2Therapeutic 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.
3Transmission 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)
4CryotherapyApplication 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.
5Hunting ResponseCauses a slight temperature increase during cooling. The extent of cooling depends on the thickness of the subcutaneous fat layer.
6Skin Response to Cold Stage 1 Response Estimated Time after Initiation Cold sensationEstimated Time after Initiation0 to 3 minutes
7Skin Response to Cold Stage 2 Response Estimated Time after Initiation Mild burning, achingEstimated Time after Initiation2 to 7 minutes
8Skin Response to Cold Stage 3 Response Estimated Time after Initiation Relative cutaneous anesthesiaEstimated Time after Initiation5 to 12 minutes
18Comparing the Physiological Variables of Crotherapy and Thermotherapy Response to Response to Variable Cryotherapy ThermotherapyMuscle spasm Decreases DecreasesPain perception Decreases DecreasesBlood flow Decreases IncreasesMetabolic rate Decreases IncreasesCollagen elasticity Decreases IncreasesJoint stiffness Increases DecreasedCapillary permeability Decreased IncreasesEdema Controversial Increases
19Thermotherapy Special Considerations in the Use of Superficial Heat Never apply heat when there is a loss of sensationNever apply heat immediately after an injuryNever apply heat when there is decreased arterial circulationNever apply heat directly to the eyes or genitalsNever heat the abdomen during pregnancyNever apply heat to a body part that exhibits signs of acute inflammation
20Thermotherapy Superficial tissue is a poor thermal conductor temperature rises quickly on the skin surface as compared with the underlying tissuesThere are limitations of superficial tissueThe 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.
21Thermotherapeutic Methods Moist Heat Packs (Hot Packs)Duration: 20 to 30 minutesIndications:Subacute inflammationChronic inflammationReduction of subacute painReduction of chronic painSubacute muscle spasmChronic spasmDecreased range of motionHematoma resolutionReduction of joint contracturesInfectionContraindicationsAcute conditionsPeripheral vascular diseaseImpaired circulationPoor thermal regulation
22Thermotherapeutic Methods Hot WhirlpoolDuration: 5 to 30 minutesTemp: 96°F to 104°FIndications:Subacute inflammationChronic inflammationPeripheral vascular diseasePeripheral nerve injuriesDistal body partsContraindicationsAcute problems to turbulenceAcute problems to gravityFeverRequiring postural supportskin conditions
23Thermotherapeutic Methods Paraffin BathDuration: 15 to 30 minutesTemp: 126°F to 130°FIndications:Subacute inflammationChronic inflammationLimited range of motion after immobilizationContraindicationsOpen woundsSkin infectionSensory lossPeripheral vascular disease
24Hydrotherapy Methods Contrast Bath Duration: 20 to 30 minutes Temp: 50°F to 60°F:96°F to 104°FIndications:Ecchymosis removalEdema removalSubacute inflammationChronic inflammationImpaired circulationContraindicationsAcute injuriesCold hypersensitivityWhirlpool contraindicationsCold application contrindicationsHot application contrindications
25Hydrotherapy Methods Acute problems to turbulence ContraindicationsAcute problems to turbulenceAcute problems to gravityRequiring postural supportSkin conditionsCardiac involvementRespiratory involvementUncovered open woundsCirculatory insufficiencyCold allergyCold hypersensitivityAnesthetized skinCold WhirlpoolDuration: 5 to 30 minutesTemp: 50°F to 60°FIndications:Subacute inflammationChronic inflammationPeripheral vascular diseasePeripheral nerve injuriesDistal body parts
26Hydrotherapy Methods Hot Whirlpool Contraindications Duration: 5 to 30 minutesTemp: 96°F to 104°FIndications:Subacute inflammationChronic inflammationPeripheral vascular diseasePeripheral nerve injuriesDistal body partsContraindicationsAcute problems to turbulenceAcute problems to gravityFeverRequiring postural supportskin conditions
27Acoustic 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.
28Acoustic Therapy: Ultrasound Ultrasound has both thermal and non-thermal effects.
29Acoustic 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.
30Acoustic Therapy: Ultrasound Non-thermal effects of ultrasound are cavitation and acoutsic microstreaming.
31Acoustic 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.
32Acoustic 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.
33Acoustic 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).
34Acoustic 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.
36Acoustic Therapy: Ultrasound Frequency of TreatmentAcute 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.
37Acoustic Therapy: Ultrasound PhonophoresisUses ultrasound to drive ions
38Acoustic Therapy: Ultrasound Indications Acute and post acute conditions (non-thermal)Soft tissue healing and repairScar tissueJoint contractureChronic inflammationIncreased extensibility of collagenReduction of muscle spasmPain modulationIncrease blood flowSoft tissue repairIncrease in protein synthesisTissue regenerationBone healingRepair of non-union fracturesInflammation of myositis ossificansPlantar wartsMyofascial trigger points
39Acoustic Therapy: Ultrasound Contraindications Acute and post acute conditions (thermal)Areas of decreased temperature sensationAreas of decreased circulationVascular insufficiencyThrombophlebitisEyesReproductive organsPelvis immediately following mensesPregnancyPacemakerMalignancyEpiphyseal areas in young childrenTotal joint replacementInfection
40Electrotherapy: 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.
41Electrotherapy: 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.
42Electrotherapy: 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.
43Electrotherapy: 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.
44Electrotherapy: Electrical Stimulation Pulsed CurrentPulsed 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).
45Electrotherapy: Electrical Stimulation DurationDuration: 10 to 30 minutesCan be used with ice or heat
46Electrotherapy: Electrical Stimulation High Voltage or Pulsed IndicationsPeripheral nerve injuries,Delaying denervationdelaying disuse atrophyPost-traumatic edema reductionIncrease local blood circulationJoint contracture preventionMaintenance of range of motionMuscle strengtheningMuscle spasm reductionInhibitation of spasticityMuscle re-educationAssist voluntary muscle functionInterferential IndicationsAcute painChronic painMuscle spasm
47Electrotherapy: Electrical Stimulation ContraindicationsDemand-type pacemakersOver pelvic or lumbar areasDuring pregnancyPain of central or unknown originAreas of particular sensitivitycarotid sinuslaryngeal musclespharyngeal musclesupper thoraxtemproal regioncancerous lesionssites of infection
48Electrotherapy: Electrical Stimulation IontophoresisUses electrical current to drive ions
49Massage TherapySports massage causes mechanical, physiological, and psychological responses.
50Massage Therapy Mechanical Response Encourages venous and lymphatic drainage, mildly stretch superficial and scar tissue
51Massage TherapyPhysiological ResponseReflex effects, relaxation, stimulation, and increased circulation
52Massage TherapyPsychological ResponseThe 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.
54Massage Therapy Stroking; divided into light and deep methods. EffleurageStroking; 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.
55Massage TherapyPetrissageKneading; a technique adaptable primarily to loosen heavy tissue areas such as the trapezius, latissimus dorsi, or the triceps.Friction heat producingOften 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.
56Massage TherapyTapotementPercussion; produces an invigorating and stimulating sensation.
57Massage TherapyVibrationRapid 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.
58Massage TherapyDeep FrictionOften precedes activity, restoring mobility to a muscle.
59Massage TherapyMassage 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.