MODALITIES: APPLICATIONS FOR THE TRAINING ROOM

Duke Sports Medicine- Tracy Ray MD

Objectives

Define modality Discuss appropriate use of modalities Examine 3 primary modalities used in training

room and associated evidence

What is a modality?

The method of application of a therapeutic agent or regimen in order to promote, maintain, or restore the physical and physiologic well-being of an individual

These include the therapeutic use of heat, cold, ultrasound, massage, and electrical stimulation to induce a healing effect.

What is a modality?

“Physical agents/modalities should be utilized only as a component of patient/client management. Without documentation which justifies the necessity of the exclusive use of physical agents/modalities, the use of physical agents/modalities in the absence of other skilled therapeutic or educational interventions should not be considered physical therapy.”

Back to the basics

Modalities: should not be the sole focus of treatment

intervention Are most effective when used in conjunction

with other treatment interventions (i.e. manual therapy, active movement/exercise)

Parameters for use vary Most have limited research evidence to

support use

What is a modality?

Heat modalities: increasing blood flow to propagate healing factors at injured area

Cold modalities: decreasing blood flow to inhibit influx of chemical byproducts and inflammatory mediators which impede healing process

Electrotherapy: altering neuromuscular excitability and increasing electrical current to improve muscle activation and strength

Contraindications

The following are applicable to most modalities: Cancer Pregnancy Vascular disease or those areas with impaired

circulation Impaired sensation Thrombophlebitis Hemorrhage Heat or cold intolerance (for cold/heat

modalities)

Types of Modalities

Cryotherapy Ice packs, ice massage, whirlpool, immersion,

sprays Thermotherapy Moist heat packs, whirlpool, paraffin, ultrasound,

phonophoresis Contrast baths (hot and cold alternating) Electrotherapy Electrical stim, interex, biowave

Iontophoresis Massage

Heat

Superficial heating(hot pack, paraffin) penetrates skin 1-2 cm

Deep heating modalities (ultrasound, diathermy) heat 2-5 cm below skin

Heating effect occurs with transfer of energy via conduction

Increases local or systemic circulation Promotes vasodilation

Heat Physiology

A localized increase in temperature causes increased metabolic rate, capillary pressure and flow, clearance of metabolites, and oxygenation of tissue

Increases extensibility of soft tissue structures In most cases should not replace active warm-up As a movement based profession, active motion

should be encouraged to increase tissue temperatures and oxygen to healing tissue via increased blood flow

Clinical Application for Heat Promote relaxation and blood flow before

stretching, prepares for other treatments Decrease muscle guarding following whiplash

type injuries in contact sports Improve local circulation to an area Used in sub-acute and chronic situations Often used after dry needling or other manual

techniques to decrease soreness and promote flexibility/blood flow

Petrofsky, J. S., Laymon, M., & Lee, H. (2013). Effect of heat and cold on tendon flexibility and force to flex the human knee. Medical science monitor: international medical journal of experimental and clinical research, 19, 661.

Cryotherapy

Most commonly applied modality in sports medicine

Examples: Cold pack, ice cup massage, whirlpool

Cryotherapy Physiology

Reduced blood flow due to vasoconstriction Reduction in inflammatory response due to

reduced metabolic rate/enzyme levels Reduced pain through gate-control theory

and inhibition of nocioceptors Altered nerve conduction velocity Tissue temp needs to be reduced 10-15

degrees for therapeutic effect to occur

Cryotherapy Physiology

Used to intervene in presence of arthrogenic muscle inhibition (AMI) which is a protective reflex mechanism following joint injury

External stimulus of cold application or low-level sensory input alters inhibitory signaling

Increased excitatory efferent signaling to muscle results in increased activation

Cryotherapy

Cryotherapy and TENS shown to increase vastus medialis motor neuron pool following artificial knee joint effusion

Hopkins et. al Cryotherapy and Transcutaneous Electric Neuromuscular Stimulation Decrease Arthrogenic Muscle Inhibition of the Vastus Medialis After Knee Joint Effusion JAthl Training

20 minutes of ice bag application/45 minutes of TENS shown to increase quadriceps activation in subjects with diagnosed tibial osteoarthritis

Pietrosimone et. al Immediate Effects of Transcutaneous Electrical Nerve Stimulation and Focal Knee Joint Cooling on Quadriceps Activation Med Sci Sports Exerc 2009

Clinical Applications

Cold pack: Suggested application varies in the literature from 10-20 minute treatments 2-4x/day up to 20-30 minutes every 2 hours

Recent research promotes intermittent sessions of 10 minutes, followed by 10 minutes off, then 10 minutes on every 2 hours

Training room application: post-practice/surgery/injury Recent study has shown decrease in temp at intercondylar

notch following cryotherapy performed after ACLR Post-op application: Ice bag DIRECTLY applied to injured area,

encourage quad strengthening exercise during application

Pietrosimone et. al Immediate Effects of Transcutaneous Electrical Nerve Stimulation and Focal Knee Joint Cooling on Quadriceps Activation Med Sci Sports Exerc 2009

