Physical Medicine Modalities

Physical Medicine Modalities

Lawrence L. Prokop


In the practice of sports medicine, the majority of injuries are musculoskeletal in nature. Acute traumas such as sprains, strains, and contusions are commonplace. Physical medicine modalities are an established method of treatment for these injuries. Manual medicine techniques are commonly used in conjunction with these modalities to treat sports injuries. Manual Combined, the two modalities aid in the athlete’s recovery from injury and speed the return to play. This chapter discusses those modalities most useful in sports medicine.


Superficial Heat

Superficial heat affects the skin and subcutaneous soft tissues and stimulates a reflex relaxation in deeper muscles. Treatment with superficial heat elevates the pain threshold and thereby causes a decrease in the pain response. It may also cause a sedative effect and aid in muscle relaxation. Heat-induced changes in the viscoelastic characteristics of connective tissue aid in stretching activities. Superficial heat increases metabolism and oxygen consumption of the tissues. The metabolic rate increases two to three times that of normal for every 10°C increase in skin temperature. This heat modality also causes vasodilatation, which may aggravate swelling, edema, and superficial or subcutaneous bleeding. The therapeutic range of heating is between 40°C and 45°C. Anything above this range becomes painful. The length of treatment time is important. After approximately 8 minutes, superficial heating has extended only 0.5 cm into tissues. After approximately 15 to 30 minutes, the heating has extended 1 to 2 cm deep into muscles. After the application of heat, the area may be passively and actively stretched to improve flexibility and range of motion.


Moist heat packs (hydrocolator packs) stored at 70°C to 80°C may be used. The packs are placed on the athlete and covered with several layers of towels. They are maintained for 15 to 30 minutes prior to the athlete’s therapeutic exercise. Paraffin baths are made with either commercially available paraffin bath wax or by melting 7 parts paraffin with 1 part mineral oil and heating to between 52°C and 54°C. They are used for hands, feet, and elbows. The body part is dipped seven times into the paraffin bath wax, allowing each layer of wax to cool before the next dipping. The area is next wrapped with plastic and towels, treated for 20 minutes, and then unwrapped. After treatment, the paraffin bath wax is peeled off and deposited back into the vat. The area then undergoes passive and active range of motion. Fluidotherapy is a technique in which hot air between 38.8°C and 47.8°C is forced through a container of fine cellulose particles. The area being treated, such as a hand or foot, is placed in these particles for 20 to 30 minutes and then removed and treated with passive and active range of motion.


Superficial heat modalities should not be used in athletes with cardiac insufficiency due to
susceptibility to heat stress, in malignant tumors due to potential stimulation of tumor growth and metastasis, in areas of bleeding or hemorrhage due to potential exacerbation of the bleeding, in acute inflammation due to exacerbation of the inflammation, and in peripheral vascular disease due to increased metabolic demands with decreased blood flow causing potential anoxia and tissue damage (1,2,3,4,5).

Deep Heat

Like superficial heating modalities, deep heating modalities aid in improving flexibility of muscles and joint range of motion. Deep heating modalities work below the skin and superficial layers of tissue to a depth of approximately 3 to 5 cm.


Ultrasound is used to treat multiple soft tissue injuries such as tendinitis, bursitis, myositis, joint contractures, and scar tissue. Ultrasound uses a frequency between 0.8 MHz and 3 MHz to deliver sound waves through the tissues. The sound waves are emitted by a piezoelectric crystal that creates vibration and produces mechanical waveforms, which are transmitted from the ultrasound unit’s sound head (transducer) through a coupling medium such as gel into the tissues. The sound waves travel through the soft tissues and are reflected off the bones in an irregular pattern, which is absorbed in the connective tissues as heat. As with superficial heat, ultrasound increases local metabolism, blood flow, and nerve conduction velocity. Heating of the collagen fibers in the connective tissues elevates the pain threshold and allows for greater tissue distensibility. Scar tissue may be denatured and become more amenable to stretching using this modality. Ultrasound increases tissue temperature up to 43.5°C.


The ultrasound unit uses a continuous sound wave setting to deliver therapeutic heating. The transducer is coupled to the skin using a gel or water interface, and it is moved over the treated area for 5 to 10 minutes in a back-and-forth or circular fashion. A water medium may be used for the hands or the feet, and where the body part is immersed in the water, the sound head is placed 0.5 to 1 inch away from the skin. After ultrasound heating, the area is treated with passive and active range of motion to improve flexibility.


Acute localized inflammatory processes such as tendinitis, tenosynovitis, and epicondylitis can be treated with a corticosteroid solution (e.g., 1% hydrocortisone cream or a local anesthetic such as 1% lidocaine) coupled with ultrasound. This technique is known as phonophoresis. The ultrasound transducer allows deeper penetration of these medications than by topical application alone. After phonophoresis, the area is further treated with passive and active range of motion, manipulative medicine procedures, and if indicated, deep friction massage to break up scar tissue.


Ultrasound with or without phonophoresis is contraindicated in peripheral vascular disease because it increases metabolic activity, in acute bleeding because it stimulates greater blood flow, and over fluid-containing organs such as the eye, the heart, or a pregnant uterus (including ultrasound over the low back in a pregnant female). Ultrasound should not be used over the testis due to potential orchitis, over malignant tissue due to potential tumor growth or metastasis, over the epiphyses in children due to abnormal growth stimulation, and over nerve roots with acute radiculopathy due to exacerbation of nerve root inflammation. Ultrasound should also not be used over pacemakers; however, it may be used over metal implants such as a joint replacement. Ultrasound may be used over anesthetized skin, but care should be taken to maintain the treatment within time parameters and monitor for side effects such as swelling or erythema.

Short Wave Diathermy

Short wave diathermy is used to treat acute and chronic pain complaints such as myositis, tendinitis, bursitis, and joint contractures. It uses radio waves at 27.12 MHz to heat the subcutaneous tissues. The unit uses a capacitor or inductor to transmit radio waves, which are absorbed in and heat the tissues. The temperature in subcutaneous fat is raised approximately 15°C while muscle is raised 4°C to 6°C by either continuous or pulsed waveforms from the unit. After short wave diathermy, the area is treated with passive and active range of motion or osteopathic manipulative medicine (OMM) to improve flexibility and range of motion.


Short wave diathermy is not used over fluid-containing organs such as a pregnant uterus, the eyes, or the head due to increased metabolic activity; it is not used over pacemakers due to possible interaction with the setting of the pacemaker. It is not used over areas of acute inflammation due to exacerbation of the inflammation, or over areas of acute infection due to exacerbation of the infection. It is contraindicated in joint replacements due to heating of the metal. It is contraindicated in cancer due to possible tumor growth and metastasis. It is not used over the epiphyses in children due to possible abnormal bone growth. It is contraindicated in athletes with cardiac problems due to potential increase in cardiac demand.

Microwave Diathermy

Microwave diathermy uses electromagnetic radiation at frequencies of 9.15 MHz and 24.50 MHz to heat subcutaneous tissues. Its effects are similar to short wave diathermy including raising subcutaneous fat temperature 10°C to 12°C and subcutaneous muscle temperature 3°C to 4°C. It has a lower depth of penetrance than short wave diathermy and therefore should not be used on deeper structures, such as hips or deep low-back musculature. It is primarily used around superficial muscles and joints. The area is treated for 15 to 30 minutes and is followed by passive and active range of motion and manual medicine procedures.

Contraindications are the same as with short wave diathermy (1,2,3,4,5).

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Aug 27, 2016 | Posted by in ORTHOPEDIC | Comments Off on Physical Medicine Modalities

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