1. Therapeutic Modalities

2. Basic Modalities
Ice
Heat
Whirlpool
Paraffin Bath

3. Cryotherapy: Ice
Typically used in acute situations to limit inflammatory response
Pain reduced by:
Decreasing nerve conduction velocity
Decreasing muscle spindle activity, which decreases muscle spasm and breaks pain/spasm cycle
Most treatments last ~15-20 minutes

4. Cryotherapy Principles
Indications
Acute/chronic pain
Acute inflammation
Muscle spasm
Post-operative pain and swelling
Contraindications
Cold allergy/sensitivity
Impaired circulation
Impaired sensation
Open wounds
Cardiac or respiratory disorders

5. Cryotherapy Applications
Ice massage
Ice frozen in cup and massaged onto small area of skin
Most common application to muscle injuries, spasms
Fast treatment time (5-7 minutes)
Ice packs/bags
Easily combined with elevation and compression
Molds easily
Ice immersion/cold whirlpool
“Ice bucket” vs. whirlpool – temps kept between 50-60˚F
Acute Injury???

6. Cryotherapy Applications
Commercial gel/chemical packs
Gel packs kept in freezer, chemical packs “activated” by squeezing
Must be careful about leaks and potential for frostbite
Intermittent compression units
Boot/sleeve with cold water circulated through it to minimize swelling, typically also elevate affected area
Vapo-coolant sprays
Flourimethane is most common, spray and stretch application for spasms/trigger points

7. Ice Massage Appropriate for delivering cold tx to small areas
Most effective for
Muscle spasm
Contusion
Other well-localized areas
Duration of tx
5-7 minutes or until ice runs out
If the purpose is analgesic, then stop when numb

8. Ice Immersion Temp. 50° - 60° F Time 10-20min Indications
Acute Injury or Inflam.
Acute or Chronic Pain
Post Surgical Pain
Decrease Muscle Soreness
Contraindications
Same as general Contraindications
Acute injury where gravity is contraindicated

9. Cold Whirlpools Duration of Tx Indications Contraindications
15-20 minutes
Temp 50° - 60 ° F
Indications
Decrased ROM
Cryokinetics
Subacute to chronic inflammation
Peripheral nerve injuries (avoid extremes)
Contraindications
Acute conditions where water turbulence would further irritate area
Gravity
Postsutural
Skin Conditions
All other contraindications

10. Thermotherapy: Heat
Typically used after inflammatory process has subsided to increase blood flow and promote healing
If used on acute injury, will worsen swelling
Vasodilation response brings oxygen and nutrients and rids waste products and debris
Increases extensibility of connective tissue – pre-stretching/rehab applications
Most treatments last ~15-20 minutes

11. Thermotherapy Principles
Indications
Pain
Subacute or chronic inflammation
Muscle spasm
Decreased ROM
Joint contracture
Contraindications
Acute inflammation
Impaired circulation
Impaired sensation
Impaired thermal regulation
Open wound considerations

12. Thermotherapy Applications
Warm whirlpool
Use of “jets” adds massage effect
Temps kept between ˚F
Moist heat pack
Hydrocollator (silicate/sand filled) packs kept at ˚F
Wrapped in covers/toweling and applied to body
Effects are superficial
Paraffin bath
Best for providing heat to contoured areas (hands, feet)
Wax and oil heated to liquid state ( ˚F)
Immersion method vs. wrap/pack/glove method

13. Moist Heat Packs Canvas pouch with silica gel or sand
Pack is kept in a water-filled heating unit (hydroculator) maintained between 160ºF -170ºF
Treatment time: minutes
Superficial heat to 1cm

14. Paraffin Bath
A mixture of wax an mineral oil in a ratio of 7 parts wax to 1 part oil
Temperature of 118º F to 126 ºF
Paraffin can provide approx 6x the amount of heat as water due to low specific heat
Used to treat small or irregular shaped areas

15. Paraffin Bath Precautions Contraindications Indications
Sensation is different from specific heat and thermal capacity - may cause burns
Avoid using with athlete who are required to catch or throw a ball - skin becomes slippery
Contraindications
Open wounds
Skin infections
Sensory loss
Peripheral vascular disease
Indications
Subacute and chronic inflammation
limitation on ROM after immobilization

16. Warm Whirlpool Contraindications Tx temperature is between 105º-110º F
Acute conditions
Fever
Patients requiring postural support
Skin conditions
Open wounds
Tx temperature is between 105º-110º F
Tx times between min once or twice daily
Indications
Decreased ROM
Subacute or chronic inflammatory conditions
Peripheral vascular disease
Peripheral nerve injuries
Irregular shaped areas

17. Contrast Bath Set Up Two tubs placed as close together as possible
Fill one tub in the range from 105 F- 110 F and the other 50 F - 60 F
Position patient on chair or bench between two tubs
Heat Tx given 1st
Contrast bath minutes at 1:2 or 3:5 minute hot:cold intervals

18. Contrast Bath Precautions Contraindications Indications
Same as with all whirlpools
Indications
Ecchymosis removal
Edema removal
Subacute or Chronic Inflammation
Impaired circulation
Pain Reduction
Contraindications
Acute injuries
Hypersensitivity to cold
Contraindication relative to whirlpool use
Contraindications relative to cold application
Contraindications relative to heat application

19. Advanced Modalities
Ultra Sound
E-Stim
Tens
LLLT

20. Ultrasound Ultrasound treatment is used to:
Relieve pain and inflammation
Speed healing
Reduce muscle spasms and
Increase ROM
Sound waves vibrate tissues deep inside the injured area
This creates heat that draws more blood into the tissues
Ultrasound is the most commonly used deep heating modality today
Penetration is between 3-5 cm.
Frequency is between .8 and 3 MHz (audible f= 15-20,000 Hz)

21. E-Stim Electrical-muscle stimulation Electrotherapy: 400 B.C.
Torpedo fish (produce electric shocks) used to treat a variety of injuries/illnesses
Electrical stimulation for pain control was used in ancient Greece: 63 A.D.
1988 First Portable Marketed Product
Reported Uses:
Facilitate faster recovery of muscle and soft tissue damage, reduce pain and swelling, increase blood circulation and range of motion, and help control muscle spasms

22. TENS Transcutaneous Electrical Nerve Stimulation
1974 First Modern TENS
Designed initially to treat chronic pain
Now used to treat many different types of pain
Sensory only
How does it work?
By selectively stimulating certain 'non-pain' nerve fibres to send signals to the brain that block other nerve signals carrying pain messages

23. LLLT Low Level Laser Therapy Used for: Indications: Contraindications:
Wound healing
Soft-tissue healing
Pain Relief
Indications:
Acceleration of collagen synthesis
Increased vascularization
Reduce pain & inflammation
Contraindications:
Cancerous tissue, over the eyes, pregnancy

24. Iontophoresis & Phonophoresis
Application of medication/drug with modality
Example: Corticosteroids
Iontophoresis:
Electrical Stimulation
Medicated Patches
Phonophoresis:
Ultrasound
Drug is in gel form

25. Traction Types: Indications: Contraindications: Manual Wall Machine
Inverted
Indications:
Decrease muscle spasm
Decrease nerve impingement
Contraindications:
Fracture

26. Massage ART ® Trigger Point Release Soft Tissue Effleurage
Active Release Technique
Deep tissue release using full range of motion
Trigger Point Release
Targeted pressure to trigger point
Soft Tissue Effleurage
Sensory message to decrease pain w/ acute injury or to increase lymphatic drainage
Grastons Technique ®
Massage w/ special metal tools