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Overview and Description

Physical Modalities are manually applied agents that yield a specific therapeutic response. This review focuses on both commonly and uncommonly used physical modalities including heat (superficial and deep), cold, sound, electricity, mechanical forces, and light.

Superficial Heat

  • Superficial heat is the use of a thermogenic agent which induces a temperature increase and subsequent physiologic changes to the superficial layer(s) of the skin, fat, tissues, blood vessels, muscles, nerves, tendons, ligaments, and joints. Superficial heat penetration is usually less than 1 cm.1,62 In contrast, the use of deep heat penetration is up to about 3-5 cm.62
  • Commonly used superficial heat modalities include hot packs, heating pads, paraffin bath, infrared, ultrasound, and fluidotherapy.
  • Transfer method: Conduction is transfer of heat between two objects at different temperature through direct contact (example: hot packs, paraffin bath). Convection is transfer of heat by fluid circulation (liquid or gas) over the surface of a body (example: fluidotherapy). Conversion is changing of one energy form into another (example: ultrasound, radiant heat).
  • Physiologic effects: Thermal energy (high temperature; heat) provides pain relief, increase in local blood flow, metabolism, and elasticity of connective tissues.2 Heat increases blood flow and subsequently may induce edema and exacerbate acute inflammation.
  • Indications: Heat is usually used for subacute to chronic conditions, and can reduce pain and muscle spasm, relax skeletal muscles, and decrease joint stiffness.
  • Contraindications: patients with peripheral vascular disease, bleeding disorders, local malignancy, acute inflammation or trauma, edema, infection, open wounds, over large scars, patients with impaired sensation (neuropathy) or impaired ability to communicate/cognitive impairments (dementia or dysphasia).

Deep Heat

  • Deep heat modalities include ultrasound, shortwave diathermy (SWD) and microwave diathermy (MWD). Ultrasound is however the most used deep heating agent. Heat penetration can be 3-5 cm or more without overheating underlying subcutaneous tissue or skin.
  • Transfer method: Same as superficial heat but deeper penetration. The ultrasound machine converts electrical energy into acoustic energy via the piezoelectric effect. SWD and MWD convert electromagnetic energy to thermal energy.
  • Physiologic effects: Same as superficial heat. The physiologic effects of ultrasound can be divided into thermal (heat) and non-thermal effects (cavitation, acoustic streaming, and standing waves). The non-thermal effects of ultrasound may improve repair of soft tissue injury, the inflammatory response, protein synthesis, and modulate membrane properties.64 
  • Indications: Ultrasound has been widely used in the treatment of various soft tissue disorders including bursitis, tendinitis, degenerative arthritis, musculoskeletal pain, contractures, and promotes wound healing.3 SWD has good bone penetration, commonly used to heat large area of deep tissues and within the joints, such as hip, knee, or ankle. MWD has more superficial heat penetration compared to SWD and ultrasound. It is commonly used to heat superficial muscles and shallow joints.
  • Contraindications: Besides the superficial heat contraindications listed above, specific ultrasound contraindications include use over the eyes, pregnant uterus, malignant area, near the heart, brain or spine, laminectomy sites, epiphyseal plates of children and patients with pacemakers. Ultrasound precautions include metal plates, screws, pins, external fixators, and joint replacement components. SWD and MWD contraindications: metal items, contact lenses, gravid or menstruating uterus, and skeletal immaturity. MWD increases the chance of miscarriages among pregnant therapists.4


