Therapeutic Modalities

Therapeutic Modalities Workout

Therapeutic Modalities

In addition to exercises, therapeutic modalities also may be used in rehabilitation programs. They should always be used as an adjunct to exercise - never as a replacement. Following are the various categories and types of modalities:

Electrical
  • Stimulation
  • Ultrasound

Thermal
  • Thermotherapy
  • Cryotherapy

Other Non-Manual
  • Intermittent compression
  • Low power laser
  • Taping/bracing/splinting/orthotics

Manual
  • Massage
  • Mobilization
  • Trigger point and acupressure

Non-manual modalities are utilized primarily to control and decrease pain and inflammation, although they may have other positive effects, as well. Because these symptoms are inherent in the acute stage of an injury, these modalities will be most frequently used in the initial phase of rehabilitation.

Manual therapies produce many therapeutic benefits such as decreased muscle soreness, improved blood circulation, increased range of motion and flexibility, faster healing of injured muscles, and reduced blood pressure, among others.

ELECTRICAL The two main classes of electrical modalities are electrical stimulation and ultrasound. Various types of electrical stimulation are conducted through devices that deliver electrical currents through the skin to targeted muscles and tissues. The modalities are primarily distinguished by their purpose:

  • Stimulate motor nerves;
  • Stimulate sensory nerves;
  • Stimulate superficial tissues; or
  • Stimulate deep tissues.

Modalities are further differentiated by the intensity, frequency, duration and direction of currents. Changing one or more of these factors can achieve different physiological responses.

Electrical muscle stimulation (EMS), or neuromuscular stimulation (NMS), utilizes a low-voltage current to stimulate motor nerves, thereby causing muscles to contract. These contractions can have many positive effects on the targeted muscles, including reeducating muscles, retarding atrophy, alleviating spasms, improving blood circulation, and increasing range of motion. Currents are delivered through electrodes that are placed on the skin over the targeted muscles.

EMS can be used during virtually any phase of rehabilitation - from acute injury or immediate post-surgery to return to function when the patient has regained nearly full strength in the affected extremity, joint or muscle group.

Transcutaneous electrical nerve stimulation (TENS) stimulates sensory nerves to alleviate pain by blocking pain signals traveling to the brain and producing endorphins, the body's natural mechanism for dealing with pain. For example, continuous high-frequency pulses are thought to block the pain signals going to the brain, while low-frequency pulses are believed to release endorphins. Low-frequency pulses are short bursts of current, while high-frequency pulses are longer in duration.

Similar to EMS, electrodes are placed on the skin over the area of pain. Stimulation is achieved through a biphasic current (a current that flows between electrodes) and variable pulse rates and widths. TENS is an effective method of pain management for both acute and chronic musculoskeletal conditions.

Iontophoresis is a method of administering a drug to a localized area of tissue by applying electrical current to a solution of the medication. Typically, the medication - an ionized drug - is applied to a special electrode that is placed over the area of tissue to be treated. An ion transfer takes place between the solution in the electrode and the skin as the drug travels into the underlying tissues.

Iontophoresis devices have two electrodes - one active and one dispersive. The principle behind the ion transfer is that like electrical charges repel.

For example, if the medication contains positive ions, then it is placed onto the positively-charged (active) electrode. The current will dispel the positive ions from the positive electrode and into the tissues through the skin. The same happens when negative ions interact with a negative current. The dispersive electrode is placed at a remote area of the same extremity.

In a rehabilitation setting, iontophoresis frequently is utilized to administer corticosteroid or anesthetic drugs to reduce joint and tissue inflammation and pain. A decrease in inflammation usually results in a decrease in pain and increase in range of motion.

Iontophoresis is generally painless, sterile, noninvasive and site-specific (can reach a targeted area).

Galvanic stimulation is used primarily to speed wound healing and decrease edema. A galvanic current produces a twin-spiked monophasic waveform and is usually characterized by high voltage and short pulses (commonly called "high-voltage pulsed
galvanic stimulation").

