1. Therapeutic Modalities
Anything used for the management of injury

2. By the end of the this unit SWBT:
Identify and explain the different methods of thermal energy transmission
Identify the physiological effects of cryotherapy
Describe the indications and contraindications for cryotherapy
Describe the stages of icing

3. By the end of the this unit SWBT:
Identify the different methods of cryotherapy and thermotherapy
Explain the adverse effects of cryotherapy
Explain cryokinetics
Describe the indications and contraindications for thermotherapy
Explain ultrasound
Identify the physiological effects of electrical stimulation

4. By the end of the this unit SWBT:
Describe the therapeutic/physiological effects of massage
Identify the contraindications of massage
Explain the different types of massage

5. Therapeutic Modalities
What are they?
Therapeutic= something that promotes healing and injury repair
Modality= the method of application of any therapeutic agent
Many different modalities to choose from
Selection is dependent on:
Prescription
Indications and Contraindications
Injury site, type and severity
Athletes willingness to accept treatment

6. 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
© 2011 McGraw-Hill Higher Education. All rights reserved 6

7. © 2011 McGraw-Hill Higher Education. All rights reserved
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)
© 2011 McGraw-Hill Higher Education. All rights reserved 7

8. What functions to modalities play?
Relieve pain
Reduce or slow swelling
Decrease spasm
Promote healing

9. Why use modalities?
They can minimize time lost from participating in a sport
Shorten recovery time

10. What is the danger of using modalities?
If used improperly or at the wrong time:
a condition may worsen
Further injury may occur

11. Gate Control Theory
Non-painful input closes the "gates" to painful input
Prevents pain sensation from traveling to the central nervous system
Therefore:
stimulation by non-noxious input is able to suppress pain

12. Gate Control Theory
Sensory nerve fibers carry information from the site of injury
Thin diameter fibers
Pain
Large diameter fibers
Touch, Pressure, Vibration

13. Gate Control Theory Thin fiber activity impedes the inhibitory cells
Tends to allow the transmission cell to fire
Large diameter fiber activity excites the inhibitory cells
Tends to inhibit transmission cell activity
More large fiber (touch, pressure, vibration) activity relative to thin fiber (pain) activity at the inhibitory cell, THE LESS PAIN IS FELT

14. Cryotherapy
The therapeutic use of cooling agents is the most widely used thermal modality in sport medicine

15. What is the benefit of cryotherapy?
It helps to manage
Pain
Swelling (Edema)
Spasm
Muscle guarding

16. What are the physiological effects of cold on the body?
Initial vasoconstriction (shrinking of blood vessels)
Reduction of tissue metabolism
Decrease in nerve velocity
The speed at which nerves send messages to the brain
Reduction of muscle spasm
Secondary vasodilatation
Increase in muscle strength after treatment

17. When should we use cryotherapy?
It is the modality of choice for acute injuries
Use for almost any musculoskeletal trauma as soon as possible

18. How long do I apply cold? Maximum of 20 minutes each treatment
Allow 2 hours between each application of cold
Or until skin and muscle temperatures return to normal levels
Apply cold as often as time will allow during waking hours

19. What else can I do for acute injuries?
Apply the acronym P.R.I.C.E. as soon as possible after an injury occurs

20. P = Protection
The purpose of protection is to avoid further injury to the area by protecting the injured structures. 
The type of protection used varies depending on the injured area.
If the athlete can move, carefully move them to a safer area using a carries or a crutch, but if there is any doubt, do not move the injured athlete.

21. R = Rest STOP doing the activity allow the injury to heal
If you continue, it will only get worse!!

22. I = Ice Apply cold for 20 minutes at a time
Give the treatment every 2 hours

23. C = Compression Wrap the ice on snugly when applying
Place a compression (Ace) wrap on in between cold applications
This “squeezes” the affected area allowing less room for swelling to occur

24. E = Elevation Raise the injured extremity above the level of the heart
This promotes venous return by using gravity
Slows blood flow to area by forcing to body to pump blood “uphill” or against gravity
It helps prevent pooling of blood in the injured area

25. CRYOTHERAPY 4 stages of icing Cold Burning- most uncomfortable Aching
Numbness

26. Skin response to cryotherapy:
Stage 1
Cold Sensation
0 – 3 min
Stage 2
Mild burning, aching
2-7 min
Stage 3
Anesthesia
5-12 min

27. What Types of Cryotherapy are there?
Ice Bags
Very economical & can be made quickly
Great for use on local areas of concern
Can be wrapped in place fairly easily
Smaller ice pellets is preferable
Important to make the ice bag properly!!!
Put ice in bag (not too much!)
Remove as much air from bag as possible
Tie bag shut with knot away from the ice a couple of inches
This allows bag to mold to body part better

