Chapter 15:
Therapeutic Modalities
Therapeutic Modalities

In any rehabilitation program, modalities
should be used primarily as adjuncts to
therapeutic exercise and certainly not at
the exclusion of range-of-motion or
strengthening exercise.
Transmission of Thermal Energy

Conduction

Convection

Radiation

Conversion
Heating through direct contact
with a hot medium (e.g., hot
pack).
Heating indirectly through
another medium such as air or
liquid (e.g., whirlpool)
Transfer of heat through space
from one object to another (e.g.,
ultraviolet therapy)
Heating through other forms of
energy (e.g., ultrasound)
Cryotherapy

Application of cold; the major therapeutic
value of cold is its ability to produce
anesthesia, allowing pain-free exercise.
Cold as a therapeutic agent is a type of
electromagnetic energy classified as
infrared radiation. Wet ice is a more
effective coolant because of the extent of
internal energy needed to melt the ice.
Hunting Response

Causes a slight temperature increase
during cooling. The extent of cooling
depends on the thickness of the
subcutaneous fat layer.
Skin Response to Cold

Stage
1

Response
– Cold sensation

Estimated Time after Initiation
– 0 to 3 minutes
Skin Response to Cold

Stage
2

Response
– Mild burning, aching

Estimated Time after Initiation
– 2 to 7 minutes
Skin Response to Cold

Stage
3

Response
– Relative cutaneous anesthesia

Estimated Time after Initiation
– 5 to 12 minutes
Physiological Variables of
Crotherapy








Variable
Response to Therapy
Muscle spasm
Decreases
Pain perception
Decreases
Blood flow
Decreases
Metabolic rate
Decreases
Collagen elasticity
Decreases
Joint stiffness
Increases
Capillary permeability
Decrease
Edema
Controversial
15 to 30 minutes
Ice Massage
Cold or Ice Water Immersion
Ice Packs (Bags)
Cold Whirlpool
Hot Whirlpool
15 to 30 minutes
Paraffin Bath
Thermotherapeutic
126°F to 130°F
C
C
I
C
C
15 to 30 minutes
Cryotherapeutic
50°F to 60°F
Hydrotherapy
15 to 30 minutes
Cryotherapeutic
I
I
I
C
C
I
C
C
C
I
I
I
C
C
I
C
C
C
C
C
C
C
C
C
C
Moist Heat Packs (Hot Packs)
I
I
I
I
C
C
C
I
I
C
I
I
I
I
C
I
I
I
I
C
I
I
C
C
C
C
I
I
C
I
C
C
I
C
C
C
I
I
I
I
C
I
C
Cryotherapeutic
I
I
C
C
I
I
C
C
15 to 30 minutes
C
Cryotherapeutic
50°F to 60°F
Hydrotherapy
15 to 30 minutes
I
Thermotherapeutic
15 to 30 minutes
C
Thermotherapeutic
96°F to 104°F
Hydrotherapy
C
Acute Conditions
Uncovered Open Wounds
Suspected Fractures
Subacute Muscle Spasm
Subacute Injury
Subacute Inflammation
Small Areas
Skin Conditions/Infections
Sensory Loss
Respiratory Involvement
Requiring Postural Support
Reduction of Subacute Pain
Reduction of Joint Contractures
Pressure Contraindications
Post-Surgical Pain
Post-Surgical Edema
Poor Thermal Regulation
Peripheral Vascular Disease
Peripheral Nerve Injuries
Muscle Strain
Infection
Hematoma Resolution
Fever
Distal Body Parts
Decreased Range of Morion
Contusions
Cold Hypersensitivity
Cold Allergy
Circulatory Insufficiencies/Impairment
Chronic Pain
Chronic Muscle Spasm
Chronic Inflammation
Cardiac Involvement
Anesthetized Skin
Acute Problems to Turbulence
Acute Problems to Gravity
Acute Pain
Acute Injury
Acute Inflammation
Cryotherapeutic Methods
Ice Massage
 Duration: 10 to 15
minutes
Indications:
 small muscle areas
 subacute injury
 subacute inflammation
 muscle strain
 Contusions
 acute pain
 chronic pain
Contraindications
 pressure
contraindications
 suspected fractures
 uncovered open wounds
 circulatory insufficiency
 cold allergy
 cold hypersensitivity
 anesthstized skin
Cryotherapeutic Methods
Cold or Ice Water
Immersion
 Duration: 10 to 20
minutes
 Temp: 50°F to 60ºF
Indications:
 Distal body parts
 Acute injury
 Acute inflammation
 Acute pain
 Chronic pain post-surgical
pain
 Post-surgical edema







