Chapter 15: Therapeutic Modalities

1. Chapter 15:Therapeutic Modalities

2. 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.

3. 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)

4. 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.

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

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

7. Skin Response to Cold • Stage 2 • Response • Mild burning, aching • Estimated Time after Initiation • 2 to 7 minutes

8. Skin Response to Cold • Stage 3 • Response • Relative cutaneous anesthesia • Estimated Time after Initiation • 5 to 12 minutes

9. 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

11. 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

12. 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

13. 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

14. 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

15. Cryokinetics Combines cryotherapy with exercise Cryotherapeutic Methods

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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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

23. 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 Thermotherapeutic Methods

24. 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

25. 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

26. 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 Hydrotherapy Methods

27. 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.

28. Acoustic Therapy:Ultrasound • Ultrasound has both thermal and non-thermal effects.

29. Acoustic Therapy:Ultrasound • 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 104°F to 113°F for a minimum of five minutes. • Temperatures below this range will be ineffective.

30. Acoustic Therapy:Ultrasound • Non-thermal effects of ultrasound are cavitation and acoutsic microstreaming.

31. 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.

32. 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.

33. 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).

34. 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.

35. 1 MHz Deeper Tissues 3 MHz Superficial Tissues Acoustic Therapy:Ultrasound

36. 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.

37. Acoustic Therapy:Ultrasound • Phonophoresis • Uses ultrasound to drive ions

38. 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

39. 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 Acoustic Therapy:Ultrasound Contraindications

40. 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.

41. 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.

42. 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.

43. 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.

44. 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).

45. Electrotherapy:Electrical Stimulation Duration • Duration: 10 to 30 minutes • Can be used with ice or heat

46. 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

47. 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

48. Electrotherapy: Electrical Stimulation • Iontophoresis • Uses electrical current to drive ions

49. Sports massage causes mechanical, physiological, and psychological responses. Massage Therapy

50. Mechanical Response Encourages venous and lymphatic drainage, mildly stretch superficial and scar tissue Massage Therapy