  • Common cold modalities include cold packs, ice massage, cold baths, vapocoolant sprays, and cold compression units. These modalities lower local tissue temperature.
  • Transfer method: Cold occurs when hot objects/areas lose heat to cold objects/areas through the Second Law of Thermodynamics and entropy. Cold therapies lower and maintain a lower temperature either physically and/or chemically. Depth of cold penetration depends on the intensity and duration of application. At least 15 minutes is necessary to achieve an analgesia effect, and 20 minutes is the usually recommended treatment duration.5 Treatment time for ice massage is usually 7-10 minutes.
  • Physiologic effects: Cold energy (low temperature) decreases pain, blood flow, edema, inflammation, muscle spasm, and metabolic demand of tissues.2 Physiologic effects works via the Lewis hunting reaction or hunting response (or hunting reflex) where there is an alternating vasodilating (initial 5 minutes and >15 minutes; decreases sympathetic neurotransmitters to arteriovenous anastomosis, which then increases blood flow and temperature) and vasoconstricting response to application of cold.63 Vapocoolant sprays such as Fluori-Methane spray produce abrupt temperature changes over a small surface area. The spray can stimulate Aβ fibers to reduce pain and decrease muscle spasm.
  • Indications: Acute inflammation and edema, spasticity, pain, arthritis, bursitis, muscle strain and ligament sprain, muscle spasm, and myofascial trigger points.
  • Contraindications: Hypersensitivity or poor tolerance to cold, Raynaud’s disease/ phenomenon, peripheral vascular disease, open wounds, burns, cryoglobulinemia, paroxysmal cold hemoglobinuria, patients with impaired sensation (neuropathy) or impaired ability to communicate/cognitive impairments (dementia or dysphasia).

Music Therapy

  • Use of often calming or soothing acoustic sounds in music which have certain wavelengths and frequencies to rehabilitate a variety of neurological/cognitive disorders and for pain control. There is no standard therapeutic protocol.
  • A variation of music therapy is Vibroacoustic therapy (VAT) which is a more specific and individualized therapeutic modality.20
  • Other Musical Therapy Types exist: Neurologic Music Therapy (NMT), 24,29 Music Supported Therapy (MST), Melodic Intonation Therapy,21,30 Music glove,67 group music therapy,68 Rhythm- and music-based intervention,69 and Musical sonification30,31
  • Transfer method: Mechanical (vibrations) to acoustic/sound waves (kinetic energy) of differing frequencies. If from radios, television, computers, or radiofrequency machine, energy is transmitted by a wide range of electromagnetic radiation.
  • Physiologic effects (many):
    1. Neuro-plastic changes and neural reorganization – Music induces neurological changes in the brain by integrating memory, attention, and senses in sensorimotor cortex which enhances speech and audio-visual processing.21 This may improve ischemic post stroke recovery and early sensory processing.22,23
    2. Associative network theory of mood and memory– Memory of events, experiences, or information are associated with certain elements of event and are stored in neural nodes and are activated by music.24 Music activates certain experiences or events associated with the specified emotion, environment, or any of our senses.24
    3. Stimulating dopaminergic & pain receptor pathways – Music not only increases reward in brain and emotional arousal, but also activates Mu opioid receptors for reducing pain and may be an adjunct for pain management.25 This pathway in the substantia nigra and basal ganglia have applications in Parkinson’s disease especially when dance music and dancing are coupled for cognitive and gait rehabilitation.26
    4. “Eco-mirror neurons”– The execution of musical movements such as singing, clapping hands, or playing instruments can provoke or alter emotions and elicit a motivational response in a person to mirror the movements.24
    5. Enhancement of blood flow – Music can increase blood circulation in acute ischemic stroke post-recovery patients.27
    6. Synesthesia – Music serves many social-cultural functions, emotional reward, and cohesiveness and allows humans to neurologically connect the sensory pathways (hearing and seeing associated with some type of event) and can allow for behavioral control over pain.25
  • Indications: Music therapy can improve sub-acute patient motor recovery,32 act as an adjunct in pain management,25 such as in burn patients,33 post-operatively,34 cancer patients,35 alleviate mild and chronic tinnitus.36,37
  • Contraindications: Gastrointestinal problems (nausea, vomiting), psychiatric conditions (hallucinosis, psychosis), depression, sensitivity to loud or evocative sounds; music needs to be tailored to personal preference28


