1. Athletic Training Modalities

2. Modalities: Objectives Legal ramifications of treating the athlete with therapeutic modalities. Relationship of therapeutic modalities and electromagnetic energy. Theoretical use of various types of modalities. Application of various types of thermotherapy and cryotherapy techniques. The physiological basis and therapeutic uses of electrical stimulating currents. How massage, traction and intermittent compression can be used as therapeutic agents.

3. Modalities: Introduction Sports medicine and athletic training use a wide variety of therapeutic modalities. The following will be discussed during this unit: –Legal Concerns –Transmission of Thermal Energy –Cryotherapy –Thermotherapy –Ultrasound –Electrotherapy –Massage –Traction –Intermittent Compression

4. Modalities: Legal Concerns Must be used with great care, No indiscriminate use, The athletic trainer must follow the laws of their state on use or restriction of use. Kentucky Revised Statutes - Chapter 311 www.kbml.ky.gov/ah/at.htm The athletic trainer must have a thorough understanding of the functions, indications of use and contraindications of each modality used.

5. Modalities: Legal Concerns The athletic trainer when deciding the appropriate modality to use the decision must be based on accurate evaluation of the injury and which modality will achieve the most effective treatment result for the injury being treated. Use of the appropriate modality is an integral part of the treatment and rehabilitation of the athlete.

6. Methods of Heat Transfer –Conduction Heating through direct contact –Convection Heating through indirect contact (air or liquid) –Conversion Heating through other forms of energy (ultrasound, electrical) –Radiation Transfer of heat through space from one object to another. (infrared, UV, heat lamps)

7. Modalities: Cryotherapy Defined as: application of cold A well accepted practice in athletic training When applied w/compression, elevation and rest reduces adverse conditions related to the inflammatory and reactive phase of an acute injury. Cryotherapy can be used for a few days or for the extent of the injury depending on the severity.

8. Modalities: Cryotherapy Physical Principles A type of electromagnetic energy (infrared radiation) When applied to a warmer object, heat is abstracted. Most common method of cold transfer is through conduction

9. Modalities: Cryotherapy The extent of tissue being cooled depends on: –Type of cold medium being applied: Wet ice penetrates deeper than dry ice. –Length of cold exposure: the longer cold exposure the deeper (38 degrees/4cm) –Conductivity of the tissue being cooled: High water content more cooling (muscle), Low water content less cooling (Fat: insulator), the thicker subcutaneous fat layer the longer it takes to cool. –Tissue that has been cooled takes longer to return to normal than heated tissue.

10. Modalities: Cryotherapy Physiological Effects Cold applied to skin for 15 minutes @ 50 degrees F, Vasoconstriction occurs. Cold applied for greater than 25-30 minutes then the “Hunting’s Response” occurs: for 4-6 minutes there are periods of vasodilation & vasoconstriction (spasm).

11. Modalities: Cryotherapy Physiological Effects Continued Cold causes: –an increase in blood viscosity and vasodialators –Decrease the extent of cell hypoxia less cell damage less rehabilitation time –Decrease in new Swelling occurring (metabolic rate) –Decrease in Muscle Spasm –Decrease in Pain Perception –Decrease in Collagen Elasticity –Increase in Joint Stiffness –Increase in Capillary Permeability –Decrease Muscle Fatigue –Increase in ability to Maintain Muscle Contraction

12. Modalities: Cryotherapy Skins Response to Cold 0-3 Minutes:Cold Sensation 2-7 Minutes:Mild Burning/Aching 5-12 Minutes:Cutaneous Anesthesia

13. Modalities: Cryotherapy Special Considerations: Adverse Reactions to therapeutic cold application are uncommon but sometimes do occur –Cooling @ 30 degrees for 1 hour: redness and edema that last for 20 hours or more. –Frostbite can occur @ subfreezing temperature (24-26 degrees) –Ice Immersion @ 41 degrees: can increase limb fluid volume by 15% –Exposure at 57-61 degrees for 90 minutes can delay the swelling from reabsorbing for up to 1 week. –Allergic Reactions: Hives, Joint Pain and Swelling.

14. Modalities: Cryotherapy Special Considerations: Continued Raynaund’s Phenomenon: Vasospasm of the digital arteries lasting for a few minutes to hours that could lead to tissue death. Signs: –Intermittent skin blanching –Cyanosis of the fingers or toes –Redness then back to normal skin color.

15. Modalities: Cryotherapy Special Considerations: Continued Paroxysmal Cold Hemoglobinuria: –Rare, can occur minutes after cold exposure –May lead to renal dysfunction/failure –Secondary hypertension –Early Symptoms: Severe pain in the back and legs Headache Vomiting Diarrhea Dark Brown Urine

16. Modalities: Cryotherapy Special Considerations: Continued Nerve Palsy: –Relatively Uncommon –Occurs when cold is applied to a body part that has motor nerves close to the skin surface. –The body part goes numb and no movement until the body part warms

17. Modalities: Cryotherapy Ice Massage –Equipment: Cup filled with water and frozen Towel –Indications: Used over small muscle areas or a bursa –Application: –Special Considerations: An athlete with normal circulation: None Consider the comfort of the athlete

