Chapter 17 Therapeutic Modalities

• Therapeutic modalities are tailored solutions for optimizing each stage of muscle healing.
• Key objectives include managing inflammation, promoting tissue repair, and ensuring proper tissue remodeling.
• Examples of modalities include Cryo/Thermo, Paraffin Wax Bath, TENS, Ultrasound, Massage Therapy, Cupping, Graston Technique, KT Tape, SMFR, Pneumatic Compression, and Blood Flow Restriction (BFR).

Stages of Muscle Healing

• Proliferation (3-7 days) involves destruction.
• Regeneration (7-21 days) involves repair.
• Remodeling (21+ days) involves strengthening.
• Muscle healing occurs in three phases: destruction, regeneration, and remodeling.
• The destruction phase involves an initial inflammatory response lasting 1-4 days, during which the body releases chemicals to protect and heal the area.
• The regeneration phase starts 24-48 hours post-injury, lasting up to 3 weeks, activating/proliferating satellite cells and leading to phagocytosis of damaged tissue.
• The remodeling phase begins soon after injury and lasts a year or more; it involves the maturation of regenerated myofibers, muscle function recovery, and the formation of fibrosis and scar tissue.
• Adaptation involves the equation: Stress + Recovery = Adaptation.

Cryotherapy (CRYO)

• Involves exposing the body to extreme cold, inducing vasoconstriction, reducing inflammation, and promoting cellular repair.
• Triggers endorphin release, inhibits pain transmission, and decreases metabolic rates in tissues.
• Local cryotherapy is used as a first-aid treatment for trauma to the musculoskeletal system to reduce local inflammation.
• Systemic WBC involves immersing the body in extremely cold air/water for several minutes for systemic health benefits.
• Use ice packs, ice massage, cold whirlpool, and cold-water compression safely.
• Exercise caution if thermoregulatory problems, sensory deficits, hypersensitivity, or heart disease are present.
• Cryo-compression boots may improve blood circulation and reduce inflammation; do not use with open wounds, active infections, deep vein thrombosis (DVT), acute pulmonary edema, or any CV concerns.
• Exposure to extremely cold temperatures (around -110°F to -140°F) in a specialized chamber for several minutes could result in multiple health benefits.

Thermotherapy (THERMO)

• Involves using heat to increase blood flow, reduce muscle stiffness, and alleviate pain.
• Heat stimulates thermoreceptors, enhances vasodilation, increases oxygen/nutrient delivery, promotes tissue repair, and elicits relaxation.

Superficial Thermotherapy

• Heats surface areas less than 2 cm deep.
• Hot packs, whirlpools, and paraffin are examples.
• Consider the target tissue.

Deep Thermotherapy

• Heats deep tissues (3-5 cm) without overheating skin/superficial structures.

• e.g. ultrasound, diathermy.

• Consider the area to be therapeutically targeted.

• Heat packs, hydrocollators, and warm whirlpools are considered safe for use.

• Apply heat for 15-20 minutes, using a barrier to prevent burns; apply 2-3 times daily, ensuring the skin cools between sessions.

• Be careful with acute injury/inflammation, impaired sensation/circulation, open wounds/infections, malignant tumors, severe cognitive impairments, or heat-sensitive conditions.

• Contrast therapy involves brief, repeated sessions alternating between warm and cold temperatures, lessening muscle fatigue and decreasing pain and swelling.

Paraffin Wax Baths

• Alleviate pain, improve joint mobility, and relax muscles.
• Heat increases blood circulation, delivering oxygen and nutrients for tissue repair, softening tissues, and reducing inflammation/accelerating healing.
• Safely melt the wax around 125°F to 130°F.
• Dip and coat only after cleaning and drying the area to be treated.
• Treatment lasts about 15-20 minutes.
• Remove the wax carefully, then massage the treated area to enhance blood flow.
• Use caution if open wounds/skin infections, acute inflammation/edema, sensory impairments, circulatory disorders, skin conditions, or allergies are present.

Transcutaneous Electrical Nerve Stimulation (TENS)

• Involves applying low-voltage electrical currents through electrodes targeting nerves to alleviate pain.
• Activates large-diameter fibers to inhibit pain signals and small-diameter fibers to stimulate endorphin release.
• Can enhance blood flow/tissue healing.
• Electrodes must be placed once the skin is cleaned & dried.
• Ensure electrodes are near the painful area.
• Settings (frequency, intensity) must be adjusted as directed.
• Starts with low settings and gradually increased to a comfortable level.
• Treatment typically lasts 30 minutes.
• Monitoring any adverse reactions.
• Use extreme caution if a pacemaker or implantable defibrillator, pregnancy, epilepsy, open wounds, or cancer is present.
• Always use 2 pads (one channel) or 4 pads (two channels) at the same time.
• Pads can be placed in vertical, horizontal, or angulated directions.
• Pads should never touch, separated by at least 1 inch to ensure effectiveness.

