Examples of modalities in physical therapy

Physical therapists have a range of modalities, or treatment methods, they can choose from to help reduce pain and inflammation, as well as improve your endurance, strength, and range of motion as you rehab from a musculoskeletal injury or movement dysfunction.

Heat application, electrical stimulation, traction, and massage are just a few of the physical therapy modalities that may be used at different stages of your recovery. While some modalities may only be able to be used during a treatment session, others can also be done at home.

This article explores 12 common physical therapy modalities, including how and why they are used. If your therapist recommends one for you, they should be prepared to explain the reason for using the modality and what to expect from treatment.

 by Victoria Bartnikowski, LPTA

Dictionary.com defines a modality as: “Medicine/Medical- the application of a therapeutic agent, usually a physical therapeutic agent”. It is also expected that the use of a modality will produce some sort of physiologic response or change. So, it follows that treatments that we provide to patients for their musculoskeletal problems can be considered modalities. In this article, I will discuss the modalities we use here at OSC, and what their purpose served if treating patients in a Physical Therapy setting. This list is not inclusive of all modalities, but gives those most commonly used.

Electrical Stimulation – The use of an adjustable electric current to reduce muscle spasms by regulating and modulating contraction rhythm. This can help increase strength in a weak muscle and also help to increase blood flow to the area as the muscle contracts to improve healing. An excellent therapy after surgery or injury.

TENS – Transcutaneous Electric Nerve Stimulation – A small, battery operated device delivers a mild electric current, similar to electrical stimulation in the clinic, through electrodes applied to the skin. The patient feels a tingling sensation from the current which moderates discomfort by disrupting the pain signal sent to the brain. It is helpful for muscle spasms and chronic pain not helped with exercise or medication. This does not need a Physical Therapist to operate, is portable and can be adjusted by the patient anywhere.

Hot Packs – These are kept in a steamer and then wrapped in towels before being placed on the patient. The steam creates moisture, which along with the heat, penetrates tight and sore muscles, relaxing them and increasing blood flow to the area. They are especially helpful for arthritis, muscle spasms and strains.

Cold Packs – These are kept in a cold box and can be wrapped in either dry or wet towels before being applied to the patient. The cold reduces blood flow and inflammation thereby providing pain relief for the patient. The reduction in swelling is very beneficial for post-surgical patients and those with acute strains and sprains.

Ultrasound – Ultrasound is used to transmit sound waves into painful areas, relaxing and warming the tissues and causing increased blood flow. This treatment is great for muscle spasms and trigger points.

Traction – the use of a modulated force to pull the body lengthwise or longitudinally, to pull apart or distract spinal vertebrae to relieve pressure on compressed nerves, thereby reducing pain and inflammation. This can be done by placing the patient on a specially designed traction machine or it can be done manually. Traction can be used for both cervical and lumbar portions of the spine.

Low Level Laser Therapy – the use of red-beam light to detect impedances (resistance) found in tissue. This modality can be used in conjunction with electrical stimulation and can be used for both acute and chronic conditions, such as decreasing edema, pain control and reducing scar tissue.

Functional Dry Needling– performed by Physical Therapists, use of a monofilament needle to release myofascial trigger points or tight muscles, reducing pain and improving range of motion.

Modalities are therapeutic tools that we use to help our patients recover from surgery, injury or a condition that causes pain and dysfunction, so they can get back to the activities they enjoy.

Therapeutic modalities refer to the administration of thermal, mechanical, electromagnetic and light energies for therapeutic purposes. [1] They are commonly used by physiotherapists to help their patients/clients achieve therapy goals [2]:

• pain relief or modulation
• reduce inflammation
• improve circulation
• tissue healing
• scar tissue remodelling
• skin condition treatment
• increase ROM
• enhance muscle activation
• decrease unwanted muscular activity
• preservation of strength after injury or surgery
• reduction or elimination of oedema [3]

Therapeutic modalities have been a part of physiotherapy-used modalities for decades.[4] They are commonly used with other physiotherapy tools e.g. exercise, manual techniques, patient education, and although there is some evidence that different patients may benefit from different modalities, it is suggested that they should not be used as stand-alone treatment. [5]

