1. Therapeutic Modalities

2. Therapeutic Modalities

3. Terminology
Modalities: methods of treating injuries, using heat, cold, ultrasound or electric stimulation
Therapeutic: referring to treatment
Indications: reasons to use a modality
Contraindications: reasons not to use a modality

4. Types of Modalities
Thermal Modalities: transfer heat into or out of the body
Mechanical Modalities: use mechanical energy to produce effects
Electrical Modalities: stimulate nerve tissues

5. General Purposes of Modalities
Alter blood flow (vasoconstriction or vasodilation)
Decrease pain
Decrease muscle spasm
Decrease swelling
Alter metabolism

6. Indications for Using Modalities
Acute injuries
Acute or chronic pain
Swelling
Chronic inflammation
Muscle spasm
Joint tightness

7. Contraindications for Using Modalities
Open wounds
Infections
Cold-related allergies
Areas of sensory or circulatory deficits
Open growth plates
Over organs (heart, eyes, etc.)
Possible fractures

8. Thermal modalities

9. Terminology
Conduction: heat transfer that occurs when objects are in direct contact
Convection: heat transfer that occurs through the movement of fluids or gases
Conversion: heat transfer that occurs as energy is changed from one form to another
Radiation: heat transfer that occurs through space from one object to another

10. Heat Transfer Principle
Heat is always transferred from the warmer object to the colder object

11. Conduction
Heat transfer that occurs when objects are in direct contact with each other
Example = hydrocollator (moist heat) pack on shoulder
How is heat transferred in this example?

12. Convection
Convection is a method of heat transfer that occurs through the movement of fluids or gases
Example: an athlete’s ankle in a cold whirlpool
How is heat transferred in the example?

13. Conversion
Conversion is a form of energy transfer that occurs when heat is generated from sound, electricity or chemical means and transferred into heat energy
Example: ultrasound application over an athlete’s quadriceps
How is heat transferred in the example?

14. Radiation
Radiation occurs as heat is transferred from one object through space to another object
Example: diathermy treatment for an athlete’s back
How is heat transferred in the example?

15. Factors influencing heat transfer
The temperature difference between the two tissues
(Bigger differential leads to higher transfer of energy)
The length of treatment time
(The longer the exposure, the greater the transfer)
The conductive properties of the area
(Fat is an insulator and takes longer to heat/cool; muscle has a high water content and is a good conductor of heat/cold)

16. cryotherapy

17. Terminology
cryotherapy: using a source of cold for treatment

18. Physiological Effects of Cold
Decreased muscle spasm
Decreased pain
Decreased blood flow (vasoconstriction)
Decreased metabolism
Decreased tissue extensibility
Increased joint stiffness

19. Indications for Cryotherapy
Acute injuries
Pain
Swelling / inflammation
Muscle spasm

20. Contraindications for Cryotherapy
Cold-related allergies
Open wounds
Cardiovascular problems
Sensory or circulatory deficits
Hypersensitivity to cold
High blood pressure
Respiratory problems
Diabetes or peripheral vascular disease
Infection

21. Cold Whirlpool Advantages: What it is:
Effective cooling in minutes
Can treat large areas
Disadvantages:
Can’t be transported
Requires prep time
Constant supervision
What it is:
Container filled with ice & water at 50 to 60°F
Cooling occurs with water movement
Where it’s used:
Treating an injured extremity

22. Ice Massage What it is: Advantages:
Water frozen in a cup; the top of the cup is peeled away and the exposed ice is rubbed over the area
Where it’s used:
Over small treatment areas (tendon, bursa, muscle belly, etc.)
Advantages:
Short treatment time (5-10 minutes)
Cheap (cup + water)
Athlete can self-treat
Disadvantages:
Only effective on small areas
Can be messy

23. Ice Pack Advantages: What it is:
Molds to the body part / treat large areas
Cheap (plastic bag) after investment of ice machine
Transportable
Disadvantages:
Requires longer treatment times (15-30 minutes)
What it is:
Flaked or crushed ice tied in a plastic bag
Where it’s used:
Any body part, especially after acute injuries

24. thermotherapy

25. Terminology
thermotherapy – using a source of heat for treatment

26. Physiologic Effects of Heat
Decreased muscle spasm
Decreased pain
Increased blood flow (vasodilation)
Increased metabolism
Increased tissue elasticity
Decreased joint stiffness

