Modalities Final Review
Introduction
Traction
Treatment Goals
Effects
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P! control
o Acute – localized, protective, 2o injury
o Chronic – >6mo p injury…central sensit.
o Referred – MUST assess well to use mods.
o Gating – epicritic  gate  proto. inhib.
o Endorphin release 2o EStim, stress, Ex.
Edema control
o Vasocontrxn,  vasc. perm., compress.
Tissue healing
o Ca2+ channels  activity   rxn rate
o Stages
 Inflam – 6d, 4 “-ors”, vasodilation
 Prolif – 20d, fibroblasts & revascularization
 Matur – p9d, collagen organized, scar strength
Muscle contraction
o nn. stimulation,  strength, mm. tone
Alter tissue extensibility
Enhance drug delivery
o Iontophoresis, phonophoresis
Jt. Distraction – 50%BW for L/S…7%BW for C/S
 disc protrusion (NOT ant., large, calcify, low force)
Stretch soft tiss – mod load, long time
Relax mm. – esp. paraspin.
Jt. Mobilization – high soft tiss., low/intermit. Capsule
Immobilization – short term…low load, long time
Indications
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Disc bulge, nn. root impinge
Paraspinal spasm
Jt. Hypomobility (generalized)
Subacute Jt. inflam. – intermittent to  P! & edema
Contraindications & Precautions
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Fx, instability, s/p surgery, sequestrated disc
<3d inflammation
Hypermobility, instability (preg., RA, Down’s)
Peripheralization of Sx
Bb. structure probs (CA, RA, osteopor., steroids)
Claustrophobia, disorientation
Adverse Effects
Compression
Effects
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 fluid in limb
o Venous, lymph., keep in vessels, “milk” back to 
o Use elevation as adjunct
Control tissue size/shape
 temp 2o insulation
Indications
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Edema control
o Venous insuff. (ulcers), lymphedema, trauma
DVT prevention
o Intermittent/sequential pump OR stockings
Residual limb shaping for prosthetic fit
 excess scarring
o Collagenase stimulation & local hypoxia
o Silicone, stocking/sleeve/glove/vest/mask
Contraindications & Precautions
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Local malignancy OR infection
aa. insuf., blocked vessels., CHF
Fragile skin
For compression pumps ALSO…
o Acute trauma/Fx,  sensory, HTN, CVA
Adverse Effects
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Numbing, fluid overload, distal edema
Procedures
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Pumps – max P < dBP (2-3hr/1-2x/2-7d)
Wraps – distal to proximal…no open areas
Garments – (low) DVT, scar, vv insuf., lymphed., resid
limb (high)
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Rebound P!
L/S P! with C/S traction
Procedures
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Lumbar – prone & unilateral options too!
o  for post., facet, upper L/S
o Neutral for ant., foramena
o Short time, static, low force  acute
o Long time, intermit, mod force  other
Cervical
o  for post., facet, foramena, lower C/S
o Neutral for disc, upper C/S
o Short time, static, low force  acute
o Long time, intermit, mod force  other
ALSO, self, manual or home traction options!
Modalities Final Review
Cryotherapy
Effects of cooling
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Vasocontriction
o Smooth mm contract, hunting response
o  blood viscosity… blood flow to area
Neuromuscular
o  A & C cond, P! (gate), str. (p 1hr), spas. (p 45min)
o  strength (p 5min)
Metabolic
o  rate
Connective tissue
o  extensibility
Indications
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Effects of heating (irreversible damage >45oC)
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Acute inflame., edema
P!
