1. Introduction to Therapeutic Modalities

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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.

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

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

12. Cryotherapy/Cold Modalities
Brrrrrrrrr!

13. 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

14. 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

15. 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

16. 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

17. 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®

18. 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.

19. Ice Packs
Application
Be aware of patients modesty and use toweling to protect them
Use compression wrap to secure bag to the area – mm Hg
Leave pack on minutes depending on treatment area and goals

20. 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

21. 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

22. 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

23. 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 minutes
Use toweling to dry off area after treatment
If treating acute injury be sure to compress and elevate after treatment

24. 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

25. 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 minutes
Check for frostbite and general comfort every 4-5 minutes.

26. 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

27. 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

28. 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

29. 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.

30. 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.

31. 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: $
Difficult to always target specific area of injury
Gravity Dependant Position