27. Indications of Thermotherapy
Chronic inflammatory conditions
Chronic pain
Chronic muscle spasm
Joint contracture
Tightened tissue

28. Contraindications of Thermotherapy
Sensory loss
Acute injury
Areas of decreased sensation/circulation
Over the abdomen during pregnancy
Over the eyes or genitals
Area over tumor / malignant tissue
Peripheral vascular disease

29. Warm Whirlpool Advantages: What it is:
Effective heating in minutes
Treat large areas
Disadvantages:
Clean after each use to prevent infection
Prep time
Can’t be transported
Constant supervision
What it is:
Basin filled with 98 to 104°F water
Heating through conduction & convection
When it’s used:
Treating an injured extremity

30. Hydrocollator (Heat) Pack
What it is:
A moist heat pack filled with gel and stored in 160°F water bath
Wrapped in towels to prevent burning
When it’s used:
Applied over large areas
Advantages:
Superficial heating in minutes
Reusable
Conforms to areas
Disadvantages:
Hydrocollator requires electricity (not transportable)

31. Paraffin Bath What it is:
Basin filled with paraffin and mineral oil heated to °F
Extremity is dipped 6 times, then wrapped in plastic bag
When it’s used:
Chronic pain/swelling in hands/feet
Advantages:
Treatment time varies from 5-20 minutes
Disadvantages:
Messy application
High risk of infection (replace wax often)
Treatment area limited
Supervision required

32. Contrast therapy and cryokinetics

33. Terminology
Contrast bath: a method of treatment alternating cold water immersion and hot water immersion
Cryokinetics: a technique that combines cryotherapy with exercise

34. Physiological Effects
COLD
Vasoconstriction
↓muscle spasm
↓tissue metabolism
↓pain
↓tissue extensibility
HEAT
Vasodilation
↓ muscle spasm
↑ tissue metabolism
↓ pain
↑tissue extensibility

35. Contrast Bath Therapy Most effective in the sub-acute stage
Primarily used for treating extremities
Fill one container with cold water (50 to 65°F)
Fill a second container with hot water (105 to 110°F)
Treat injury using a 3:1 ratio (3 minutes in heat, 1 minute in cold) or 4:1 ratio for about 20 minutes
Usually end with cold treatment

36. Contrast Bath Therapy (cont.)
Why use contrast bath therapy?
Changing from cold to heat causes a mild temperature increase
Temperature increase allows for increased blood flow to area (speed up healing without causing more swelling)
Still a popular theory, but no evidence that it actually works

37. Cryokinetics Used in acute stage of injury
Combines cryotherapy with exercise
Start w/ cold whirlpool, ice pack or ice massage to numb the body part (about minutes)
Begin exercise within pain tolerance (about 3-5 minutes)
Repeat cold water immersion and exercise 3 more times, ending with cold

38. Cryokinetics (cont.) Exercise should be active
Exercise should be pain-free
Exercise should be performed normally (without limping)
Exercise should progress in complexity and difficulty but stay within pain-free guidelines

39. Therapeutic ultrasound

40. Terminology
therapeutic ultrasound: a modality that is used for deep heating or tissue repair

41. Therapeutic Ultrasound
Ultrasound machine
Sound head

42. How Ultrasound Works
The ultrasound unit contains a generator, which provides an electrical current that is transmitted to a crystal located in the sound head
The electrical current causes the crystal to vibrate, producing a high-frequency sound wave
Humans can hear 18,000 – 20,000 Hz (cycles/second)
Ultrasound is either 1 million (1MHz) or 3 million (3MHz)

43. How Ultrasound Works (cont.)
The sound wave is absorbed by tissues with a high protein content (tendons, ligaments, joint capsules, and muscle)
The sound wave is poorly absorbed by bone tissue; the majority is reflected or refracted

44. Ultrasound Parameters
Frequency: cycles per second (Hz)
1 MHz – heats tissues from 2 to 5 cm deep
3MHz – heats superficial tissues
Intensity: the amount of energy transferred to the tissues, expressed in W/cm² (ranges from 0.1 to 5.0 W/cm²)
Continuous or pulsed sound beam:
Continuous output produces thermal effects
Pulsed output produces mechanical effects for tissue healing

