Therapeutic Therapeutic ModalitiesModalities

Basic ModalitiesBasic Modalities

IceIce

HeatHeat

WhirlpoolWhirlpool

Paraffin BathParaffin Bath

Cryotherapy: IceCryotherapy: Ice

Typically used in acute situations to limit Typically used in acute situations to limit inflammatory response inflammatory response

Pain reduced by:Pain reduced by: Decreasing nerve conduction velocity Decreasing nerve conduction velocity Decreasing muscle spindle activity, which Decreasing muscle spindle activity, which

decreases muscle spasm and breaks decreases muscle spasm and breaks pain/spasm cyclepain/spasm cycle

Most treatments last ~15-20 minutesMost treatments last ~15-20 minutes

Cryotherapy PrinciplesCryotherapy Principles

IndicationsIndications Acute/chronic painAcute/chronic pain Acute inflammationAcute inflammation Muscle spasmMuscle spasm Post-operative pain Post-operative pain

and swellingand swelling

ContraindicationsContraindications Cold allergy/sensitivityCold allergy/sensitivity Impaired circulationImpaired circulation Impaired sensationImpaired sensation Open wounds Open wounds Cardiac or respiratory Cardiac or respiratory

disordersdisorders

Cryotherapy ApplicationsCryotherapy Applications Ice massageIce massage

Ice frozen in cup and massaged onto small area of Ice frozen in cup and massaged onto small area of skinskin

Most common application to muscle injuries, Most common application to muscle injuries, spasmsspasms

Fast treatment time (5-7 minutes)Fast treatment time (5-7 minutes) Ice packs/bagsIce packs/bags

Easily combined with elevation and compressionEasily combined with elevation and compression Molds easilyMolds easily

Ice immersion/cold whirlpoolIce immersion/cold whirlpool ““Ice bucket” vs. whirlpool – temps kept between 50-Ice bucket” vs. whirlpool – temps kept between 50-

6060˚F˚F Acute Injury???Acute Injury???

Cryotherapy ApplicationsCryotherapy Applications Commercial gel/chemical packsCommercial gel/chemical packs

Gel packs kept in freezer, chemical packs “activated” Gel packs kept in freezer, chemical packs “activated” by squeezingby squeezing

Must be careful about leaks and potential for frostbiteMust be careful about leaks and potential for frostbite Intermittent compression unitsIntermittent compression units

Boot/sleeve with cold water circulated through it to Boot/sleeve with cold water circulated through it to minimize swelling, typically also elevate affected areaminimize swelling, typically also elevate affected area

Vapo-coolant spraysVapo-coolant sprays Flourimethane is most common, spray and stretch Flourimethane is most common, spray and stretch

application for spasms/trigger pointsapplication for spasms/trigger points

Ice MassageIce Massage

Appropriate for Appropriate for delivering cold tx to delivering cold tx to small areas small areas

Most effective forMost effective for Muscle spasmMuscle spasm Contusion Contusion Other well-localized Other well-localized

areasareas

Duration of txDuration of tx 5-7 minutes or until 5-7 minutes or until

ice runs outice runs out If the purpose is If the purpose is

analgesic, then stop analgesic, then stop when numbwhen numb

Ice ImmersionIce Immersion

Temp. 50° - 60° FTemp. 50° - 60° F Time 10-20minTime 10-20min IndicationsIndications

Acute Injury or Inflam.Acute Injury or Inflam. Acute or Chronic PainAcute or Chronic Pain Post Surgical PainPost Surgical Pain Decrease Muscle Decrease Muscle

SorenessSoreness

ContraindicationsContraindications Same as general Same as general

ContraindicationsContraindications Acute injury where Acute injury where

gravity is gravity is contraindicatedcontraindicated

Cold WhirlpoolsCold Whirlpools

Duration of TxDuration of Tx 15-20 minutes15-20 minutes Temp 50° - 60 ° FTemp 50° - 60 ° F

IndicationsIndications Decrased ROMDecrased ROM CryokineticsCryokinetics Subacute to chronic Subacute to chronic

inflammationinflammation Peripheral nerve injuries Peripheral nerve injuries

(avoid extremes)(avoid extremes)

ContraindicationsContraindications Acute conditions Acute conditions

where water where water turbulence would turbulence would further irritate areafurther irritate area

GravityGravity PostsuturalPostsutural Skin ConditionsSkin Conditions All other All other

contraindicationscontraindications

Thermotherapy: HeatThermotherapy: Heat

Typically used after inflammatory process has Typically used after inflammatory process has subsided to increase blood flow and promote subsided to increase blood flow and promote healinghealing If used on acute injury, will worsen swellingIf used on acute injury, will worsen swelling Vasodilation response brings oxygen and nutrients Vasodilation response brings oxygen and nutrients

and rids waste products and debrisand rids waste products and debris

Increases extensibility of connective tissue – Increases extensibility of connective tissue – pre-stretching/rehab applicationspre-stretching/rehab applications

