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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 l.jpg

Chapter 15: Using Therapeutic Modalities

© 2011 McGraw-Hill Higher Education. All rights reserved


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  • 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


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Classification of Therapeutic Modalities various techniques of therapeutic exercise

  • 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


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  • Acoustic various techniques of therapeutic exercise

    • 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


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Electromagnetic Modalities various techniques of therapeutic exercise

© 2011 McGraw-Hill Higher Education. All rights reserved


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Thermotherapy various techniques of therapeutic exercise

  • 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

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  • Extensibility of collagen various techniques of therapeutic exercise

    • 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


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  • Superficial Heat various techniques of therapeutic exercise

    • 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


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Transmission of Thermal Energy various techniques of therapeutic exercise

  • 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


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  • Convection various techniques of therapeutic exercise

    • 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


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Hydrocollator Packs various techniques of therapeutic exercise

  • 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


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  • Indications various techniques of therapeutic exercise

    • 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


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  • Whirlpool Bath various techniques of therapeutic exercise

    • 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


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Special Considerations various techniques of therapeutic exercise

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


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  • Paraffin Bath various techniques of therapeutic exercise

    • 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


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  • Fluidotherapy various techniques of therapeutic exercise

    • 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


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Figure 15-3 various techniques of therapeutic exercise

Figure 15-4

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  • Special Consideration w/ Superficial Heat various techniques of therapeutic exercise

    • 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


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Cryotherapy various techniques of therapeutic exercise

  • 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


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  • Physiological Effects of Cold various techniques of therapeutic exercise

    • 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


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  • Vasoconstriction various techniques of therapeutic exercise

    • 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


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  • Decreases muscle spasm various techniques of therapeutic exercise

    • 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


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  • Ice Massage various techniques of therapeutic exercise

    • 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


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Figure 15-5 various techniques of therapeutic exercise

© 2011 McGraw-Hill Higher Education. All rights reserved


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  • Cold or Ice Water Immersion various techniques of therapeutic exercise

    • 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


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  • Cold or Ice Water Immersion (continued) various techniques of therapeutic exercise

    • 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


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  • Ice Packs (Bags) various techniques of therapeutic exercise

    • 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


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  • Special Considerations various techniques of therapeutic exercise

    • 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


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  • Vapocoolant Sprays various techniques of therapeutic exercise

    • 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


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  • Vapocoolant Spray (continued) various techniques of therapeutic exercise

    • 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


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Figure 15-7 various techniques of therapeutic exercise

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  • Cryokinetics various techniques of therapeutic exercise

    • 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


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  • Special Considerations for Cryotherapy various techniques of therapeutic exercise

    • 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


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  • Special medical conditions various techniques of therapeutic exercise

    • 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


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Electrical Stimulating Currents various techniques of therapeutic exercise

  • 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


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  • Equipment various techniques of therapeutic exercise

    • 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)

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Figure 15-8 various techniques of therapeutic exercise

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  • Biphasic various techniques of therapeutic exercise

    • 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


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    Figure 15-9 various techniques of therapeutic exercise

    Figure 15-10

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    • Modulation various techniques of therapeutic exercise

      • 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


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    • Polarity various techniques of therapeutic exercise

      • 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


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    • Indications various techniques of therapeutic exercise

      • 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


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    • Muscle Contraction various techniques of therapeutic exercise

      • 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


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    • Muscle strengthening various techniques of therapeutic exercise

      • 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


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    • Iontophoresis various techniques of therapeutic exercise

      • 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


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    • Application various techniques of therapeutic exercise

      • 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


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    • Interferential Currents various techniques of therapeutic exercise

      • 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


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    • Low Intensity Stimulators various techniques of therapeutic exercise

      • 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


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    Shortwave Diathermy various techniques of therapeutic exercise

    • 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


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    • Pulsed diathermy is relatively new various techniques of therapeutic exercise

