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Chapter 15: Therapeutic Modalities

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Title: Chapter 15: Therapeutic Modalities


1
Chapter 15Therapeutic Modalities
2
Therapeutic 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.

3
Transmission 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)

4
Cryotherapy
  • Application 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.

5
Hunting Response
  • Causes a slight temperature increase during
    cooling. The extent of cooling depends on the
    thickness of the subcutaneous fat layer.

6
Skin Response to Cold
  • Stage 1
  • Response
  • Cold sensation
  • Estimated Time after Initiation
  • 0 to 3 minutes

7
Skin Response to Cold
  • Stage 2
  • Response
  • Mild burning, aching
  • Estimated Time after Initiation
  • 2 to 7 minutes

8
Skin Response to Cold
  • Stage 3
  • Response
  • Relative cutaneous anesthesia
  • Estimated Time after Initiation
  • 5 to 12 minutes

9
Physiological Variables of Crotherapy
  • Variable Response to Therapy
  • Muscle spasm Decreases
  • Pain perception Decreases
  • Blood flow Decreases
  • Metabolic rate Decreases
  • Collagen elasticity Decreases
  • Joint stiffness Increases
  • Capillary permeability Decrease
  • Edema Controversial

10
Cryotherapeutic Methods
  • Ice Massage
  • Duration 10 to 15 minutes
  • Indications
  • small muscle areas
  • subacute injury
  • subacute inflammation
  • muscle strain
  • Contusions
  • acute pain
  • chronic pain
  • Contraindications
  • pressure contraindications
  • suspected fractures
  • uncovered open wounds
  • circulatory insufficiency
  • cold allergy
  • cold hypersensitivity
  • anesthstized skin

11
Cryotherapeutic Methods
  • Cold or Ice Water Immersion
  • Duration 10 to 20 minutes
  • Temp 50F to 60ºF
  • Indications
  • Distal body parts
  • Acute injury
  • Acute inflammation
  • Acute pain
  • Chronic pain post-surgical pain
  • Post-surgical edema
  • Contraindications
  • Cardiac involvement,
  • Respiratory involvement
  • Uncovered open wounds
  • Circulatory insufficiency
  • Cold allergy
  • Cold hypersensitivity
  • Anesthetized skin

12
Cryotherapeutic Methods
  • Ice Packs (Bags)
  • Duration 15 to 30 minutes
  • Indications
  • Acute injury
  • Acute inflammation
  • Acute pain
  • Chronic pain
  • Post-surgical pain
  • Post-surgical edema
  • Contraindications
  • Cardiac involvement
  • Respiratory involvement
  • Uncovered open wounds
  • Circulatory insufficiency
  • Cold allergy
  • Cold hypersensitivity
  • Anesthetized skin

13
Cryotherapeutic Methods
  • Contraindications
  • Acute problems to turbulence
  • Acute problems to gravity
  • Requiring postural support
  • Skin conditions
  • Cardiac involvement
  • Respiratory involvement
  • Uncovered open wounds
  • Circulatory insufficiency
  • Cold allergy
  • Cold hypersensitivity
  • Anesthetized skin
  • Cold Whirlpool
  • Duration 5 to 30 minutes
  • Temp 50F to 60F
  • Indications
  • Subacute inflammation
  • Chronic inflammation
  • Peripheral vascular disease
  • Peripheral nerve injuries
  • Distal body parts

14
Cryotherapeutic Methods
  • Cryokinetics
  • Combines cryotherapy with exercise

15
Thermotherapy
  • Application of heat Heat has the capacity to
    increase the extensibility of collagen tissue.

16
Physiological Variables of Thermotherapy
  • Variable Response to Therapy
  • Muscle spasm Decreases
  • Pain perception Decreases
  • Blood flow Increase
  • Metabolic rate Increase
  • Collagen elasticity Increase
  • Joint stiffness Decrease
  • Capillary permeability Increase
  • Edema Increase

17
Comparing the Physiological Variables of
Crotherapy and Thermotherapy
  • Response to Response to Variable
    Cryotherapy Thermotherapy
  • Muscle spasm Decreases Decreases
  • Pain perception Decreases Decreases
  • Blood flow Decreases Increases
  • Metabolic rate Decreases Increases
  • Collagen elasticity Decreases Increases
  • Joint stiffness Increases Decreased
  • Capillary permeability Decreased Increases
  • Edema Controversial Increases

