Chapter 15: Therapeutic Modalities

• Therapeutic modalities can be an effective adjunct to various techniques of therapeutic exercise

• A variety of modalities can be utilized by athletic trainers including cryotherapy,electrical stimulation, ultrasound, massage, traction, diathermy, lasers and magnets

Legal Concerns• Modalities must be used w/ great care and should not involve

indiscriminate use• Modality usage varies greatly state to state

– ATC’s must follow guidelines established by their individual state

• ATC’s must have knowledge concerning function, indication and contraindications for each modality

• Selection of a modality should be based on an accurate evaluation

• Decisions regarding use of a particular modality should be made according to the desired target tissue and specific results

How are Modalities Related?• Electromagnetic energy modalities

– Electrical stimulation, shortwave and microwave diathermy, infrared modalities, ultraviolet therapy

• Acoustic energy modalities– Ultrasound

• Characteristics of Electromagnetic Modalities– Transmitted w/out medium for support– Travel at 300 million meters/second in a vacuum– Energy forms travel in a straight line– Can be reflected, refracted, absorbed or transmitted– Operate at specific wavelengths and frequencies

Transmission of Thermal Energy

• Conduction– Heat is transferred from a warmer object to a

cooler one– Dependent on temperature and exposure time– Temperatures of 116.6o F will cause tissue

damage and temperatures of 113o F should not be in contact w/ the skin longer than 30 minutes

– Examples include moist hot packs, paraffin, ice packs and cold packs

• Convection– Transfer of heat through movement of fluids or gases– Temperature, speed of movement, and conductivity of part impact

heating– Whirlpools

• Radiation– Heating is transferred from one object through space to another

object– Shortwave diathermy, infrared heating and ultraviolet therapy

• Conversion– Generation of heat from another object (sound, electricity or

chemical agents)

Cryotherapy• Used in first aid treatment of trauma to the

musculoskeletal system• When applied intermittently w/ compression, rest

and elevation it reduces many adverse conditions related to inflammation and the reactive phase of an acute injury

• RICE (rest, ice compression, elevation) may be used for the initial days of and injury and lasting up to 2 weeks after injury

• Physical Principles– Type of electromagnetic energy (infrared radiation)– Relies on conduction -- degree of cooling depends on the

medium, length of exposure and conductivity• At a temperature of 38.3oF, muscle temperature can be reduced as deep

as 4cm

– Tissue w/ a high water content is an excellent conductor– Most common means of cold therapy are ice packs and ice

immersion• Wet ice is a more effective coolant due to the energy required to melt

ice

• Physiological Principles– Vasoconstriction

• Reflex action of smooth muscle due to sympathetic nervous system and adrenal medulla

• Also caused by cooled blood circulating to anterior hypothalamus

– Increase in blood viscosity and decrease in vasodilator metabolites

– Decreases extent of hypoxic injury to cells-- • Decreases cell metabolic rate and the need for oxygen through

circulation, resulting in less tissue damage

– Decreased metabolic rate and vasoconstriction decreases swelling associated w/ inflammatory response

– Decreases muscle spasm• Result of decreased metabolism & waste products that would act as

irritants to the muscle

• Decrease activity in gamma motor neurons, GTO and muscle spindle activity

• Muscle becomes more amenable to stretch as a result of decreased GTO and muscle spindle activity

– Decreases free nerve ending and peripheral nerve excitability• Analgesia raises nerve threshold

– Cold is more penetrating than heat – Ability to decrease muscle fatigue and increase and maintain

muscular contraction• Attributed to the decrease of local metabolic rates and tissue temperature

• Special Considerations– Cooling for an hour at 15.8o - 30.2o F produces redness

and edema that lasts for 24 hours post exposure

– Immersion at 41oF increases limb fluid volume by 15%

– Exposure for 90 minutes at 57.2o -60.8o F can delay resolution of swelling up to one week

– Some individuals are allergic to cold and react w/ hives and joint pain

– Icing through a towel or bandage limits the reduction in temperature -- could limit effectiveness of treatment