The term “therapeutic modalities” is often used interchangeably with the term “electrophysical agents” to describe all interventions that create physiological therapeutic effects. [1] Examples of therapeutic modalities include:

• Electrical stimulation / Iontophoresis
• Biofeedback
• Thermotherapy (superficial or deep)
• Cryotherapy
• Ultrasound / Phonophoresis
• Extracorporeal Shockwave Therapy (ESWT)
• Laser therapy
• Magnetic therapy
• Massage
• Mechanical traction

Clinical guidelines argue for the use of therapeutic modalities according to various grades of evidence. [6] However, the choice of which modality to use may depend on a specific condition, clinician’s preferences and patient’s needs and goals. [7] This page will look at the rationale for use of a modality and its safety considerations.

For further information about therapeutic modalities, see the following pages:

Electrical Stimulation

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Electrical stimulating currents such as transcutaneous electrical nerve stimulation (TENS) and interferential current (IFC) utilize electrical energy, the flow of electrons or other charged particles from one area to another, causing depolarization of muscle or nervous tissue. Electrical stimulation has most commonly been used for the modulation of pain through stimulation of cutaneous sensory nerves and the following analgesic mechanisms:[8]

1. Activation of large diameter A-beta fibers inhibits the pain transmission, carried by A-delta and C afferent fibers, from the spinal cord to the brain – also known as the gate control theory of pain
2. Stimulation of A-delta and C fibers causes the release of endogenous opioids (endorphin and enkephalin) resulting in prolonged activation of descending analgesic pathways

Iontophoresis refers to the introduction of ions into the body tissues by means of a direct electrical current. [9] The rationale behind this technique is that the therapeutic effects of a drug may be maximised while minimising possible adverse reactions. [9]

Contraindications

Precautions

Risks 

• Deep venous thrombosis or thrombophlebitis

• Hemorrhagic conditions
• Pregnancy
• Eyes, anterior neck, carotid sinus, head, reproductive organs
• Impaired cognition or communication
• Regenerating nerves
• Cardiac failure (local)
• Damaged or at-risk skin (local)
• Infection or tuberculosis (local)
• Malignancy (local)
• Recently radiated tissue (local)
• Electronic device (local)
• Impaired sensation (local)

• Active epiphysis

• Skin disease
• Impaired circulation
• Chest, heart

• Pain
• Skin irritation
• Surge

[8]

Additional considerations

• Test sensory integrity prior to application by asking patients to differentiate between light touch and painful stimuli
• Tissue with high resistance to electrical current include skin, bone, and necrotic tissue – electrodes should not be placed directly over bony prominences
• Factors increasing skin impedance include the presence of hair and oil, and cooler skin temperatures
• Applying IFC or TENS in combination with a thermal modality is not recommended as it increases the likelihood of an adverse effect
• Large electrodes are more comfortable and allow current to travel deeper but the target is less specific – only large electrodes should be used with medium frequencies (IFC) to disperse the current
• Placing electrodes further apart will allow the current to travel deeper – at least 1 inch apart for pain control
• With any electrical device, increasing the intensity will first cause an electrical sensation followed by a motor response and finally noxious stimuli
• Remember that the modulation of pain is not treating the cause of pain

[8]

Biofeedback uses visual, physical, auditory feedback in real-time as a way to better control body functions and thus, maximise patient performance. [10] There are different types of biofeedback, with their applications varying in the clinical setting. [11] As a technique, it is generally considered safe and there are no absolute contraindications. [12] However, the patient must be able to comprehend and follow commands in order to actively participate in the process. This is possibly the reason why biofeedback should be used with caution in acute psychiatric episodes. [13] Patients will complete paralysis are also not suitable candidates for this modality.

Thermal Energy 

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Thermotherapy and cryotherapy, the application of therapeutic heat and cold, are referred to as conductive modalities – they utilise the conduction of thermal energy to produce a local and occasionally a generalised heating or cooling of superficial tissues with a maximum depth of penetration of 1 cm or less.[8]

Thermotherapy can involve the use of superficial or deep tissue thermal energy to induce a specific biological response. Superficial heating may be induced by a warm whirlpool, warm hydrocollator packs, paraffin baths, sauna, infrared radiation and fluidotherapy. Deep tissue heating involves the use of modalities such as ultrasound, radiowave, microwave and Tecar diathermies.

