Download Chapter 15: Therapeutic Modalities

Chapter 15: Using
Therapeutic Modalities
© 2011 McGraw-Hill Higher Education. All rights reserved
• 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
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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
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• 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
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Electromagnetic Modalities
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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
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– 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
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• 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
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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
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• 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)
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Hydrocollator Packs
• Equipment
– Silicate gel pads
submersed in 160170o F water
– Maintains heat for
20-30 minutes;
must use 6 layers
of terry cloth to
protect skin
Figure 15-1
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• 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
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• 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
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• Special Considerations
– Must be careful with fullbody 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
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• 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
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• 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
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Figure 15-3
Figure 15-4
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• 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
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2010 McGraw-Hill Higher Education. All rights reserved
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
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• 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
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– 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
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– 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
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• 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
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Figure 15-5 © 2011 McGraw-Hill Higher Education. All rights reserved
• 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
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• 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
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• 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
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• Special
Considerations
– Avoid excessive cold
exposure
– With any indication
of allergy or
abnormal pain,
treatment should be
stopped
– When using gel
packs, a single layer
of toweling should be
used
– Crushed or flaked ice
can be directly
applied to skin
Figure 15-6
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• 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
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• 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
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Figure 15-7
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• 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
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• 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
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– Special medical conditions
• Raynaud’s phenomenon
• Paroxysmal cold hemoglobinuria
– Application of ice (very rare) can cause
nerve palsy
• Motor nerves close to skin overexposed to cold
(peroneal nerve at head of fibula)
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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
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• 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)
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Figure 15-8
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• 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
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Figure 15-9
Figure 15-10
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– 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
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– 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
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• 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
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– 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
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• 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
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• Iontophoresis
– Introduction of ions into body tissue via
direct electrical current
– Equipment
• Iontophoresis generator which produces a
continuous monophasic current
– Indications
• Used to treat musculoskeletal inflammatory
conditions, analgesic effects, scar modification,
wound healing, calcium deposits, hyperhidrosis
– Medication
• Dexamethasone and hydrocortisone are two
commonly used
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– 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
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• 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
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• Low Intensity Stimulators
– Equipment
• Micro-current electrical nerve stimulator
• Operates at low frequencies and intensities (subsensory)
– 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
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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
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– 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
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Figure 15-12
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• 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
– Special Considerations
• Can generate heating equal to that achieved via
ultrasound
• Useful for large treatment areas
• Does not require constant monitoring
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– 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
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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 galliumarsenide lasers are
currently being explored by
the FDA
Figure 15-13
© 2011 McGraw-Hill Higher Education. All rights reserved
• 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)
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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)
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• 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
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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
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• 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
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• 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
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– 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
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– Dosage and Time
• Varies according to depth of tissue to be
treated and the state of injury
• Duration tends to last 5-10 minutes
• Intensity varies
– Low 0.1-0.3 W/cm2
– Medium 0.4 - 1.5 W/cm2
– High 1.5 - 3.0 W/cm2
– Special Considerations
• While it is a relatively safe modality,
precautions still must be taken
• Be careful with anesthetized areas, reduced
circulation
• Avoid high fluid regions of the body, acute
injuries, and epiphyseal areas of children
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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)
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Figure 15-15
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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
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Mechanical Modalities
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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
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• 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
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– 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
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Figure 15-17
Figure 15-19
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Figure 15-16
Figure 15-18
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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
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• 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
Figure 15-20
© 2011 McGraw-Hill Higher Education. All rights reserved
• 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
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• 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
Figure 15-21
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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
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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
• 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
– 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
– 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
• 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
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• 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
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• 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
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• 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
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• 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
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• 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
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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
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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
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• 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
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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
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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
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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
– Evidence should be carefully questioned and
considered
– Best evidence should be put into practice
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