Contraindications
Cardiac involvement
Respiratory involvement
Uncovered open wounds
Circulatory insufficiency
Cold allergy
Cold hypersensitivity
Anesthetized skin
Cryotherapeutic Methods
Ice Packs (Bags)
 Duration: 15 to 30
minutes
Indications:
 Acute injury
 Acute inflammation
 Acute pain
 Chronic pain
 Post-surgical pain
 Post-surgical edema
Contraindications
 Cardiac involvement
 Respiratory involvement
 Uncovered open wounds
 Circulatory insufficiency
 Cold allergy
 Cold hypersensitivity
 Anesthetized skin
Cryotherapeutic Methods







Cold Whirlpool
Duration: 5 to 30 minutes
Temp: 50°F to 60°F
Indications:
Subacute inflammation
Chronic inflammation
Peripheral vascular
disease
Peripheral nerve injuries
Distal body parts
Contraindications
 Acute problems to turbulence
 Acute problems to gravity
 Requiring postural support
 Skin conditions
 Cardiac involvement
 Respiratory involvement
 Uncovered open wounds
 Circulatory insufficiency
 Cold allergy
 Cold hypersensitivity
 Anesthetized skin
Cryotherapeutic Methods
Cryokinetics

Combines cryotherapy with exercise
Thermotherapy

Application of heat; Heat has the capacity
to increase the extensibility of collagen
tissue.
Physiological Variables of
Thermotherapy








Variable
Response to Therapy
Muscle spasm
Decreases
Pain perception
Decreases
Blood flow
Increase
Metabolic rate
Increase
Collagen elasticity
Increase
Joint stiffness
Decrease
Capillary permeability
Increase
Edema
Increase
Comparing the Physiological Variables
of Crotherapy and Thermotherapy








Variable
Muscle spasm
Pain perception
Blood flow
Metabolic rate
Collagen elasticity
Joint stiffness
Capillary permeability
Edema
Response to
Cryotherapy
Decreases
Decreases
Decreases
Decreases
Decreases
Increases
Decreased
Controversial
Response to
Thermotherapy
Decreases
Decreases
Increases
Increases
Increases
Decreased
Increases
Increases
Thermotherapy






Special Considerations in the Use of Superficial
Heat
Never apply heat when there is a loss of
sensation
Never apply heat immediately after an injury
Never apply heat when there is decreased
arterial circulation
Never apply heat directly to the eyes or genitals
Never heat the abdomen during pregnancy
Never apply heat to a body part that exhibits
signs of acute inflammation
Thermotherapy
Superficial tissue is a poor thermal conductor
 temperature rises quickly on the skin surface as
compared with the underlying tissues
 There are limitations of superficial tissue
 The deeper tissues, including the musculature,
are not significantly heated because the heat
transfer from the skin surface into deeper
tissues is inhibited by the subcutaneous fat,
which acts as a thermal insulator, and by the
increased skin flow, which cools and carries
away the heat externally applied.

Thermotherapeutic Methods
Moist Heat Packs (Hot Packs)
 Duration: 20 to 30 minutes
Indications:
 Subacute inflammation
 Chronic inflammation
 Reduction of subacute pain
 Reduction of chronic pain
 Subacute muscle spasm
 Chronic spasm
 Decreased range of motion
 Hematoma resolution
 Reduction of joint contractures
 Infection
Contraindications
 Acute conditions
 Peripheral vascular
disease
 Impaired circulation
 Poor thermal
regulation
Thermotherapeutic Methods
Hot Whirlpool
 Duration: 5 to 30 minutes
 Temp: 96°F to 104°F
Indications:
 Subacute inflammation
 Chronic inflammation
 Peripheral vascular disease
 Peripheral nerve injuries
 Distal body parts
Contraindications
 Acute problems to
turbulence
 Acute problems to gravity
 Fever
 Requiring postural support
 skin conditions
Thermotherapeutic Methods





Paraffin Bath
Duration: 15 to 30 minutes
Temp: 126°F to 130°F
Indications:
Subacute inflammation
Chronic inflammation
Limited range of motion
after immobilization




Contraindications
Open wounds
Skin infection
Sensory loss
Peripheral vascular
disease
Hydrotherapy Methods
Contrast Bath
 Duration: 20 to 30 minutes
 Temp: 50°F to 60°F:96°F to
104°F
Indications:
 Ecchymosis removal
 Edema removal
 Subacute inflammation
 Chronic inflammation
 Impaired circulation





Contraindications
Acute injuries
Cold hypersensitivity
Whirlpool
contraindications
Cold application
contrindications
Hot application
contrindications
Hydrotherapy Methods







