General Principles
Modalities are best thought of as an adjunct to the body’s own recovery process. It would be a mistake to think of them as all that any patient needs to rehabilitate. However, they do play a role in therapy, particularly in sports medicine, where any tool that hastens return to play is valuable. Some experts may claim that certain modalities are an integral part of healing and recovery from injury, although minimal evidence exists to support many claims.
Superficial Heat
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Modality requires direct contact with skin.
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The greatest heating effect is achieved superficially.
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If maintained long enough, heat energy gets conducted into deeper structures.
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Increase in tissue temperature has the following beneficial effects:
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Vasodilation
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Increased blood flow to and from the site
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Increased cell metabolism
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Increased elasticity of collagen tissues
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Decreased pain
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Decreased muscle tone
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Decreased muscle spasm
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Devices for Heat
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Devices conduct thermal energy across the skin to provide a rise in tissue temperature.
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Moist heat packs
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Canvas covers filled with silica gel
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Heated in hot water tanks (approximately 160°F)
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Packs placed in insulating layers of towels or cloth covers
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Covers have to be kept clean to prevent spread of skin disorders.
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Heat dissipates quickly, usually within 15 minutes.
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Easier to get the patient in a comfortable position
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Dry heating pads
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Plug-in electrical or microwaveable varieties
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Do not heat tissue as rapidly and comfortably as moist heat packs
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Heat does not dissipate as rapidly so can be used for longer time
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Skin can be burned by prolonged or overly intense heat exposure.
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Whirlpools
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The body part immersed in a tub with a motor that moves water.
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Water temperature usually ranges between 102°F and 110°F.
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Lower temperatures used when more of the body is immersed.
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More of the body part heated as it is surrounded by water
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Water circulation keeps the temperature next to the skin constant and not dissipated into a body part.
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Circulating water has a massaging effect.
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Water is an excellent transmitter of bacteria into open wounds, so care must be taken to keep the wound and tank clean.
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Whirlpool can be used for the debridement of superficial wounds.
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Clean whirlpools thoroughly to prevent disease transmission.
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Paraffin baths
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Mixture of wax and mineral oil melted to a liquid state (118°F–126°F)
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Apply to a body part by dipping or brushing on.
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Effective with irregularly shaped body parts such as hands and feet
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Applying multiple coats and allowing to cool
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Cooling wax solidifies and thereby transfers heat into tissues.
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Low specific heat of wax allows for comfort at higher temperatures.
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Exercise for Heat
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Heat is a by-product of muscular work.
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The more intense the exercise, the greater and quicker the heating
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Heat is transmitted from muscle into other body tissues and is carried away by the bloodstream.
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Temperature increase occurs deeper in the tissues.
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A combination of exercise and superficial heat modalities results in the greatest increase in tissue temperature.
Uses of Treatment
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Injuries no longer in the acute inflammatory phase
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Chronic pain
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Injuries resulting in decreased range of motion (ROM)
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Swelling
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In preparation for therapeutic exercise
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Injuries wherein the goal of treatment is to increase circulation
Contraindications
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Acute injuries (risk of increased swelling)
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Uncovered open wounds
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Tumors
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Thrombophlebitis
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Nerve sensitivities
Precautions
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Fair skin that burns easily
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Areas of decreased sensation
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Dermatologic problems and disease transmittal
Cryotherapy
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Cryotherapy involves the application of cold to affect changes in the body for therapeutic benefits. Various methods are used (see Methods of Cryotherapy ).
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Each method attempts to draw heat from the body’s tissues through the skin, which raises the temperature of the cold device rather than allowing the cold to penetrate the body. This loss of thermal energy and subsequent decrease in tissue temperature results in:
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Vasoconstriction
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Decreased blood flow to the area
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Decreased swelling
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Reduction in inflammatory mediators and pain-producing substances
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Decreased cell metabolism
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Reduced elasticity in collagen tissues
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Slowed conduction of nerve impulses; analgesia
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Decreased muscle spasm
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Decreased force production in muscle
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Because of these responses to cold application, cryotherapy is the most successful treatment modality for acute injuries. The reduction in pain, swelling, and inflammatory reaction helps the patient’s healing process progress more quickly, which allows a faster return to activity. Other conditions that can benefit from cryotherapy include:
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Injuries wherein pain is the predominant symptom
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Postoperative conditions
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Preexisting injuries (immediately following activity)
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Problems wherein pain inhibits activity or therapy
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Situations wherein anesthesia is desired
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Elevation of the injured body part to levels higher than the heart causes a decrease in vascular hydrostatic pressure. In addition, the force of gravity increases venous and lymphatic return, further reducing fluid collection in the injured area.
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The reduction in swelling at the time of injury decreases pain for the patient as well as the time taken eventually to return to full activity.
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The duration of cold application in acute injuries should not be a concern. Prolonged cold application, as occurs in the previously listed cryotherapy methods, has not been shown to result in a reflexive body warming. Longer cold application results in additional beneficial effects in acute injuries.
Methods of Cryotherapy
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Ice bags
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Crushed ice in plastic bags
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Smaller ice cubes allow for greater surface coverage.
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Less air in ice bag allows for more ice in contact with skin.
