Chapter 15: Using

Therapeutic Modalities

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• 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 160-
170o F water
– Maintains heat for
20-30 minutes;
must use 6 layers
of terry cloth to Figure 15-1
protect skin

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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 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 Figure 15-2
– Contraindicated for acute
injuries due to gravity
dependent position
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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 (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
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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
Figure 15-13
– Helium-neon and gallium-
arsenide lasers are
currently being explored by
the FDA

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• 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 Figure 15-14
to the sound head (W/cm2)
– Can be delivered as either
pulsed or continuous
ultrasound
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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
Figure 15-20
critical to effective
treatment
– With electrical stimulation,
muscle pumping can be
incorporated to facilitate
lymphatic flow
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• 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
Figure 15-21
– Can be customized for
various time, temperature
and compression settings

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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 Figure 15-22
– Can be used as a
sedative or to move
fluids
– Multiple stroking
variations exist
– Pressure variations

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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