Chapter 15
Extended Lecture Outline
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Legal Concerns
 Specific laws governing the use of therapeutic modalities vary considerably from state to
state
Classification of Therapeutic Modalities
 Electromagnetic modalities: Therapeutic agents that emit or produce similar types of
energy (cryotherapy, thermotherapy, electrical stimulating currents, short-wave
diathermy and the low-powered laser)
 All forms of electromagnetic energy travel at 300 million meters per second in a vacuum
 Energy waveforms travel in a straight line
 When comes in contact with human tissue it can be reflected, refracted, absorbed or
transmitted
 In human tissue the energy must be absorbed before any physiological effects can take
place
 Acoustic modalities: Ultrasound therapy
 Relies on molecular collisions for energy transfer
 Ultrasound travels best in more dense tissues in the form of a wave of vibration
propagated through the entire medium
 Vibration of the tissues produces heat and also effects changes in cell membrane
permeability that can aid in tissue healing
 Mechanical modalities (traction, intermittent compression and massage)
 Mechanically stretch, compress and manipulate soft tissue and/or joint structures
Electromagnetic Modalities
o Thermotherapy
 Application of heat to treat disease and injuries
 Physiological Effects of Heat (See Table 15-1)
 Body’s response to heat is dependent upon type of heat energy applied, the intensity,
the duration and the unique tissue response to heat
 Heat must be absorbed into the tissues for physiological response to occur
 Desired therapeutic effects: increased extensibility of collagen tissue, decreased joint
stiffness, reduced pain, relieved muscle spasm, reduced inflammation, edema and
exudates in the post-acute phase of healing and increased blood flow
 Relieves pain via the gate control theory of pain modulation (Chapter 10)
 Thermal energy is transmitted through conduction, convection, radiation and
conversion
 Conduction
o Heat is transferred from a warmer object to a cooler one
o Ratio of heat exchange is dependent upon the temperature and the
exposure time
o Moist hot packs, paraffin baths, electric heating pads, ice packs and
cold pack
 Convection
o Transference of heat through the movement of fluids or gases
o Factors influencing convection heating are temperature, speed of
movement, and conductivity of the part
o Whirlpool baths
 Radiation
o Heat energy is transferred from one object through space to another
object
o Shortwave and microwave diathermy, infrared heating and ultraviolet
therapy
 Conversion
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Generation of heat from another energy form such as sound, electricity,
and chemical agents.
o Ultrasound therapy, chemical agents (liniments, and balms)
 Hydrocollator Packs
 Use results in general relaxation and reduction of the pain-spasm-ischemiahypoxia-pain cycle
 Deeper tissues are not heated – inhibited by subcutaneous fat
 Treat area for 15-20 minutes
 Patients should not lie on the packs
 Whirlpool Baths
 Combination of massage and water immersion
 Three types of whirlpools (extremity tanks, lowboy tank, highboy tank)
 Provides both conduction and convection
 Assists the body part by reducing swelling, muscle spasm and pain
 Water temp set according to table 15-2
 Contraindicated in acute injuries – full body immersion should not be done at
temperatures exceeding 104 degrees
 Paraffin Bath
 Used to apply heat to distal extremity
 Especially effective in treating angular areas of the body as the hands, wrists,
elbows, ankles and feet
 Body part can be dipped and wrapped in a plastic bag or dipped and immersed
to form eight to ten layers
 Fluidotherapy
 Creates a therapeutic environment with dry heat and forced convection through
a suspended airstream
 Results in decreased pain, increased joint range of motion and decreased spasm
and swelling
Cryotherapy
 Physiological Effects of Cold (See Table 15-4)
 Most common method for cold transfer to tissue is through conduction
 The longer the cold exposure the deeper the cooling
 Vasoconstriction of arterioles and venules in area occurs
 Hunting response: causes a slight increase in temperature during cooling –
reaction against tissue damage from too much cold exposure
 Immediate use of ice after injury decreases the extent of ischemic injury to those
cells on the periphery of the primary injury by slowing their metabolic rate –
swelling will be reduced in the acute inflammatory response
 Decrease muscle spasm by slowing metabolism in the area – decreasing waste
products that act as muscle irritants and cause spasm
 Skin response to cold (see Table 15-3)
 Analgesia caused by raising the nerve’s threshold
 Cold is more penetrating than heat, decreases muscle fatigue and increases and
