Therapeutic Modalities

• What is a Modality?• What role do modalities play in injury

rehabilitation? • How do we use Therapeutic Modalities?• When should we Modalities?

-Specific Types -Background -examples of application

Foundations of Therapeutic Modalities

What are Therapeutic Modalities?

• mo·dal·i·ty /mōˈdalitē/– An intervention used to heal

someone – Agents such as light, heat, air, water,

manual, or electronic– All athletic trainers use therapeutic

modalities, some simple techniques other complex.

Role of Modalities in Injury Rehabilitation

• Management or reduction of pain associated with an injury

• Return of full non-restricted ROM to an injury body part

• Maintenance or improvement of strength throughout the full ROM

o Use of Therapeutic Modalities inexact science, no cookbook for treatment

Pain Management

• Control of pain is an essential aspect of caring for the injured patient

• Athletic trainer has several therapeutic agents with analgesic properties from which to choose– Acute Pain- pain of sudden onset – Chronic Pain- pain lasting for more

than 6 months

Categories of Therapeutic Modalities

• Infrared Modalities– Therapeutic Heat & Cold– Ultrasound– Shortwave and Microwave Diathermy

• Electrical Modalities– Electrical Stimulating Currents– Iontophoresis

• Mechanical Modalities– Therapeutic sports Massage– Intermittent compression Devices– Spinal Traction

• Others

Infrared Modalities• Thermotherapy- Heating techniques

used for therapeutic purposes – Used when a rise in tissue

temperature is the goal of treatment • Cryotherapy- The use of cold

– Used in the acute stages of the healing process immediately following injury when a loss of tissue temperature is the goal of therapy

Hot &Cold Modalities Cont’d

• Most effective use of infrared modalities should be to provide analgesia or reduce sensation of pain associated with injury – Gate control theory of pain

modulation

Cryotherapy• General agreement that cold should

be initial treatment for musculoskeletal injuries – Primary reason for using cold in acute

injury is to lower temperature in injured area thus reducing metabolic rate with a corresponding decrease in production of metabolites and metabolic heat (secondary hypoxic response) • More effective when combined with

compression

Cryotherapy

• Cryotherapy techniques include

– Ice massage– Cold packs– Ice packs – Cold whirlpool – Cold spray

– Contrast baths– Ice immersion– Cryo-cuff– Cryokinetics

Cryotherapy Techniques

• Application of cryotherapy produces a three- to four-stage sensation– Uncomfortable sensation of cold – Stinging– Burning or aching feeling– Numbness

• Caution should be exercised when applying intense cold directly to the skin

Ice Massage

• Remove top 2/3 of paper or Styrofoam cup leaving 1” on bottom of cup as handle

• Apply using overlappingcircular or longitudinal strokes

• Once the skin is numb to fine touch treatment ends(7-10 min)

• Thermopane develops under ice cup the allows for smooth gliding

Commercial Cold Packs

• Cold pack should be placed against wet toweling

• Mold cold pack around joint • Treatment time required

is about 20 minutes on - 20 minutes off

• Should be repeated for 2 hours

Cold Whirlpool

• Fill appropriate size whirlpool with cold water and ice until temp. at 50° to 60° F

• Use for massaging action• Gravity-dependent positions should

be avoided with acute and subacute injuries

• A toe cap made of neoprene can be used

Cold Spray & Stretch

• Flourimethane is used• Cooling is superficial• Useful in treating trigger

points • Spraying Technique

– Same direction– Proximal to distal

• Gate Control pain modulation• Stretching Technique

Thermotherapy• Local superficial heating (infrared heat) is

recommended in subacute conditions for reducing pain and inflammation through analgesic effects

• Produces a relaxation effect and a reduction in muscle guarding by:– Relieving pain– Producing sedation– Decreasing spasticity, tenderness, and spasm– Decreasing tightness in muscles and related

structures

Thermotherapy Techniques

• Warm Whirlpool• Hydrocollator Packs• Paraffin Bath• Infrared Lamps• Fluidotherapy

Warm Whirpool

• Temperature Range– Upper Extremity 98° -110° F – Lower Extremity 98- 104° F – Full body 98° - 102° F

• Time of application should be 15 to 20 minutes

• Caution is indicated in gravity-dependent position in subacute injuries

• Whirlpool maintainance

Hydrocollator Packs

• Canvas pouches of petroleum distillate

• Water temperature 170o

• 6 layers (1”) of toweling recommended

• Don’t lie on top of hot pack• Time of application should

be 15 to 20 minutes

Paraffin Bath

• Mixture ratio of paraffin to mineral oil 2 pounds:1 gallon

• Mineral oil reduces temp of the paraffin to 126° F

• Extremity dipped into paraffin for a couple of seconds then removed to allow paraffin to harden

• Repeat until 6 layers have accumulated • Wrap in a plastic bag with several

layers of toweling

Therapeutic Ultrasound

• Inaudible , acoustic vibrations of high frequency that produce either thermal or non-thermal physiologic effects

Frequency of Wave Transmission

• Audible sound = 16-20 kHz• Ultrasound > 20 kHz• Therapeutic Ultrasound = 0.75-3 MHz

