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Chapter 15: Using Therapeutic Modalities

Chapter 15: Using Therapeutic Modalities. Therapeutic modalities can be an effective adjunct to various techniques of therapeutic exercise Knowledge of the healing process is critical

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Chapter 15: Using Therapeutic Modalities

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  1. Chapter 15: Using Therapeutic Modalities © 2011 McGraw-Hill Higher Education. All rights reserved

  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 © 2011 McGraw-Hill Higher Education. All rights reserved

  3. Classification of Therapeutic Modalities • Electromagnetic • Includes cryotherapy, thermotherapy, electrical stimulating currents, diathermy and lasers • Rely on electromagnetic energy, which travels at the speed of light • Energy travels in a straight line • The energy can be absorbed, refracted, reflected or transmitted © 2011 McGraw-Hill Higher Education. All rights reserved

  4. Acoustic • Ultrasound utilizes acoustic energy • High frequency sound waves • Relies on molecular collisions for energy transfer • Vibration of tissue produces heat and impacts cell membrane permeability • Mechanical • Traction, intermittent compression, massage • Involves mechanically stretching, compressing and manipulating soft tissue and joint structures © 2011 McGraw-Hill Higher Education. All rights reserved

  5. Electromagnetic Modalities © 2011 McGraw-Hill Higher Education. All rights reserved

  6. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  7. Extensibility of collagen • Permits increases in extensibility through stretching • Pain relief • Activates gate control mechanism • Muscle spasm • Increased blood flow reduces ischemia • Assistance w/ healing process • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  8. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  9. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  10. 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) © 2011 McGraw-Hill Higher Education. All rights reserved

  11. Hydrocollator 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 Figure 15-1 © 2011 McGraw-Hill Higher Education. All rights reserved

  12. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  13. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  14. Special Considerations Must be careful with full-body immersion Proper maintenance is necessary to avoid infection As volume of body part immersion increases, temperature should decrease Safety is a major concern Electrical outlets Athlete should not turn whirlpool on or off Contraindicated for acute injuries due to gravity dependent position Figure 15-2 © 2011 McGraw-Hill Higher Education. All rights reserved

  15. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  16. 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 • Patient should be comfortable • Treatment time = 15-20 minutes • Exercise can be performed while in cabinet © 2011 McGraw-Hill Higher Education. All rights reserved

  17. Figure 15-3 Figure 15-4 © 2011 McGraw-Hill Higher Education. All rights reserved

  18. 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 © 2010 McGraw-Hill Higher Education. All rights reserved © 2011 McGraw-Hill Higher Education. All rights reserved

  19. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  20. Physiological Effects of Cold • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  21. Vasoconstriction • Reflex action of smooth muscle due to sympathetic nervous system and adrenal medulla • Hunting response • Intermittent period of vasodilation will occur if cooling continues for >20 minutes • Blood viscosity will also increase with extended cooling • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  22. Decreases muscle spasm • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  23. 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 • Patient 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  24. Figure 15-5 © 2011 McGraw-Hill Higher Education. All rights reserved

  25. 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 • Patient immerses 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  26. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  27. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  28. Special Considerations • Avoid excessive cold exposure • With any indication of allergy or abnormal pain, treatment should be stopped • When using gel packs, a single layer of toweling should be used • Crushed or flaked ice can be directly applied to skin Figure 15-6 © 2011 McGraw-Hill Higher Education. All rights reserved

  29. Vapocoolant 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  30. Vapocoolant 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  31. Figure 15-7 © 2011 McGraw-Hill Higher Education. All rights reserved

  32. Cryokinetics • Technique that combines cryotherapy with exercise • Goal is to numb region to point of analgesia and work towards achieving normal ROM • Equipment • Treat area with ice pack, massage or immersion • Application • When analgesia is experienced, exercises should be performed (window will last 4-5 minutes) • As pain returns, process may be repeated • Sequence can be repeated 5 times • Exercises should be pain free • Changes in intensity should be limited by both healing and patient’s perception of pain © 2011 McGraw-Hill Higher Education. All rights reserved