maintains muscular contraction
 Wet ice is more effective coolant because of the extent of internal energy needed
to melt the ice – melting ice is more effective at lowering skin and intramuscular
temperatures
 Adverse reactions to cold (Focus Box 15-1)
 Raynaud’s phenomenon: vasospasm of digital arteries lasting form minutes to
hours, which could lead to tissue death
 Nerve palsy
 Ice Massage
 Cold or Ice Water Immersion
 Ice Packs (Bags)
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 Vapocoolant Sprays
 Cryokinetics (combines exercise with application of cold, see focus box 15-2)
Electrical Stimulating Currents
 Physical Properties of Electricity
o Implies a flow of electrons between two points
o Amperes: volume or amount of current
o Ohms: resistance to the passing of an electrical current along a
conductor
o Voltage: the force that moves the current along
o Watts: measure of electrical power
o An electrical current applied to nerve tissue at a sufficient intensity and
duration to reach that tissues excitability threshold will result in
membrane depolarization or firing of the nerve
o Three types of nerve fibers (sensory, motor, and pain)
o Threshold of depolarization reaches sensory fibers first, then motor
fibers and then pain fibers
 Equipment
o Three types of current: monophasic, biphasic and pulsatile
o All are transcutaneous electrical stimulators (TENS, NMES, EMS,
MENS and LIS)
 Monophasic (Direct) Current
 Flows in one direction from the positive pole to the
negative pole
 May be used for pain modulation or muscle
contraction or to produce ion movement
 Biphasic (Alternating) Current
 Direction of flow reverses itself once during each
cycle
 Used for pain modulation or muscle contraction
 Pulsatile Current
 Contain three or more pulses grouped together
 Pulses are interrupted for short periods of time and
repeat themselves at regular intervals
 Used in interferential and Russian currents
 Current Parameters
 Waveforms
o Modulation
o Intensity
o Duration
o Frequency
o Polarity
o Electrode Set-Up
 Indications
o Produce depolarization of sensory nerves for the purpose of modulating
pain
o Produce a depolarization of motor nerve fibers to elicit a muscle
contraction
o Create an electrical field to the biological tissues to stimulate or alter
the healing process at the cellular level
o Create an electrical field on the skin surface to transport ions beneficial
to the healing process into the deeper target tissues
 Application
o Pain Modulation
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Gate Control: stimulation of the sensory nerves will evoke the
gate control mechanism and decrease awareness of painful
stimuli
 Descending Pain Control: intense stimulation of the smaller
pain fibers at trigger and acupuncture points for short period
of time causes stimulation of descending neurons which affect
transmission of pain by closing the gate at the spinal cord level
 Opiate Pain Control Theory: Stimulation of sensory nerves
releases enkephalin from local sites throughout the central
nervous system and the release of β-endorphins form the
pituitary gland into the cerebral spinal fluid
o Muscle Contraction
 Muscle Pumping: used to stimulate circulation (high voltage
monophasic current – intensity is muscle contraction –
frequency 20-40 pps – surged mode
 Muscle Strengthening: used to facilitate strength gains (highfrequency biphasic current – intensity is muscle contraction –
frequency 50-60 pps – surging current
 Retardation of Atrophy: used to minimize atrophy and loss of
muscle function that occurs with immobilization (Highfrequency biphasic current – intensity increased to 30-60 pps –
interrupted current mode
o Muscle Re-education: used to reduce muscle inhibition after surgery or
injury (30-50 pps using either interrupted or surged current)
 Iontophoresis
o Chemical ions are transported through the intact skin using an electrical
current
 Interferential Currents
o Make use of two separate electrical generators that emit currents at two
slightly different frequencies, currents cross one another creating an
interference pattern at a central point of stimulation
o 20-25 pps for muscle contraction and 50-120 pps for pain management
 Low-Intensity Stimulators
o Microcurrent electrical nerve stimulators (MENS) – deliver current to
the patient at a very low frequency (1pps) and at extremely low
intensities (less than 1 milliamp) that are subsensory
o Based on theory, little research information to support its use
o Shortwave Diathermy
 Physiological Effects of Diathermy
 Produces temperature increases in the deeper tissues
 Used in two ways: through a condenser that uses electrostatic field heating or
through electromagnetic or induction field heating
 Shortwave Diathermy Treatments
 Equipment
 Indications
 Application
 Special Considerations