– Special medical conditions• Raynaud’s phenomenon

• Paroxysmal cold hemoglobinuaria

– Application of ice (very rare) can cause nerve palsy

• Motor nerves close to skin overexposed to cold (peronial nerve at head of fibula)

Cryotherapy Techniques• Ice Massage

– Equipment• Foam cup with frozen water - creating a cylinder of ice (towel will be

required to absorb water)– Indications

• Used over small muscle areas (tendons, belly of muscle, bursa, trigger points)

– Application• Ice is rubbed over skin in overlapping circles (10-15 cm diameters) for 5-

10 minutes• Athlete should experience sensations of cold, burning, aching, &

numbness --when analgesia is reached athlete can engage in rehab activities

– Special considerations• Keep in mind comfort of the athlete during treatment

• Cold or Ice Water Immersion– Equipment

• Variety of basins or containers can be used, small whirlpool• Temperature should be 50-60 degrees F

– Indications• Circumferential cooling a body part

– Application• Athlete immerse body part in water and goes through four stages of cold

response• Treatment may last 10-15 minutes• Once numb body part can be removed from immersion and ROM exercise

can be performed• As pain returns re-immersion should take place• Cycle can be repeated 3 times

• Cold or Ice Water Immersion (continued)– Special Considerations

• Cold treatment makes collagen brittle -- must be cautious with return to activity following icing

• Be aware of allergic reactions and overcooling

• Ice Packs (Bags)– Equipment

• Wet ice (flaked ice in wet towel)• Crushed or chipped ice in self sealing bag

– Not as efficient, but less messy– Useful for approximately 15-20 minutes– Towel should be placed between skin and pack

• Chemical Cold packs– Gel pack– Liquid pack

– Indications• Athlete experiences four stages of cooling and then proceeds with ROM exercises

– Special Considerations• Avoid excessive cold exposure; w/ any indication of allergy or abnormal pain, treatment

should be stopped

• Vasocoolant Sprays– Equipment

• Fluori-methane, non-flammable substance that is released in fine spray from pressurized canister

– Indications• Reduces muscle spasm, increases ROM, effective on trigger point

– Application• For spasm and ROM

– Hold can 12-18 inches from skin, treat entire length of muscle - covering an area 4 inches/second

– Apply spray 2-3 times, while gradually applying a stretch

• Vasocoolant Spray (continued)– Application

• For trigger points– Locate trigger point– Position athlete in relaxed position; place muscle on stretch;

apply spray in specific region and over the length of the muscle

– Apply passive stretch while spraying– After first session, heat area and then repeat if necessary– When stretch is complete, have athlete move limb

throughout ROM; but do not overload

• Cryokinetics– Technique that combines cryotherapy with

exercise

– Goal is to numb region and work towards completion of rehab program (ROM….etc)

– Treat area with ice pack, massage or immersion

– When analgesia is experienced, exercises should be performed (window will last 4-5 minutes)

– As pain returns, process may be repeated

Thermotherapy

• Physiological Effects of Heat– Dependent on type of heat energy applied, intensity

of energy, duration of exposure and tissue response– Heat must be absorbed to increase molecular activity– Desired effects

• Increase collagen extensibility; decreasing joint stiffness; reducing pain; relieving muscle spasm; reduction of edema and swelling; increasing blood flow

– Extensibility of collagen• Increases viscous flow of collagen resulting in relaxation of tension

– Pain relief• Activates gate control mechanism and secretion of endorphins to

block pain and free nerve endings

– Assistance w/ inflammation• Raises tissue temperature; increases metabolism resulting in

reduction of oxygen tension, lowering pH, increasing capillary permeability and releasing bradykinins and histamine resulting in vasodilation

• Parasympathetic impulses stimulated by heat are also believed to be a reason for vasodilation

