow (vasoconstriction)• Decreased metabolism• Decreased tissue extensibility• Increased joint stiffness

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Indications for Cryotherapy

• Acute injuries• Pain• Swelling / inflammation• Muscle spasm

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Contraindications for Cryotherapy

• Cold-related allergies• Open wounds• Cardiovascular problems• Sensory or circulatory deficits• Hypersensitivity to cold• High blood pressure• Respiratory problems• Diabetes or peripheral vascular disease• Infection

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Cold Whirlpool

• What it is:• Container filled with ice

& water at 50 to 60°F• Cooling occurs with

water movement• Where it’s used:• Treating an injured

extremity

• Advantages:• Effective cooling in 10-

15 minutes• Can treat large areas

• Disadvantages:• Can’t be transported• Requires prep time• Constant supervision

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Ice Massage• What it is:• Water frozen in a cup;

the top of the cup is peeled away and the exposed ice is rubbed over the area

• Where it’s used:• Over small treatment

areas (tendon, bursa, muscle belly, etc.)

• Advantages:• Short treatment time

(5-10 minutes)• Cheap (cup + water)• Athlete can self-treat• Disadvantages:• Only effective on

small areas• Can be messy

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Ice Pack• What it is:• Flaked or crushed ice

tied in a plastic bag

• Where it’s used:• Any body part,

especially after acute injuries

• Advantages:• Molds to the body part /

treat large areas• Cheap (plastic bag) after

investment of ice machine• Transportable• Disadvantages:• Requires longer treatment

times (15-30 minutes)

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THERMOTHERAPY

Terminology

• thermotherapy – using a source of heat for treatment

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Physiologic Effects of Heat

• Decreased muscle spasm• Decreased pain• Increased blood flow (vasodilation)• Increased metabolism• Increased tissue elasticity• Decreased joint stiffness

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Indications of Thermotherapy

• Chronic inflammatory conditions• Chronic pain• Chronic muscle spasm• Joint contracture• Tightened tissue

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Contraindications of Thermotherapy

• Sensory loss• Acute injury• Areas of decreased sensation/circulation• Over the abdomen during pregnancy• Over the eyes or genitals• Area over tumor / malignant tissue• Peripheral vascular disease

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Warm Whirlpool

• What it is:• Basin filled with 98 to

104°F water• Heating through

conduction & convection

• When it’s used:• Treating an injured

extremity

• Advantages:• Effective heating in 10-20

minutes• Treat large areas• Disadvantages:• Clean after each use to

prevent infection• Prep time• Can’t be transported• Constant supervision

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Hydrocollator (Heat) Pack• What it is:A moist heat pack filled

with gel and stored in 160°F water bath

• Wrapped in towels to prevent burning

• When it’s used:• Applied over large

areas

• Advantages:• Superficial heating in 15-

20 minutes• Reusable• Conforms to areas• Disadvantages:• Hydrocollator requires

electricity (not transportable)

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Paraffin Bath• What it is:• Basin filled with

paraffin and mineral oil heated to 126-130°F

• Extremity is dipped 6 times, then wrapped in plastic bag

• When it’s used:• Chronic pain/swelling

in hands/feet

• Advantages:• Treatment time varies

from 5-20 minutes• Disadvantages:• Messy application• High risk of infection

(replace wax often)• Treatment area limited• Supervision required

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CONTRAST THERAPY AND CRYOKINETICS

Terminology

• Contrast bath: a method of treatment alternating cold water immersion and hot water immersion

• Cryokinetics: a technique that combines cryotherapy with exercise

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Physiological Effects

• COLD• Vasoconstriction• ↓muscle spasm• ↓tissue metabolism• ↓pain• ↓tissue extensibility

• HEAT• Vasodilation• ↓ muscle spasm• ↑ tissue metabolism• ↓ pain• ↑tissue extensibility

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Contrast Bath Therapy

• Most effective in the sub-acute stage• Primarily used for treating extremities• Fill one container with cold water (50 to 65°F)• Fill a second container with hot water (105 to

110°F)• Treat injury using a 3:1 ratio (3 minutes in heat,

1 minute in cold) or 4:1 ratio for about 20 minutes

• Usually end with cold treatment35

Contrast Bath Therapy (cont.)

• Why use contrast bath therapy? • Changing from cold to heat causes a mild

temperature increase• Temperature increase allows for increased

blood flow to area (speed up healing without causing more swelling)

• Still a popular theory, but no evidence that it actually works

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Cryokinetics

• Used in acute stage of injury• Combines cryotherapy with exercise• Start w/ cold whirlpool, ice pack or ice massage

to numb the body part (about 12-20 minutes) • Begin exercise within pain tolerance (about 3-5

minutes)• Repeat cold water immersion and exercise 3

more times, ending with cold

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Cryokinetics (cont.)

• Exercise should be active• Exercise should be pain-free• Exercise should be performed normally

(without limping)• Exercise should progress in complexity and

difficulty but stay within pain-free guidelines

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THERAPEUTIC ULTRASOUND

Terminology

• therapeutic ultrasound: a modality that is used for deep heating or tissue repair

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Therapeutic Ultrasound• Ultrasound machine

Sound head

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How Ultrasound Works

• The ultrasound unit contains a generator, which provides an electrical current that is transmitted to a crystal located in the sound head

• The electrical current causes the crystal to vibrate, producing a high-frequency sound wave– Humans can hear 18,000 – 20,000 Hz (cycles/second)– Ultrasound is either 1 million (1MHz) or 3 million

(3MHz)

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How Ultrasound Works (cont.)