Rashkovska, A., Trobec, R., Avbelj, V., & Veselko, M. (2013). Knee temperatures measured in vivo after arthroscopic ACL reconstruction followed by cryotherapy with gel-packs or computer controlled heat extraction. Knee Surgery, Sports Traumatology, Arthroscopy, 1-9

Compression Devices

Often used in conjunction with cryotherapy and elevation

Most popular device is the Game Ready Also seeing more use of pneumatic

compression devices such as Normatec

Electrical Stimulation

Used for acute/sub acute/chronic injuries Settings vary depending on acuity of pain and

effects desired Most often used in combination with heat or

ice An athlete modality of choice

Electrical Stimulation

Based on the gate control theory in the dorsal horn of the spinal cord

Pain travels through small diameter afferent nerve fibers (A-delta and C fibers)

By activating the larger diameter afferent fibers (A-beta) through touch, pressure, or electrical currents, the gate is closed on pain fibers

Training room application: used during exercise in post-op period, everyday use

Electrical Stimulation Clinical Applications Russian wave form for post op quad

activation Low pulsatile current for longer acting pain

control High pusatile current for immediate pain

control, but short term benefits Should be an adjunct to exercise, not a stand

alone treatment Gondin, J., Cozzone, P. J., & Bendahan, D. (2011). Is high-frequency neuromuscular electrical stimulation a suitable

tool for muscle performance improvement in both healthy humans and athletes?. European journal of applied physiology, 111(10), 2473-2487.

Biowave Latest technology in electrotherapy Similar to TENS/Interferential that uses

surface electrodes to reduce pain Claims to use “Deep tissue signal technology” Provides deeper delivery of stimulation while

also being more comfortable for pt Research very limited so far

Summary

Modality application most effective when used with other treatment measures

Modalities should not be the sole focus of treatment

Implementation of modalities promote the healing and recovery of injured tissues

More research is needed to support parameters and effectiveness of modalities in treating a variety of musculoskeletal conditions

References Axman, T., Esfeld, S., Jackson, C., Moore, A., & Quillin, D. (2013). The effects of

cryotherapy and hot-pack treatments on quadriceps femoris strength measured by an isokinetic machine.

Bleakley CM. 2006. Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports Med; 40: 700-705

Doucet, B. M., Lam, A., & Griffin, L. (2012). Neuromuscular electrical stimulation for skeletal muscle function. The Yale journal of biology and medicine, 85(2), 201.

Gondin, J., Cozzone, P. J., & Bendahan, D. (2011). Is high-frequency neuromuscular electrical stimulation a suitable tool for muscle performance improvement in both healthy humans and athletes?. European journal of applied physiology, 111(10), 2473-2487.

Hopkins et. al Cryotherapy and Transcutaneous Electric Neuromuscular Stimulation Decrease Arthrogenic Muscle Inhibition of the Vastus Medialis After Knee Joint Effusion JAthl Training

Johnson, M. I., Ashton, C. H., & Thompson, J. W. (1991). An in-depth study of long-term users of transcutaneous electrical nerve stimulation (TENS). Implications for clinical use of TENS. Pain, 44(3), 221-229.

References Lake, D. A., & Wofford, N. H. (2011). Effect of Therapeutic Modalities on Patients With

Patellofemoral Pain Syndrome A Systematic Review. Sports Health: A Multidisciplinary Approach, 3(2), 182-189.

Lamba, D., Verma, S., Basera, K., Taragi, M., & Biswas, A. (2012). A study to compare the effects of moist heat therapy with ultrasonic therapy and ultrasonic therapy alone in lateral epicondylitis. Indian Journal of, 6(2), 41.

Nyland, J. Nolan, M. (2004). Therapeutic Modality: Rehabilitation of the Injured Athlete. Clin Journ of Sports Med; 23 (299-313)

Petrofsky, J. S., Laymon, M., & Lee, H. (2013). Effect of heat and cold on tendon flexibility and force to flex the human knee. Medical science monitor: international medical journal of experimental and clinical research, 19, 661.

Pietrosimone et. al Immediate Effects of Transcutaneous Electrical Nerve Stimulation and Focal Knee Joint Cooling on Quadriceps Activation Med Sci Sports Exerc 2009

Prentice, William E. Therapeutic Modalities: for Sports Medicine and Athletic Training. 5th ed. New York: McGraw-Hill 2003

Rashkovska, A., Trobec, R., Avbelj, V., & Veselko, M. (2013). Knee temperatures measured in vivo after arthroscopic ACL reconstruction followed by cryotherapy with gel-packs or computer controlled heat extraction. Knee Surgery, Sports Traumatology, Arthroscopy, 1-9