28. What Types of Cryotherapy are there?
Gel Packs
Commercially manufactured
Made of a mixture that does not freeze solid, but remains pliable when cold
Stored in a freezer & available for use immediately
Molds well to body parts
Retains cold longer than ice
Treatment time is shorter
Place a thin cloth between you and the gel pack

29. What Types of Cryotherapy are there?
Chemical Cold Bags
Becomes cold when the bag is squeezed causing contents to mix creating a chemical reaction
More expensive and doesn’t form to body well
Can be stored for long periods of time at room temperature
Treatment time can be longer as it is not as cold

30. What Types of Cryotherapy are there?
Ice Massage
Useful for localized problems
May be done with an ice cube, water frozen in a paper cup, or a commercially produced reusable plastic container
Rubbing over affected area gives the desired affect
Combines effects of cold with those of massage (manipulation of soft tissue by friction)
Requires a shorter treatment time

31. What Types of Cryotherapy are there?
Cold Water Compression
Simultaneously combines cold with compression
A sleeve with an internal bladder is applied to the athlete
Raising a water container will use gravity to apply pressure or a pump may be employed to push the water through
Some units will use intermittent pressure

32. What Types of Cryotherapy are there?
Ice Baths or Ice Immersion
This is the standard bucket of ice
Allow for complete & uniform coverage of body part
Athlete can perform movement during treatment
Water temperature should be approximately 50 – 55 degrees F
Treatment time is approximately 10 minutes

33. What Types of Cryotherapy are there?
Whirlpool
Is basically the same as Ice Immersion, but add a motor that moves the water
This uses convection to pull heat away from the body creating a colder effect

34. What precautions are there?
Individuals with any of the following conditions should use cold with caution
Thermoregulatory problems
Sensory deficits
Hypersensitivity to cold
Impaired circulation
Heart disease
Always monitor any reactions to cold applications and do not apply cold for too long

35. Adverse Conditions to Cryotherapy
hypothermia
frostbite
cold allergies
Raynaud's phenomenon
Hunting response
Intermittent period of vasodilation will occur if cooling continues for >20 minutes

36. Raynaud’s Phenomenon
Raynaud's phenomenon is characterized by a pale to blue to red sequence of color changes of the digits, most commonly after exposure to cold.
Raynaud's phenomenon occurs because of spasm of blood vessels.

37. It sure feels a lot better than cold therapy!
Heating Agents
It sure feels a lot better than cold therapy!

38. What are the benefits of heating?
Reduced pain
Promotion of healing
Increased range of motion
Muscle relaxation

39. What are the physiological responses of the body to heat?
Increased vasodilation
= increased blood flow
Increased temperature
= increased metabolic rate & oxygenation of tissues

40. When is use of heat appropriate?
Only when natural responses to acute inflammation or trauma have subsided
That’s 48 – 72 hours post-injury
Useful or healing purposes in subacute or chronic states of injury

41. What are the forms of Heat?

42. Hydrocollator Packs Moist heat packs Used for superficial heating
Kept in a heated stainless steel container filled with hot water
Used for superficial heating
Easy to apply and cost effective
Packs should be covered in insulated coverings for use
Treatment times of 10 – 20 minutes

43. Electrical Heating Pads
A form of dry heat
Treatment time of 10 – 20 minutes
Use at comfortably warm temperature
Alternate form of dry heat
Bean bag or rice bag heated in microwave

44. Warm Whirlpool Advantages Disadvantages
Can treat a large area of an extremity
Allow ROM exercises to be performed
Disadvantages
Extra time/effort to fill and clean
Physical space the whirlpool takes up
Expense of equipment
Cannot elevate body part
Temperature is 95 – 104 degrees F
Treatment time of 10 – 20 minutes

45. Contrast Therapy Alternating use of hot & cold water baths
For use with subacute injuries
Goal is to reduce swelling/pain & increase ROM
Treatment times
4 min Hot f/b 1 min cold – 4 cycles – end with cold
Any time schedule can be used

46. CRYOKINETICS Conduction / Convection
Allows exercise which is pain-free, relatively soon after injury
Ice done initially for up to 20 minutes (typically shorter) to numb the area and decrease the pain
Active exercise then follows, done within an amount of time and intensity that does not cause the pain to return

47. CRYOKINETICS
Ice is then repeated for 3-5 minutes, followed by 3-5 minutes of exercise
Process typically repeated 3-5 times
Key to success is progressing as quickly as possible from one exercise to another, until pain returns or fatigue sets in

48. Cryokinetics - Benefits
Exercise increases blood flow to injured area, assisting with healing
Re-establishes neuromuscular function
Makes exercise possible much sooner than normal
Decreases muscle atrophy
Reduces swelling through combination of cooling and exercise

49. Using sound to create heat

50. Ultrasound (US)
Technically known as ultrasonic diathermy (through heat)
This is a deep heating modality
Can heat to a depth of 5 cm
Treatment time is 5 – 10 minutes
For use with subacute & chronic injury

