15._Modalities.ppt

© 2009 McGraw-Hill Higher Education. All rights reserved
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
• A variety of modalities can be utilized by
athletic trainers including cryotherapy,
electrical stimulation, ultrasound, massage,
traction, diathermy, lasers and magnets

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

• 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

Electromagnetic Modalities

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

– 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

• 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

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

• 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)

• 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
– 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

• 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

• 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

• 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

• 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

• 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

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

• 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

– 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

– 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

• 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

• 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

• 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

• 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
• Avoid excessive cold exposure; w/ any indication of
allergy or abnormal pain, treatment should be stopped

• 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

• 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

• 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

• 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

– 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)

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

• 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)

Figure 15-8

• 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

Figure 15-9 & 10

– 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

– 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

• 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
• 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

• Ionotophoresis
– 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, hyperhydrosis

– 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

• 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

• 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

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

– 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

Figure 15-12

• Indications
– 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
• Can generate heating equal to that achieved via
ultrasound
• Useful for large treatment areas
• Does not require constant monitoring

– Special Considerations (continued)
• 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

Low Level Laser Therapy
• 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

• Application
– 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)

Ultrasound Therapy
• 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)

• 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
– 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 - 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

• 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

– Gel pad technique
• 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

– 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
• 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

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)

Phonophoresis
• 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

Mechanical Modalities

Traction
• 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

• Indications
– 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

– Mechanical Traction
• 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

Intermittent Compression Units
• 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

• Indications
– 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

• On/Off Time
– 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

• Cryo-Cuff
– 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

Massage
• 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

• 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

Application
• 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

Stroking Variations

• Petrissage
– Kneading
– Involves picking up
skin between thumb
and forefinger, rolling
and twisting in
opposite directions
– Used for deep tissue
work Figure 15-25

• Friction
– 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

– Tapotement
• 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

Figure 15-27

• Special Considerations
– 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

• Sports Massage
– 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

• Ensure Patient Privacy and Athletic Trainer
Integrity
– 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

• Deep Transverse Friction Massage
– 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

Figure 15-28

• Acupressure Massage
– 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

Magnet Therapy
• 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

Extracorporeal Shock Wave
Therapy (ESWT)
• 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

• Rarely found in clinical setting – primarily
in hospitals
• 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

Recording Therapeutic Modality
Treatments
• 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

Safety in Using Therapeutic
Modalities
• Equipment must be used and maintained in
appropriate manner
• Following manufacturer recommendations
– Regarding use and maintenance
• Failure to follow recommendations =
negligence

Evidence-Based Data Regarding
Therapeutic Modality Use
• 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
– Of that which exists much should be carefully
questioned and considered
– Best evidence should be put into practice

15._Modalities.ppt

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