1. Chapter 15: Therapeutic Modalities

2. Therapeutic Modalities
In any rehabilitation program, modalities should be used primarily as adjuncts to therapeutic exercise and certainly not at the exclusion of range-of-motion or strengthening exercise.

3. Transmission of Thermal Energy
Conduction Heating through direct contact with a hot medium (e.g., hot pack).
Convection Heating indirectly through another medium such as air or liquid (e.g., whirlpool)
Radiation Transfer of heat through space from one object to another (e.g., ultraviolet therapy)
Conversion Heating through other forms of energy (e.g., ultrasound)

4. Cryotherapy
Application of cold; the major therapeutic value of cold is its ability to produce anesthesia, allowing pain-free exercise. Cold as a therapeutic agent is a type of electromagnetic energy classified as infrared radiation. Wet ice is a more effective coolant because of the extent of internal energy needed to melt the ice.

5. Hunting Response
Causes a slight temperature increase during cooling. The extent of cooling depends on the thickness of the subcutaneous fat layer.

6. Skin Response to Cold Stage 1 Response Estimated Time after Initiation
Cold sensation
Estimated Time after Initiation
0 to 3 minutes

7. Skin Response to Cold Stage 2 Response Estimated Time after Initiation
Mild burning, aching
Estimated Time after Initiation
2 to 7 minutes

8. Skin Response to Cold Stage 3 Response Estimated Time after Initiation
Relative cutaneous anesthesia
Estimated Time after Initiation
5 to 12 minutes

9. Physiological Variables of Crotherapy
Variable Response to Therapy
Muscle spasm Decreases
Pain perception Decreases
Blood flow Decreases
Metabolic rate Decreases
Collagen elasticity Decreases
Joint stiffness Increases
Capillary permeability Decrease
Edema Controversial

10. Acute Problems to Gravity Acute Problems to Turbulence
Acute Conditions
Acute Inflammation
Acute Injury
Acute Pain
Acute Problems to Gravity
Acute Problems to Turbulence
Anesthetized Skin
Cardiac Involvement
Chronic Inflammation
Chronic Muscle Spasm
Chronic Pain
Circulatory Insufficiencies/Impairment
Cold Allergy
Cold Hypersensitivity
Contusions
Decreased Range of Morion
Distal Body Parts
Fever
Hematoma Resolution
Infection
Muscle Strain
Peripheral Nerve Injuries
Peripheral Vascular Disease
Poor Thermal Regulation
Post-Surgical Edema
Post-Surgical Pain
Pressure Contraindications
Reduction of Joint Contractures
Reduction of Subacute Pain
Requiring Postural Support
Respiratory Involvement
Sensory Loss
Skin Conditions/Infections
Small Areas
Subacute Inflammation
Subacute Injury
Subacute Muscle Spasm
Suspected Fractures
Uncovered Open Wounds
Ice Massage I C
15 to 30 minutes
Cryotherapeutic
Cold or Ice Water Immersion
50°F to 60°F
Hydrotherapy
Ice Packs (Bags)
Cold Whirlpool
Moist Heat Packs (Hot Packs)
Thermotherapeutic
Hot Whirlpool
96°F to 104°F
Paraffin Bath
126°F to 130°F

11. Cryotherapeutic Methods
Ice Massage
Duration: 10 to 15 minutes
Indications:
small muscle areas
subacute injury
subacute inflammation
muscle strain
Contusions
acute pain
chronic pain
Contraindications
pressure contraindications
suspected fractures
uncovered open wounds
circulatory insufficiency
cold allergy
cold hypersensitivity
anesthstized skin

12. Cryotherapeutic Methods
Cold or Ice Water Immersion
Duration: 10 to 20 minutes
Temp: 50°F to 60ºF
Indications:
Distal body parts
Acute injury
Acute inflammation
Acute pain
Chronic pain post-surgical pain
Post-surgical edema
Contraindications
Cardiac involvement
Respiratory involvement
Uncovered open wounds
Circulatory insufficiency
Cold allergy
Cold hypersensitivity
Anesthetized skin

13. Cryotherapeutic Methods
Ice Packs (Bags)
Duration: 15 to 30 minutes
Indications:
Acute injury
Acute inflammation
Acute pain
Chronic pain
Post-surgical pain
Post-surgical edema
Contraindications
Cardiac involvement
Respiratory involvement
Uncovered open wounds
Circulatory insufficiency
Cold allergy
Cold hypersensitivity
Anesthetized skin

