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 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

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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
– Contraindicated for acute
injuries due to gravity Figure 15-2
dependent position

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• 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

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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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• 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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 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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• 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
– Special Considerations
• Avoid excessive cold exposure; w/ any indication of allergy or abnormal pain, treatment
should be stopped

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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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• 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 hemoglobinuaria
– Application of ice (very rare) can cause nerve
palsy
• Motor nerves close to skin overexposed to cold
(peronial 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 & 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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• 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

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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
– 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 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 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

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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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 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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 Intermittent Compression Units
• Equipment
– Utilizes nylon inflatable sleeve
– Sleeve is inflated to specific pressure using either
water or air
– Utilized to facilitate movement of lymphatic fluids
• Parameters
– Able to adjust on/off time, pressure and treatment
time

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• Indications
– Used for controlling or reducing swelling after
acute injury
– Good for pitting edema, which develops several
hours after injury
– Elevation of extremity is critical to effective
treatment
– With electrical stimulation, muscle pumping can be
incorporated to facilitate lymphatic flow

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

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Stroking Variations

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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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Figure 15-28

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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
– Of that which exists much should be carefully questioned
and considered
– Best evidence should be put into practice

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