(1,000,000 cycles/sec)• Lower frequencies have greater depth

of penetration• Higher frequencies more superficial

absorption

Ultrasound Cont’d

• Electrical Output

• Mechanical Vibration

• Acoustic Sound wave

• Absorbed In The Tissues

Thermal Effects of Ultrasound

• Increased collagen extensibility• Increased blood flow• Decreased pain• Reduction of muscle spasm• Decreased Joint stiffness• Reduction of chronic inflammation

Non-Thermal Effects of Ultrasound

• Increased fibroblastic activity• Increased protein synthesis• Tissue regeneration• Reduction of edema• Bone healing• Pain modulation

Methods of ApplicationDirect Contact• Transducer should be small enough to

treat the injured area• Gel should be applied liberally• Heating of gel does not increase the

effectiveness of the treatment

Methods Cont’d

Immersion• Good for treating irregular

surfaces• A plastic, ceramic, or rubber

basin should be used

• Tap water is useful as a coupling medium

• Transducer should move parallel to the surface at .3-5 cm

• Air bubbles should be wiped away

Considerations for Determining Treatment

• Size of the area to be treated• What exactly are you trying to accomplish

– Thermal vs. non-thermal effects• Intensity of treatment

Electrical Stimulating Currents

• Creating muscle contraction through nerve or muscle stimulation

• Stimulating sensory nerves to help in treating pain

• Creating an electrical field in biologic tissues to stimulate or alter the healing process

Uses of Therapeutic E-Stim

• Muscle reeducation• Muscle pump contractions• Retardation of atrophy• Muscle strengthening• Increasing range of motion• Reducing Edema

Muscle Re-Education

• Muscular inhibition after surgery or injury is primary indication

• A muscle contraction usually can be forced by electrically stimulating the muscle

• Patient feels the muscle contract, sees the muscle contract, and can attempt to duplicate this muscular response

Muscle Pump Contractions

• Used to duplicate the regular muscle contractions that help stimulate circulation by pumping fluid and blood through venous and lymphatic channels back to the heart

• Can help in reestablishing proper circulatory pattern while keeping injured part protected

Muscle Strengthening

• Current intensity should make muscle develop 60% of torque developed in a maximum voluntary isometric contraction (MVIC)

• Pulse duration should be set as close as possible to the duration needed for the motor nerve to be stimulated

Electrode Placement

• Electrodes may be placed:– On or around the painful area – Close to spinal cord segment that innervates

an area that is painful – Over sites where peripheral nerves that

innervate the painful area becomes superficial and can be easily stimulated

– Over superficial vascular structures– Over trigger point locations– Over acupuncture points– In a criss-cross pattern around the point to be

stimulated so the area to be treated is central to the location of the electrodes

• If treatment is not working- change placement

Therapeutic Sports Massage

• Mechanical stimulation of tissues by rhythmically applied pressure and stretching

• Effects of massage may be either reflexive or mechanical

Guidelines for Massage• Positioning will allow relaxation,

prevent fatigue, and permit free movement of arms, hands, and body

• Weight evenly distributed and should shift from one foot to the other

• Fit your hands to contour of area being treated

• Hands should be warm• Appropriate Medium

Hoffa Massage

• Classical massage technique which uses a variety of superficial strokes– Effleurage – Petrissage – Tapotment – Vibration

Effleurage (Stroking)

• Every massage begins and ends with effleurage

• Increases venous and lymphatic flow

• Increases circulation to skin surface

• Start with a light pressure, move centripetally or centrifugally cosistently throughout treatment

Petrissage(Kneading)

• Consists of kneading manipulations that press and roll muscles under fingers or hands

• Muscles are gently squeezed, lifted, and relaxed

• Hands may remain stationary or move along length of muscle or limb

• Purpose is to increase venous and lymphatic return and to press metabolic waste products out of affected areas through intensive vigorous action

• Can also break up adhesions between skin and underlying tissue

Tapotment(Percussion)

• Uses a variety of percussive or beating techniques

• Used to increase circulation and blood flow

• Used to stimulate peripheral nerve endings

Tapotment• Hacking• Slapping• Beating• Tapping • Clapping or cupping

Transverse Friction Massage

• Technique for treating chronic tendon inflammation

• Purpose is to increase inflammatory response to progress healing process

• Use strong pressure in perpendicular direction to fibers for 7 to 10 minutes every other day

Indications For Massage• increase coordination• decrease pain • decrease

neuromuscular excitibility

• stimulate circulation • facilitate healing• restore joint mobility• remove lactic acid

• alleviate muscle cramps

• increase blood flow• increase venous return• retard muscle atrophy• increase range of

motion• edema• myofascial trigger

points• stretching scar tissue

Contraindications for Massage

• arteriosclerosis• thrombosis • embolism• severe varicose

veins• acute phlebitis• cellulitis

• synovitis• abscesses• skin infections • cancers • acute inflammatory

conditions

Prentice, William E. Therapeutic Modalities: for Sports Medicine and Athletic Training. 5th ed. New York: McGraw-Hill 2003.