14. Cryotherapeutic Methods
Contraindications
Acute problems to turbulence
Acute problems to gravity
Requiring postural support
Skin conditions
Cardiac involvement
Respiratory involvement
Uncovered open wounds
Circulatory insufficiency
Cold allergy
Cold hypersensitivity
Anesthetized skin
Cold Whirlpool
Duration: 5 to 30 minutes
Temp: 50°F to 60°F
Indications:
Subacute inflammation
Chronic inflammation
Peripheral vascular disease
Peripheral nerve injuries
Distal body parts

15. Cryotherapeutic Methods
Cryokinetics
Combines cryotherapy with exercise

16. Thermotherapy
Application of heat; Heat has the capacity to increase the extensibility of collagen tissue.

17. Physiological Variables of Thermotherapy
Variable Response to Therapy
Muscle spasm Decreases
Pain perception Decreases
Blood flow Increase
Metabolic rate Increase
Collagen elasticity Increase
Joint stiffness Decrease
Capillary permeability Increase
Edema Increase

18. Comparing the Physiological Variables of Crotherapy and Thermotherapy
Response to Response to Variable Cryotherapy Thermotherapy
Muscle spasm Decreases Decreases
Pain perception Decreases Decreases
Blood flow Decreases Increases
Metabolic rate Decreases Increases
Collagen elasticity Decreases Increases
Joint stiffness Increases Decreased
Capillary permeability Decreased Increases
Edema Controversial Increases

19. Thermotherapy Special Considerations in the Use of Superficial Heat
Never apply heat when there is a loss of sensation
Never apply heat immediately after an injury
Never apply heat when there is decreased arterial circulation
Never apply heat directly to the eyes or genitals
Never heat the abdomen during pregnancy
Never apply heat to a body part that exhibits signs of acute inflammation

20. Thermotherapy Superficial tissue is a poor thermal conductor
temperature rises quickly on the skin surface as compared with the underlying tissues
There are limitations of superficial tissue
The deeper tissues, including the musculature, are not significantly heated because the heat transfer from the skin surface into deeper tissues is inhibited by the subcutaneous fat, which acts as a thermal insulator, and by the increased skin flow, which cools and carries away the heat externally applied.

21. Thermotherapeutic Methods
Moist Heat Packs (Hot Packs)
Duration: 20 to 30 minutes
Indications:
Subacute inflammation
Chronic inflammation
Reduction of subacute pain
Reduction of chronic pain
Subacute muscle spasm
Chronic spasm
Decreased range of motion
Hematoma resolution
Reduction of joint contractures
Infection
Contraindications
Acute conditions
Peripheral vascular disease
Impaired circulation
Poor thermal regulation

22. Thermotherapeutic Methods
Hot Whirlpool
Duration: 5 to 30 minutes
Temp: 96°F to 104°F
Indications:
Subacute inflammation
Chronic inflammation
Peripheral vascular disease
Peripheral nerve injuries
Distal body parts
Contraindications
Acute problems to turbulence
Acute problems to gravity
Fever
Requiring postural support
skin conditions

23. Thermotherapeutic Methods
Paraffin Bath
Duration: 15 to 30 minutes
Temp: 126°F to 130°F
Indications:
Subacute inflammation
Chronic inflammation
Limited range of motion after immobilization
Contraindications
Open wounds
Skin infection
Sensory loss
Peripheral vascular disease

24. Hydrotherapy Methods Contrast Bath Duration: 20 to 30 minutes
Temp: 50°F to 60°F:96°F to 104°F
Indications:
Ecchymosis removal
Edema removal
Subacute inflammation
Chronic inflammation
Impaired circulation
Contraindications
Acute injuries
Cold hypersensitivity
Whirlpool contraindications
Cold application contrindications
Hot application contrindications

25. Hydrotherapy Methods Acute problems to turbulence
Contraindications
Acute problems to turbulence
Acute problems to gravity
Requiring postural support
Skin conditions
Cardiac involvement
Respiratory involvement
Uncovered open wounds
Circulatory insufficiency
Cold allergy
Cold hypersensitivity
Anesthetized skin
Cold Whirlpool
Duration: 5 to 30 minutes
Temp: 50°F to 60°F
Indications:
Subacute inflammation
Chronic inflammation
Peripheral vascular disease
Peripheral nerve injuries
Distal body parts