spasticity, trigger point
facilitate mm contraction
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Contraindications & Precautions
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Cold sensitivity/poor reaction
 circulation, Vv insufficiency, lymphatic compromise
Superficial or regenerating peripheral nn
HTN
 sensory or mentation
Very young OR very old
Adverse Effects
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Frostnip (<59oF)  blanch & temporary  sensation
Frostbite (<39oF)  waxy skin, long  sensation
Nerve palsy
Cryotherapy Types
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Cold pack or ice pack – 10-15min
Ice bath – 15-45min
Spray & stretch
Contrast bath – 2 basins – 80-104oF & 55-67oF
o Warm 3-4min…cold 1min…repeat 5-6x
Diathermy
Background Information
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Radiowaves for thermal & non-thermal effects
o 10-100MHz short…300MHz-300GHz micro
Induced electrical current by magnetic field
o Drum & coil v. capacitive plates (superficial)
Effects
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Deep heat large area
If pulsed – tissue healing &  edema
Indications
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P!, mm spasm, shortened soft tissue, to  circulation
Contraindications & Precautions
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Metal, electronic devices, other equipment
Pregnancy, growth plates
Eyes, gonads, fat, acute inflammation, bleeding
 circulation or sensation
Procedures
 Remove metal…clean/inspect…position…towel wrap
20min…feel mild warmth for short wave
General Thermal Modalities
Concepts
Specific heat – water > skin > mm > fat > bone > metal
Conduction – heat from warm  cold 2o dir. Contact
o Rate depends on SA, conduct., temp dif, thickness
Convection – conduction but w/ circulating medium
o Hydrotherapy, fluidotherapy
Conversion – non-thermal energy  heat
o Ultrasound, diathermy
Radiation – heat transfer w/o medium or contact
o Infrared
o Rate depends on intens., source size, distance, angle
Evaporation – fluid vaporized by heat absorption
o Sweat, spray & stretch
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Vasodilation
o  O2, nutrients, waste removal, edema, inflame.
o Smooth mm relax, SNS activity
Neuromuscular
o  spasm, strength for 30min
o nn cond., P! threshold, strength from 30min-2hr
Metabolic
o  rate of healing, O2 input, inflammation
Connective Tissue
o  extensibility (plasticity from 40-44oC)
Indications
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Increase ROM…decrease stiffness
Decrease P! (gate &  ischemia)
Decrease mm spasm
Increase healing rate
For skin, scars, superficial mm & jt
Contraindications & Precautions
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Acute injury/inflammation
 circulation or  insufficiency
Hemorrhage, thrombosis
 sensory or mentation
Local CA, pregnancy, metal, topical agents
For whirlpool
o Maceration, bleed, infection, skin graft
For full body immersion
o  instab., infection, epilepsy, respir.prob., MS
Adverse Effects
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Burn (temp, duration, sensitivity)
Faintin
Bleeds
For whirlpool
o edema
For full body immersion
o Drowning, burns, fainting, infection, edema
Thermotherapy Types
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Hot pack – inspect skin…6-8 layers
Paraffin – dip wrap, dip immerse, pain…~20min
Fluidotherapy – corn blower…~20min +/- manual Tx
Hydrotherapy – whirlpool or full body immersion
Modalities Final Review
Infrared Therapy
Background Information
Ultraviolet Therapy
Background Information
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Contraindications & Precautions
Radiation lamp w/ 3 ’s (A, B, C)
Temperature – power, , distance, angle, skin color
Contraindications & Precautions
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See superficial heating modalities
LASER Therapy
Laser Background
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Monochromatic – single wavelength
Coherent – all have same path
Directional – doesn’t spread out
NONlaser Background (LED or SLD)
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Wider beam, larger area
Multi-frequency, less energy, more superficial
Lower cost
General Information
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Absorption – density, color, , f, angle, power
o Shallow & wounds – 3-4mm, visible red
o Deep – 30-40mm, infrared
High energy  great effective depth
Effects
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 ATP prod., tissue repair
Immune stimulation
P! control (serotonin & endorphins)
Vasodilation (N2O)
Indications
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Carpal tunnel, tendonitis (4-8J/cm2  <30J/cm2)
Wounds (4-24J/cm2)
Pain (10-12J/cm2)
Trigger point (10-20J/cm2)
Arthritis (2-4J/cm2  4-8J/cm2)
Scars
Hematomas
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Eyes, thyroid, endocrine glands
Pregnancy, growth plates
Cancer
Photophobia, light sensitivity
Procedures
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Directly to lesion or P! site
Nerve root or trunk
Trigger points & tender sites
Acupuncture points
Eyes; photosensitivity
CA, TB, Dz, kidney Dz, liver Dz, SLE, fever
Recent radiation
Wait for prior dose’s effects to disappear
Ultrasound
Background Information
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Intensity (W/cm2) – rate & depth of heating
Frequency (MHz) – depth…as f , depth 
Duty cycle – continuous v. pulsed ( heating)
Effective radiating area – Tx = 2x size of soundhead
BNR – high  chance of burn
Indications for Thermal Ultrasound
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Before stretch,  circulation,  P!