45. Ultrasound Parameters
Duty cycle: the amount of time the ultrasound is on
20% means it’s on 1 out of every 5 seconds
100% means it’s on continuously
Treatment area: should be about twice the size of the sound head
Treatment length: usually 5-10 minutes

46. Ultrasound Guidelines
A medium is required to transmit the sound waves into the tissue (either cream, gel or water)
The sound head must be moved about 2-4 cm per second to prevent burning
Requires constant supervision by AT
Requires a doctor’s script

47. Indications for Ultrasound
Acute injuries (tissue healing, non-thermal effects)
Chronic injuries
Muscle strains
Ligament sprains
Muscle spasm
Tissue tightness
Scar tissue

48. Contraindications for Ultrasound
Areas with sensory or circulatory deficits
Over fractures or open growth plates
Over tumors
Over artificial joints
Over heart, eyes, brain, spinal cord
Over reproductive organs
Over abdomen during pregnancy
Over herniated discs
Acute injuries (in continuous heat setting)

49. Sample Treatments* Condition Frequency Duty Cycle Deep muscle adhesion
1 MHz
100%
Deep bursitis
20-50%
Superficial scar
3 MHz
Superficial tendinitis
*Table from France, Robert C. Introduction to Sports Medicine & Athletic Training (Clifton Park, NY: Thomson DelMar Learning, 2004), 220.

50. Therapeutic massage

51. Terminology
Massage: intentional and methodical kneading and stroking of soft tissues
Effleurage: using the palm to stroke the tissue in a smooth and rhythmical way
Petrissage: kneading or squeezing the tissue between the hands
vibration massage: causing the tissue to shake vigorously

52. Terminology (cont.)
percussion massage (tapotement): applying repetitive light chopping motions to the tissue
friction massage: using the finger, thumb, or elbow to apply pressure to deep tissues

53. Indications for Massage
Increase circulation
Decrease muscle spasm
Relieve swelling
Increase joint mobility
Relaxation
Break up scar tissue

54. Contraindications of Massage
Local or general infection
Acute stage of injury

55. Desired Therapeutic Effects
Break up scar tissue?
Increase circulation?
Relaxation?
Improve joint mobility?
Decrease muscle spasm?
Relieve swelling?

56. Therapeutic Effects by Massage Strokes
Break up scar tissue? - Friction
Increase circulation? – Percussion, petrissage, effleurage
Relaxation? Effleurage, percussion
Improve joint mobility? – Vibration, petrissage
Decrease muscle spasm? - Friction
Relieve swelling? Effleurage, vibration

57. Guidelines for effective massage
Position athlete comfortably on a table
Make sure the room temperature is at a comfortable setting
Drape athlete’s body to expose only the necessary body part
Use lotion or a massage lubricant to allow the hands to slide over the skin
Explain what massage strokes you are using
Be confident

58. Electrical Stimulation

59. Terminology
electrical stimulation (E-Stim): using electricity to target a motor nerve and cause a muscle response
transcutaneous electrical nerve stimulation (TENS): using electricity to target a sensory nerve to decrease pain

60. Electrical Modalities
E-Stim Unit
TENS unit

61. E-Stim and TENS Comparison
Similarities
1. Both are electrical modalities
2. Both transmit electricity through electrodes
3. Both stimulate nerves
4. Both produce therapeutic effects
Differences
1. E-Stim is used to stimulate motor nerves; TENS stimulates sensory nerves
2. E-stim produces muscle contractions; TENS controls pain
3. An E-stim unit can function as a TENS

62. How Electrical Stimulation Units Work
The unit generates an electrical current
The current is transmitted by the electrodes (two or more electrodes are required to complete an electrical circuit)
The electrodes are placed on the skin
The current carried by the electrodes is used to stimulate a nerve (sensory or motor)
The amount of electricity is controlled to produce a therapeutic effect

63. Indications of Electrical Stimulation
Increase range of motion
Increase muscle strength
Muscle re-education
Improve muscle tone
Improve muscle function
Control pain
Accelerate wound healing
Decrease muscle spasm
Prevent atrophy

64. Contraindications of E-Stim
Over the carotid sinus
During pregnancy
Individuals with pacemakers
Sensitivity to electricity
When active ROM is contraindicated

65. Treatment Parameters
1. Waveform 2. Modulation 3. Intensity 4. Duration 5. Frequency 6. Polarity 7. Electrode setup