26. Hydrotherapy Methods Hot Whirlpool Contraindications
Duration: 5 to 30 minutes
Temp: 96°F to 104°F
Indications:
Subacute inflammation
Chronic inflammation
Peripheral vascular disease
Peripheral nerve injuries
Distal body parts
Contraindications
Acute problems to turbulence
Acute problems to gravity
Fever
Requiring postural support
skin conditions

27. Acoustic Therapy: Ultrasound
Relies on molecular collision for transmission.
Ultrasound is a mechanical wave in which energy is transmitted by the vibrations of the molecules of the biological medium through which the wave is traveling.

28. Acoustic Therapy: Ultrasound
Ultrasound has both thermal and non-thermal effects.

29. Acoustic Therapy: Ultrasound
When used for thermal changes, non-thermal changes also occur.
For the majority of thermal effects to occur, the tissue temperature must be raised to a level of 104°F to 113°F for a minimum of five minutes.
Temperatures below this range will be ineffective.

30. Acoustic Therapy: Ultrasound
Non-thermal effects of ultrasound are cavitation and acoutsic microstreaming.

31. Acoustic Therapy: Ultrasound
Cavitation is the formation of gas-filled bubbles that expand and compress because of ultrasonically induced pressure changes in tissue fluids.
Cavitation results in an increased flow in the fluid around these vibrating bubbles.

32. Acoustic Therapy: Ultrasound
Microstreaming is the unidirectional movement of fluids along the boundaries of cell membranes resulting from the mechanical pressure wave in an ultrasonic field.
Microstreaming can alter cell membrane structure and function because of changes in cell membrane permeability to sodium and calcium ions important in the healing process.
As long as the cell membrane is not damaged, microstreaming can be of therapeutic value in accelerating the healing process.

33. Acoustic Therapy: Ultrasound
The non-thermal effects of therapeutic ultrasound in the treatment of injured tissues may be as important as the thermal effects and perhaps are even more important.
The non-thermal effects of cavitation and microstreaming can be maximized while the thermal effects are minimized by using an intensity of 0.1 to 0.2 W/cm² with continuous ultrasound or 1.0 W/cm² at a duty cycle of 20 percent (pulsed).

34. Acoustic Therapy: Ultrasound
Ultrasound energy generated at a frequency of 1 MHz is transmitted through more superficial tissues and absorbed primarily in the deeper tissues at depths of 3 to 5 cm.
A 1 MHz frequency is most useful in individuals with high percent body fat and whenever the desired effects are in the deeper structures.
At a frequency of 3 MHz the energy is absorbed in the more superficial tissues with the depth of penetration between 1 and 2 cm.

35. Acoustic Therapy: Ultrasound
1 MHz
Deeper Tissues
3 MHz
Superficial Tissues

36. Acoustic Therapy: Ultrasound
Frequency of Treatment
Acute injuries require more frequent treatments over a shorter period of time (pulsed duty cycle).
Chronic conditions require fewer treatments over a longer period of time (continuous duty cycle).
Should begin as soon as possible after the injury (at least within 48 hours).
Treatments should be limited to no more than 14 treatments then avoid ultra sound for two weeks.

37. Acoustic Therapy: Ultrasound
Phonophoresis
Uses ultrasound to drive ions

38. Acoustic Therapy: Ultrasound Indications
Acute and post acute conditions (non-thermal)
Soft tissue healing and repair
Scar tissue
Joint contracture
Chronic inflammation
Increased extensibility of collagen
Reduction of muscle spasm
Pain modulation
Increase blood flow
Soft tissue repair
Increase in protein synthesis
Tissue regeneration
Bone healing
Repair of non-union fractures
Inflammation of myositis ossificans
Plantar warts
Myofascial trigger points

39. Acoustic Therapy: Ultrasound Contraindications
Acute and post acute conditions (thermal)
Areas of decreased temperature sensation
Areas of decreased circulation
Vascular insufficiency
Thrombophlebitis
Eyes
Reproductive organs
Pelvis immediately following menses
Pregnancy
Pacemaker
Malignancy
Epiphyseal areas in young children
Total joint replacement
Infection

40. Electrotherapy: Electrical Stimulation
Electricity is a form of energy that displays magnetic, chemical, mechanical, and thermal effects on tissue.
It implies a flow of electrons between two points.

