Chapter 15: Therapeutic
Modalities
• Read Use of Modalities/Choosing a
Modality/Methods of Heat Transfer (pgs
22-3 to 22-4)
• Therapeutic modalities can be an effective
addition to various techniques of therapeutic
exercise.
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.
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.
• RICE (rest, ice compression, elevation) may be
used for the initial days of and injury and lasting
up to 2 weeks after injury.
• Most common means of cold therapy are ice packs
and ice immersion
Phases of Sensation
1. A cold sensation lasting 0-3 minutes.
2. Mild burning and aching lasting 2-7
minutes.
3. Relative numbness lasting 5-12 minutes.
• Physiological Principles
– Vasoconstriction
– 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
– Cold is more penetrating than heat.
Guidelines for Cryotherapy
• Except for ice massage, use a barrier such as a towel to
protect skin form frostbite.
• Never apply any form of cold on an open wound without a
protective covering.
• Never apply any form of cold to anesthetized skin.
• Except for vapo-coolant sprays, do not apply cryotherapy
to patients with decreased circulation, diabetes, or cardiac
conditions.
• Some individuals are allergic to cold and react w/ hives
and joint pain
Guidelines Cont.
• Montior the patients for signs of cold
allergy, or Raynaud’s Phenomenon (pg 226)
• Applications should not exceed 30 minutes!
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
• Cold or Ice Water Immersion (pg 22-10)
– 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 through the
stages of cold response
• Treatment may last 10-15 minutes
• Once numb body part can be removed from
immersion, 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) (pg 22-7)
– 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 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
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
• decreasing joint stiffness; reducing pain; relieving
muscle spasm; reduction of edema and swelling;
increasing blood flow
• 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 (pg 22-16)
– 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 (pg 22-12)
– 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
– 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 (pg 22-18)
– 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 (pg 22-13)
– 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 (pg 22-16)
– Equipment
• Unit which contains cellulose particles through which
warm air is circulated (dry whirlpool!)
• 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
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)
– 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
– Acute conditions require more treatments over a
shorter period and chronic conditions require
fewer treatments over a longer period
– Dosage and Time
• Varies according to depth of tissue to be treated and
the state of injury
• Duration tends to last 5-10 minutes
– 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
Guidelines for Electrical
Modalities
•
•
•
•
•
Follow MDs order.
Make sure equipment is in working order.
Explain the procedure to the client.
Expose the area to be treated.
Cleanse the treatment area with soap and water
and dry.
• Place electrode pads according to the manuf.
Directions.
• Turn off the channel before you remove the
electrodes.
Cont.
• Never use on an open wound.
• Do not use on a person with a pacemaker
without MD order.
• Avoid high fluid areas.
• Do not put over carotid arteries.
• Do not use on trunk of a pregnant women.
• Stop the treatment if it increases pain.
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
• 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
EMS
• Used to re-educate injured or impaired
muscles, slow the effects of atrophy, and
increase the strength of healthy muscles
through electrical stimulation. The pads are
placed on the skin at both ends of the
muscle. Wires are attached to the pads and
to the control unit.
TENS
• Used to block the sensation of chronic or
acute pain. Often, a 30-minute to one-hour
application will relieve pain for hours after
the treatment. The use of TENS will allow
the patient to perform therapeutic exercise
without pain.
Diathermy
• Uses high frequency electrical current to heat the
body’s tissue. It will increase the blood flow and
tissue metabolism. It also decreases deep muscle
spasms. It is used for chronic strains, sprains,
limited ROM, sub-acute inflammations (bursitis,
epicondylitis, tendonitis, arthritis).
• Avoid growth plates, open wounds, malignancy,
and areas with limited circulation.
• Ionotophoresis
– Chemical ions are transported through intact skin
using electrical current -- used to treat skin infections
or to produce a counterirritant effect
– Pads and wires are used to connect the patient to the
machine. One pad delivers the medication and the
other pad serves as a ground
– Can be used for superficial tendonitis and bursititis
to decrease edema, inflammation and pain.
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
• 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
• 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