18
Thermotherapy
  • Special Considerations in the Use of Superficial
    Heat
  • Never apply heat when there is a loss of
    sensation
  • Never apply heat immediately after an injury
  • Never apply heat when there is decreased arterial
    circulation
  • Never apply heat directly to the eyes or genitals
  • Never heat the abdomen during pregnancy
  • Never apply heat to a body part that exhibits
    signs of acute inflammation

19
Thermotherapy
  • Superficial tissue is a poor thermal conductor
  • temperature rises quickly on the skin surface as
    compared with the underlying tissues
  • There are limitations of superficial tissue
  • The 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.

20
Thermotherapeutic Methods
  • Moist Heat Packs (Hot Packs)
  • Duration 20 to 30 minutes
  • Indications
  • Subacute inflammation
  • Chronic inflammation
  • Reduction of subacute pain
  • Reduction of chronic pain
  • Subacute muscle spasm
  • Chronic spasm
  • Decreased range of motion
  • Hematoma resolution
  • Reduction of joint contractures
  • Infection
  • Contraindications
  • Acute conditions
  • Peripheral vascular disease
  • Impaired circulation
  • Poor thermal regulation

21
Thermotherapeutic Methods
  • Hot Whirlpool
  • Duration 5 to 30 minutes
  • Temp 96F to 104F
  • Indications
  • Subacute inflammation
  • Chronic inflammation
  • Peripheral vascular disease
  • Peripheral nerve injuries
  • Distal body parts
  • Contraindications
  • Acute problems to turbulence
  • Acute problems to gravity
  • Fever
  • Requiring postural support
  • skin conditions

22
Thermotherapeutic Methods
  • Paraffin Bath
  • Duration 15 to 30 minutes
  • Temp 126F to 130F
  • Indications
  • Subacute inflammation
  • Chronic inflammation
  • Limited range of motion after immobilization
  • Contraindications
  • Open wounds
  • Skin infection
  • Sensory loss
  • Peripheral vascular disease

23
Hydrotherapy Methods
  • Contrast Bath
  • Duration 20 to 30 minutes
  • Temp 50F to 60F96F to 104F
  • Indications
  • Ecchymosis removal
  • Edema removal
  • Subacute inflammation
  • Chronic inflammation
  • Impaired circulation
  • Contraindications
  • Acute injuries
  • Cold hypersensitivity
  • Whirlpool contraindications
  • Cold application contrindications
  • Hot application contrindications

24
Hydrotherapy Methods
  • Contraindications
  • Acute problems to turbulence
  • Acute problems to gravity
  • Requiring postural support
  • Skin conditions
  • Cardiac involvement
  • Respiratory involvement
  • Uncovered open wounds
  • Circulatory insufficiency
  • Cold allergy
  • Cold hypersensitivity
  • Anesthetized skin
  • Cold Whirlpool
  • Duration 5 to 30 minutes
  • Temp 50F to 60F
  • Indications
  • Subacute inflammation
  • Chronic inflammation
  • Peripheral vascular disease
  • Peripheral nerve injuries
  • Distal body parts

25
Hydrotherapy Methods
  • Hot Whirlpool
  • Duration 5 to 30 minutes
  • Temp 96F to 104F
  • Indications
  • Subacute inflammation
  • Chronic inflammation
  • Peripheral vascular disease
  • Peripheral nerve injuries
  • Distal body parts
  • Contraindications
  • Acute problems to turbulence
  • Acute problems to gravity
  • Fever
  • Requiring postural support
  • skin conditions

26
Acoustic TherapyUltrasound
  • 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.

27
Acoustic TherapyUltrasound
  • Ultrasound has both thermal and non-thermal
    effects.

28
Acoustic TherapyUltrasound
  • 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
    104F to 113F for a minimum of five minutes.
  • Temperatures below this range will be
    ineffective.