Cold Whirlpool
Duration: 5 to 30 minutes
Temp: 50°F to 60°F
Indications:
Subacute inflammation
Chronic inflammation
Peripheral vascular
disease
Peripheral nerve injuries
Distal body parts
Contraindications
 Acute problems to turbulence
 Acute problems to gravity
 Requiring postural support
 Skin conditions
 Cardiac involvement
 Respiratory involvement
 Uncovered open wounds
 Circulatory insufficiency
 Cold allergy
 Cold hypersensitivity
 Anesthetized skin
Hydrotherapy Methods
Hot Whirlpool
 Duration: 5 to 30 minutes
 Temp: 96°F to 104°F
Indications:
 Subacute inflammation
 Chronic inflammation
 Peripheral vascular disease
 Peripheral nerve injuries
 Distal body parts
Contraindications
 Acute problems to
turbulence
 Acute problems to gravity
 Fever
 Requiring postural support
 skin conditions
Acoustic Therapy:
Ultrasound
Relies on molecular collision for
transmission.
 Ultrasound is a mechanical wave in which
energy is transmitted by the vibrations of
the molecules of the biological medium
through which the wave is traveling.

Acoustic Therapy:
Ultrasound

Ultrasound has both thermal and nonthermal effects.
Acoustic Therapy:
Ultrasound
When used for thermal changes, nonthermal changes also occur.
 For the majority of thermal effects to
occur, the tissue temperature must be
raised to a level of 104°F to 113°F for a
minimum of five minutes.
 Temperatures below this range will be
ineffective.

Acoustic Therapy:
Ultrasound

Non-thermal effects of ultrasound are
cavitation and acoutsic microstreaming.
Acoustic Therapy:
Ultrasound
Cavitation is the formation of gas-filled
bubbles that expand and compress
because of ultrasonically induced pressure
changes in tissue fluids.
 Cavitation results in an increased flow in
the fluid around these vibrating bubbles.

Acoustic Therapy:
Ultrasound
Microstreaming is the unidirectional movement
of fluids along the boundaries of cell membranes
resulting from the mechanical pressure wave in
an ultrasonic field.
 Microstreaming can alter cell membrane
structure and function because of changes in cell
membrane permeability to sodium and calcium
ions important in the healing process.
 As long as the cell membrane is not damaged,
microstreaming can be of therapeutic value in
accelerating the healing process.

Acoustic Therapy:
Ultrasound
The non-thermal effects of therapeutic
ultrasound in the treatment of injured tissues
may be as important as the thermal effects and
perhaps are even more important.
 The non-thermal effects of cavitation and
microstreaming can be maximized while the
thermal effects are minimized by using an
intensity of 0.1 to 0.2 W/cm² with continuous
ultrasound or 1.0 W/cm² at a duty cycle of 20
percent (pulsed).

Acoustic Therapy:
Ultrasound
Ultrasound energy generated at a frequency of 1
MHz is transmitted through more superficial
tissues and absorbed primarily in the deeper
tissues at depths of 3 to 5 cm.
 A 1 MHz frequency is most useful in individuals
with high percent body fat and whenever the
desired effects are in the deeper structures.
 At a frequency of 3 MHz the energy is absorbed
in the more superficial tissues with the depth of
penetration between 1 and 2 cm.

Acoustic Therapy:
Ultrasound

1 MHz
Deeper Tissues

3 MHz
Superficial Tissues
20
20
15
15
10
10
5
5
0
0
-5
1
5
9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73
-5 1
-10
-10
-15
-15
-20
-20
6 11 16 21 26 31 36 41 46 51 56 61 66 71
Acoustic Therapy:
Ultrasound




Frequency of Treatment
Acute injuries require more frequent treatments
over a shorter period of time (pulsed duty
cycle).
Chronic conditions require fewer treatments over
a longer period of time (continuous duty cycle).
Should begin as soon as possible after the injury
(at least within 48 hours).
Treatments should be limited to no more than
14 treatments then avoid ultra sound for two
weeks.
Acoustic Therapy:
Ultrasound

Phonophoresis

Uses ultrasound to drive ions
Acoustic Therapy:
Ultrasound Indications
Acute and post acute
conditions (non-thermal)
 Soft tissue healing and
repair
 Scar tissue
 Joint contracture
 Chronic inflammation
 Increased extensibility of
collagen
 Reduction of muscle
spasm
 Pain modulation

Increase blood flow
Soft tissue repair
Increase in protein
synthesis
 Tissue regeneration
 Bone healing
 Repair of non-union
fractures
 Inflammation of myositis
ossificans
 Plantar warts
 Myofascial trigger points



Acoustic Therapy:
Ultrasound Contraindications
Acute and post acute
conditions (thermal)
 Areas of decreased
temperature sensation
 Areas of decreased
circulation
 Vascular insufficiency
 Thrombophlebitis
 Eyes
 Reproductive organs

Pelvis immediately
following menses
 Pregnancy
 Pacemaker
 Malignancy
 Epiphyseal areas in young
children
 Total joint replacement
 Infection

Electrotherapy:
Electrical Stimulation

Electricity is a form of energy that displays
magnetic, chemical, mechanical, and
thermal effects on tissue.