In principle, it works in a manner similar to iontophoresis. Edema contains negatively charged ions, and when a negative electrode is placed over the edematous area with a positive electrode over a distal site, the current disperses the ions from the edema and increases circulation around the area, thereby aiding in the reduction of edema.

Interferential current stimulation utilizes two medium frequency currents, each of slightly differing frequency, to produce a low-frequency current at the point of pain or injury.

For example, medium frequency currents of 4000 Hz and 4100 Hz would "cancel" each other out to produce a low-frequency current of 100 Hz. Two pairs of electrodes are crossed and placed on the skin equidistant from the focal point. The resulting current stimulates the targeted nerves and tissue to reduce pain, edema and inflammation and to promote soft tissue healing.

The advantage of interferential current therapy is that characteristics of both medium and low frequency currents are retained. That is, medium frequencies penetrate deeper into the tissues than would standard low-voltage devices, yet the longer duration of a lower frequency current stimulates the nerves and tissues more effectively than does a medium frequency.

Because of its ability to relieve pain and increase circulation, interferential therapy is likely to be used post-operatively as an adjunct to narcotics for pain relief and to speed healing and recovery.

Diathermy is a form of electrical stimulation utilized to generate heat deep within body tissues. This heat may be generated either through electromagnetic or electrostatic energy produced when electrical currents flow through a conductor to the skin and tissues.

Depending upon the type of conductor used, electrical currents produce either high frequency alternating magnetic fields (electromagnetic energy) or electrical fields (electrostatic energy) around the conductor, which in turn generate high frequency alternating currents within body tissues.

There are two types of diathermy: shortwave and microwave (also called microthermy). The main difference between the two is their frequency-wavelength relationship: shortwave diathermy produces a wavelength of approximately 11 meters, whereas microwave diathermy yields a much shorter wavelength of approximately 12 cm. The shorter wavelength of microthermy enables the energy to be focused on a smaller, more localized target area of tissue, thereby allowing for greater penetration.

Neither type of diathermy is as widely used today as it has been in the past, perhaps because of a cheaper, safer, and equally effective alternative: ultrasound.

Ultrasound also generates deep-heating effects; it produces high frequency vibrational sound waves that penetrate tissue at depths of 4 cm or more, providing mechanical, chemical, biological and thermal effects.

Although ultrasound does not transmit electrical currents to the tissue, the properties of the ultrasonic energy it creates are electrical in nature, thus it is classified as an electrical modality.

Ultrasound is transmitted through a device that generates a high frequency alternating current. Inside the handheld component of the device - the transducer - is a quartz or synthetic crystal that vibrates from the high frequency current to produce ultrasonic energy.

A coupling agent such as ultrasound gel is applied to the skin over the target area to provide effective conduction between the transducer and the skin. As the transducer is moved in a circular pattern over the focal area, the tissues absorb the ultrasonic energy as heat.

Ultrasound is indicated for a range of conditions, including tendinitis, bursitis, muscle spasms, neuromas and hematomas, contractures (shortening of muscle or tendon), and adhesions (scar tissue that can restrict motion).

Some of the effects of ultrasound include temporary analgesia (pain relief), increased blood flow and vascularity relating to hyperemia, and increased tissue regeneration and repair.

Phonophoresis is the use of ultrasound to topically deliver medications such as hydrocortisone or lidocaine to underlying tissues. The drugs are in an ointment or cream form and are mixed with the coupling agent for transmission through the skin. Phonophoresis is non-invasive and effective in decreasing tissue inflammation and promoting pain relief.

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THERMAL Thermal modalities refer to the use of cold and heat in treating an injury. They also are frequently utilized in athletics as an adjunct to reconditioning and rehabilitation in the absence of acute injury. By stimulating cutaneous nerve receptors, these modalities act as pain relievers and anti-inflammatories.

Cryotherapy, in the form of ice packs, ice massage or cold whirlpool, is the application of cold to treat an injury, most often in its acute or subacute stages. It is generally utilized to help reduce inflammation by decreasing blood flow to the area in which the cold is applied. The numbness that ensues after a few minutes of cold therapy also decreases pain.