To  heating… intensity &/or  frequency
CAREFUL… circulation increases heating rate
Parameters for Thermal Ultrasound
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Deep – 1MHz, continuous, 1.5-2 W/cm2, 10min
Superficial – 3MHz, continuous, .5-.75 W/cm2, 10min
Mechanisms for NONthermal Ultrasound
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Stable cavitation – air bubbles oscillate in size
Microcurrents – fluid around bubbles “stirred up”
Acoustic streaming –  fluid mvmt in the cell
Cell activation &  Ca2+ in cell
 collagen production
Mast cell release of histamine & chemotactic factors
 drug penetration of skin
Indications for NONthermal Ultrasound
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Contraindications & Precautions
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UVA (320-400nm) UVB (290-320nm) UVC (<290nm)
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Tissue healing
o Tendon – low-level pulsed
o Wound – 20%, .5-.75W/cm2
o Fx Healing – 20%, .15-.25W/cm2, 15-20min/day
Inflammation modulation
Phonophoresis – 20% .5-.75W/cm2, 3MHz
Parameters for NONthermal Ultrasound
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Deep – 1MHz, 20%, .5-.75W/cm2, 10min
Superficial – 3MHz, 20%, .5-.75W/cm2, 10min
Contraindications & Precautions for BOTH types
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Malignancy, thrombus, infection, abscess
Pregnancy, growth plates
CNS tissue, eyes, gonads
Cement, polyethelene
Pacemaker
For thermal ultrasound
o  circulation/sensation, breast implant, Fx
Modalities Final Review
Soft Tissue Mobilization
Taping
Assessment
General Taping Tips
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Observe alignment, symmetry, bulk, guarding, temp
Heavy-handed, confident 1st contact
Superficial & deep tension levels
General Massage Techniques
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Effleurage – no deep movement…good warm-up
Skin-rolling – grasp & lift tissue…good for scars
Petrissage – lift & wring tissue…kneading motion
Stroking/Stripping – deep…targets mm
Cross-friction – like stroking…breaks adhesions
Contraindications for Massage
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Systemic infection or disease
Open skin wounds
Active cancer or DVT condition
Effects
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P!
o Psychological
o Neurological (gate, vagus nn, endorphins)
o Local ( flow,  scar/adhesion)
o Indirect ( deep sleep)
 edema
o  blood, lymph, synovial, interstitial flow
 spasm
o Involuntary contrxn   tension,  length
 circulation
o Affects lymphatic > local vv/aa
o inflammation…nutrients/healing rate
 mobility
o Addresses  length, adhesions, contractures
o With immobility, get strength (mm & tt)
 elasticity
o Creep deformation – slow, gradual stretch
Prevent adhesions
o Inflammatory phase –  edema & pain
o Regeneration phase –  excess crosslinks
o Remodeling phase –  scar tissue
Promote functional healing
o Heal under mvmt  better formation to handle it
Soft Tissue Mobilization Variables
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Location – more acute  work distally
Direction – acute to lesion v. chronic to stretch
Contact surface – acute  broad hand
Depth to tolerance
Force – less for acute
Time – less with greater force
Amplitude
Rhythm
Rate – fast & short for chronic
No tension at tape ends
Take Pt through painfree ROM before taping
Tension variations
o Edema – 0-10% of stretch removed
o Mm – 20-50% of stretch removed
o Ll – 75-100% of stretch removed
Athletic Tape Rules
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Overlap ½ of width
Do in strips…NOT continuous
Smooth & mold to fit contours
McConnel Tape Rules
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Wash w/ alcohol & dry skin
Cover roll
Leukotape w/ directional force…expect small wrinkles
Left on as long as there’s no irritation
DON’T rip off quickly…toughen skin w/ alcohol
Kinesiotape Rules
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Waterproof, breathable, hypoallergenic