It implies a flow of electrons between two
points.
Electrotherapy:
Electrical Stimulation
All therapeutic electrical generators are
transcutaneous electrical stimulators.
 The majority of these generators are used to
stimulate peripheral nerves and are correctly called
transcutaneous electrical nerve stimulators (TENS).
 Occassionally the terms neuromuscular electrical
stimulator (NMES) or electrical muscle stimulator
(EMS) are used; however, these terms are only
appropriate when the electrical current is being
used to stimulate muscle directly, as would be the
case with denervated muscle in which peripheral
nerves are not functioning.

Electrotherapy:
Electrical Stimulation
Direct Current (DC current)
 Flows in one direction only from the positive
pole to the negative pole.
 Direct current may be used for pain
modulation or muscle contraction or to
produce ion movement.
Electrotherapy:
Electrical Stimulation
Alternating Current (AC current)
 The direction of current flow reverses itself
once during each cycle.
 Alternating current may be used for pain
modulation or muscle contraction.
Electrotherapy:
Electrical Stimulation
Pulsed Current
 Pulsed currents usually contain three or
more pulses grouped together.
 These groups of pulses are interrupted for
short periods of time and repeat themselves
at regular interval.
 Pulsed currents are used in interferential
and so-called Russian currents (currents
interfere with each other).
Electrotherapy:
Electrical Stimulation
Duration

Duration: 10 to 30 minutes

Can be used with ice or heat
Electrotherapy:
Electrical Stimulation












High Voltage or Pulsed Indications
Peripheral nerve injuries,
Delaying denervation
delaying disuse atrophy
Post-traumatic edema reduction
Increase local blood circulation
Joint contracture prevention
Maintenance of range of motion
Muscle strengthening
Muscle spasm reduction
Inhibitation of spasticity
Muscle re-education
Assist voluntary muscle function



Interferential Indications
Acute pain
Chronic pain
Muscle spasm
Electrotherapy:
Electrical Stimulation




Contraindications
Demand-type
pacemakers
Over pelvic or
lumbar areas
During pregnancy
Pain of central or
unknown origin
Areas of particular sensitivity
–
–
–
–
–
–
–
carotid sinus
laryngeal muscles
pharyngeal muscles
upper thorax
temproal region
cancerous lesions
sites of infection
Electrotherapy:
Electrical Stimulation

Iontophoresis

Uses electrical current to drive ions
Massage Therapy
Sports massage causes mechanical,
physiological, and psychological responses.
Massage Therapy
Mechanical Response
Encourages venous and lymphatic drainage,
mildly stretch superficial and scar tissue
Massage Therapy
Physiological Response
Reflex effects, relaxation, stimulation, and
increased circulation
Massage Therapy
Psychological Response
The tactile system is one of the most
sensitive systems in the human organism.
Humans respond psychologically to being
touched and is an important means for
creating a bond of confidence between the
athletic trainer and the athlete.
Massage Therapy
Massage Strokes
Effleurage
 Petrissage
 Tapotement
 Vibration
 Deep Friction

Massage Therapy
Effleurage
 Stroking; divided into light and deep
methods.
 Light stroking is designed primarily to be
sedative.
 It is also used in the early stages of injury
treatment.
 Deep stroking is therapeutic compression of
soft tissue, which encourages venous and
lymphatic drainage.
Massage Therapy
Petrissage
 Kneading; a technique adaptable primarily
to loosen heavy tissue areas such as the
trapezius, latissimus dorsi, or the triceps.
 Friction heat producing
 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.
Massage Therapy
Tapotement

Percussion; produces an invigorating and
stimulating sensation.
Massage Therapy
Vibration
 Rapid shaking; rapid movement that
produces a quivering or trembling effect.
 It is used because of its ability to relax and
soothe.
 Although vibration can be done manually,
the machine vibrator is usually the
preferred modality.
Massage Therapy
Deep Friction

Often precedes activity, restoring mobility to
a muscle.
Massage Therapy
Massage in sports is usually confined to a
specific area and is seldom given to the full
body.
 The time required for giving an adequate
and complete body massage is excessive in
athletics.
 It is not usually feasible to devote this much
time to one athlete.
 Five minutes is usually all that is required
for massaging a given area.