• The sound wave is absorbed by tissues with a high protein content (tendons, ligaments, joint capsules, and muscle)

• The sound wave is poorly absorbed by bone tissue; the majority is reflected or refracted

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Ultrasound Parameters

• Frequency: cycles per second (Hz)– 1 MHz – heats tissues from 2 to 5 cm deep– 3MHz – heats superficial tissues

• Intensity: the amount of energy transferred to the tissues, expressed in W/cm² (ranges from 0.1 to 5.0 W/cm²)

• Continuous or pulsed sound beam:Continuous output produces thermal effectsPulsed output produces mechanical effects for tissue healing

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Ultrasound Parameters

• Duty cycle: the amount of time the ultrasound is on

20% means it’s on 1 out of every 5 seconds

100% means it’s on continuously• Treatment area: should be about twice the

size of the sound head• Treatment length: usually 5-10 minutes

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Ultrasound Guidelines

• A medium is required to transmit the sound waves into the tissue (either cream, gel or water)

• The sound head must be moved about 2-4 cm per second to prevent burning

• Requires constant supervision by AT• Requires a doctor’s script

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Indications for Ultrasound

• Acute injuries (tissue healing, non-thermal effects)

• Chronic injuries• Muscle strains• Ligament sprains• Muscle spasm• Tissue tightness• Scar tissue

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Contraindications for Ultrasound

• Areas with sensory or circulatory deficits• Over fractures or open growth plates• Over tumors• Over artificial joints• Over heart, eyes, brain, spinal cord• Over reproductive organs• Over abdomen during pregnancy• Over herniated discs• Acute injuries (in continuous heat setting)

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Sample Treatments*Condition Frequency Duty Cycle

Deep muscle adhesion 1 MHz 100%

Deep bursitis 1 MHz 20-50%

Superficial scar 3 MHz 100%

Superficial tendinitis 3 MHz 20-50%

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*Table from France, Robert C. Introduction to Sports Medicine & Athletic Training (Clifton Park, NY: Thomson DelMar Learning, 2004), 220.

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THERAPEUTIC MASSAGE

Terminology

• Massage: intentional and methodical kneading and stroking of soft tissues

• Effleurage: using the palm to stroke the tissue in a smooth and rhythmical way

• Petrissage: kneading or squeezing the tissue between the hands

• vibration massage: causing the tissue to shake vigorously

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Terminology (cont.)

• percussion massage (tapotement): applying repetitive light chopping motions to the tissue

• friction massage: using the finger, thumb, or elbow to apply pressure to deep tissues

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Indications for Massage

• Increase circulation• Decrease muscle spasm• Relieve swelling• Increase joint mobility• Relaxation• Break up scar tissue

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Contraindications of Massage

• Local or general infection• Acute stage of injury

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Desired Therapeutic Effects

1. Break up scar tissue?2. Increase circulation?3. Relaxation?4. Improve joint mobility?5. Decrease muscle spasm?6. Relieve swelling?

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Therapeutic Effects by Massage Strokes

1. Break up scar tissue? - Friction2. Increase circulation? – Percussion,

petrissage, effleurage3. Relaxation? Effleurage, percussion4. Improve joint mobility? – Vibration,

petrissage5. Decrease muscle spasm? - Friction6. Relieve swelling? Effleurage, vibration

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Guidelines for effective massage

1. Position athlete comfortably on a table2. Make sure the room temperature is at a

comfortable setting3. Drape athlete’s body to expose only the

necessary body part4. Use lotion or a massage lubricant to allow

the hands to slide over the skin5. Explain what massage strokes you are using6. Be confident

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ELECTRICAL STIMULATION

Terminology

• electrical stimulation (E-Stim): using electricity to target a motor nerve and cause a muscle response

• transcutaneous electrical nerve stimulation (TENS): using electricity to target a sensory nerve to decrease pain

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Electrical Modalities

• TENS unit

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• E-Stim Unit

E-Stim and TENS Comparison• Similarities1. Both are electrical

modalities2. Both transmit

electricity through electrodes

3. Both stimulate nerves4. Both produce

therapeutic effects

• Differences1. E-Stim is used to

stimulate motor nerves; TENS stimulates sensory nerves

2. E-stim produces muscle contractions; TENS controls pain

3. An E-stim unit can function as a TENS

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How Electrical Stimulation Units Work

• The unit generates an electrical current• The current is transmitted by the electrodes

(two or more electrodes are required to complete an electrical circuit)

• The electrodes are placed on the skin• The current carried by the electrodes is used to

stimulate a nerve (sensory or motor)• The amount of electricity is controlled to

produce a therapeutic effect62

Indications of Electrical Stimulation

• Increase range of motion• Increase muscle strength• Muscle re-education• Improve muscle tone• Improve muscle function• Control pain• Accelerate wound healing• Decrease muscle spasm• Prevent atrophy

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Contraindications of E-Stim

• Over the carotid sinus• During pregnancy• Individuals with pacemakers• Sensitivity to electricity• When active ROM is contraindicated

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Treatment Parameters

1. Waveform 2. Modulation3. Intensity4. Duration5. Frequency6. Polarity7. Electrode setup

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