Thermotherapy, or heat, increases blood flow to the area in which the heat is applied. In the presence of swelling following an acute injury, ice should always be applied prior to heat. Heat applications such as a heating pad, paraffin bath, hot bath, fluidotherapy or whirlpool promote pain relief by increasing blood flow and muscle temperature.

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OTHER Additional non-manual modalities that may be utilized in the course of physical rehabilitation include:

Intermittent compression devices are utilized to control or decrease swelling and edema in acute injuries of the extremities. The affected arm or leg is fitted with a pneumatic inflatable sleeve that is pressurized evenly around the extremity. The pressurized sleeve controls swelling by facilitating the movement of lymphatic fluid and reducing the amount of space in which edema may accumulate. Compression units may also be used simultaneously with cold and/or electrical stimulation.

Low-power (cold) laser may be used in the treatment of open wounds or lesions, or for pain management. Laser is actually an acronym that stands for light amplification by stimulated emission of radiation. This amplified, unidirectional light source is thought to have a healing effect on open wounds because it can permeate the skin on a cellular level to accelerate collagen synthesis and increase vascularization. The laser is administered directly to the wound or lesion.

With respect to pain management, the laser is applied directly to trigger points, acupuncture points, or nerve roots within the focal area. It provides relief by stimulating the underlying tissues. The depth of penetration depends upon which type of laser is utilized (helium-neon, or HeNe, provides shallow penetration of approximately 2-5 mm while gallium arsenide, or GaAs, directly penetrates 1-2 cm below the skin).

Taping is a convenient and popular modality, especially among athletes. During sporting events, it provides support to soft-tissue injuries while allowing the athlete to continue play.

Because tape is readily available at sporting goods and discount stores, many amateur and weekend athletes will attempt to tape themselves. In reality, there is a science to taping - and doing it the wrong way could cause more harm than good.

For example, the type of tape used and the technique for taping differ depending upon the site and nature of the injury. Both the kind of tape and wrapping technique have different effects on tissue and blood flow to the affected area. The clinician also must determine whether the taping is to be used to prevent or decrease edema, restrict movement, or to protect, support, immobilize, or provide heat to tissues and joints.

Bracing has the same functionality as taping but to a greater degree. A brace aids the healing process, but should never take the place of rehabilitation, nor should it give a premature sense of security to resume activity before an injury has healed.

The effectiveness of a brace is influenced by several factors, including comfort, fit, stability, contact area, tendency for slippage, range of motion permitted, degree of joint prominence and cost. Comfort and fit are the most influential factors; after all, if a brace isn't comfortable, then the patient won't wear it. And if it doesn't fit properly, then it can't perform as intended.

Physicians should be mindful of these factors and should fit the brace based on the patient's activities and preferences. To maximize the benefit of a brace, it is important for patients to communicate with their physician about its comfort, fit and usage.

A patient who has difficulty achieving a desired range of motion through exercise and stretching may be a candidate for dynamic splinting. Dynamic splinting is a type of brace that helps increase range of motion by providing a steady, gentle stretch to a joint for a prolonged period of time. This "low load" force can be applied to a joint during flexion or extension.

Range of motion becomes limited when connective tissues such as ligaments and tendons are scarred or when muscle tissue is shortened. The stretching force applied by a dynamic splint helps stimulate tissue growth. The growth of new tissue decreases scarring and lengthens muscle tissue, which ultimately enhances range of motion.

Dynamic splints utilize a tension spring to provide the stretch. The spring can be adjusted to increase or decrease tension as range of motion varies.

Many people think of orthotics as "arch supports" when, in fact, they are much more. Orthotics are custom-made shoe inserts that function to correct an irregular walking pattern. Strains, aches, and pains in the legs, thighs, and lower back may actually be a result of abnormal foot function. By altering the angles at which the foot strikes a surface, orthotics improve foot function and minimize stress forces on the feet and lower body.

There are three types of orthotics:

  • Rigid
  • Soft
  • Semi-rigid

The primary objective of rigid orthotics is to control motion in two major foot joints that lie directly below the ankle. Rigid orthotics are constructed from firm materials such as plastic or carbon fiber and, as such, are durable and long-lasting. They are most often used in walking or dress shoes.