Primary physiological effects of heat include:[8]

• Vasodilation and increased blood flow
• Increased metabolic rate
• Relaxation of muscle spasm
• Pain relief via the gate-control mechanism and reduced ischemia
• Increased elasticity of connective tissue

It also works by stimulating fibroblast proliferation[14], accelerating endothelial cell proliferation[15], and improved phagocytic activity of inflammatory cells[16]. Heat is believed to have a relaxing effect on muscle tone by reducing muscle spindle and gamma efferent firing rates; there is also the theory that relaxation of muscle is assumed to occur with the disappearance of pain.[8]

Contraindications

Precautions

Risks 

• Deep venous thrombosis or thrombophlebitis
• Hemorrhagic conditions
• Reproductive organs
• Impaired cognition or communication
• Acute injury or inflammation (local)
• Impaired circulation or sensation (local)
• Damaged or at-risk skin (local)
• Infection or tuberculosis (local)
• Malignancy (local)
• Recently radiated tissue (local)
• Skin disease (local)

• Active epiphysis
• Cardiac insufficiency or failure
• Pregnancy
• Eyes, anterior neck, carotid sinus
• Metal (jewelry, metal implants or staples, bullets)
• Topical irritants

• Burn
• Fainting or dizziness (vaso-vagal response)
• Bleeding (open wounds)

Additional Considerations

• Test sensory integrity by asking patients to differentiate between hot and cold stimuli
• Wrap heating pads in 6 – 8 layers of toweling to protect the skin from burns
• Check patient after initial 5 minutes for excessive redness, blistering, signs of burning, generalised sweating (increased core temperature)
• Risk of burn increases with decrease in the amount of subcutaneous fat because fat serves as an insulator
• Patients should not lie on top of hot packs or pads as pressure that compresses skin capillaries compromises the normal vasodilator response

Cryotherapy includes ice massage, cold hydrocollator packs, cold whirlpool, cold spray, contrast baths, ice immersion, cold compression, and cryokinetics, Primary physiological effects of cold include:[8]

• Vasoconstriction and decreased blood flow (within first 15 – 20 minutes)
• Decreased metabolic rate
• Pain relief with decreased muscle spasm via gate-control mechanism and decreased nerve conduction velocity

Restriction of local blood flow reduces the potential for edema to develop. Slower metabolism releases fewer inflammatory mediators, reduces edema formation and decreases oxygen demand of tissues to minimize their chances of further injury from ischemia.[17][18] Cold decreases local neural activity, appears to raise the threshold stimulus of muscle spindles and depresses the excitability of free nerve endings, resulting in an increased pain threshold and reduced muscle spasm.[19][20]

Contraindications

Precautions

Risks 

• Deep venous thrombosis or thrombophlebitis
• Hemorrhagic conditions
• Chronic wound
• Impaired cognition or communication
• Cold hypersensitivity or urticaria
• Vasospastic pathology
• Cryoglobulinemia or hemoglobulinemia
• Anterior neck, carotid sinus, regenerating nerves
• Impaired circulation (local)
• Tuberculosis (local)

• Damaged or at-risk skin
• Cardiac failure
• Hypertension
• Impaired sensation
• Infection
• Eyes
• Superficial main branch of a nerve

• Frostbite
• Fainting (vaso-vagal response)
• Negative impact on nerves (superficial)

Additional Considerations

• Test sensory integrity by asking patients to differentiate between hot and cold stimuli
• Cold has the greatest benefit in acute injuries – avoid cold if healing is delayed because it could further impair recovery
• Rate of skin cooling is reduced with a towel between the agent and skin – 1 or 2 layers of protection is sufficient
• Water has a higher conductivity than air – apply moisture to the towel
• Patient will report uncomfortable sensation of cold, stinging or burning, aching sensation, and complete numbness
• If core temperature is not maintained, reflex shivering results in increased tone
• Re-warming period should be at least twice as long as the treatment time (too frequent application increases likelihood of frostbite)
• Hierarchy of cooling, from most to least efficient, is as follows: ice immersion, crushed ice, frozen peas, gel pack – choose an agent with less cooling potential if the patient has risk factors for an adverse reaction
• Local pain awareness, proprioception, muscle strength, and agility are reduced immediately post-cryotherapy – caution in prescribing activity

Also see page for cryotherapy guidelines.

