Chapter 15: Therapeutic Modalities

1. Chapter 15: Therapeutic Modalities

2. Therapeutic modalities can be an effective adjunct to various techniques of therapeutic exercise • Knowledge of the healing process is critical • A variety of modalities can be utilized by athletic trainers including cryotherapy,electrical stimulation, ultrasound, massage, traction, diathermy, lasers and magnets

3. 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 • Decisions regarding use of a particular modality should be made according to the desired target tissue and specific results

4. How are Modalities Related? • Electromagnetic energy modalities • Electrical stimulation, shortwave and microwave diathermy, infrared modalities, ultraviolet therapy • Acoustic energy modalities • Ultrasound • Characteristics of Electromagnetic Modalities • Transmitted w/out medium for support • Travel at 300 million meters/second in a vacuum • Energy forms travel in a straight line • Can be reflected, refracted, absorbed or transmitted • Operate at specific wavelengths and frequencies

5. 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

6. 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)

7. 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 and the reactive phase of an acute injury • RICE (rest, ice compression, elevation) may be used for the initial days of and injury and continue up to 2 weeks after injury

8. Physical Principles • Type of electromagnetic energy (infrared radiation) • Relies on conduction -- degree of cooling depends on the medium, length of exposure and conductivity • At a temperature of 38.3oF, muscle temperature can be reduced as deep as 4cm • Tissue w/ a high water content is an excellent conductor • Most common means of cold therapy are ice packs and ice immersion • Wet ice is a more effective coolant due to the energy required to melt ice

9. Physiological Principles • Vasoconstriction • Reflex action of smooth muscle due to sympathetic nervous system and adrenal medulla • Also caused by cooled blood circulating to anterior hypothalamus • Increase in blood viscosity and decrease in vasodilator metabolites • 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

10. Decreases muscle spasm • Result of decreased metabolism & waste products that would act as irritants to the muscle • Decrease activity in gamma motor neurons, GTO and muscle spindle activity • Muscle becomes more amenable to stretch as a result of decreased GTO and muscle spindle activity • Decreases free nerve ending and peripheral nerve excitability • Analgesia caused by raising nerve threshold • Cold is more penetrating than heat • Ability to decrease muscle fatigue and increase and maintain muscular contraction • Attributed to the decrease of local metabolic rates and tissue temperature

11. Special Considerations • Cooling for an hour at 15.8o - 30.2o F produces redness and edema that lasts for 24 hours post exposure • Immersion at 41oF increases limb fluid volume by 15% • Exposure for 90 minutes at 57.2o -60.8o F can delay resolution of swelling up to one week • Some individuals are allergic to cold and react w/ hives and joint pain • Icing through a towel or bandage limits the reduction in temperature -- could limit effectiveness of treatment

12. Special medical conditions • Raynaud’s phenomenon • Paroxysmal cold hemoglobinuaria • Application of ice (very rare) can cause nerve palsy • Motor nerves close to skin overexposed to cold (peronial nerve at head of fibula)

13. 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

15. Cold or Ice Water Immersion • Equipment • Variety of basins or containers can be used, small whirlpool • Temperature should be 50-60 degrees F • Indications • Circumferential cooling of a body part • Application • Athlete immerse body part in water and goes through four stages of cold response • Treatment may last 10-15 minutes • Once numb body part can be removed from immersion and ROM exercise can be performed • As pain returns re-immersion should take place • Cycle can be repeated 3 times

16. 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

17. Ice Packs (Bags) • 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 four 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

18. 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

19. Vasocoolant Spray (continued) • Application • For trigger points • Locate trigger point • Position athlete in relaxed position; place muscle on stretch; apply spray in specific region and over the length of the muscle • Apply passive stretch while spraying • After first session, heat area and then repeat if necessary • When stretch is complete, have athlete move limb throughout ROM; but do not overload

21. Cryokinetics • Technique that combines cryotherapy with exercise • Goal is to numb region and work towards completion of rehab program (ROM….etc) • Treat area with ice pack, massage or immersion • When analgesia is experienced, exercises should be performed (window will last 4-5 minutes) • As pain returns, process may be repeated

22. 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 • Increase collagen extensibility; decreasing joint stiffness; reducing pain; relieving muscle spasm; reduction of edema and swelling; increasing blood flow

23. Extensibility of collagen • Increases viscous flow of collagen resulting in relaxation of tension • Pain relief • Activates gate control mechanism and secretion of endorphins to block pain and free nerve endings • Assistance w/ inflammation • Raises tissue temperature, increases metabolism resulting in reduction of oxygen tension, lowering pH, increasing capillary permeability and releasing bradykinins and histamine resulting in vasodilation • Parasympathetic impulses stimulated by heat are also believed to be a reason for vasodilation

24. Superficial Heat • Form of electromagnetic energy (infrared region of spectrum) • Increases subcutaneous temperature, indirectly spreading to deeper tissue • Muscle temperature increases through reflexive effect of circulation through conduction • Moist heat versus dry heat

25. 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)

26. Moist Heat Packs • 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

27. Whirlpool Bath • 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 • Athlete should be set up to be reached by agitator (8-12” from agitator) • Do not place directly on injured site • Maximum treatment time for acute injuries should not exceed 20 minutes

28. 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

29. Paraffin Bath • 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

31. Contrast Bath • 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

32. Fluidotherapy • Equipment • Unit which contains cellulose particles through which warm air is circulated • 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

34. 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)

