Therapeutic Modalities

Therapeutic Modalities exercise (strengthening/stretching) infrared heat cold

Therapeutic Modalities electromagnetic produce radiant energy no transmitting medium needed acoustic produce sound waves require a conducting medium Electromagnetic – similar to intraferential unit Acoustic – more like an ultrasounds Gel medium allows ultrasound waves to penetrate skin

Choosing a modality type and severity of injury anatomy of the region indications/contraindications of each efficacy of a treatment protocol How well is it working continual monitoring of progress Improvements, good, but do not use exact same settings every single time Do not use stagnant settings – customize treatment program to specific individual situation of the injury

Wavelength and Frequency distance between peaks Frequency number of cycles (waves) in one second Measured in hertz Wavelength: distance between each peak Frequency: number of wavelengths in each second. Measured in hertz

Contact with tissue Three possible occurrences when energy hits tissue 1- reflected off – nothing gets through 2- refracted/bent 3- absorbed

Cryotherapy limited to 1 cm penetration ( likely deeper up to 5 cm ??) superficial effects cutaneous blood vessels cutaneous nerve receptors cold  stinging  burning/aching  numbness Crytherapy: application of cold Likely goes deeper then 1cm of penetration Also dependant on what type of cryotherapy is being used. Ex: ice cup vs cold tub Vascular and Nervous responses to cold 4 phases to cold

Physiological Responses  blood flow due to vasoconstriction of local blood vessels  inflammation due to reduced metabolic rate Vasoconstriction and decreased pain (decrease in Nervous sensation) Potential decrease in pain Decreased inflammation due to a decreased metabolic rate

Physiological Responses  muscle spasm due to  motor nerve conduction velocity and muscle spindle excitability  pain due to cold-induced anesthesia

Contraindications/ Precautions hypersensitivity Raynaud’s disease patches of altered sensation ex. from cutaneous nerves severed during surgery use insulating layer with chemical packs Hypersensitive to ice Raynaud’s allergic to ice – physiological responses occur, but the burning sensation that occurs is magnified signifcantly Altered sensitivity – ex: Chemical packs are colder then normal ice packs therefore there is an increased chance of frost bite

Treatment ice pack ice massage 15 - 20 minutes every hour during acute phase ice massage 5 - 15 minutes until anesthesia occurs No real benefits for to icing longer then 15-20 minutes at a time Just ice repeatedly Time – accomplish four stages of healing No real benefits for to icing longer then 15-20 minutes at a time Just ice repeatedly Careful icing certain areas due to nerves being very close to the skin Lateral Knee – peroneal nerve Later elbow – ulnar nerve Can result in nerve damage

Cryotherapy

Thermotherapy limited to 1 cm penetration superficial effects cutaneous blood vessels cutaneous nerve receptors Cold goes much deeper then heat Heat before practice, but ice after practice If an athlete is not practicing at all then use ice for all modalities due to deeper penetration Ice and heat accomplish similar tasks, but physiologically there are a few minor differences.

Physiological Responses  blood flow due to vasodilatation of local blood vessels  metabolism, capillary permeability, leukocytes, phagocytosis  edema formation**  lymphatic and venous drainage Due to increased blood flow

Physiological Responses  pain due to heat-induced anesthesia  elasticity of muscles, ligaments, capsule  muscle spasm

Contraindications/ Precautions acute injuries (active hemorrhaging or swelling) if infection is present sensory or circulatory impairment toweling for protection (5 min. check) fair skin, red hair* Acute injuries – will increase edema – due to increase blood flow and metabolism Infection – tracking causing pain in lymph nodes, puss, redness, potential fever, Sensory or circulatory impairment – use towels in order to avoid burning or overheating

Treatment hydrocollator pack whirlpool 15 - 20 minutes 36 - 43° C (96 - 106° F)

Contrast Baths hot - 104-106° F cold - 50-60° F for sub-acute swelling alternate hot and cold immersion hot - 104-106° F cold - 50-60° F 3 (hot) : 1 (cold) or 4 : 1 for 20 min Also a good way to move an athlete from cold to hot – see how the athlete reacts, but make sure the athlete finishes in the cold tub Have them do active muscle movements while in the warm tub

Ultrasound fetal development cancerous tumors stimulate tissue repair imaging of internal structures fetal development destruction of tissue cancerous tumors therapeutic (deep heating) agent stimulate tissue repair pain relief

Transducer electric current delivered to crystal crystal vibrates to create sound wave Crystal is very important – changes electrical energy to acoustic energy Crystal compresses and relaxes repeatedly in order to create acoustic wave impulses – depending on what mode you choose there may be a pulse of continuous current PIEZOELECTRIC crystal

Energy Characteristics Ultrasound tends to penetrate tissue easily that has high water content Absorbed easily by tissues that are high in protein Reflected a lot by boney tissue – if transducer is not constantly moved the bone will reflected the bone back and interact with another incoming wave – these waves can collide, heat up, and burn the patient 3Mhz tissue will heat up tissue faster to cause greater elasticity of a tissue – ex: 3Mhz on an Achilles tendon immediate heating of the tissue and can be stretched out right away But 1Mhz heat penetrates deeper into the tissues – ex: used on quads and hams