Ultrasound utilises sound energy, pressure waves created by the mechanical vibration of particles through a medium. The flow of ultrasound may be delivered as an uninterrupted stream (continuous mode) or delivered with periodic interruptions (pulsed mode). Ultrasound is classified as a deep heating modality capable of producing a temperature increase in tissues of considerable depth because it travels very well through homogenous tissue (e.g. fat tissue).[21][22] Traditionally it has been used for its thermal effects but it is capable of enhancing healing at the cellular level. Continuous ultrasound is most commonly used when thermal effects are desired but non-thermal effects will also occur.[23] It has been shown to alter all phases of tissue repair: stimulates phagocytic activity of inflammatory cells such as macrophages,[24] and promotes release of chemical mediators from inflammatory cells which attract and activate fibroblasts to the site of injury, stimulates and optimizes collagen production, organization and ultimately functional strength of scar tissue.[25] An examination of research studies to assess changes in blow flow with ultrasound produced inconclusive results; however, recent studies show that nitric oxide released by ultrasound therapy may be a potent stimulator of new blood vessel growth at the site of injury.[26] Ultrasound also aids in pain relief and the literature has proposed reduced conduction of pain transmission as a possible mechnism for the analgesic effects.[27] More recently, low-intensity pulsed ultrasound has been shown to accelerate the rate of healing of fresh fractures due to the enhancement of angiogenic, chondrogenic, and osteogenic activity.[28]

Phonophoresis uses acoustic energy in the form of ultrasound to transfer molecules across the skin into the tissues. [8]

Pulsed Ultrasound

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Contraindications

Precautions

Risks 

• Hemorrhagic conditions

• Eyes, anterior neck, carotid sinus, reproductive organs
• Electronic device
• Deep venous thrombosis or thrombophlebitis (local)
• Malignancy (local)
• Pregnancy (local)
• Tuberculosis (local)
• Recently radiated tissue (local)

• Active epiphysis

• Acute injury or inflammation
• Damaged or at-risk skin
• Infection
• Skin disease
• Impaired circulation or sensation
• Impaired cognition or communication
• Plastic or cement implants
• Regenerating nerves

• Pain
• Surge

Continuous Ultrasound

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Contraindications

Precautions

Risks 

• Acute injury or inflammation
• Hemorrhagic conditions
• Impaired circulation or sensation
• Impaired cognition or communication
• Eyes, anterior neck, carotid sinus, reproductive organs
• Deep venous thrombosis or thrombophlebitis (local)
• Infection or tuberculosis (local)
• Malignancy (local)
• Recently radiated tissue (local)
• Pregnancy (local)
• Skin disease (local) e.g. psoriasis, eczema, etc.
• Electronic device (local)
• Plastic or cement implants (local)

• Active epiphysis
• Chronic wound
• Damaged or at-risk skin
• Regenerating nerves

• Burn
• Pain
• Surge

Additional Considerations

• Test sensory integrity by asking patients to differentiate between hot and cold stimuli or between light touch and painful stimuli
• Avoid pre-treatment of the area with superficial heating or cooling agents – cumulative effect of a hot pack and ultrasound can lead to skin damage
• Recommended treatment is 2 – 3x the effective radiating area (ERA)
• Circular head movement produces more even delivery of ultrasound energy since hot spots are dissipated better
• To minimize the impedance difference at the steel/air interface, a suitable coupling medium must be utilized
• Best absorption of ultrasound energy in tendon, ligament, fascia, joint capsule and scar tissue [29] 

Extracorporeal Shockwave Therapy (ESWT)

