Chapter 15: Therapeutic Modalities

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Chapter 15Therapeutic Modalities
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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.

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Transmission of Thermal Energy

• Conduction Heating through direct contact
  with a hot medium (e.g. hot pack).
• Convection Heating indirectly through another
  medium such as air or liquid (e.g. whirlpool)
• Radiation Transfer of heat through space from
  one object to another (e.g. ultraviolet
  therapy)
• Conversion Heating through other forms of
  energy (e.g. ultrasound)

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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.

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Hunting Response

• Causes a slight temperature increase during
  cooling. The extent of cooling depends on the
  thickness of the subcutaneous fat layer.

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Skin Response to Cold

• Stage 1
• Response
• Cold sensation
• Estimated Time after Initiation
• 0 to 3 minutes

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Skin Response to Cold

• Stage 2
• Response
• Mild burning aching
• Estimated Time after Initiation
• 2 to 7 minutes

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Skin Response to Cold

• Stage 3
• Response
• Relative cutaneous anesthesia
• Estimated Time after Initiation
• 5 to 12 minutes

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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

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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

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Cryotherapeutic Methods

• Cold or Ice Water Immersion
• Duration 10 to 20 minutes
• Temp 50F 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

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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

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Cryotherapeutic Methods

• 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

• Cold Whirlpool
• Duration 5 to 30 minutes
• Temp 50F to 60F
• Indications
• Subacute inflammation
• Chronic inflammation
• Peripheral vascular disease
• Peripheral nerve injuries
• Distal body parts

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Cryotherapeutic Methods

• Cryokinetics
• Combines cryotherapy with exercise

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Thermotherapy

• Application of heat Heat has the capacity to
  increase the extensibility of collagen tissue.

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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

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Comparing the Physiological Variables of
Crotherapy and Thermotherapy

• Response to Response to Variable
  Cryotherapy Thermotherapy
• Muscle spasm Decreases Decreases
• Pain perception Decreases Decreases
• Blood flow Decreases Increases
• Metabolic rate Decreases Increases
• Collagen elasticity Decreases Increases
• Joint stiffness Increases Decreased
• Capillary permeability Decreased Increases
• Edema Controversial Increases

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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

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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.

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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

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Thermotherapeutic Methods

• Hot Whirlpool
• Duration 5 to 30 minutes
• Temp 96F to 104F
• 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

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Thermotherapeutic Methods

• Paraffin Bath
• Duration 15 to 30 minutes
• Temp 126F to 130F
• Indications
• Subacute inflammation
• Chronic inflammation
• Limited range of motion after immobilization

• Contraindications
• Open wounds
• Skin infection
• Sensory loss
• Peripheral vascular disease

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Hydrotherapy Methods

• Contrast Bath
• Duration 20 to 30 minutes
• Temp 50F to 60F96F to 104F
• Indications
• Ecchymosis removal
• Edema removal
• Subacute inflammation
• Chronic inflammation
• Impaired circulation

• Contraindications
• Acute injuries
• Cold hypersensitivity
• Whirlpool contraindications
• Cold application contrindications
• Hot application contrindications

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Hydrotherapy Methods

• 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

• Cold Whirlpool
• Duration 5 to 30 minutes
• Temp 50F to 60F
• Indications
• Subacute inflammation
• Chronic inflammation
• Peripheral vascular disease
• Peripheral nerve injuries
• Distal body parts

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Hydrotherapy Methods

• Hot Whirlpool
• Duration 5 to 30 minutes
• Temp 96F to 104F
• 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

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Acoustic TherapyUltrasound

• 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.

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Acoustic TherapyUltrasound

• Ultrasound has both thermal and non-thermal
  effects.

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Acoustic TherapyUltrasound

• When used for thermal changes non-thermal
  changes also occur.
• For the majority of thermal effects to occur the
  tissue temperature must be raised to a level of
  104F to 113F for a minimum of five minutes.
• Temperatures below this range will be
  ineffective.

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Acoustic TherapyUltrasound

• Non-thermal effects of ultrasound are cavitation
  and acoutsic microstreaming.

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Acoustic TherapyUltrasound

• 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.

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Acoustic TherapyUltrasound

• 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.

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Acoustic TherapyUltrasound

• 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).

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Acoustic TherapyUltrasound

• 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.

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Acoustic TherapyUltrasound

• 1 MHz
• Deeper Tissues

• 3 MHz
• Superficial Tissues

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Acoustic TherapyUltrasound

• 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.

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Acoustic TherapyUltrasound

• Phonophoresis
• Uses ultrasound to drive ions

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Acoustic TherapyUltrasound 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

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Acoustic TherapyUltrasound 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

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ElectrotherapyElectrical 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.

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ElectrotherapyElectrical 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.

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ElectrotherapyElectrical 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.

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ElectrotherapyElectrical 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.

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ElectrotherapyElectrical 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).

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ElectrotherapyElectrical Stimulation

• Duration
• Duration 10 to 30 minutes
• Can be used with ice or heat

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ElectrotherapyElectrical 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

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ElectrotherapyElectrical 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

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Electrotherapy Electrical Stimulation

• Iontophoresis
• Uses electrical current to drive ions

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Massage Therapy

• Sports massage causes mechanical physiological
  and psychological responses.

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Massage Therapy

• Mechanical Response
• Encourages venous and lymphatic drainage mildly
  stretch superficial and scar tissue

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Massage Therapy

• Physiological Response
• Reflex effects relaxation stimulation and
  increased circulation

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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.

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Massage Therapy

• Massage Strokes
• Effleurage
• Petrissage
• Tapotement
• Vibration
• Deep Friction

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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.

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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.

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Massage Therapy

• Tapotement
• Percussion produces an invigorating and
  stimulating sensation.

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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.

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Massage Therapy

• Deep Friction
• Often precedes activity restoring mobility to a
  muscle.

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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.