Most treatments last ~15-20 minutesMost treatments last ~15-20 minutes

Thermotherapy PrinciplesThermotherapy Principles

IndicationsIndications PainPain Subacute or chronic Subacute or chronic

inflammationinflammation Muscle spasmMuscle spasm Decreased ROMDecreased ROM Joint contractureJoint contracture

ContraindicationsContraindications Acute inflammationAcute inflammation Impaired circulationImpaired circulation Impaired sensationImpaired sensation Impaired thermal Impaired thermal

regulationregulation Open wound Open wound

considerationsconsiderations

Thermotherapy Thermotherapy ApplicationsApplications

Warm whirlpoolWarm whirlpool Use of “jets” adds massage effectUse of “jets” adds massage effect Temps kept between 102-110Temps kept between 102-110˚F˚F

Moist heat packMoist heat pack Hydrocollator (silicate/sand filled) packs kept at 158-Hydrocollator (silicate/sand filled) packs kept at 158-

170170˚F˚F Wrapped in covers/toweling and applied to bodyWrapped in covers/toweling and applied to body Effects are superficialEffects are superficial

Paraffin bathParaffin bath Best for providing heat to contoured areas (hands, Best for providing heat to contoured areas (hands,

feet)feet) Wax and oil heated to liquid state (118-126Wax and oil heated to liquid state (118-126˚F)˚F) Immersion method vs. wrap/pack/glove methodImmersion method vs. wrap/pack/glove method

Moist Heat PacksMoist Heat Packs

Canvas pouch with silica gel or sandCanvas pouch with silica gel or sand Pack is kept in a water-filled heating unit Pack is kept in a water-filled heating unit

(hydroculator) maintained between 160ºF -(hydroculator) maintained between 160ºF -170ºF170ºF

Treatment time: 20-30 minutesTreatment time: 20-30 minutes Superficial heat to 1cmSuperficial heat to 1cm

Paraffin BathParaffin Bath

A mixture of wax an mineral oil in a ratio A mixture of wax an mineral oil in a ratio of 7 parts wax to 1 part oilof 7 parts wax to 1 part oil

Temperature of 118º F to 126 ºFTemperature of 118º F to 126 ºF Paraffin can provide approx 6x the Paraffin can provide approx 6x the

amount of heat as water due to low amount of heat as water due to low specific heatspecific heat

Used to treat small or irregular shaped Used to treat small or irregular shaped areasareas

Paraffin BathParaffin Bath

PrecautionsPrecautions Sensation is different Sensation is different

from specific heat and from specific heat and thermal capacity - thermal capacity - may cause burnsmay cause burns

Avoid using with Avoid using with athlete who are athlete who are required to catch or required to catch or throw a ball - skin throw a ball - skin becomes slipperybecomes slippery

ContraindicationsContraindications Open woundsOpen wounds Skin infectionsSkin infections Sensory lossSensory loss Peripheral vascular diseasePeripheral vascular disease

IndicationsIndications Subacute and chronic Subacute and chronic

inflammationinflammation limitation on ROM after limitation on ROM after

immobilizationimmobilization

Warm WhirlpoolWarm Whirlpool Tx temperature is Tx temperature is

between 105º-110º F between 105º-110º F Tx times between 20-30 Tx times between 20-30

min once or twice dailymin once or twice daily IndicationsIndications

Decreased ROMDecreased ROM Subacute or chronic Subacute or chronic

inflammatory conditionsinflammatory conditions Peripheral vascular diseasePeripheral vascular disease Peripheral nerve injuriesPeripheral nerve injuries Irregular shaped areasIrregular shaped areas

ContraindicationsContraindications Acute conditions Acute conditions FeverFever Patients requiring Patients requiring

postural supportpostural support Skin conditionsSkin conditions Open woundsOpen wounds

Contrast Bath Set UpContrast Bath Set Up

Two tubs placed as close together as Two tubs placed as close together as possiblepossible

Fill one tub in the range from 105 F- 110 F Fill one tub in the range from 105 F- 110 F and the other 50 F - 60 Fand the other 50 F - 60 F

Position patient on chair or bench between Position patient on chair or bench between two tubstwo tubs

Heat Tx given 1stHeat Tx given 1st Contrast bath 20 -30 minutes at 1:2 or 3:5 Contrast bath 20 -30 minutes at 1:2 or 3:5

minute hot:cold intervalsminute hot:cold intervals

Contrast BathContrast Bath

PrecautionsPrecautions Same as with all Same as with all

whirlpoolswhirlpools

IndicationsIndications Ecchymosis removalEcchymosis removal Edema removalEdema removal Subacute or Chronic Subacute or Chronic

