Modalities: When to use them and how they can help
Feb 09, 2021
Heat or Ice?
It is not uncommon to instinctually grab for heat or ice following an injury or when experiencing pain. Yet, in some circumstances, it is not always clear which can be best. So, when to choose heat or ice?
Ice:
Ice, or cryotherapy, can be used therapeutically to help (1) control swelling, (2) decrease pain, and (3) limit the damaging of tissue secondary to the injury itself. Generally, ice is used for acute injuries or conditions that present with inflammation.
The body’s inflammatory response to an acute injury, such as an ankle sprain, is an essential part of tissue healing; however, just because some is good, does not mean more is better. Secondary tissue damage is a consequence of persistent swelling. While inflammation is the result of an increase of blood flow to the area of injury itself, it is suggested that inflammation causes an occluding of the vessels supplying the surrounding tissue resulting in a lack of blood flow to these areas. Without proper oxygenation to these tissues, secondary damage can occur.
Pain can be decreased indirectly by managing the inflammation present. Additionally, cryotherapy also directly has impact over pain through a numbing affect that is achieved by altering the conduction velocity of the nerve.
What can we do in combination with cryotherapy to manage the presence of inflammation? RICE is a common acronym used that summarizes the complimenting interventions that can help to reduce swelling and minimize the risk of secondary tissue damage.
Rest
Ice
Compression
Elevation
SAFETY: It is important to note that there can be adverse reactions to cryotherapy and certain contraindications to its use. Some include known hypersensitivity to the cold, impaired circulation or sensation, and Raynaud’s Disease. Proper application and adherence to a safe treatment schedule is important in preventing the risk of frostbite and resulting tissue damage. Treatment times are to be limited to 20-30 minutes, and prior to application, the ice pack should be wrapped in a damp towel. Adding compression can help to more effectively cool the tissue, but it is important to monitor the skin throughout the treatment especially within the first 5 minutes. The sensation of intense cold or burning / aching pain with the application of ice should not last long than the initial 5-7 minutes. If this discomfort persists, remove the ice and allow the skin to rewarm.
Heat:
Heat can be used therapeutically to help (1) decrease pain, (2) increase range of motion and (3) improve tissue healing. Typically, heat is used for more chronic conditions or pain that does not present with acute inflammation or swelling.
The immediate effect of heat on pain can be explained using the pain gate mechanism. In brief, this theory describes a phenomenon where the receptors in our body that receive information about temperature overwhelm the pathways that transmit pain signals and further block these signals from reaching the brain. Range of motion is then indirectly increased through the use of heat by decreasing pain and directly impacted through increasing the tissues extensibility and its tolerance to stretch. Tissue healing can be enhanced through the use of heat by increasing cellular activity and blood flow. Increasing cellular activity allows for more cell growth and an increase in blood flow improves oxygenation to the damaged tissue. Increasing range of motion and facilitating tissue healing further have indirect and more long-term effects with regards to managing pain.
SAFETY: Similar to cryotherapy, there can be adverse reactions to heat and certain contraindications to its use. Impaired sensation and circulation, acute inflammation, hemorrhagic conditions and local infection are all instances where heat is contraindicated. Treatment times of 15-20 minutes are recommended. The sensation of heat should be moderately warm, but not hot and most definitely not painful. In these circumstances, adding additional barriers between the heat pack and skin (i.e., a towel) would be indicated. Heat should not cause any systemic responses such as generalized sweating, sudden changes in blood pressure or feelings of light headedness. In these instances, the hot pack should be removed immediately.
Ultrasound
Unlike heat or ice, therapeutic ultrasound is limited to clinic use. So, what is it? And why is it used?
Ultrasound utilizes high frequency mechanical vibrations that carry the same properties as sound waves. In a therapeutic setting, ultrasound is most typically applied for its thermal effects. As with superficial heat, thermal ultrasound can help to (1) decrease pain, (2) increase range of motion and (3) improve tissue healing. The difference between superficial heat and thermal ultrasound is the depth of the tissue that can be effectively reached. However, the treatment area for ultrasound is comparatively smaller than that of superficial heat and as a result is more typically used for focal heating. Structures like ligaments and the menisci of the knee are common targets of thermal ultrasound with the goal of improving tissue healing by promoting blood flow. Additionally, ultrasound may be used to help increase range of motion and decrease pain in instances where scar tissue limits mobility.
Interferential Current
Buzzing machine? Feel good machine? The chances are if you’ve come in for an assessment or treatment you’ve likely ended the session with some interferential current or IFC. So, what exactly is IFC?
IFC is a therapeutic modality that utilizes electrical current through the affected area with the primary goal to control pain. Pain is modulated by (1) the stimulation of nerve cells that block the transmission of pain signals through the pain gate mechanism as seen with thermal modalities and (2) stimulating the release of pain reducing endorphins in the body. Between these two mechanisms there is both an immediate pain relief as well as potential for a longer duration (i.e., hours) relief from pain.
Treatment time typically last for 15 minutes. Throughout this time a tingling sensation or “pins and needles” will be felt at the area of contact and depending on the tolerated intensity muscle twitches may also be experienced. Patients are encouraged to increase the intensity as high as tolerable without an onset of pain.
SAFETY: IFC is contraindicated in individuals with pacemakers, over the low back or abdomen of women who are pregnant and over areas with any known or suspected risk of malignant tumours. As intensity is determined by patient comfort, impaired sensation may also be considered a contraindication to the use of this modality.
References:
Armijo-Olivo S, Fuentes J, Muir I, Gross DP, (2013). “Usage patterns and beliefs about therapeutic ultrasound by Canadian physical therapists: an exploratory population-based cross-sectional survey.” Physiotherapy Canada, 65(3), 289-299.
Hubbard, T. & Denegar, C. 2004, "Does cryotherapy improve outcomes with soft tissue injury?", Journal of Athletic Training, vol. 39, no. 3, pp. 278-279.
Merrick, M.A. 2002, "Secondary Injury After Musculoskeletal Trauma: A Review and Update", Journal of Athletic Training, vol. 37, no. 2, pp. 209-217.
Michlovitz, S.L., Bellew J.W., Nolan T.M. Jr. 2012, Modalities for Therapeutic Intervention, eds. S.L. Michlovitz, Bellew, J.W., T.M. Nolan, 5th edn, F.A. Davies, Philadelphia.
Robertson, V., Ward, A., Low, J. & Reed, A. 2006, Electrotherapy Explained: Principles and Practice, 4th edn, Butterworh Heinemann Elsevier, Edinburgh.
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