Modalities

Chapter 15: Using Therapeutic
Modalities
© 2009 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

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 Figure 15-2
dependent position

• Paraffin Bath
– Equipment
• A paraffin wax and mineral oil combination, heated to 126-130 o 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 104 o
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

Modalities

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Chapter 15: Using Therapeutic

© 2009 McGraw-Hill Higher Education. All rights reserved

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• Descending Pain Control

• Opiate Pain Control Theory

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