InflammationInflammation Impaired circulationImpaired circulation Pain ReductionPain Reduction

ContraindicationsContraindications Acute injuriesAcute injuries Hypersensitivity to coldHypersensitivity to cold Contraindication relative Contraindication relative

to whirlpool useto whirlpool use Contraindications relative Contraindications relative

to cold applicationto cold application Contraindications relative Contraindications relative

to heat applicationto heat application

Advanced ModalitiesAdvanced Modalities Ultra SoundUltra Sound E-StimE-Stim TensTens LLLTLLLT

UltrasoundUltrasound Ultrasound treatment is used to:Ultrasound treatment is used to:

Relieve pain and inflammationRelieve pain and inflammation Speed healingSpeed healing Reduce muscle spasms andReduce muscle spasms and Increase ROMIncrease ROM

Sound waves vibrate tissues deep inside the injured Sound waves vibrate tissues deep inside the injured areaarea This creates heat that draws more blood into the tissues This creates heat that draws more blood into the tissues

Ultrasound is the most commonly used deep heating Ultrasound is the most commonly used deep heating modality today modality today Penetration is between 3-5 cm.Penetration is between 3-5 cm.

Frequency is between .8 and 3 MHz (audible f= 15-Frequency is between .8 and 3 MHz (audible f= 15-20,000 Hz)20,000 Hz)

E-StimE-Stim Electrical-muscle stimulationElectrical-muscle stimulation Electrotherapy: Electrotherapy: 400 B.C.400 B.C.

Torpedo fish (produce electric shocks) used to treat Torpedo fish (produce electric shocks) used to treat a variety of injuries/illnesses a variety of injuries/illnesses

Electrical stimulation for pain control was used Electrical stimulation for pain control was used in ancient in ancient Greece: : 63 A.D.63 A.D.

1988 1988 First Portable Marketed Product First Portable Marketed Product Reported Uses:Reported Uses:

Facilitate faster recovery of muscle and soft tissue Facilitate faster recovery of muscle and soft tissue damage, reduce pain and swelling, increase blood damage, reduce pain and swelling, increase blood circulation and range of motion, and help control circulation and range of motion, and help control muscle spasms muscle spasms

TENSTENS

Transcutaneous Electrical Nerve Stimulation Transcutaneous Electrical Nerve Stimulation 1974 First Modern TENS1974 First Modern TENS Designed initially to treat chronic painDesigned initially to treat chronic pain

Now used to treat many different types of painNow used to treat many different types of pain

Sensory onlySensory only How does it work?How does it work?

By selectively stimulating certain 'non-pain' nerve By selectively stimulating certain 'non-pain' nerve fibres to send signals to the brain that block other fibres to send signals to the brain that block other nerve signals carrying pain messages nerve signals carrying pain messages

LLLTLLLT Low Level Laser TherapyLow Level Laser Therapy Used for: Used for:

Wound healingWound healing Soft-tissue healingSoft-tissue healing Pain ReliefPain Relief

Indications:Indications: Acceleration of collagen synthesisAcceleration of collagen synthesis Increased vascularizationIncreased vascularization Reduce pain & inflammationReduce pain & inflammation

Contraindications:Contraindications: Cancerous tissue, over the eyes, pregnancyCancerous tissue, over the eyes, pregnancy

Iontophoresis &Iontophoresis &PhonophoresisPhonophoresis

Application of medication/drug with modalityApplication of medication/drug with modality Example: CorticosteroidsExample: Corticosteroids

Iontophoresis:Iontophoresis: Electrical StimulationElectrical Stimulation Medicated PatchesMedicated Patches

Phonophoresis:Phonophoresis: UltrasoundUltrasound Drug is in gel formDrug is in gel form

TractionTraction Types: Types:

ManualManual WallWall MachineMachine InvertedInverted

Indications:Indications: Decrease muscle spasmDecrease muscle spasm Decrease nerve impingementDecrease nerve impingement

Contraindications:Contraindications: FractureFracture

MassageMassage ART ®ART ®

Active Release TechniqueActive Release Technique Deep tissue release using full range of motionDeep tissue release using full range of motion

Trigger Point ReleaseTrigger Point Release Targeted pressure to trigger pointTargeted pressure to trigger point

Soft Tissue EffleurageSoft Tissue Effleurage Sensory message to decrease pain w/ acute injury Sensory message to decrease pain w/ acute injury

or to increase lymphatic drainageor to increase lymphatic drainage Grastons Technique ®Grastons Technique ®

Massage w/ special metal toolsMassage w/ special metal tools