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Chapter 15: Therapeutic Modalities

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1 Chapter 15: Therapeutic Modalities

2 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

3 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

4 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

5 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

6 Convection Radiation Conversion
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)

7 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

8 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

9 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

10 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

11 Special Considerations
Cooling for an hour at 15.8o o 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

12 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)

13 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


15 Cold or Ice Water Immersion
Equipment Variety of basins or containers can be used, small whirlpool Temperature should be 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 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

16 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

17 Ice Packs (Bags) Equipment Indications Special Considerations
Wet ice (flaked ice in wet towel) Crushed or chipped ice in self sealing bag Not as efficient, but less messy Useful for approximately 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

18 Vasocoolant Sprays Equipment Indications Application
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 inches from skin, treat entire length of muscle - covering an area 4 inches/second Apply spray 2-3 times, while gradually applying a stretch

19 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


21 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

22 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

23 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

24 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

25 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)

26 Moist Heat Packs Equipment Indications Application
Silicate gel pads submersed in o F water Maintains heat for 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 minutes Athlete must be comfortable and should not lay on pack

27 Whirlpool Bath Equipment Indications Application
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

28 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

29 Paraffin Bath Equipment Indications Application
A paraffin wax and mineral oil combination, heated to o 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 minutes w/out moving it


31 Contrast Bath Equipment Indications Application
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

32 Fluidotherapy Equipment Indications Application
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 o F Particle agitation should be controlled for comfort Athlete should be comfortable Treatment time = minutes Exercise can be performed while in cabinet


34 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)

35 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

36 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


38 Application Direct skin application Underwater 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

39 Bladder technique Moving the transducer
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

40 Special Considerations
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 W/cm2 Medium W/cm2 High 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

41 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)

42 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

43 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

44 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

45 Current Parameters Waveforms Modulation 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

46 Duration(pulse width or pulse duration)
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


48 Indications Pain Modulation Muscle Contraction 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

49 Retardation of atrophy
Muscle pump Used to stimulate circulation High-volt, DC stimulator; pps; surge mode (on/off 5 seconds each; elevation w/ active contraction Treatment time minutes Muscle strengthening High frequency AC current; pps; 10:50 seconds on/off ratio; 10 repetitions 3x per week; perform with active contractions Retardation of atrophy High frequency AC current pps; w/ voluntary muscle contraction encouraged; minutes Muscle re-education Level of comfortable contraction pps; w/ either interrupted or surge current Athlete should attempt to contract muscle along w/ stim Treatment time minutes and repeated multiple times over the course of a week

50 Interferential Currents
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

51 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

52 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

53 Psychological Responses
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

54 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

55 Stroking Variations

56 Petrissage Kneading Involves picking up skin between thumb and forefinger, rolling and twisting in opposite directions Used for deep tissue work

57 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

58 Tapotement Vibration Cupping Hacking Pincing
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


60 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

61 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

62 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


64 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

65 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

66 Indications Application 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

67 Wall-Mounted Traction
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



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