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More conforming to the body part, which also results in greater cold effects
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Longer application means deeper cooling
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Application usually lasts for 15–20 minutes
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Reusable ice packs
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Silica gel pack kept in a freezer
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Allows for multiple uses
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Requires an insulating layer between the pack and skin (wet towel) because packs can get colder than ice bags and result in skin irritation
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Application is for 15–20 minutes
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Ice massage
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Water frozen in paper cups and directly applied to skin
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Peel paper from the cup to expose ice
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Effective at cooling superficial tissues
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Movement and pressure of application has similar benefits to massage
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Limitations include smaller area of cooling and labor-intensive process
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Application is for 10–15 minutes
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Chemical cold packs
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Water and ammonium nitrate separated within a pack
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Chemicals mix when barrier is broken by squeezing
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Can be stored indefinitely and broken when needed
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More expensive version of icing
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Chemicals can irritate skin if bag leaks
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Cold is not as long-lasting
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Ice immersion
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Ice and water mixture in small container for lower legs and arms
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Surrounds entire body part; helpful for joint injuries
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Make immersion as cold as tolerable
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With appendage immersion, there is less core temperature reduction
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Ice water circulating units
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Commercially available units that combine cold and compression
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Cold therapy can be applied for a longer duration; stays cold for a longer duration
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Use in different locations
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Commonly used after surgery or in chronic conditions; easier for multiple applications
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More costly
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Cold-water immersion (cold baths)
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Larger-sized tanks for immersion of more of the body
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Used for cooling larger and deeper areas of the body
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May use whirlpool action to keep colder at skin contact areas
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Bath temperatures of 50°F–60°F recommended to achieve therapeutic benefit while avoiding too large a drop in core temperature
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Used more frequently for muscle recovery than injury care
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Application is for 10–15 minutes
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Similar concerns as warm whirlpool in terms of open wounds and hygiene
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Some evidence exists that cold-water immersion reduces delayed-onset muscle soreness, but insufficient evidence that this provides any other benefits
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Exact physiologic rationale has not been shown. Possible mechanisms include anti-inflammatory effects, vasoconstriction, and decreased nerve transmission, all caused by cooling.
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Systematic review: Bleakley C et al. Cochrane Database Syst Rev. 2012;2:1-136.
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Whole body cryotherapy (Cryosauna)
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A device (chamber- or barrel-like) that exposes the body to extreme cold (<100°C) for short time periods (2–4 minutes) in order to ease muscle soreness after exercise.
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These units use liquid nitrogen and refrigerated air to subject a person’s skin while wearing minimal clothing (socks, shorts, gloves, and sports bras).
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The mechanism of action is to drastically reduce the skin temperature and thereby produce a reflex vasoconstriction that will consequently result in posttreatment vasodilation, thereby washing out the components of muscle soreness.
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Currently, research on the effectiveness of whole body cryotherapy is inconclusive. However, previous studies have revealed no evidence of adverse effects.
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Whole body cryotherapy is most commonly used after strenuous workouts by elite athletes when muscle soreness and fatigue are present. In addition, certain benefits have been shown in patients having multiple sclerosis.
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Evidence: systematic review in Costello JT et al. Cochrane Database Syst Rev. 2015;9:1-65.
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Vapocooling sprays
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Chemical spray (ethyl chloride) topically applied on skin
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Cools rapidly and evaporates quickly
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Cools only superficially
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Used whenever quick numbing is desired; trigger point treatment
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RICE
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Use rest, ice, compression, and elevation (RICE), particularly with acute injuries.
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Compression can take the form of:
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Tightly applied ice bag
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Ice bag applied over top a wetted ace wrap (to enhance thermal exchange)
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Use of adhesive expandable tapes
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Commercially designed device
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Compression works by:
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Increasing heat exchange by squeezing tissues together and closer to the surface
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Decreasing tissue spaces where fluid can accumulate
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Decreasing blood flow so that less warm blood enters into the affected area
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Increases contact areas of cold application on the skin
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When to Use Heat Versus Cold
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It is not uncommon for a clinician to be confronted with a dilemma regarding when to use heat or when to use cold.
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Most simplistic guide to follow is, if pain is the primary symptom, use cold; if stiffness is the chief complaint, use heat.
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Injuries in the acute inflammatory phase warrant ice application. As swelling on an injury site increases, it becomes more painful and also takes longer to improve. Modalities that increase temperature will result in more swelling. The duration of the acute injury phase can be variable, but certainly not <24 hours after injury.
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Application of ice is effective as an anesthetic. When the patient has pain at rest or has high levels of pain, use some form of cryotherapy.
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Heat can be safely applied whenever the patient is out of the acute inflammatory phase.
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The application of heat before exercise can often make the workout more comfortable. The tissues are more elastic and flexible. Most bodily functions work more effectively at slightly higher temperatures, particularly those relating to athletic activity.
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After completion of a workout, particularly if the workout produces any pain in the injured area, ice is the appropriate treatment. This can reduce any inflammatory effects brought on by the activity.
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Certain chronic conditions may still benefit from cryotherapy. With the presence of a long-term injury, it is not always clear as to which will be the most effective modality. The clinician may have to use trial and error or revert to the aforementioned guidelines.
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When in doubt, apply ice. There is less risk of inappropriate application of ice compared with heat.
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