Soft orthotics are primarily protective in nature, helping to absorb shock, increase balance, and relieve pressure from sore spots. They are made of soft, compressible materials and therefore need to be replaced or refurbished from time to time. Soft orthotics frequently are indicated for older arthritic or diabetic feet.

Semi-rigid, or sports orthotics, provide a combination of functional control and protection. They dynamically balance the foot while walking or participating in sports, thereby enabling the muscles and tendons to perform more efficiently. They are composed of firm but flexible materials.

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MANUAL As the name implies, manual therapies are performed by a therapist with his or her hands and may include:

Massage, the most familiar form of manual therapy, targets soft tissue. The therapist manipulates the body's soft tissues in order to normalize them and restore harmony within the physiologic system.

Massage can have mechanical, neurological, psychological or reflexive effects. For example, it can relieve muscle soreness and spasms, promote muscle relaxation, mobilize intertissue fluids, decrease edema, prevent or eliminate scar tissue, and increase feelings of well-being.

Methods of massage can differ vastly. Within the two main "schools" of massage - Eastern and Western - there are many variants. The most familiar Eastern approaches include Shiatsu, reflexology and auriculotherapy.

Shiatsu is a Japanese method based on the traditional Chinese theory that there are 12 meridians, or channels, of the body in which energy known as Chi circulates. It is believed that disease may result from an imbalance of energy within the meridians, and that applying pressure to certain points along the meridians may restore balance. This is known as acupressure. Reflexology and auriculotherapy involve acupressure applied specifically to points within the feet and ears, respectively.

Western massage is the most common form of massage in the U.S. and includes approaches such as effleurage, petrissage, tapotement, friction and vibration, among others.

Effleurage is characterized by either superficial or deep massage strokes involving gliding motions of the hands over the targeted area(s). Oils, lotions or powders are used to minimize friction and produce a most relaxing effect.

This approach is used for several reasons:

  • To increase blood circulation and lymph flow
  • To identify areas of muscle tightness, tenderness or spasm
  • To passively stretch muscle groups

Petrissage is a more aggressive approach, involving motions such as kneading, squeezing and skinrolling that compress skin and muscle between hands or between the fingers and thumb of one hand. The main benefits of petrissage include increased circulation and the release of adhesions (scar tissue) within muscles.

Tapotement involves striking soft tissue with rapid, repetitive movements such as hacking, cupping, slapping or beating for a mostly stimulating effect. Although it sounds harsh, the motions are performed gently and rhythmically and can be either superficial or deep.

Friction is a type of deep massage in which pressure is applied to targeted soft tissues with the ball of the thumb or fingertips. Movements may be made in circular, longitudinal or transverse (cross) directions, each of which may produce different
physiological effects.

In general, this approach helps separate and release deep tissue adhesions, relieve muscle spasms, soften tissue nodules, and stimulate blood flow.

Many people are familiar with deep tissue massage, which is a variation of friction. With deep tissue massage, the therapist uses deep-finger pressure along with long strokes to relieve muscle tension and soreness.

Vibration, a light shaking of the muscles, helps loosen soft tissue and increase circulation. Many of the commercially-available massage devices sold in retail stores employ this technique. It usually produces a stimulating or soothing effect on
overfatigued muscles.

Another popular massage, the Swedish massage, is a combination of the five strokes, all directed toward the heart. Massage strokes are performed in the direction of the heart to facilitate venous return from the extremities. The primary benefit of Swedish massage is muscle relaxation.

The elements of massage, such as rhythm, rate, pressure, direction and duration vary according to the approach used and treatment goals. For instance, light pressure may be used to induce relaxation and decrease muscle spasm; medium pressure may be required to treat edema and heavier pressure may be necessary to reach the deeper tissue levels and break down scar tissue.

Massage strokes usually are performed parallel to muscle fibers. However, if the goal is to eliminate adhesions, the therapist will use circular motions or cross-friction techniques that access muscle fibers in all directions.

