Chapter 15: Therapeutic Modalities

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Chapter 15 Therapeutic Modalities
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• 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

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Legal Concerns

• Modalities must be used w/ great care and should
  not involve indiscriminate use
• Modality usage varies greatly state to state
• ATCs must follow guidelines established by their
  individual state
• ATCs 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

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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

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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

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• 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)

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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

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• 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

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• 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

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• 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

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• Special Considerations
• Cooling for an hour at 15.8o - 30.2o 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

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• Special medical conditions
• Raynauds 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)

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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

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• Cold or Ice Water Immersion
• Equipment
• Variety of basins or containers can be used,
  small whirlpool
• Temperature should be 50-60 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 10-15 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

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• 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

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• Ice Packs (Bags)
• Equipment
• Wet ice (flaked ice in wet towel)
• Crushed or chipped ice in self sealing bag
• Not as efficient, but less messy
• Useful for approximately 15-20 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

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• Vasocoolant Sprays
• Equipment
• 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 12-18 inches from skin, treat entire
  length of muscle - covering an area 4
  inches/second
• Apply spray 2-3 times, while gradually applying a
  stretch

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• 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

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• 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

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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

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• 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

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• 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

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• 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)

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• Moist Heat Packs
• Equipment
• Silicate gel pads submersed in 160-170o F water
• Maintains heat for 20-30 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 15-20 minutes
• Athlete must be comfortable and should not lay on
  pack

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• Whirlpool Bath
• Equipment
• 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

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• 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

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• Paraffin Bath
• Equipment
• A paraffin wax and mineral oil combination,
  heated to 126-130o 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 20-30 minutes w/out
  moving it

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• Contrast Bath
• Equipment
• 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

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• Fluidotherapy
• Equipment
• 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 100-113o F
• Particle agitation should be controlled for
  comfort
• Athlete should be comfortable
• Treatment time 15-20 minutes
• Exercise can be performed while in cabinet

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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)

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• 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

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• 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

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• Application
• Direct skin 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

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• Bladder technique
• 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

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• 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 0.1-0.3 W/cm2
• Medium 0.4 - 1.5 W/cm2
• High 1.5 - 3.0 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

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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)

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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

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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

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• 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

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• 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

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• 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

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• Indications
• Pain Modulation
• 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

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• Muscle pump
• Used to stimulate circulation
• High-volt, DC stimulator 20-40 pps surge mode
  (on/off 5 seconds each elevation w/ active
  contraction
• Treatment time 20-30 minutes
• Muscle strengthening
• High frequency AC current 50-60 pps 1050
  seconds on/off ratio 10 repetitions 3x per week
  perform with active contractions
• Retardation of atrophy
• High frequency AC current 30-60 pps w/ voluntary
  muscle contraction encouraged 15-20 minutes
• Muscle re-education
• Level of comfortable contraction -- 30-50 pps w/
  either interrupted or surge current
• Athlete should attempt to contract muscle along
  w/ stim
• Treatment time 15-20 minutes and repeated
  multiple times over the course of a week

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• 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

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• 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

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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

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• 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

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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

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Stroking Variations
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Petrissage

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

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• 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

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• Tapotement
• Cupping
• 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

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• 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

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• 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

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• 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

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• 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

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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

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• Indications
• 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

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• 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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