• Superficial Heat– Form of electromagnetic energy (infrared

region of spectrum)– Increases subcutaneous temperature, indirectly

spreading to deeper tissue– Muscle temperature increases through reflexive

effect of circulation through conduction– Moist heat versus dry heat

• Special Consideration w/ Superficial Heat– Important contraindications

• Never apply heat when there is loss of sensation• Never apply heat immediately after injury• Never apply heat when there is decreased arterial circulation• Never apply heat directly to eyes or the genitals• Never heat the abdomen during pregnancy• Never apply heat to a body part that exhibits signs of acute inflammation

– Moist Heat Therapies• Difficult to control therapeutic effects primarily as a result of rapid

dissipation of heat which makes it difficult to maintain a constant temperature• Superficial tissue is a poor thermal conductor - temperature rises quickly on

the surface compared w/ underlying tissue (deep tissue experiences little rise in temperature)

• Moist Heat Packs– Equipment

• Silicate gel pads submersed in 160-170o F water

• Maintains heat for 20-30 minutes; must use 6 layers of terry cloth to protect skin

– Indications• Used for general muscle relaxation and reduction of pain-spasm-ischemia-

hypoxia-pain cycle

• Limitation - unable to heat deeper tissues effectively

– Application• Pack removed from water; covered w/ 6 layers of toweling which are removed as

cooling occurs; area treated for 15-20 minutes

• Athlete must be comfortable and should not lay on pack

• Whirlpool Bath– Equipment

• Varying sizes used to treat a variety of body parts• Tank w/ turbine that regulates flow • Agitation (amount of movement) is controlled by air emitted

– Indications• Combination of massage and water immersion• Provides conduction and convection • Swelling, muscle spasm and pain

– Application• Temperature is set according to treatment goals• Athlete should be set up to be reached by agitator (8-12” from agitator)

– Do not place directly on injured site

• Maximum treatment time for acute injuries should not exceed 20 minutes

• Special Considerations – Must be careful with

full-body immersion– Proper maintenance is

necessary to avoid infection

– Safety is a major concern

• Electrical outlets• Athlete should not turn

whirlpool on or off

• Paraffin Bath– Equipment

• A paraffin wax and mineral oil combination, heated to 126-130o F, plastic bags, paper towels and towels

– Indications• Useful in treating chronic injuries

• Effective for angular areas of body such as hands, wrists, elbows, ankles and feet

– Application• Body part is cleaned and dried

• Dip and wrap technique– Hand dipped 6-12 times, wrapped in a plastic bag and then draped w/ a towel to maintain heat

for 30 minutes

• Soak technique– Body part remains in wax 20-30 minutes w/out moving it

• Contrast Bath– Equipment

• Requires use of hot and cold tubs/whirlpools

– Indications• Used when changing treatment modality from cold to heat -- allows for

transitional period when introducing mild tissue temperature increase

• Minimal temperature changes occur superficially

• Does not produce pumping action through vasomechanics

– Application• Treatment ratio used (move from primarily cold to heat)

• Water temperature should be kept constant and athlete should be comfortable

• Fluidotherapy– Equipment

• Unit which contains cellulose particles through which warm air is circulated• Allows for high heating (higher than water and paraffin)

– Indications• Used to treat distal extremities in effort to decrease pain, increase ROM and

decrease swelling and spasm

– Application• Temperature ranges from 100-113o F• Particle agitation should be controlled for comfort• Athlete should be comfortable• Treatment time = 15-20 minutes• Exercise can be performed while in cabinet

Ultrasound

• Modality which stimulates repair of soft tissue and pain relief

• Form of acoustic energy used for deep tissue heating– Operates at inaudible frequency– Sound scatters and is absorbed as it penetrates

tissues -- losing energy = attenuation– Impedance and penetration are determined by

properties of media (densities)