      • 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

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    Figure 15-12 various techniques of therapeutic exercise

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    • Indications various techniques of therapeutic exercise

      • Effective for bursitis, capsulitis, osteoarthritis, deep muscle spasm and strains

      • Penetrates up to 2 inches

    • Application

      • For superficial heating a condenser plate is used while coil systems are used for deep heating

      • Special Considerations

        • Can generate heating equal to that achieved via ultrasound

        • Useful for large treatment areas

        • Does not require constant monitoring

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Special Considerations (continued) various techniques of therapeutic exercise

      • Difficult to treat local areas

      • Dosage is subjective

      • Good chance of deep tissue burning

      • Toweling is critical

      • Avoid use with loss of sensation

      • Do not use if patient has metal implants

      • Avoid use if patient is pregnant or has open wounds

      • Avoid heating eyes, testicle, ovaries, bony prominences, bone-growth areas

      • Deep aching sensation during treatment may indicate overheating

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    Low Level Laser Therapy various techniques of therapeutic exercise

    Light Amplification by Stimulated Emission of Radiation

    Indications

    Used for collagen synthesis, control of microorganisms, increased vascularization, and pain/inflammation reduction

    Equipment

    Helium-neon and gallium-arsenide lasers are currently being explored by the FDA

    Figure 15-13

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Application various techniques of therapeutic exercise

      • Ideally done with gentle contact – should be perpendicular to treatment area

      • Dosage is critical for desired response – however, not exactly determined as of yet

      • Utilize a grid technique to perform treatment

    • Special considerations

      • No deleterious effects have been noted

      • Contraindications include lasing over cancerous tissue, over the eyes, pregnancy

      • Pain may initially increase – not an indicate for cessation

      • Syncope has occurred in some patients during treatment (self-resolving)

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    Ultrasound Therapy various techniques of therapeutic exercise

    • 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)

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Equipment various techniques of therapeutic exercise

      • 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

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • 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

    • Intensity is determined by amount of energy delivered to the sound head (W/cm2)

    • Can be delivered as either pulsed or continuous ultrasound

    Figure 15-14

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Indications radiating area

      • 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 - useful with acute injuries

          • For solely non-thermal effects, intensity must remain below .2 W/cm2

          • Frequency resonance hypothesis relates to alterations in protein signaling frequency which impact permeability, healing and protein production

      • Acute conditions require more treatments over a shorter period and chronic conditions require fewer treatments over a longer period

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Application radiating area

      • 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

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Gel pad technique radiating area

      • Used when body part can not be immersed in water

      • Gel pad applied to treatment area

      • 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

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Dosage and Time radiating area

      • 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

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    Ultrasound in combination w other modalities l.jpg
    Ultrasound in Combination w/ Other Modalities radiating area

    • 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)

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    Figure 15-15 radiating area

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    Phonophoresis radiating area

    • Method of driving molecules through the skin using mechanical vibration

      • Process which moves medication to injured tissues

    • Indications

      • 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 are also available

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    Mechanical Modalities radiating area

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    Traction radiating area

    • Drawing tension applied to a body segment

    • Physiological Effects

      • Produces separation of vertebral bodies impacting ligaments, capsules, paraspinal muscles; increases articular facet separation, and relief of nerve root pain; decreases central pressure of vertebral disks; increases proprioceptive changes; relief of joint compression due to normal posture

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    • Indications radiating area

      • Spinal nerve root impingement

      • Decrease muscle guarding, treat muscle strain

      • Treat sprain of spinal ligaments

      • Relax discomfort from normal spinal compression

    • Application

      • Manual and traction machines can be used

      • Manual

        • Adaptable and allows for great flexibility

        • Changes in force, direction, duration and patient positioning can be made instantaneously

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    • Mechanical Traction radiating area

      • Can be used to apply cervical or lumbar traction

    • Positional Traction

      • Used on trial and error basis to determine maximum position of comfort to accomplish specific goal

