Introduction to Therapeutic Modalities

Fix Me! Intervene to… Restore normal tissue relationship After injury the relationship of a variety of tissues are altered Muscle, Tendon, Nerve, Joint Capsule, & Fascial layers Restore normal activity level Restore normal kinetic chain activities

Making Clinical Decisions Athletic Trainers/Therapists Have A Choice Of A Variety of Therapeutic Techniques Many Eventually Choose To Use Therapeutic Modalities How You Choose To Use A Therapeutic Modality Is An Individual Decision The Choice Must Be Based On Theoretical Knowledge And Practical Experience

Continuum of Levels of Evidence Voodoo Science (Tradition, Art, Experience, Theory) Use both theoretical knowledge and practical experience regardless of the approach of your mentors or peers

Problem Solving Approach Recognition of the Problem Prioritization of the Problem Goal Setting Treatment Planning Reevaluation Assess Needs Develop Plan Implement Plan Evaluate Plan Feedback Loop

Where do therapeutic modalities fit? Acute Injury Care (inactive) Immobilization Phase (assistive) Restoration Phase (resistive) Return to Activity Phase (aggressive) Maintenance Phase Inflammation Fibroblastic Repair (Proliferation) Maturation and Remodeling (Regeneration)

Where to modalities fit? Sequential BUT also overlapping steps of rehabilitation Wound healing Pain relief Flexibility and ROM Muscular strength Muscular endurance Cardiorespiratory endurance Muscular speed Muscular coordination Muscular power Agility Sport skill

Where to modalities fit? Range of Motion Muscle Strength and Endurance Power Sport Skill Static and Dynamic Neuromuscular control Sequential BUT also overlapping steps of rehabilitation Wound healing Pain relief Flexibility and ROM Muscular strength Muscular endurance Cardiorespiratory endurance Muscular speed Muscular coordination Muscular power Agility Sport skill

To Select Most Effective Modality You must: Know what you want to accomplish with the modality - that is, have specific therapeutic goals. Understand the modalities effects, indications, and contraindications. Match your therapeutic goal with a modality that will help you achieve that goal.

Classification of Therapeutic Modalities Cryotherapy Thermotherapy Hydrotherapy Electrotherapy Light therapy Mechanotherapy Exercise

Therapeutic Treatment Plan When? Where? How? Art + Science Electromagnetic & acoustic principles Overload Principle SAID Principle Process of Inflammation

Cryotherapy/Cold Modalities Brrrrrrrrr! http://school.discoveryeducation.com/clipart/images/ice-cold.gif

Cryotherapy/Cold Modalities What is cold? A state that allows for decreases in molecular motion (decrease in kinetic energy) Primary Benefit = Reduction in cellular metabolism Pain is decreased Inflammatory process is slowed Cells need less energy to survive Body losses its heat – cold object becomes warmer Cryotherapy Temperatures range from 32° to 65°F(0° to18°C). Secondary injury: enzamatic..neutophils friendly fire: eat every thing leave a lot of waste behind

Indications Acute/Subacute Inflammation Acute and Chronic Pain Muscle Spasm Sprain Strain Contusion Bursitis Tendonitis DOMS Post-surgically Small, superficial burns In conjunction with Rehabilitation Exercises CRYOKINETICS

Contraindications Precautions Open wounds or skin conditions (whirlpools) Hypersensitivity or Allergy Anesthetic Skin Circulatory Insufficiency Advanced Diabetes Reynaud's Phenomenon vascular reaction to cold or stress that results in white, red, or blue discoloration of extremities. Fingers and toes are first affected. Infection Precautions Frostbite = Occurs when skin temperature drops below 32° F (0° C). Skin should not look pale or cyanotic as an indication of lack of circulation

Sensations of Cold Modalities Everyone is effected differently by ice. Cold Burning Aching Numbness Analgesia Most apparent during ice-immersion Lewis Pugh - Swims the North Pole

Types of Cold Modalities Commercial Ice Pack Ice Pack Ice Massage Ice Immersion Cryocuff™ Cold Whirlpool Cryokinetics Cryostretch/Cold Sprays Cold Ointments - BioFreeze Game Ready® Polar Care®

Ice Packs Materials needed: Application Ice machine Plastic bags Towels Compression wrap (optional) Application Fill plastic bag with desired amount of ice Remove air from bag Tie knot close to top of bag Apply to injured area being sure to mold it to the part being treated.