• Equipment– High frequency generator which provides electrical current through a

coaxial cable to a transducer applicator• Through piezoelectric effect electrical current is transformed into acoustic

energy through contraction and expansion of piezoelectric crystals

– Frequency range between .75 and 3.0 MHz• 1 MHz ultrasound allows for deeper penetration while 3 MHz is absorbed

more superficially

– Area of transducer that produces sound is the effective radiating area• Produces a beam of acoustic energy - collimated cylindrical beam with non-

uniform distribution• Variability in the beam (beam non-uniformity ratio - BNR) =lower BNR =

more uniform energy output

– Intensity is determined by amount of energy delivered to the sound head (W/cm2)

– Can be delivered as either pulsed or continuous ultrasound

• Indications– Produces thermal and non-thermal effects

• Generally used for tissue heating (must increase tissue temp between 104o and 113oF

• Non-thermal effects include microstreaming and cavitation which impacts tissue permeability and fluid movement

– For solely non-thermal effects, intensity must remain below .2 W/cm2

– Acute conditions require more treatments over a shorter period and chronic conditions require fewer treatments over a longer period

• Application– Direct skin application

• Requires a coupling medium to provide airtight contact w/ skin and a low friction surface

– Underwater application• Used for irregularly shaped structures

• Body part is submerged in water, ultrasound head is placed 1” from surface

• Water serves as coupling medium, air bubbles should be continually swept away

• Sound head should be moved in circular or longitudinal pattern

• Should be performed in non-metal container to avoid reflection

– Bladder technique• Used when body part can not be immersed in water• Balloon filled w/ gel or water to allow for transmission --

coated with gel to enhance contact surface

– Moving the transducer• Leads to more even distribution of energy, reducing likelihood

of hot spots• Should be moved at a rate of 4cm/second• Must maintain contact of transducer with surface of skin• Circular or stroking patterns should be used• Should not treat an area larger than 3 times the ERA

– Dosage and Time• Varies according to depth of tissue to be treated and the state of injury• Duration tends to last 5-10 minutes• Intensity varies

– Low 0.1-0.3 W/cm2

– Medium 0.4 - 1.5 W/cm2

– High 1.5 - 3.0 W/cm2

– Special Considerations• While it is a relatively safe modality, precautions still must be taken• Be careful with anesthetized areas, reduced circulation• Avoid high fluid regions of the body, acute injuries, and epiphyseal

areas of children

Ultrasound in Combination w/ Other Modalities

• Ultrasound can be used w/ a variety of modalities to accomplish a series of treatment goals– Use of hot packs with ultrasound may have an additive

effect on muscle temperature– Cold packs, while often used in conjunction with

ultrasound, may interfere with heating and is not recommended

– With electrical stimulation, it is often useful for trigger point treatment (blood flow, muscle contraction and pain modulation)

Phonophoresis• Method of driving molecules through the skin using mechanical

vibration– Process which moves medication to injured tissues– Primarily used to drive hydrocortisone and anesthetics into the

tissue– Used on trigger points, tendinitis and bursitis– Effectiveness of treatments is still being explored– Generally involves the use of a 10% hydrocortisone ointment,

which rubbed into the area; followed by application of coupling medium and ultrasound treatment

– Chem pads, impregnated with medication is also being explored

Electrotherapy• Physical Principles

– Electricity displays magnetic, chemical, mechanical, and thermal effects on tissue

• Volume of current (ampere)• Rate of flow of 1 amp = 1 coulomb • Resistance = ohms• Force that current moves along = voltage

– Electricity is applied to nerve tissue at certain intensities and duration to reach tissue excitability thresholds resulting in membrane depolarization

• Target sensory, motor, and pain nerve fibers in an effort to produce specific physiological effects

• Electrical Stimulating Units– Three types of units

• TENS - transcutaneous electrical nerve stimulators

• NMES/EMS - neuromuscular electrical stimulators or electrical muscle stimulators• MENS/LIS - microcurrent electrical nerve stimulators or low-intensity stimulators

– Generate 3 types of current• Monophasic

– Direct current or galvanic current - flow in one direction only from (+) to (-) or vice versa

– Used to produce muscle contraction, pain modulation, ion movement (determined by specific parameters)