29
Acoustic TherapyUltrasound
  • Non-thermal effects of ultrasound are cavitation
    and acoutsic microstreaming.

30
Acoustic TherapyUltrasound
  • 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.

31
Acoustic TherapyUltrasound
  • 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.

32
Acoustic TherapyUltrasound
  • 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).

33
Acoustic TherapyUltrasound
  • 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.

34
Acoustic TherapyUltrasound
  • 1 MHz
  • Deeper Tissues
  • 3 MHz
  • Superficial Tissues

35
Acoustic TherapyUltrasound
  • Frequency of Treatment
  • Acute 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.

36
Acoustic TherapyUltrasound
  • Phonophoresis
  • Uses ultrasound to drive ions

37
Acoustic TherapyUltrasound Indications
  • Acute and post acute conditions (non-thermal)
  • Soft tissue healing and repair
  • Scar tissue
  • Joint contracture
  • Chronic inflammation
  • Increased extensibility of collagen
  • Reduction of muscle spasm
  • Pain modulation
  • Increase blood flow
  • Soft tissue repair
  • Increase in protein synthesis
  • Tissue regeneration
  • Bone healing
  • Repair of non-union fractures
  • Inflammation of myositis ossificans
  • Plantar warts
  • Myofascial trigger points

38
Acoustic TherapyUltrasound Contraindications
  • Acute and post acute conditions (thermal)
  • Areas of decreased temperature sensation
  • Areas of decreased circulation
  • Vascular insufficiency
  • Thrombophlebitis
  • Eyes
  • Reproductive organs
  • Pelvis immediately following menses
  • Pregnancy
  • Pacemaker
  • Malignancy
  • Epiphyseal areas in young children
  • Total joint replacement
  • Infection

39
ElectrotherapyElectrical 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.

40
ElectrotherapyElectrical 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.

41
ElectrotherapyElectrical 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.

42
ElectrotherapyElectrical 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.

43
ElectrotherapyElectrical Stimulation
  • Pulsed Current
  • Pulsed 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).

44
ElectrotherapyElectrical Stimulation
  • Duration
  • Duration 10 to 30 minutes
  • Can be used with ice or heat

45
ElectrotherapyElectrical Stimulation
  • High Voltage or Pulsed Indications
  • Peripheral nerve injuries,
  • Delaying denervation
  • delaying disuse atrophy
  • Post-traumatic edema reduction
  • Increase local blood circulation
  • Joint contracture prevention
  • Maintenance of range of motion
  • Muscle strengthening
  • Muscle spasm reduction
  • Inhibitation of spasticity
  • Muscle re-education
  • Assist voluntary muscle function
  • Interferential Indications
  • Acute pain
  • Chronic pain
  • Muscle spasm

46
ElectrotherapyElectrical Stimulation
  • Contraindications
  • Demand-type pacemakers
  • Over pelvic or lumbar areas
  • During pregnancy
  • Pain of central or unknown origin
  • Areas of particular sensitivity
  • carotid sinus
  • laryngeal muscles
  • pharyngeal muscles
  • upper thorax
  • temproal region
  • cancerous lesions
  • sites of infection

47
Electrotherapy Electrical Stimulation
  • Iontophoresis
  • Uses electrical current to drive ions

48
Massage Therapy
  • Sports massage causes mechanical, physiological,
    and psychological responses.

49
Massage Therapy
  • Mechanical Response
  • Encourages venous and lymphatic drainage, mildly
    stretch superficial and scar tissue

50
Massage Therapy
  • Physiological Response
  • Reflex effects, relaxation, stimulation, and
    increased circulation

51
Massage Therapy
  • Psychological Response
  • The 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.

52
Massage Therapy
  • Massage Strokes
  • Effleurage
  • Petrissage
  • Tapotement
  • Vibration
  • Deep Friction

53
Massage Therapy
  • Effleurage
  • Stroking 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.

54
Massage Therapy
  • Petrissage
  • Kneading a technique adaptable primarily to
    loosen heavy tissue areas such as the trapezius,
    latissimus dorsi, or the triceps.
  • Friction heat producing
  • Often 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.

55
Massage Therapy
  • Tapotement
  • Percussion produces an invigorating and
    stimulating sensation.

56
Massage Therapy
  • Vibration
  • Rapid 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.

57
Massage Therapy
  • Deep Friction
  • Often precedes activity, restoring mobility to a
    muscle.

58
Massage Therapy
  • Massage 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.
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