35. Equipment • High frequency generator which provides electrical current through a coaxial cable to a transducer applicator • Through piezoelectric effect electrical current is transformed into acoustic energy through contraction and expansion of piezoelectric crystals • Frequency ranges between .75 and 3.0 MHz • 1 MHz ultrasound allows for deeper penetration while 3 MHz is absorbed more superficially • Area of transducer that produces sound is the effective radiating area • Produces a beam of acoustic energy - collimated cylindrical beam with non-uniform distribution • Variability in the beam (beam non-uniformity ratio - BNR) =lower BNR = more uniform energy output

36. 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 • Non-thermal effects include microstreaming and cavitation which impacts tissue permeability and fluid movement • For solely non-thermal effects, intensity must remain below .2 W/cm2 • Acute conditions require more treatments over a shorter period and chronic conditions require fewer treatments over a longer period

38. Application • Direct skin application • Requires a coupling medium to provide airtight contact w/ skin and a low friction surface • Underwater application • Used for irregularly shaped structures • Body part is submerged in water, ultrasound head is placed 1” from surface • Water serves as coupling medium, air bubbles should be continually swept away • Sound head should be moved in circular or longitudinal pattern • Should be performed in non-metal container to avoid reflection

39. Bladder technique • Used when body part can not be immersed in water • Balloon filled w/ gel or water to allow for transmission --coated with gel to enhance contact surface • Moving the transducer • Leads to more even distribution of energy, reducing likelihood of hot spots • Should be moved at a rate of 4cm/second • Must maintain contact of transducer with surface of skin • Circular or stroking patterns should be used • Should not treat an area larger than 3 times the ERA

40. Dosage and Time • Varies according to depth of tissue to be treated and the state of injury • Duration tends to last 5-10 minutes • Intensity varies • Low 0.1-0.3 W/cm2 • Medium 0.4 - 1.5 W/cm2 • High 1.5 - 3.0 W/cm2 • 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

41. Ultrasound in Combination w/ Other Modalities • Ultrasound can be used w/ a variety of modalities to accomplish a series of treatment goals • Use of hot packs with ultrasound may have an additive effect on muscle temperature • Cold packs, while often used in conjunction with ultrasound, may interfere with heating • With electrical stimulation, it is often useful for trigger point treatment (blood flow, muscle contraction and pain modulation)

42. 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 (rubbed into the area), followed by application of coupling medium and ultrasound treatment • Chem pads, impregnated with medication is also being explored

43. Electrotherapy • Physical Principles • Electricity displays magnetic, chemical, mechanical, and thermal effects on tissue • Volume of current (ampere) • Rate of flow of 1 amp = 1 coulomb • Resistance = ohms • Force that current moves along = voltage • Electricity is applied to nerve tissue at certain intensities and duration to reach tissue excitability thresholds resulting in membrane depolarization • Target sensory, motor, and pain nerve fibers in an effort to produce specific physiological effects

44. 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 • Generate 3 types of current • Monophasic • Direct current or galvanic current - flow in one direction only from (+) to (-) or vice versa • Used to produce muscle contraction, pain modulation, ion movement (determined by specific parameters) • Biphasic • Alternating current where direction of flow reverses during each cycle • Useful in pain modulation and muscle contractions

45. Polyphasic • Pulsed currents usually contain three or more pulses grouped together • Generally interrupted for short periods of time and repeat themselves at regular intervals • Used in interferential and so-called Russian currents • Current Parameters • Waveforms • Different generators have differing abilities relative to the production of various waveforms • A graphical representation of shape, direction, amplitude and direction of current • Can be sine, square or triangular in shape • Modulation • Ability of stim unit to change or alter the magnitude and duration of a waveform • May be continuous, interrupted or surged for both AC and DC currents

46. Intensity • Voltage output of stimulating unit • High and low voltage units • Duration(pulse width or pulse duration) • Refers to the length of time that current is flowing • Pre-set on most high voltage DC units • Frequency • Number of waveform cycles per second

47. Polarity • Direction of flow -- either positive or negative • Electrode Set-up • Use of moist electrodes fixed to the skin • Can include monopolar (active and dispersive pad) or bipolar set-up • Current generally felt under and between both pads unless monopolar set-up is used --then current is felt under the smaller active pad

49. Indications • Pain Modulation • Gate Control • Intensity should produce tingling w/out a muscular contraction; high frequency and pulse duration • Descending Pain Control • High current intensity approaching noxious; pulse duration of 10 msec; frequency should be 80 pps • Opiate Pain Control Theory • Point stimulator should be used with current intensity set as tolerable; pulse duration should be at maximum; w/ a frequency of 1-5 pps • Muscle Contraction • Quality of contraction will change according to current parameters • Increased frequency results in increased tension (50pps results in tetany) • Increased intensity spreads current over larger area • Increased current duration causes more motor unit activation

50. Muscle pump • Used to stimulate circulation • High-volt, DC stimulator; 20-40 pps; surge mode (on/off 5 seconds each; elevation w/ active contraction • Treatment time 20-30 minutes • Muscle strengthening • High frequency AC current; 50-60 pps; 10:50 seconds on/off ratio; 10 repetitions 3x per week; perform with active contractions • Retardation of atrophy • High frequency AC current 30-60 pps; w/ voluntary muscle contraction encouraged; 15-20 minutes • Muscle re-education • Level of comfortable contraction -- 30-50 pps; w/ either interrupted or surge current • Athlete should attempt to contract muscle along w/ stim • Treatment time 15-20 minutes and repeated multiple times over the course of a week