• Biphasic– Alternating current where direction of flow reverses during each cycle

– Useful in pain modulation and muscle contractions

• Polyphasic– Pulsed currents usually contain three or more pulses grouped together– Generally interrupted for short periods of time and repeat themselves at regular intervals– Used in interferential and so-called Russian currents

• Current Parameters– Waveforms

• Different generators have differing abilities relative to the production of various waveforms

• A graphical representation of shape, direction, amplitude and direction of current

• Can be sine, square or triangular in shape

– Modulation• Ability of stim unit to change or alter the magnitude and duration of a

waveform• May be continuous, interrupted or surged

– Intensity• Voltage output of stimulating unit• High and low voltage units

– Duration(pulse width or pulse duration)• Refers to the length of time that current is flowing• Pre-set on most high voltage DC units

– Frequency• Number of waveform cycles per second

– Polarity• Direction of flow -- either positive or negative

– Electrode Set-up• Use of moist electrodes fixed to the skin• Can include monopolar (active and dispersive pad) or bipolar set-up• Current generally felt under and between both pads unless monopolar set-up is used --then

current is felt under the smaller active pad

• Indications– Pain Modulation

• Gate Control– Intensity should produce tingling w/out a muscular contraction; high frequency and

pulse duration

• Descending Pain Control– High current intensity approaching noxious; pulse duration of 10 msec; frequency

should be > 80 pps

• Opiate Pain Control Theory– Point stimulator should be used with current intensity set as tolerable; pulse

duration should be at maximum; w/ a frequency of 1-5 pps

– Muscle Contraction• Quality of contraction will change according to current parameters

– Increased frequency results in increased tension (50pps results in tetany)– Increased intensity spreads current over larger area– Increased current duration causes more motor unit activation

• Muscle pump– Used to stimulate circulation– High-volt, DC stimulator; 20-40 pps; surge mode (on/off 5 seconds each; elevation

w/ active contraction– Treatment time 20-30 minutes

• Muscle strengthening– High frequency AC current; 50-60 pps; 10:50 seconds on/off ratio; 10 repetitions 3x

per week; perform with active contractions

• Retardation of atrophy– High frequency AC current 30-60 pps; w/ voluntary muscle contraction encouraged;

15-20 minutes

• Muscle re-education– Level of comfortable contraction -- 30-50 pps; w/ either interrupted or surge current– Athlete should attempt to contract muscle along w/ stim– Treatment time 15-20 minutes and repeated multiple times over the course of a week

• Ionotophoresis– Chemical ions are transported through intact skin using electrical

current -- used to treat skin infections or to produce a counterirritant effect

• Requires use of low voltage direct current on continuous mode w/ a long pulse duration (allows for migration of ions)

• Polarity of pads is set relative to the medication/solution being used

• Interferential Currents– Makes use of 2 separate generators, emitting current at slightly

different frequencies– Quad polar pad placement is used creating interference pattern

• Creates a broader area of stimulation

• Low Intensity Stimulators– Microcurrent electrical nerve stimulator– Operates at low frequencies and intensities (sub-sensory)– Used to stimulate healing of soft tissue and bone

• Biofeedback– Use electronic/electrochemical instruments to measure, process

and feed back reinforcing information through visual and auditory signs

– Provides athlete with information regarding performance– Measures electrical activity associated w/ muscle contractions

and provides feedback• Used for muscle re-education, to decrease muscle guarding or for pain

reduction

Massage• Systematic manipulation of soft tissue• Therapeutic Effects

– Mechanical Responses• Occur as a direct result of pressures and movements

• Encourages venous flow and mild stretching of superficial tissue

– Physiological Responses• Increases circulation aiding circulation, removal of metabolites,

overcoming venostasis

• Reflex effect - response to nerve impulses initiated through superficial contact