51. How does Ultrasound Work?
It is a high frequency sound wave that is absorbed by protein-rich tissues
Tendons, ligaments, joint capsules, muscle tissue
Some is absorbed by bone & the rest reflects off

52. How does Ultrasound Work?
1 cycle/sec = Hertz (Hz)
Humans can hear up to 20,000 Hz
Therapeutic US uses frequencies of 1 -3 MHz
MHz = 1 million cycles/sec
1 MHz used for deep structures
Penetrates 2 – 5 cm
3 MHz used for superficial structures
Penetrates 1 – 2 cm

53. How does Ultrasound Work?
Pulsed (or low-intensity) US
Interrupted flow
Has non-thermal effects that facilitate tissue repair
Uses 20% duty cycle
The fraction of time when the US beam is flowing during one pulse

54. How does Ultrasound Work?
Continuous US
Uninterrupted flow
Transforms to deep heat within targeted muscle
Uses 100% duty cycle

55. How does Ultrasound Work?
Ultrasonic beam is created by a vibrating synthetic crystal
This is housed in a metal shield called the sound head or transducer
Treatment area should be no larger than 2x the size of the transducer

56. How does Ultrasound Work?
A coupling agent must be used to provide a medium for the sonic waves to penetrate the skin
The transducer must remain in motion on the skin during treatment

57. LASER Light Amplification by Stimulated Emission of Radiation
Introduced in the 60’s
Less pain and inflammation after surgery then conventional

58. Behaves according to the basic laws of light
Can be transmitted, reflected, refracted, and absorbed
Therapy lasers
Lower Lever Laser Therapy (LLLT)
Low Intensity Laser Therapy
AKA: Cold Laser

59. Laser
Sun’s photonic rays cause a seed to sprout through RNA & DNA changes.
Sun’s rays are full-spectrum light, but only one specific wavelength or frequency causes the seed to germinate

60. Has no effect on blood flow
Acts on the smallest cellular components of the tissues to “jump start” the healing process
Has been shown to significantly accelerate and enhance the body’s natural defense and repair abilities.
Pain relief, reduce cell damage due to the injury and resulting loss of function

61. Laser
Cell functions are stimulated, especially the increase of a cell’s ATP
Associated with increase cell metabolism, increased collagen synthesis, stimulation of DNA formation, improved immune system function and increased new formation of capillaries
Increase neurotransmitters (serotonin), to increase and enhance tissue regeneration through increasing fibroblasts and keratinocytes.
Increase antioxidants and accelerate bone and scar healing

62. Electrical Modalities
Stimulation of nerve tissues

63. Electrical Stimulation (E-Stim)
The stimulation of motor nerves to produce muscle contractions

64. What are the benefits of electrical stimulation?
Increasing ROM
Increasing muscle strength
Reeducating muscles
Improving muscle tone
Enhancing muscle function
Controlling pain
Accelerating wound healing
Reducing muscle spasm

65. Neuromuscular Electrical Stimulation (NMES)
Stimulation of a peripheral nerve to cause either a sensory or motor response
Most common type of stimulation

66. Functional Electrical Stimulation
Use of stimulation to improve function
Transcutaneous electrical nerve stimulation (TENS)
Reduces pain by stimulating sensory and pain-signaling nerves
Applied with a portable unit

67. How is electrical stimulation applied?
It uses surface electrode pads in contact with the skin
2 electrodes are required to complete the electric circuit

68. When should I NOT use electrical stimulation?
During pregnancy
In people with pacemakers
On people sensitive to electricity
Any time active motion is restricted

69. MASSAGE
The systematic manipulation, methodical pressure, friction, & kneading of soft tissues

70. Massage Basics Why is it used?
Stimulate muscles
Decrease muscle spasm
Increase circulation
Decrease edema
Promote relaxation
Use of a lubricant is recommended to reduce skin friction

71. Effleurage
Use of strokes that glide over the skin without moving deep muscle groups
Done with palms or fingers
Usually used to begin or end treatment
Can be used to detect muscle tightness

72. Petrissage
Kneading the soft tissues between the thumb and fingers (or palm)
Rolling & twisting motion
Stimulates fluid drainage

73. Deep Friction Used primarily on joints & areas with little tissue mass
Thumbs & fingers rotated in a circular pattern
Can use a transverse friction pattern
Apply enough pressure to contact underlying tissue
Increases circulation and decreases scar tissue

74. Tapotement (Percussion)
Beating the hands or fingers on the skin
Can be done with:
Clenched hands
Palms
Ulnar borders of palms
Fingertips
Used to "wake up" the nervous system and can release lymphatic build up

75. Vibration Uses quick motions of the fingers
Or vibrating machine
Increases circulation and lymphatic drainage

76. When is massage contraindicated?
Contusions
Sprains
Strains
Fractures
Open wounds
Areas of infection