Therapeutic Modalities

1. Therapeutic Modalities

2. Foundations of Therapeutic Modalities • What is a Modality? • What role do modalities play in injury rehabilitation? • How do we use Therapeutic Modalities? • When should we Modalities? • Specific Types • Background • examples of application

3. What are Therapeutic Modalities? • mo·dal·i·ty/mōˈdalitē/ • An intervention used to heal someone • Agents such as light, heat, air, water, manual, or electronic • All athletic trainers use therapeutic modalities, some simple techniques other complex.

4. Role of Modalities in Injury Rehabilitation • Management or reduction of pain associated with an injury • Return of full non-restricted ROM to an injury body part • Maintenance or improvement of strength throughout the full ROM • Use of Therapeutic Modalities inexact science, no cookbook for treatment

5. Pain Management • Control of pain is an essential aspect of caring for the injured patient • Athletic trainer has several therapeutic agents with analgesic properties from which to choose • Acute Pain- pain of sudden onset • Chronic Pain- pain lasting for more than 6 months

6. Categories of Therapeutic Modalities • Infrared Modalities • Therapeutic Heat & Cold • Ultrasound • Shortwave and Microwave Diathermy • Electrical Modalities • Electrical Stimulating Currents • Iontophoresis • Mechanical Modalities • Therapeutic sports Massage • Intermittent compression Devices • Spinal Traction • Others

7. Infrared Modalities • Thermotherapy- Heating techniques used for therapeutic purposes • Used when a rise in tissue temperature is the goal of treatment • Cryotherapy- The use of cold • Used in the acute stages of the healing process immediately following injury when a loss of tissue temperature is the goal of therapy

8. Hot &Cold Modalities Cont’d • Most effective use of infrared modalities should be to provide analgesia or reduce sensation of pain associated with injury • Gate control theory of pain modulation

9. Cryotherapy • General agreement that cold should be initial treatment for musculoskeletal injuries • Primary reason for using cold in acute injury is to lower temperature in injured area thus reducing metabolic rate with a corresponding decrease in production of metabolites and metabolic heat (secondary hypoxic response) • More effective when combined with compression

10. Cryotherapy • Cryotherapy techniques include • Ice massage • Cold packs • Ice packs • Cold whirlpool • Cold spray • Contrast baths • Ice immersion • Cryo-cuff • Cryokinetics

11. Cryotherapy Techniques • Application of cryotherapy produces a three- to four-stage sensation • Uncomfortable sensation of cold • Stinging • Burning or aching feeling • Numbness • Caution should be exercised when applying intense cold directly to the skin

12. Ice Massage • Remove top 2/3 of paper or Styrofoam cup leaving 1” on bottom of cup as handle • Apply using overlapping circular or longitudinal strokes • Once the skin is numb to fine touch treatment ends(7-10 min) • Thermopane develops under ice cup the allows for smooth gliding

13. Commercial Cold Packs • Cold pack should be placed against wet toweling • Mold cold pack around joint • Treatment time required is about 20 minutes on - 20 minutes off • Should be repeated for 2 hours

14. Cold Whirlpool • Fill appropriate size whirlpool with cold water and ice until temp. at 50° to 60° F • Use for massaging action • Gravity-dependent positions should be avoided with acute and subacute injuries • A toe cap made of neoprene can be used

15. Cold Spray & Stretch • Flourimethane is used • Cooling is superficial • Useful in treating trigger points • Spraying Technique • Same direction • Proximal to distal • Gate Control pain modulation • Stretching Technique

16. Thermotherapy • Local superficial heating (infrared heat) is recommended in subacute conditions for reducing pain and inflammation through analgesic effects • Produces a relaxation effect and a reduction in muscle guarding by: • Relieving pain • Producing sedation • Decreasing spasticity, tenderness, and spasm • Decreasing tightness in muscles and related structures

17. Thermotherapy Techniques • Warm Whirlpool • Hydrocollator Packs • Paraffin Bath • Infrared Lamps • Fluidotherapy

18. Warm Whirpool • Temperature Range • Upper Extremity 98° -110° F • Lower Extremity 98- 104° F • Full body 98° - 102° F • Time of application should be 15 to 20 minutes • Caution is indicated in gravity-dependent position in subacute injuries • Whirlpool maintainance

19. Hydrocollator Packs • Canvas pouches of petroleum distillate • Water temperature 170o • 6 layers (1”) of toweling recommended • Don’t lie on top of hot pack • Time of application should be 15 to 20 minutes

20. Paraffin Bath • Mixture ratio of paraffin to mineral oil 2 pounds:1 gallon • Mineral oil reduces temp of the paraffin to 126° F • Extremity dipped into paraffin for a couple of seconds then removed to allow paraffin to harden • Repeat until 6 layers have accumulated • Wrap in a plastic bag with several layers of toweling

21. Therapeutic Ultrasound • Inaudible , acoustic vibrations of high frequency that produce either thermal or non-thermal physiologic effects