– Impacts body relaxation, stimulation, and increased circulation

• Relaxation can be induced by slow superficial stroking of skin• Stimulation achieved by quick brisk strokes, causing

contraction of tissue– Primarily psychological impacts

• Increased circulation through reflexive and mechanical stimuli– Capillary dilation, stimulation of cell metabolism, decreasing toxins and

increase lymphatic and venous circulation

– Psychological Responses• Tactile system is one of the most sensitive systems of the body• Because the laying on of hands is used w/ massage it can be an

important means of creating a bond of confidence between the athlete and the ATC

Massage Strokes

• Effleurage– Stroking divided into

light and deep

– Can be used as a sedative or to move fluids

– Multiple stroking variations exist

– Pressure variations

Stroking Variations

• Petrissage– Kneading

– Involves picking up skin between thumb and forefinger, rolling and twisting in opposite directions

– Used for deep tissue work

• Friction– Used around joints and in areas where tissue is thin

– Areas w/ underlying scarring, adhesions, spasms and fascia

– Goal is to stretch underlying tissue, develop friction and increase circulation

– Tapotement• Cupping

– Produces invigorating and stimulating sensation

– Series of percussion movements rapidly duplicated at a constant tempo

• Hacking– Used to treat heavy muscle areas, similar to cupping

• Pincing– Lifting of small amounts of tissue between thumb and first finger in quick,

gentle pinching movements

– Vibration• Rapid movement that produces quivering or trembling effect to tissue

• Used to relax and soothe

• Guidelines for an Effective Massage– Make the athlete comfortable

• Positioning, padding, temperature, privacy

– Develop confident, gentle approach to massage• Good body positioning (clinician and athlete) an develop good

technique

– Stroke towards heart to enhance lymphatic and venous drainage

– Know when to avoid massage• Acute conditions, skin conditions, areas where clots can become

dislodged

• Sports Massage– Usually confined to a specific area - rarely given to full body– Full body massage is time consuming, generally not feasible– Five minute treatment can be effective– Massage lubricants

• Enables hands to slide and move easily over body, reducing friction• Rubbing dry area can irritate skin• Mediums include powder, lotion, oil or liniments

– Positioning of Athlete• Area must be easily accessible and must be relaxed

– Exhibit Confidence

• Deep Transverse Friction Massage– Transverse or Cyriax method used to treat muscle,

tendon, ligaments and joint capsules– Goal is mobilization of soft tissue– Generally precedes activity– Movement is across the grain of the affected tissue– Avoid treatment with acute injuries– Treatment will produce numbing effect allowing for

exercise mobilization

• Acupressure Massage– Based on Chinese art of acupuncture– Physiological explanation and effectiveness may be based on pain

modulation mechanisms– ATC can utilize acupuncture points in treatment– Locate through measurement of electrical impedance or palpation– Small circular motions are used to treat points (pressure to tolerance

of athlete = generally more pressure = more effective treatment)– Treatment time ranges from 1-5 minutes– Can treat one or more points, working distal to proximal– Will produce dulling or numbing sensation w/ results lasting from

minutes to hours

Traction

• Drawing tension applied to a body segment

• Physiological Effects– Produces separation of vertebral bodies

impacting ligaments, capsules, paraspinal muscles; increases articular facet separation, and relief of nerve root pain; decreases central pressure of vertebral disks; increases proprioceptive changes; relief of joint compression due to normal posture

• Indications– Spinal nerve root impingement– Decrease muscle guarding, treat muscle strain– Treat sprain of spinal ligaments– Relax discomfort from normal spinal compression

• Application– Manual and traction machines can be used– Manual

• Adaptable and allows for great flexibility

• Changes in force, direction, duration and patient positioning can be made instantaneously

– Mechanical Traction• Can be used to apply cervical or lumbar traction

– Positional Traction• Used on trial and error basis to determine maximum position of comfort

to accomplish specific goal

– Wall-Mounted Traction• Cervical traction can be accomplished w/ this unit• Involves use of plates, sand bags or water bags for weight• Relatively inexpensive and effective

– Inverted Traction• Utilizes special equipment or simply inverting ones self• Weight of trunk lengthens spine, providing a stretch