Ultrasound Therapy

• Involves using high-frequency sound waves (1-3 MHz) to penetrate tissues, generating thermal and non-thermal effects.
• Thermal effects increase blood flow, relax tissues, and aid in healing by promoting collagen synthesis; may also stimulate collagen production.
• Set the frequency (1-3 MHz) according to the treatment plan, ensuring skin is clean and applying conductive gel.
• Move the transducer in circular/linear motions over the treatment area while avoiding bony prominences and sustaining continuous contact.
• Treatment lasts 5-10 minutes per area.
• Remove gel and assess the patient response to determine if follow-up adjustments are required.
• Use caution if malignant tumors, pregnancy, central nervous system issues, metal implants, thrombophlebitis, or impaired sensation are present.

Manual Manipulation Techniques

• They help relax tight muscles around joints to lessen pain response and improve flexibility.
• Includes Graston Technique, Trigger Point Therapy, Cupping, and SMFR.
• Improved circulation, muscle relaxation, injury prevention, enhanced recovery, and psychological benefits are benefits of manual manipulation.
• The Graston technique uses a stainless-steel instrument to stretch and relax muscle tissues, increase blood flow, and restore movement patterns in injured tissues via manual massage/scraping of the skin.
• A trigger point is a hyperirritable spot within a taut band of skeletal muscle.
• Trigger points produce local/referred pain, with pain perceived in a different area.
• They are characterized by palpable nodules in the muscle.
• Active trigger points have constant pain, reducing the flexibility of muscles.
• Latent trigger points are painful only when compressed.
• Cupping therapy places suction cups to create negative pressure, drawing blood to the surface and enhancing microcirculation and lymphatic drainage.
• Cupping releases myofascial tension, reducing pain and inflammation.
• It triggers endogenous hormone release and alters the PNS to improve pain relief and tissue repair.
• Self-myofascial release (SMR or SMFR) involves foam rolling therapy, applying mechanical pressure to myofascial tissues, promoting blood flow, reducing muscle tightness, and enhancing lymphatic drainage.
• SMR stimulates mechanoreceptors, reduces neuromuscular inhibition, and increases joint ROM.
• Safely perform by placing the foam roller under the targeted muscle group and applying moderate pressure while slowly rolling back and forth over tight or tender spots, holding for 20-30 seconds.

KT Tape

• It alleviates pain and facilitates lymphatic drainage by microscopically lifting the skin.
• The taped portion forms convolutions in the skin, increasing interstitial space, alleviating pain.
• Athletic tape is used to create support around a joint, restricting motion.
• Kinesio tape can stretch up to 40% while retaining its elasticity, allowing support without restricting the body's movements.

Percussion therapy

• It enhances muscle recovery using rapid, repetitive pressure waves and increasing blood flow.
• It reduces muscle stiffness and promotes lymphatic drainage.
• Targeting neuromuscular pathways, it has been shown to improve tissue repair and mitigate pain relief.
• The Theragun is designed to "talk with the nervous system" using 3 key parts: amplitude (~16mm), frequency(2400 pulses per minute on high and 1750 on low speed), and torque pressure.

Pneumatic Compression Therapy

• Uses controlled pressure to increase blood flow in your legs and improve blood flow to the heart, supporting your veins and decreasing swelling.
• Fast Flush Technology allows the boots to complete one full cycle in just 60 seconds.
• The compression therapy saturates your lower body with fresh, nutrient-rich blood and counteracts DOMS promoting recovery, flushing muscle toxins.
• A 2014 article states compression therapy might help recovery.
• Compression therapy saturates your lower body with fresh, nutrient-rich blood and counteracts DOMS promoting recovery, flushing muscle toxins.

Blood Flow Restriction (BFR) Training

• Combines low-intensity exercise with blood flow occlusion, producing similar results to high-intensity training, where blood still comes into muscles through arteries.
• Muscle experiences swelling, fatigue, and oxygen depletion as blood flow is restricted from leaving through veins.
• Low-load exercises and blood flow restriction training allows for maximum strength gains with minimal and safe loads.
• This restriction creates FPS (Fractional Protein Synthesis), where muscle growth can occur even if the training loads are kept to a minimum.
• Apply the BFR cuff securely but not too tight, around the proximal part of the limb.
• Adjust the cuff to the predetermined pressure, typically between 50-80% of the limb's arterial occlusion pressure for the upper body and 40-60% for the lower body.
• Resistance training/aerobic exercises at low intensity (20-30% of one-rep max) is done, with the cuff in place (do not exceed recommended limits on the device).
• Use caution if Cardiovascular Disease, Deep Vein Thrombosis (DVT), Severe Varicose Veins, Peripheral Vascular Disease, or Pregnancy are present.