22. Frequency of Wave Transmission • Audible sound = 16-20 kHz • Ultrasound > 20 kHz • Therapeutic Ultrasound = 0.75-3 MHz (1,000,000 cycles/sec) • Lower frequencies have greater depth of penetration • Higher frequencies more superficial absorption

23. Ultrasound Cont’d • Electrical Output • Mechanical Vibration • Acoustic Sound wave • Absorbed In The Tissues

24. Thermal Effects of Ultrasound • Increased collagen extensibility • Increased blood flow • Decreased pain • Reduction of muscle spasm • Decreased Joint stiffness • Reduction of chronic inflammation

25. Non-Thermal Effects of Ultrasound • Increased fibroblastic activity • Increased protein synthesis • Tissue regeneration • Reduction of edema • Bone healing • Pain modulation

26. Methods of Application Direct Contact • Transducer should be small enough to treat the injured area • Gel should be applied liberally • Heating of gel does not increase the effectiveness of the treatment

27. Methods Cont’d Immersion • Good for treating irregular surfaces • A plastic, ceramic, or rubber basin should be used • Tap water is useful as a coupling medium • Transducer should move parallel to the surface at .3-5 cm • Air bubbles should be wiped away

28. Considerations for Determining Treatment • Size of the area to be treated • What exactly are you trying to accomplish • Thermal vs. non-thermal effects • Intensity of treatment

29. Electrical Stimulating Currents • Creating muscle contraction through nerve or muscle stimulation • Stimulating sensory nerves to help in treating pain • Creating an electrical field in biologic tissues to stimulate or alter the healing process

30. Uses of Therapeutic E-Stim • Muscle reeducation • Muscle pump contractions • Retardation of atrophy • Muscle strengthening • Increasing range of motion • Reducing Edema

31. Muscle Re-Education • Muscular inhibition after surgery or injury is primary indication • A muscle contraction usually can be forced by electrically stimulating the muscle • Patient feels the muscle contract, sees the muscle contract, and can attempt to duplicate this muscular response

32. Muscle Pump Contractions • Used to duplicate the regular muscle contractions that help stimulate circulation by pumping fluid and blood through venous and lymphatic channels back to the heart • Can help in reestablishing proper circulatory pattern while keeping injured part protected

33. Muscle Strengthening • Current intensity should make muscle develop 60% of torque developed in a maximum voluntary isometric contraction (MVIC) • Pulse duration should be set as close as possible to the duration needed for the motor nerve to be stimulated

34. Electrode Placement • Electrodes may be placed: • On or around the painful area • Close to spinal cord segment that innervates an area that is painful • Over sites where peripheral nerves that innervate the painful area becomes superficial and can be easily stimulated • Over superficial vascular structures • Over trigger point locations • Over acupuncture points • In a criss-cross pattern around the point to be stimulated so the area to be treated is central to the location of the electrodes • If treatment is not working- change placement

35. Therapeutic Sports Massage • Mechanical stimulation of tissues by rhythmically applied pressure and stretching • Effects of massage may be either reflexiveor mechanical

36. Guidelines for Massage • Positioning will allow relaxation, prevent fatigue, and permit free movement of arms, hands, and body • Weight evenly distributed and should shift from one foot to the other • Fit your hands to contour of area being treated • Hands should be warm • Appropriate Medium

37. Hoffa Massage • Classical massage technique which uses a variety of superficial strokes • Effleurage • Petrissage • Tapotment • Vibration

38. Effleurage (Stroking) • Every massage begins and ends with effleurage • Increases venous and lymphatic flow • Increases circulation to skin surface • Start with a light pressure, move centripetally or centrifugally cosistently throughout treatment

39. Petrissage(Kneading) • Consists of kneading manipulations that press and roll muscles under fingers or hands • Muscles are gently squeezed, lifted, and relaxed • Hands may remain stationary or move along length of muscle or limb • Purpose is to increase venous and lymphatic return and to press metabolic waste products out of affected areas through intensive vigorous action • Can also break up adhesions between skin and underlying tissue

40. Tapotment(Percussion) • Uses a variety of percussive or beating techniques • Used to increase circulation and blood flow • Used to stimulate peripheral nerve endings

41. Tapotment • Hacking • Slapping • Beating • Tapping • Clapping or cupping

42. Transverse Friction Massage • Technique for treating chronic tendon inflammation • Purpose is to increase inflammatory response to progress healing process • Use strong pressure in perpendicular direction to fibers for 7 to 10 minutes every other day

43. Indications For Massage • increase coordination • decrease pain • decrease neuromuscular excitibility • stimulate circulation • facilitate healing • restore joint mobility • remove lactic acid • alleviate muscle cramps • increase blood flow • increase venous return • retard muscle atrophy • increase range of motion • edema • myofascial trigger points • stretching scar tissue

44. Contraindications for Massage • arteriosclerosis • thrombosis • embolism • severe varicose veins • acute phlebitis • cellulitis • synovitis • abscesses • skin infections • cancers • acute inflammatory conditions

45. Prentice, William E. Therapeutic Modalities: for Sports Medicine and Athletic Training. 5th ed. New York: McGraw-Hill 2003.