o Low-Level Laser Therapy (Light amplification by stimulated emission of radiation)
 Equipment
 Indications
 Application
 Special Considerations
Acoustic Modalities
o Ultrasound Therapy
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Deep heating modality – stimulates the repair of soft-tissue injuries and relieves
pain
 Form of acoustic rather than electromagnetic energy
 May produce thermal and non-thermal physiological effects
 Tissue penetration depends on impedance or acoustical properties of the media
that are proportional to tissue density – the greater the impedance the greater the
reflection, and the more heat produced (greatest heat is developed between bone
and adjacent soft-tissue interface)
Therapeutic Ultrasound
 Equipment
 Piezoelectric effect: causes expansion and contraction of the
crystals in the soundhead which produces oscillation voltage
o Frequency
 1 MHZ frequency – transmits through superficial tissues and
is absorbed in the deeper tissues at depths of 3-5 cm. Useful in
individuals with high percent of body fat and to reach deeper
structures
 3MHZ frequency – energy absorbed in superficial tissues – 12 cm
o Ultrasound beam
 Effective radiating area: portion of the surface of the
ultrasound transducer that produces the sound wave
 BNR (beam nonuniformity ratio): Amount of variability of
intensity in the beam – the lower the BNR the more uniform
the energy output, optimally should be 1:1
o Intensity
 Determined by the amount of energy delivered to the sound
head (applicator)
 Expressed in watts per square centimeter
o Pulsed vs. Continuous Ultrasound
 Continuous: intensity remains constant throughout the
treatment and the energy is produced 100% of the time: used
for thermal effects
 Pulsed: intensity is periodically interrupted and no ultrasound
energy is produced during the off period
 Duty Cycle: percentage of time that ultrasound is being
generated
 Indications
o Thermal versus nonthermal effects
 Application
o Direct skin application
o Underwater application
o Gel pad technique
o Moving the transducer
o Dosage and treatment time
 Special Considerations
o Ultrasound in Combination with other Modalities
o Hot packs and ultrasound
o Cold packs and ultrasound
o Ultrasound and electrical stimulating currents for trigger points and
acupuncture points
Phonophoresis
 Method of transporting molecules through the skin using the mechanical
vibration of the ultrasound
 Designed to move medication into injured tissues
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 Effectiveness is questionable and needs further research
Mechanical Modalities
o Traction
 Physiological Effects
 Used to produce separation of the vertebral bodies – stretches the ligaments and
joint capsules of spine
 Relieves pressure on nerves and nerve roots, decreases central pressure of the
intervertebral disks
 Indications
 Application
 Manual Traction
 Mechanical Traction
 Positional Traction
 Wall-Mounted Traction
 Inverted Traction
 Special Considerations
o Intermittent Compression
 Equipment
 Indications
 Application
 Special Considerations
 Game Ready Accelerated Recovery System
o Massage
o Therapeutic Effects of Massage
 Indications
 Mechanical Responses
o Encourage venous and lymphatic drainage
o Mildly stretch superficial and scar tissue
 Physiological Responses
o Increase circulation, increase metabolism to musculature and aid in
removal of metabolites such as lactic acid
o Helps to overcome venostasis and edema
o Induces reflex responses of relaxation, stimulation and increased
circulation
 Psychological Responses
 Application: Massage Strokes broken down into 5 categories
 Effleurage
o Stroking variations (hand-over-hand and cross-body method)
 Petrissage
o Adaptable primarily to loose and heavy tissue areas such as trapezius,
latissimus dorsi or triceps muscles
o Consists of picking up the muscle and skin tissue between thumb and
forefinger and rolling and twisting tissue in opposite directions
 Friction
o 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
 Tapotement
o Most popular methods include cupping, hacking and pincing
movements
 Vibration
o Rapid movement that produces a quivering or trembling effect
o Machine vibration is usually preferred
 Special Considerations
 Massage lubricants
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 Positioning the patient
 Confidence
 Ensuring patient privacy and athletic trainer integrity
 Guidelines for and Effective Massage (Focus Box 15-4)
 Deep Transverse Friction Massage
 Indications
 Application
 Special Considerations
 Acupressure Massage
 Indications
 Application
 Special Considerations
Modalities Not Commonly Used by Athletic Trainers
o Magnet Therapy
o Extracorporeal Shock Wave Therapy (ESWT)
Recording Therapeutic Modality Treatments
Safety in Using Therapeutic Modalities (Focus Box 15-5)
Evidence-Based Data Regarding Therapeutic Modality Use