41. Electrotherapy: Electrical Stimulation
All therapeutic electrical generators are transcutaneous electrical stimulators.
The majority of these generators are used to stimulate peripheral nerves and are correctly called transcutaneous electrical nerve stimulators (TENS).
Occassionally the terms neuromuscular electrical stimulator (NMES) or electrical muscle stimulator (EMS) are used; however, these terms are only appropriate when the electrical current is being used to stimulate muscle directly, as would be the case with denervated muscle in which peripheral nerves are not functioning.

42. Electrotherapy: Electrical Stimulation
Direct Current (DC current)
Flows in one direction only from the positive pole to the negative pole.
Direct current may be used for pain modulation or muscle contraction or to produce ion movement.

43. Electrotherapy: Electrical Stimulation
Alternating Current (AC current)
The direction of current flow reverses itself once during each cycle.
Alternating current may be used for pain modulation or muscle contraction.

44. Electrotherapy: Electrical Stimulation
Pulsed Current
Pulsed currents usually contain three or more pulses grouped together.
These groups of pulses are interrupted for short periods of time and repeat themselves at regular interval.
Pulsed currents are used in interferential and so-called Russian currents (currents interfere with each other).

45. Electrotherapy: Electrical Stimulation
Duration
Duration: 10 to 30 minutes
Can be used with ice or heat

46. Electrotherapy: Electrical Stimulation
High Voltage or Pulsed Indications
Peripheral nerve injuries,
Delaying denervation
delaying disuse atrophy
Post-traumatic edema reduction
Increase local blood circulation
Joint contracture prevention
Maintenance of range of motion
Muscle strengthening
Muscle spasm reduction
Inhibitation of spasticity
Muscle re-education
Assist voluntary muscle function
Interferential Indications
Acute pain
Chronic pain
Muscle spasm

47. Electrotherapy: Electrical Stimulation
Contraindications
Demand-type pacemakers
Over pelvic or lumbar areas
During pregnancy
Pain of central or unknown origin
Areas of particular sensitivity
carotid sinus
laryngeal muscles
pharyngeal muscles
upper thorax
temproal region
cancerous lesions
sites of infection

48. Electrotherapy: Electrical Stimulation
Iontophoresis
Uses electrical current to drive ions

49. Massage Therapy
Sports massage causes mechanical, physiological, and psychological responses.

50. Massage Therapy Mechanical Response
Encourages venous and lymphatic drainage, mildly stretch superficial and scar tissue

51. Massage Therapy
Physiological Response
Reflex effects, relaxation, stimulation, and increased circulation

52. Massage Therapy
Psychological Response
The tactile system is one of the most sensitive systems in the human organism. Humans respond psychologically to being touched and is an important means for creating a bond of confidence between the athletic trainer and the athlete.

53. Massage Therapy Massage Strokes Effleurage Petrissage Tapotement
Vibration
Deep Friction

54. Massage Therapy Stroking; divided into light and deep methods.
Effleurage
Stroking; divided into light and deep methods.
Light stroking is designed primarily to be sedative.
It is also used in the early stages of injury treatment.
Deep stroking is therapeutic compression of soft tissue, which encourages venous and lymphatic drainage.

55. Massage Therapy
Petrissage
Kneading; a technique adaptable primarily to loosen heavy tissue areas such as the trapezius, latissimus dorsi, or the triceps.
Friction heat producing
Often used around joints and other areas where tissue is thin and is used on tissues that are especially unyielding such as scars, adhesions, muscle spasms, and fascia.

56. Massage Therapy
Tapotement
Percussion; produces an invigorating and stimulating sensation.

57. Massage Therapy
Vibration
Rapid shaking; rapid movement that produces a quivering or trembling effect.
It is used because of its ability to relax and soothe.
Although vibration can be done manually, the machine vibrator is usually the preferred modality.

58. Massage Therapy
Deep Friction
Often precedes activity, restoring mobility to a muscle.

59. Massage Therapy
Massage in sports is usually confined to a specific area and is seldom given to the full body.
The time required for giving an adequate and complete body massage is excessive in athletics.
It is not usually feasible to devote this much time to one athlete.
Five minutes is usually all that is required for massaging a given area.