18. Modalities: Cryotherapy Ice Water Immersion –Equipment: Depending on the body part; A container filled w/water and ice Towel –Indications: Used when circumferential of the body part is needed. –Application: –Special Considerations: Protect the toes/fingers from frostbite Water needs to be no colder then 45-50 degrees Athlete can not return to full performance until rewarmed

19. Modalities: Cryotherapy Ice Packs: Most common type used –Equipment: Depending on the body part; A plastic bag filled with ice Commercial Ice Packs (towel) Chemical Ice packs –Indications: Anywhere cooling is needed –Application: –Special Considerations: Use of wet towel between commercial ice packs and skin Watch for chemical burns with chemical ice packs Athlete can not return to full performance until rewarmed

20. Modalities: Cryotherapy Vapocoolant Sprays –Equipment: Fluori-Methane Non-flammable and non-toxic –Indications: Acute muscle spasm Increase range of motion from muscle spasm Acute contusions –Application: Spray and stretch –Special Considerations: Care to prevent frostbite

21. Modalities: Cryotherapy Cryokinetics –Combines cold therapy with exercise – Goal: Numb the injured body part and work the injured body part to achieve normal range of motion Use progressive active exercise Return to full sport activity –Application: Apply cold until the analgesic phase is achieved Exercise should be pain free (3-5 minutes) Reapply cold Repeat process 3-5 times –Special Considerations: If the analgesic phase is not achieved in 20 minutes, continue on with the exercise phase Intensity limited by healing process and pain perception

22. Modalities: Thermotherapy The application of heat has been used for centuries to treat disease and traumatic injuries. Heat is an energy form the increases molecular activity.

23. Modalities: Thermotherapy Methods of Heat Transfer: –Conduction Heating through direct contact –Convection Heating through indirect contact (air or liquid) –Conversion Heating through other forms of energy (ultrasound, electrical) –Radiation Transfer of heat through space from one object to another. (infrared, UV, heat lamps)

24. Modalities: Thermotherapy Physiological Effect of Heat –The body’s response depends on the type of heat energy applied, duration, intensity, and the type of tissue applied to. –For a physiological effect to occur the heat energy must be absorbed to cause an increase in metabolic activity. –Once the heat energy is absorbed, the heat will be spread to adjacent tissue.

25. Modalities: Thermotherapy To achieve a therapeutic effect from the heat the correct amount must be applied: –To little: no change occurs –To much: tissue damage

26. Modalities: Thermotherapy Physiological Effects: –Muscle Spasm:Decreases –Pain Perception:Decreases –Blood Flow:Increases –Metabolic Rate:Increases –Collagen Elasticity:Increases –Joint Stiffness:Decreases –Capillary Permeability:Increases –Edema:Increases

27. Modalities: Thermotherapy Superficial Heat Therapies: –Usually a safe modality as long as: The intensity is kept reasonable The application is not to long –Moist heat will penetrate deeper than dry heat –Cause vasodilatation that continues for up to 1 hour after its removal.

28. Modalities: Thermotherapy Special Considerations: –Never apply heat when there is a loss of sensation –Never apply heat on an Acute injury. –Never apply heat when there is a decrease in arterial circulation. –Never apply heat directly to the eyes. –Never apply heat directly to the genitals. –Never heat the abdomen during pregnancy. –Never apply heat to a body part that exhibits signs of acute inflammation (swelling, redness, heat).

29. Modalities: Thermotherapy Types of Thermotherapy –Moist Heat Moist Heat Packs (Hydrocollator Packs) Whirlpool Paraffin Bath –Deep Heat Shortwave/Microwave Diathermy Therapeutic Ultrasound

30. Modalities: Thermotherapy Types of Thermotherapy (2) –Electrotherapy Electrical Stimulating Units –Alternating Current (AC) –Direct Current (DC) Laser (Low Power) TENS (Transcutaneous Nerve Stimulation) –Additional Massage Acupressure/Acupuncture Traction Intermittent Compression Devices

31. Modalities: Thermotherapy Types of Thermotherapy: –Moist Heat: Most widely used form of thermotherapy Readily available A disadvantage of trying to control therapeutic effects because of the rapid dissipation of heat which makes maintaining a constant skin temperature difficult.

32. Modalities: Thermotherapy Types of Thermotherapy: –Moist Heat: Moist Heat Packs (Hydrocollator Packs) –Heats by conduction Equipment: –Packs contain a silicon gel in a cotton pack –Immersed in hot water (160-170) –Stays hot for 15-30 minutes –Toweling

33. Modalities: Thermotherapy Moist Heat: Hydrocollator Packs (2) Indications: –General relaxation of the body part –Reduction of the Pain-Spasm-Pain Cycle Application: –Athlete should be in a comfortable position –Remove from the water and the water to drain off –Cover the pack with layers of toweling –Treatment time: 15-30 minutes –As pack cools: remove the toweling layers to continue heating

34. Modalities: Thermotherapy Moist Heat: Hydrocollator Packs (3) –Special Considerations: Athlete should not lay on the packs Make sure the athlete is in a comfortable position If athlete feels like it is burning the skin: add more toweling.