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