Chapter 15: Therapeutic
Modalities
• 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
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
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
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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
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
• 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)
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
• 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
• 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
– 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
• 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
– 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)
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
• 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
• 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
• 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
• 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
• 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
• 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
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
– 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
• 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
• 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)
• 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
• 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
• 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
• 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
• 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
• 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
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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
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)
• 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
– 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
• 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
– 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
– 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
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)
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
Electrotherapy
• Physical Principles
– Electricity displays magnetic, chemical,
mechanical, and thermal effects on tissue
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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
• 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
• 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
– 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
• 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
• 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; 10:50 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
• 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
• 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
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
• 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
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
Stroking Variations
• Petrissage
– Kneading
– Involves picking up
skin between thumb
and forefinger, rolling
and twisting in
opposite directions
– Used for deep tissue
work
• 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
– 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
• 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
• 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
• 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
• 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
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
• Indications
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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
– 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