    • Wall-Mounted Traction

      • Cervical traction can be accomplished w/ this unit

      • Involves use of plates, sand bags or water bags for weight

      • Relatively inexpensive and effective

    • Inverted Traction

      • Utilizes special equipment or simply inverting ones self

      • Weight of trunk lengthens spine, providing a stretch

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    Figure 15-17 radiating area

    Figure 15-19

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    Figure 15-16 radiating area

    Figure 15-18

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    Intermittent Compression Units radiating area

    • Equipment

      • Utilizes nylon inflatable sleeve

      • Sleeve is inflated to specific pressure using either water or air

      • Utilized to facilitate movement of lymphatic fluids

    • Parameters

      • Able to adjust on/off time, pressure and treatment time

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    • Indications radiating area

      • Used for controlling or reducing swelling after acute injury

      • Good for pitting edema, which develops several hours after injury

      • Elevation of extremity is critical to effective treatment

      • With electrical stimulation, muscle pumping can be incorporated to facilitate lymphatic flow

    Figure 15-20

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    • On/Off Time radiating area

      • Will often vary (1:2, 2:1, or 4:1)

      • Not research based

    • Pressures

      • Must be mindful of blood pressure

      • Upper extremity 30-50 mm Hg

      • Lower extremity 30-60 mm Hg

    • Some units allow for combining cold along with compression

    • Electric stim can also be combined during some treatments

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    Cryo-Cuff radiating area

    Uses both compression and cold simultaneously

    Elevation of cooler results in increased cuff pressure

    Also allows for circulation of cooler water

    Portable and easy to use

    Game Ready System

    Circulates water with compression

    Can be customized for various time, temperature and compression settings

    Figure 15-21

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    Massage radiating area

    • Systematic manipulation of soft tissue

    • Therapeutic Effects

      • Mechanical Responses

        • Occur as a direct result of pressures and movements

        • Encourages venous flow and mild stretching of superficial tissue

      • Physiological Responses

        • Increases circulation aiding circulation, removal of metabolites, overcoming venostasis

        • Reflex effect - response to nerve impulses initiated through superficial contact

          • Impacts body relaxation, stimulation, and increased circulation

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    • Relaxation can be induced by slow superficial stroking of skin

    • Stimulation achieved by quick brisk strokes, causing contraction of tissue

      • Primarily psychological impacts

    • Increased circulation through reflexive and mechanical stimuli

      • Capillary dilation, stimulation of cell metabolism, decreasing toxins and increase lymphatic and venous circulation

  • Psychological Responses

    • Tactile system is one of the most sensitive systems of the body

    • Because the laying on of hands is used w/ massage it can be an important means of creating a bond of confidence between the athlete and the clinician

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    Application skin

    Effleurage

    Stroking divided into light and deep

    Can be used as a sedative or to move fluids

    Multiple stroking variations exist

    Pressure variations

    Figure 15-22

    Figure 15-23

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    Petrissage skin

    Kneading

    Involves picking up skin between thumb and forefinger, rolling and twisting in opposite directions

    Used for deep tissue work

    Figure 15-25

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    Friction skin

    Used around joints and in areas where tissue is thin

    Areas w/ underlying scarring, adhesions, spasms and fascia

    Goal is to stretch underlying tissue, develop friction and increase circulation

    Figure 15-26

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    • Tapotement skin

      • Cupping

        • Produces invigorating and stimulating sensation

        • Series of percussion movements rapidly duplicated at a constant tempo

      • Hacking

        • Used to treat heavy muscle areas, similar to cupping

      • Pincing

        • Lifting of small amounts of tissue between thumb and first finger in quick, gentle pinching movements

    • Vibration

      • Rapid movement that produces quivering or trembling effect to tissue

      • Used to relax and soothe

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    Figure 15-27 skin

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    • Special Considerations skin

