Chapter 15: Using Therapeutic Modalities McGraw-Hill Higher Education. All rights reserved

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1 Chapter 15: Using Therapeutic Modalities

2 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

3 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

4 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

5 Electromagnetic Modalities

6 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

7 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

8 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

9 Transmission of Thermal Energy Conduction Heat is transferred from a warmer object to a cooler one Dependent on temperature and exposure time Temperatures of o F will cause tissue damage and temperatures of 113 o F should not be in contact w/ the skin longer than 30 minutes Examples include moist hot packs, paraffin, ice packs and cold packs

10 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)

11 Hydrocollator Packs Equipment Silicate gel pads submersed in o F water Maintains heat for 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 minutes Athlete must be comfortable and should not lay on pack

12 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

13 Special Considerations Must be careful with fullbody 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 dependent position Figure 15-2

14 Paraffin Bath Equipment A paraffin wax and mineral oil combination, heated to 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 minutes w/out moving it

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16 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 o F Particle agitation should be controlled for comfort Patient should be comfortable Treatment time = minutes Exercise can be performed while in cabinet

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18 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

19 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

20 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 38.3 o F, 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

21 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

22 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

23 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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25 Cold or Ice Water Immersion Equipment Variety of basins or containers can be used, small whirlpool Temperature should be 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 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

26 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

27 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 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

28 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 inches from skin, treat entire length of muscle - covering an area 4 inches/second Apply spray 2-3 times, while gradually applying a stretch

29 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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31 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

32 Special Considerations for Cryotherapy Cooling for an hour at 15.8 o o F produces redness and edema that lasts for 24 hours post exposure Immersion at 41 o F increases limb fluid volume by 15% Exposure for 90 minutes at 57.2 o o 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

33 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)

34 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

35 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)

36 Figure 15-8

37 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

38 Figure 15-9 & 10

39 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

40 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

41 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

42 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; pps; surge mode (on/off 5 seconds each; elevation w/ active contraction Treatment time minutes

43 Muscle strengthening High frequency AC current; pps; 10:50 seconds on/off ratio; 10 repetitions 3x per week; perform with active contractions Retardation of atrophy High frequency AC current pps; w/ voluntary muscle contraction encouraged; minutes Muscle re-education Level of comfortable contraction pps; w/ either interrupted or surge current Athlete should attempt to contract muscle along w/ stim Treatment time minutes and repeated multiple times over the course of a week

44 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

45 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 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

46 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

47 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

48 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

49 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

50 Figure 15-12

51 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

52 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

53 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 galliumarsenide lasers are currently being explored by the FDA

54 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)

55 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)

56 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

57 Area of transducer that produces sound is the effective radiating area Produces a beam of acoustic energy - collimated cylindrical beam with nonuniform distribution Variability in the beam (beam nonuniformity ratio - BNR) =lower BNR = more uniform energy output Intensity is determined by amount of energy delivered to the sound head (W/cm 2 ) Can be delivered as either pulsed or continuous ultrasound

58 Indications Produces thermal and non-thermal effects Generally used for tissue heating (must increase tissue temp between 104 o and 113 o F 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/cm 2 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

59 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

60 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

61 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 W/cm 2 Medium W/cm 2 High W/cm 2 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

62 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)

63 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

64 Mechanical Modalities

65 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

66 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

67 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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70 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

71 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

72 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 mm Hg Lower extremity mm Hg Some units allow for combining cold along with compression Electric stim can also be combined during some treatments

73 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

74 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

75 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

76 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

77 Stroking Variations

78 Petrissage Kneading Involves picking up skin between thumb and forefinger, rolling and twisting in opposite directions Used for deep tissue work Figure 15-25

79 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

80 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

81 Figure 15-27

82 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

83 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

84 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

85 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

86 Figure 15-28

87 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

88 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

89 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 minutes

90 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

91 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

92 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

93 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