1. Therapeutic Modalities

2. Foundations of 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

3. 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.

4. 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
Use of Therapeutic Modalities inexact science, no cookbook for treatment

5. 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

6. 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

7. 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

8. 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

9. 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

10. Cryotherapy Cryotherapy techniques include Ice massage Contrast baths
Cold packs
Ice packs
Cold whirlpool
Cold spray
Contrast baths
Ice immersion
Cryo-cuff
Cryokinetics

11. 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

12. Ice Massage
Remove top 2/3 of paper or Styrofoam cup leaving 1” on bottom of cup as handle
Apply using overlapping circular 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

13. Commercial Cold Packs Cold pack should be placed against wet toweling
Mold cold pack around joint
Treatment time required is about 20 minutes on minutes off
Should be repeated for hours

14. 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

15. 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

16. 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

17. Thermotherapy Techniques
Warm Whirlpool
Hydrocollator Packs
Paraffin Bath
Infrared Lamps
Fluidotherapy

18. Warm Whirpool Temperature Range
Upper Extremity 98° -110° F
Lower Extremity ° 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

19. 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

20. 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

21. Therapeutic Ultrasound
Inaudible , acoustic vibrations of high frequency that produce either thermal or non-thermal physiologic effects

22. Frequency of Wave Transmission
Audible sound = kHz
Ultrasound > 20 kHz
Therapeutic Ultrasound = MHz (1,000,000 cycles/sec)
Lower frequencies have greater depth of penetration
Higher frequencies more superficial absorption

23. Ultrasound Cont’d Electrical Output Mechanical Vibration
Acoustic Sound wave
Absorbed In The Tissues

24. Thermal Effects of Ultrasound
Increased collagen extensibility
Increased blood flow
Decreased pain
Reduction of muscle spasm
Decreased Joint stiffness
Reduction of chronic inflammation

25. Non-Thermal Effects of Ultrasound
Increased fibroblastic activity
Increased protein synthesis
Tissue regeneration
Reduction of edema
Bone healing
Pain modulation

26. Methods of Application
Direct 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

27. 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

28. 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

29. 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

30. Uses of Therapeutic E-Stim
Muscle reeducation
Muscle pump contractions
Retardation of atrophy
Muscle strengthening
Increasing range of motion
Reducing Edema

31. 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

32. 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

33. 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

34. 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

35. Therapeutic Sports Massage
Mechanical stimulation of tissues by rhythmically applied pressure and stretching
Effects of massage may be either reflexive or mechanical

36. 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

37. Hoffa Massage
Classical massage technique which uses a variety of superficial strokes
Effleurage
Petrissage
Tapotment
Vibration

38. 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

39. 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

40. Tapotment (Percussion)
Uses a variety of percussive or beating techniques
Used to increase circulation and blood flow
Used to stimulate peripheral nerve endings

41. Tapotment
Hacking
Slapping
Beating
Tapping
Clapping or cupping

42. 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

43. 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

44. Contraindications for Massage
arteriosclerosis
thrombosis
embolism
severe varicose veins
acute phlebitis
cellulitis
synovitis
abscesses
skin infections
cancers
acute inflammatory conditions

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