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ESWT involve the application of low frequency sound waves with specific parameters that produce significantly greater peak pressures than ultrasound waves. [30]

ContraindicationsPrecautionsRisks

• Pregnancy
• Over major blood vessels and nerves
• Pacemakers or other implanted devices
• Joint replacements
• Open wounds
• Epiphysis
• Blood clotting disorders
• Infection
• Cancerous tissues

• Cooperation issues
• Osgood-Schlatter disease
• Sever’s disease

• Redness
• Swelling
• Bruising
• Soreness
• Numbness

Light Amplification for the Stimulated Emission of Radiation (LASER) utilizes electromagnetic radiant energy, the movement of photons through space. The low-power or cold laser produces little or no thermal effects but seems to have some significant effect on soft-tissue and fracture healing as well as on pain management. Light at the wavelength typically employed in laser therapy is readily absorbed by enzymes, hemoglobin, fibroblasts, and neurologic tissue. Laser has been shown to stimulate cell degranulation causing the release of potent inflammatory mediators such as growth factors,[31] activate phagocytic processes at the site of injury,[32] and activate fibroblast cell function to increase collagen deposition and improve tensile strength.[33].Some reports also show a small decrease in edema produced by inflammation following laser therapy.[34].Absorption by hemoglobin releases nitirc oxide resulting in endothelial cell proliferation and increased microcirculation.[35] Low dosages also result in significantly decreased sensory nerve conduction velocity effect in reducing pain.[36]

Contraindications

Precautions

Risks 

• Hemorrhagic conditions
• Eyes, reproductive organs
• Deep venous thrombosis or thrombophlebitis (local)
• Malignancy (local)
• Pregnancy (local)
• Tuberculosis (local)

• Impaired cognition or communication
• Infection
• Photosensitivity or systemic lupus
• Recently radiate tissue
• Anterior neck, carotid sinus

• Eye damage
• Bleeding (open wounds)

Additional Considerations

• Reduce the risk of adverse effect on the eyes by applying laser in a closed environment, providing protective goggles when necessary, and performing an ‘in-contact’ technique

Magnetic Therapy

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Magnetic therapy is a type of therapy where the body is exposed to a particular form of energy i.e. low frequency magnetic field. When body tissues are exposed to magnetic fields, a weak electrical current is produced which may:

• Enhance cellular permeability and ability to reduce swelling
• Regulate painful stimuli and reduce pain
• Improve blood circulation through a visolidating effect
• Promote muscle relaxation and bone healing [37]
• Strengthen the immune system

Massage involves the use of the hands of the therapist on the patient’s body to help decrease pain, improve circulation and promote muscle relaxation. There are many massage techniques, e.g.

• Effleurage (Stroking)
• Petrissage (Kneading)
• Tapotement or Percussion
• Myofascial release
• Trigger point therapy
• Reflexology
• Deep transverse frictions
• Compression massage
• Cross-fibre massage
• Lymph drainage massage

ContraindicationsPrecautionsRisks

• Serious circulatory problems
• Active processes e.g. inflammatory, infectious
• Fever
• Cancer
• Skin infections
• Severe osteoporosis

• Hypo/Hypertension
• Dermatitis
• Impaired sensation
• Fibromyalgia
• Autoimmune disorders
• Pericarditis/endocarditis
• Osteopenia

• Bruising
• Blood clots
• Fractures
• Nerve damage
• Transmission of infectious skin conditions

Traction is a manual technique aiming to reduce pressure on the affected painful segments of the spine and stretch soft tissues. By pulling the vertebra away from the disc, pressure is released from the disc and associated structures. Several types of traction are described in the literature.

[38]ContraindicationsPrecautionsRisks

• Spinal malignancy
• Spinal cord compression
• Spinal infections
• Osteoporosis
• Acute fracture
• Aortic or iliac aneurysm
• Pregnancy

• Elderly

• Midline disc herniations
• Abdominal problems (lumbar region)

• Headache
• Nausea
• Fainting
• Soft tissue injury

The focus of this page is the rationale for use of a modality and its safety considerations. Contraindications, precautions, risks, and safety considerations are outlined in detail by Houghton et al.[39]