      • Make the patient comfortable

        • Positioning, padding, temperature, privacy

      • Develop confident, gentle approach to massage

        • Good body positioning (clinician and athlete) an develop good technique

      • Stroke towards heart to enhance lymphatic and venous drainage

      • Know when to avoid massage

        • Acute conditions, skin conditions, areas where clots can become dislodged

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    • Sports Massage skin

      • Usually confined to a specific area - rarely given to full body

      • Full body massage is time consuming, generally not feasible

      • Five minute treatment can be effective

      • Massage lubricants

        • Enables hands to slide and move easily over body, reducing friction

        • Rubbing dry area can irritate skin

        • Mediums include powder, lotion, oil or liniments

      • Positioning of Athlete

        • Area must be easily accessible and must be relaxed

      • Exhibit Confidence

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    • Ensure Patient Privacy and Athletic Trainer Integrity skin

      • Due to direct physical contact professionalism must be maintained at all times

      • Critical when dealing with patient of opposite sex

      • Be sure that area being treated is the only area exposed

      • An additional athlete or athletic trainer should also be present

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    • Deep Transverse Friction Massage skin

      • Transverse or Cyriax method used to treat muscle, tendon, ligaments and joint capsules

      • Goal is mobilization of soft tissue

      • Generally precedes activity

      • Movement is across the grain of the affected tissue

      • Avoid treatment with acute injuries

      • Treatment will produce numbing effect allowing for exercise mobilization

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    • Acupressure Massage skin

      • Based on Chinese art of acupuncture

      • Physiological explanation and effectiveness may be based on pain modulation mechanisms

      • Clinician can utilize acupuncture points in treatment

      • Locate through measurement of electrical impedance or palpation

      • Small circular motions are used to treat points (pressure to tolerance of athlete = generally more pressure = more effective treatment)

      • Treatment time ranges from 1-5 minutes

      • Can treat one or more points, working distal to proximal

      • Will produce dulling or numbing sensation w/ results lasting from minutes to hours

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    Magnet Therapy skin

    • Becoming popular amongst competitive and recreational athletes

    • Used in cases of musculoskeletal ailments

    • Limited research on magnetic therapy

    • Utilizes magnetic fields to physiologically impact body

      • Change polarity of damaged cells, increase blood flow, increase muscle strength and hormone secretion, increase cell division and enzyme activity, increase lymphatic flow and alter blood pH

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    Extracorporeal Shock Wave Therapy (ESWT) skin

    • Used initially for kidney stone fragmentation

    • Involves a pulsed, high-pressured, short-duration acoustical sound wave with little attenuation

    • Concentrated in focal area (2.8 mm in diameter)

    • Treatment lasts 15-30 minutes

    © 2011 McGraw-Hill Higher Education. All rights reserved


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    • Rarely found in clinical setting – primarily in hospitals skin

    • Applied to point of maximal tenderness

    • Utilized in cases of tennis elbow, plantar fascitis, non-union fractures, and analgesia

    • Enhances metabolism, circulation and revascularization

    • Techniques are not standardized

      • Dosages and frequencies have not been studied extensively

      • May require imaging devices to direct treatment

      • Use of anesthesia is still uncertain as well

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    Recording Therapeutic Modality Treatments skin

    • Specifics of treatment should be recorded on original SOAP note, progress note and treatment log

    • Changes in treatment parameters and modalities should always be noted

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    Safety in Using Therapeutic Modalities skin

    • Equipment must be used and maintained in appropriate manner

    • Following manufacturer recommendations

      • Regarding use and maintenance

    • Failure to follow recommendations = negligence

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    Evidence-Based Data Regarding Therapeutic Modality Use skin

    • Clinical effectiveness has yet to be established for a variety of conditions

    • Often rely on efficacy generated by manufacturers rather than research

    • Minimal modality-related evidence-based information available

      • Evidence should be carefully questioned and considered

      • Best evidence should be put into practice

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