  33. Special Considerations for Cryotherapy • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  34. Special medical conditions • Raynaud’s phenomenon • Paroxysmal cold hemoglobinuria • Application of ice (very rare) can cause nerve palsy • Motor nerves close to skin overexposed to cold (peroneal nerve at head of fibula) © 2011 McGraw-Hill Higher Education. All rights reserved

  35. Electrical Stimulating Currents • Physical Properties of Electricity • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  36. Equipment • 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) © 2011 McGraw-Hill Higher Education. All rights reserved

  37. Figure 15-8 © 2011 McGraw-Hill Higher Education. All rights reserved

  38. Biphasic • Alternating current where direction of flow reverses during each cycle • Useful in pain modulation and muscle contractions • Pulsatile • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  39. Figure 15-9 Figure 15-10 © 2011 McGraw-Hill Higher Education. All rights reserved

  40. 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 • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  41. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  42. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  43. 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 • 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  44. 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 © 2011 McGraw-Hill Higher Education. All rights reserved

  45. Iontophoresis • Introduction of ions into body tissue via direct electrical current • Equipment • Iontophoresis generator which produces a continuous monophasic current • Indications • Used to treat musculoskeletal inflammatory conditions, analgesic effects, scar modification, wound healing, calcium deposits, hyperhidrosis • Medication • Dexamethasone and hydrocortisone are two commonly used © 2011 McGraw-Hill Higher Education. All rights reserved

  46. Application • Reusable or commercially produced electrodes • Three application techniques • Active pad over medication saturate gauze • Body part and active electrode submerged in tub of ion solution • Special active electrode with medication reservoir • Utilize large dispersive pad • Movement of positively and negatively charged ions relative to electrode charges (poles) • Treatment last 10-20 minutes depending on current intensity and ion concentrations in solution • Requires use of low voltage direct current on continuous mode w/ a long pulse duration (allows for migration of ions) • Must be careful to avoid chemical burns and certain to utilize appropriate medications for specific conditions © 2011 McGraw-Hill Higher Education. All rights reserved

  47. Interferential Currents • Equipment • Uses 2 separate generators, emitting current at slightly different frequencies • Quad polar pad placement is used, creating interference pattern • Creates a broader area of stimulation • Indications • Pain control (including joints), swelling, neuritis, retardation of callus formation following fracture & restricted mobility • Application • Pads must be placed to ensure that current is centered over painful area • Similar treatment parameters can be used © 2011 McGraw-Hill Higher Education. All rights reserved

  48. Low Intensity Stimulators • Equipment • Micro-current electrical nerve stimulator • Operates at low frequencies and intensities (sub-sensory) • Indications • Used to stimulate healing of soft tissue and bone • Modulate pain, promote wound healing, promote non-union fracture healing, tendon and ligament healing • Based on theory, little research support • Application • Utilizes same electrical currents as previously described • Using large dispersive pad maintains current density at thresholds which will not result in sensory nerve depolarization © 2011 McGraw-Hill Higher Education. All rights reserved

  49. Shortwave Diathermy • Physiological Effects • Generates deep tissue heating • Higher water content facilitates healing • Dependent on thickness of subcutaneous tissue • Heats tissue by introducing high frequency electrical current • Heats tissue by introducing high frequency electrical current © 2011 McGraw-Hill Higher Education. All rights reserved

  50. Pulsed diathermy is relatively new • Not continuous – reduces likelihood of significant tissue temperature increase • Utilizes drum electrode • Produces both thermal and non-thermal effects • Equipment • Frequency generator with an oscillator along with amplifier for converting AC current to DC • Also has circuit that tunes to patient • Treatment applicator is either condenser or inductive type • With condenser, patient is part of circuit and requires use of flexible electrodes • Inductive – utilizes drum or cable electrodes © 2011 McGraw-Hill Higher Education. All rights reserved

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