Worn for multiple days
Adhesive is heat-activated
DON’T touch adhesive, to the extent possible
Effects
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 P! – unloading & gate
 edema – helps lymphatics
 mm function – proprio., strength, stability, endurance
 ROM
Mm inhibition – proprioception of stretch,  spasm
Modalities Final Review
Electrical Stimulation
Stimulated v. Volitional Contractions
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Large  small v. small  large neuron recruitment
Fast  slow v. slow  fast fiber recruitment
Synchronous v. asynchronous firing
Tension  by recruitment v. recruitment & firing rate
Ortho & antidromic v. orthodromic only
Activation Pattern Determinants
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Fiber diameter (larger = more myelinated)
 amplitude   number & depth of stimulation
o Preferentially target fast-twitch
o Cutaneous afferents 1st, then motor response
Current
o Density greater superficially
o Density greater w/ small electrodes
o Far-spaced electrodes for deep penetration
General Considerations
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Cathode (–), anode (+)
Long on-time  fatigue & P!…4on:12off ratio standard
o Longer  less current needed… nn recruitment
High frequency  fatigue, but better sensory drive
o 35+pps for tetanic contraction
Wave Nomenclature
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DC v. AC v. pulsed
Interferential (P!, edema), high voltage (50-100sec),
Russian (NMES)
Monophasic v. biphasic
Symmetric (300sec, glute/ham/quad…= depolarize.) v.
asymmetric (all other mms…1 o elect’d on motor point)
Contraindications & Precautions
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Pacemaker, arrhythmia,  cond. prob., surface metal
 active contrxn
Fetus
Open wound, fragile skin, surg incision site
Active tumor, DM, LMN injury, epilepsy, ANS dysrefl
Over carotid sinus
NMES for obese or adult trunk mm >3/5 contrxn
NMES programs
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Strengthening & Endurance
o 60% MVIC…comfort f…10:50…15reps
o 3+/5…35pps…4:12…30-60’ on time
Facilitation / Re-education – bombard CNS w/ info
o 3+/5…35pps…trigger or 4:12…10-30’/2-3x/day
o 3+/5…35pps…trigger or comfy…10-30’/1-2x/day
ROM / Contracture management
o 3+/5…35pps…4:12 or  spas…60-90 / 200 reps
Spasticity management
o Recip Inhib –  3+/5…35pps…4:12…good 20-30’
o Rens Inhib – 3+/5…35pps…4:12…good 20-30’
Edema management – mm pump (can do bucket Tx)
o 1-3/5…35pps w/ 4:12 or 1-2pps w/ cont…frequent
Shoulder subluxation – p CVA
o 12-20pps…4:12…30’x3  6-8hrs/day
o 2012pps…4:1224:2…6-8hrs/day
Electroanalgesia
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Acute – gating (<2mo)
o 50-200pps…20-100sec…sensory…modul…15’
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Motor for chronic P! / spasm (>2mo)
o For P!
 1-5pps…250-300sec…motor…45-60min
o For spasm
 35pps…>100sec…motor…cycled…30-60min
Noxious for chronic (>6mo) / phantom P!
o 1-5pps…500sec…noxious…8-12pts 15-30sec
Iontophoresis
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Screen for allergies & EStim contraindications
Effectiveness
o # ions transferred
 Current density, duration, intensity, [ions], skin
resistance
o Depth of penetration – 3-20mm
o Don’t want ions to become inactive
o Don’t want ions picked up by capillaries
Main ions used
o Dexamethasone (+ or –)…anti-inflammatory
o Lidocaine (+)…analgesia
Current considerations
o Density greater w/ smaller electrodes
o Caustic reaction at cathode (–)
o 65mAmin dose for efficacy
o Adjust current SLOWLY!!!
Wound Healing (50-60%  closure rate)
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For DM or SCI Pts
 O2, fibroblasts
Current of Injury
Low intensity DC or high voltage
o DC…<1mA…1-2hr/2x/day
Circulation Improvement
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Wound care, CRPS, Reynaud’s Dz Pts
Mechanisms
o Reflex activation of ANS
 2-150sec…50-150pps…sens, pulsed…45min
o Pumping via mm contraction (RHYTHMIC)
 >100sec…<35pps…10% MVIC…10min