Ice Packs Application Be aware of patients modesty and use toweling to protect them Use compression wrap to secure bag to the area – 50-60 mm Hg Leave pack on 12-45 minutes depending on treatment area and goals http://sportsmedicineinternational.com/services/taping-shoulder

Ice Massage Materials Needed: Application: Paper Cups or commercial Ice massage cups Water Freezer Towels Application: Fill cups ¾ with water Freeze overnight Drape treatment area with towels to prevent mess and preserve modesty of patient

Ice Massage Application Tear away a portion of the paper cup Check for any jagged edges on the ice cup Pin-point treatment area Apply ice cup to injured area using circular or longitudinal strokes Be sure to apply some pressure to get a massaging effect Treat area for 7-15 minutes depending on target tissues. Wipe up excess water

Ice Immersion Application Materials Needed: Basin or bucket Water Ice Toe caps Toweling Application Fill bucket or basin ¾ full of ice Fill with water Temperature should range between 33-41°F (1-5°C) Jutte (2007) Most sensation decrease with 1°C water Make sure toweling is on hand to clean up any spillage

Ice Immersion Application Use toweling to dry off area after treatment Allow patient to use toe caps for highly sensitive areas Instruct patient to submerge the injured area into the bucket Treatment time should range from 10-20 minutes Use toweling to dry off area after treatment If treating acute injury be sure to compress and elevate after treatment

Commercial Cold (Gel) Packs Contained in a cold hydrocollator kept at 15°F (-9°C) or freezer unit Each pack contains petroleum distillate gel Only energy withdrawn from body is used to heat water – NO phase change Used any time a cold pack is indicated Tx Application: Protect patient’s modesty Place wet towel on the skin of the tx area These are cold on the outside Apply cold pack over toweling Apply dry towel over cold pack

Commercial Cold Packs Application (Con’t) Secure cold pack to the injured area with wrap – need barrier between pack and skin Elevate as needed Time for 20-30 minutes Check for frostbite and general comfort every 4-5 minutes.

Cryo-cuff Materials Needed: Application Cryo-cuff Water Ice Fill cooler with ice to specified line Fill cooler with water Attach bladder to the injured area Attach hose to cooler Open spout and lift cooler above injured area Once bladder is filled to desired level, close spout and lower cooler When water warms, repeat above process

Continuous circulating water Game Ready® or Polar Care® or others Game Ready - the secret is the intermittent compression and the ability to have different levels of compression

Game Ready® System Cryotherapy & Intermittent pneumatic compression Game Ready® allows continuous circulation of water with varying levels of intermittent pneumatic compression. Fabric therapeutic wraps surround the affected area. Cold water continuously cycles throughout every part of the therapeutic wrap. Compression can be adjusted at 4 levels. None, Low (5-30mmHg), Medium (5-50 mmHg), and High (5-75 mmHg) Cyclical – varies between 1-3 minute cycles. Automatic cycles – 30 on/30 off/30 on/30 off

Cold Whirlpool Materials Needed: Water Ice Towels Turn on turbine before athlete gets into whirlpool Application: Choose appropriate sized whirlpool Fill with water and ice Temperature should range between 50-60°F for whole body 45°F for leg Temperature of water MUST increase as the body area being treated increases.

Cold Whirlpool Application (cont’d): Allow athlete to position themselves appropriately Treatment time is between 5 and 30 minutes Goals determine Turn off turbine after athlete has exited the whirlpool Drain and clean whirlpool Take precautions about electrocution and be sure to have GFI switch.

Cold Whirlpool Pros Cons Treatment of large areas Decrease Tx Time Decrease likelihood of pain Gate control – Temperature, motion of water, and reduced compressive stress Aids in Cryokinetics Helps weed out fakers Cons Initially Expensive!!! Start-up costs: $1500-4000 Difficult to always target specific area of injury Gravity Dependant Position