Increasingly, athletes and athletic programs are incorporating massage into their training and conditioning activities. For an athlete, massage and stretching can help increase range of motion, improve flexibility, decrease muscle soreness, remove the metabolic toxins that build up in muscles during exercise, and more efficiently deliver nutrients and oxygen to muscles.

These physiological effects translate into benefits such as enhanced power and performance, shortened recovery time between workouts, reduced chance of injuries, and faster healing and pain relief in the event of injury.

Sports massage, as it is commonly called, may be used for preventive maintenance, to supplement the warm-up phase before an event, to speed recuperation following an event or activity, or to rehabilitate an injury.

Trigger-point therapy is the western cousin of acupressure. Myofascial (muscle and fascia) trigger points are hypersensitive areas in muscle and connective tissue, that, when compressed, trigger an impulse within the muscle and refer pain to another muscle or muscles, sometimes even in a different part of the body.

Interestingly, trigger points exhibit consistent patterns of referred pain. That is, they do not differ among individuals.

Trigger points also may cause a decrease in both range of motion and strength as well as increased fatigue in daily activities. Common causes include misuse, overuse or trauma.

Trigger points can be active or latent. Active, or acute, trigger points are always tender and painful, even without activity or compression. Latent trigger points lie dormant without causing pain unless pressure is applied to the point.

Massage is the most effective treatment in the elimination of trigger points. Typically, trigger-point massage begins with effleurage performed in a circular pattern, then progresses to finger petrissage. Finally, circular deep friction through firm compression with the thumb is applied to the point.

In conjunction with massage, trigger point therapy for pain relief may include a combination of ice, heat, ultrasound or transcutaneous electrical nerve stimulation (TENS).

In rehabilitation, the use of traction is largely confined to treating low back (lumbar) and neck (cervical) pain. Because of the volume of people with low back pain, lumbar traction is much more common than cervical traction.

Traction employs a pulling force applied to the body to stretch the spine or to separate two or more vertebrae. Doing so enhances mobility of the spine by easing tension within tissues and decreasing spinal pressure.

Traction is indicated for a number of conditions, such as low back pain, herniated disc and degenerative disc disease, joint hypomobility (lack of range of motion), muscle spasm, and muscle and ligament tightness.

There are several types of traction, including:

  • Mechanical
  • Positional
  • Manual
  • Passive

With mechanical traction, the patient lies on a split, friction-free table and is placed in a pelvic halter for lumbar traction or head halter for cervical traction. A weight-and-pulley system attached to the halter administers the pulling force. There also are a variety of home traction units available, most of which require a prescription.

The condition being treated determines:
(a) whether the patient will lie face-up (supine) or face-down (prone) and
(b) whether constant or intermittent traction is applied.

Positional traction is accomplished by placing the patient in various positions to generate a longitudinal pull on the spinal structures. Propping items such as pillows or blocks may be used to enhance a position.

Manual traction is administered directly by the therapist. He or she grasps the patient and applies a pulling force, either for a few seconds or as a sudden, quick thrust.

Manual and positional traction easily can be combined to isolate individual segments of the spine. This combination of techniques is beneficial when treatment needs to be applied only to a highly specific area of the spine.

Passive traction is achieved through gravity by the patient hanging upright or inverted. Gravity boots are a popular example of passive traction that is commercially available. Another method is to simply hang upright from a strong overhead object. Outpatient rehabilitation clinics often use an inversion table.

Mobilization is a graded stretch to a joint within or up to its available range of motion.

Indicated for joint hypomobility (lack of range of motion), mobilization involves the use of small, passive movements and gentle stretches on painful, stiff joints. These movements are applied with varying grades of pressure - from Grade One (light pressure) to Grade Four (heavier pressure). Each level has a slightly different purpose:

  • Grade One - facilitate normal movement in acute patients
  • Grade Two - relieve pain
  • Grade Three - relieve pain and improve range of motion
  • Grade Four - stretch tight tissue and improve range of motion for chronic conditions

Because joint mobilizations are performed slowly and gently, they are especially effective in treating sensitive arthritic joints and severe muscle spasms. They also are safe because the patient can stop the therapist if the pain becomes uncomfortable.

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