Ultrasound Ultrasound tends to penetrate tissue easily that has high water content Absorbed easily by tissues that are high in protein Reflected a lot by boney tissue – if transducer is not constantly moved the bone will reflected the bone back and interact with another incoming wave – these waves can collide, heat up, and burn the patient 3Mhz tissue will heat up tissue faster to cause greater elasticity of a tissue – ex: 3Mhz on an Achilles tendon immediate heating of the tissue and can be stretched out right away But 1Mhz heat penetrates deeper into the tissues – ex: used on quads and hams

Frequency greater the frequency, less the depth of penetration superficial condition? 3MHz deeper injuries? 1 MHz

Frequency greater the frequency, less the depth of penetration greater the frequency, faster the tissue is heated

Intensity rate at which energy is delivered, per unit area (of sound head) measured in W/cm2 use lowest intensity of u/s energy at highest frequency which will transmit energy to specific tissue

Application Continuous Pulsed Continuous: continuous burst Provides more thermal/heating effects with the constant waves entering It is still possible to have non-thermal continuous – lower intensity! Pulse: burst, break, burst, break Provides more healing effects, slight increase in MR, BF Cavitations occurs with both pulsed and continuous But can be less controlled during pulse Pulsed

Application Pulse period Pulse duration Duty cycle on time + off time % time u/s is being generated during one pulse period

Pulsed u/s Pulsed u/s Average intensity over time is reduced A way to get non-thermal effects without heating

Thermal Effects Increase of: 1° C -  metabolism and healing 2-3° C -  pain and spasm 4° C and above -  extensibility of collagen,  joint stiffness

Non-thermal effects cavitation formation of bubbles that expand and contract  flow in fluid around vibrating bubbles

Contraindications not applied near eyes, heart, testicles or pregnant uterus not over areas of decreased sensation or decreased vascularity not applied over active epiphyseal plates

Application

Decision making depth of injury site desired effect intensity 1 MHz or 3 MHz? desired effect thermal or non- thermal effects? pulsed or continuous? intensity treatment time

Phonophoresis u/s used to drive molecules of a topically applied medication into the tissues anti-inflammatory, ex. Hydrocortisone (pensaid) tendinitis, bursitis anesthetics, ex. lidocaine trigger points

Phonophoresis medication rubbed into skin over treatment area thermal effect of u/s increases tissue permeability acoustic pressure of u/s beam drives medication into tissues

Electrical Stimulating Currents create muscle contraction by nerve or muscle stimulation stimulate sensory nerves to treat pain drive ions beneficial for healing through the skin create an electrical field in tissue to stimulate healing process Sensory nerves, motor nerves, and those nerves that response to noxious stimuli

Electrical Stimulating Currents as current intensity or duration is increased: sensory effect “pins and needles” or “tapping” sensation from stimulation of sensory nerves close to electrodes motor effect  motor neurons stimulated to create isometric or concentric muscle actions noxious stimulation

Muscle Stimulation muscle strengthening* retardation of atrophy muscle re-education muscle “pump” contractions reducing swelling increasing ROM

Muscle Stimulation

Electrode Location

Electrode Location

Contraindications known or suspected cardiac arrhythmias pacemakers severely obese pregnancy externally fixated fractures over the carotid sinus

Sensory Nerve Stimulation TENS – trans-cutaneous electrical nerve stimulation maximally stimulate the sensory nerve fibers without stimulating the motor or pain fibers to control acute and chronic pain

Effects?? stimulate large diameter sensory fibers to block pain impulses from ascending tracts of spinal cord stimulate large diameter sensory fibers to produce endorphins, inhibiting pain transmission in ascending tracts

Effects?? stimulation of areas of brain stem activates descending efferent fibers in spinal cord, causing release of endorphins inhibits transmission of impulses to ascending tracts pain perception influenced by emotions, previous experience

Effects?? beta endorphin release ACTH release corticosteroid release from adrenal glands

Current Parameters Modulation continuous interrupted burst ramped Continuous – tend to get used to this stimulation the most Interrupted –

Current Parameters frequency number of pulses per second tapping  pins and needles Lower frequency will provide more of a muscle contraction – potential for increased pain – but have a higher endorphin release Higher Frequency – pain relief but effects are not as long lasting Lower frequency (1-10, 1-50hz) will provide more of a muscle contraction Potential for increase pain and higher endorphin release Higher freq. Pain relief, but the healing effects wont be as long lasting.

IFC IFC – interferential Current Electrodes placed in a square alignment and interferential currents are passed though a homogeneous medium , a predictable pattern of interference will occur Resembles a four petal flower , with max interference taking place in the middle of the flower , and decreasing as we move outwards

IFC However we are not a homogeneous medium , so we cannot perdict the exact interference point , , need help of the patient We want the max effect at the area of the patients discomfort, poorly localized pain makes this harder to do , we can add in a scan feature which broadens the treatment area

Electrode Location (IFC)

IFC Pain higher pps ( 50 – 120 ) Swelling lower pps ( 10 – 50 ) Pain management – gate therapy , endorphins Swelling – pulsing , pumping effect , movement of the current through the injured area