  • This modality uses electricity (electromagnetic radiation) to stimulate nerve or muscle.
  • Common types of electrotherapy: transcutaneous nerve stimulation (TENS), interferential therapy (IFT), neuromuscular electrical stimulation (NMES), and iontophoresis.
  • Transfer Method: There are two postulated theories. First, stimulating large myelinated afferent A-beta fibers can block the transmission of pain signals to the brain (gate control theory). Secondly, electrical stimulation stimulates the body’s production and release of endogenous opioids and neurotransmitters. High frequency (HF) and low frequency (LF) TENS activate different opioid receptors. LF TENS activate mu receptors while HF TENS activate delta receptors. As most opioid analgesics work on mu-opioid receptors, HF TENS is more effective in treating opioid tolerant patients.7
  • Physiologic effects: Decreases pain, edema, and effusions. Increases muscle bulk. Improves soft tissue and bone healing.
  • Indications: acute and chronic pain, neuromuscular disease, joint effusion and edema, disuse muscle atrophy, wound and bone healing.
  • Contraindications: use over carotid sinus, heart, pregnant uterus or infected area, pacemakers, AICDs, battery operated implant devices (intrathecal pumps, spinal cord simulators, vagal nerve stimulators, etc.), seizure disorder, active hemorrhage, malignancy, circulatory impairments, arterial or venous thrombosis, thrombophlebitis, decreased sensation, and atrophic skin.6

Mechanical force

  • Mechanical force can involve touch, pressure, pulling, traction, stretching, pushing, effleurage (stroking), kneading (petrissage), friction, gliding, resisting, vibrating/oscillating, and/or translating in different vectors and planes to enact a therapeutic effect.
  • Spinal traction, light touch, superficial massage, deep tissue massage, manual lymphatic drainage, and Extracorporeal shockwave therapy (ESWT) are common examples of mechanical force modalities.
  • Complete Decongestive Therapy (CDT) is another form of lymphatic therapy which incorporates manual lymphatic drainage with other non-manual techniques to holistically treat lymphedema.76
  • Transfer Method: Spinal traction and massage (superficial and deep) use stretching and pressure to elicit the desired therapeutic effect. Light touch involves brief stroking or touching skin/body to activate whole body mechanical sensory receptors to prevent swaying of body and falls.72,73,74,75 Manual lymphatic drainage works by compressing lymphatic channels to facilitate lymph drainage. With ESWT, the use of high frequency vibrational energy (sound waves) transfers mechanical energy to tissues for therapeutic effect.
  • Physiologic effects: Spinal traction can provide a distracting force to the spine and intervertebral joints and provide stretching to the ligaments, muscles, and facet joints5, reduce compression and nerve root and disc irritation. Light touch improves cueing to stand and improves balance. Tissue massage can inhibit pains, reduce edema, decrease muscle spasms, improve blood flow, and reduce inflammation. ESWT improved wound healing around soft tissue, bony, and tendinous areas, decrease pains, release trigger points, reduce inflammation, and break up calcifications. Manual lymphatic drainage can help remove edema, improve circulation, prevent sickness, reduce adhesions/scar tissues, potentially improve function/range of motion, and decrease pains.76,77
  • Indications: Spinal traction and deep tissue massage are used for disc herniation with nerve impingement, spondylolisthesis, narrowed intervertebral foramen, degenerative facet joints, joint hypomobility, discogenic pain, and muscle spasm.5 Superficial tissue massage is indicated mainly for myofascial pains and dysfunctions. Light touch contact is used as a balance aid for the neurologically impaired (stroke) and older adults with balance problems to correct postural dynamics while ambulating. 72,73,74,75 ESWT is used for chronic recalcitrant tendinopathies, plantar fasciitis, trigger points, pseudoarthrosis, and lateral epicondylitis. Manual lymphatic drainage aids in removal of lymph buildup in the body, especially for those with Breast cancer-related lymphoedema (BCRL),78 burns, fractures, and systemic diseases, comfort for those palliative, dependent edema in stroke patients, those with sinusitis, common colds, Lyme disease, and post-surgical procedures.
  • Contraindications of spinal traction: Spine malignancy, osteoporosis, osteomyelitis, fracture, instability (as in Rheumatoid arthritis, Down syndrome, Marfan syndrome, Ehlers-Danlos syndrome, atlantoaxial subluxation), cord compression, congenital spinal deformity, acute sprain or strain, pregnancy, uncontrolled hypertension, and cardiovascular disease.
  • Contraindications of light touch: Personal preference, hypersensitivity to touch, open wounds, ulcers, gangrene, or infected skin.
  • Contraindications of superficial massage: Hypersensitivity to superficial pressure and/or pains, thrombophlebitis, bleeding disorders, malignancy, open wounds, skin atrophy, ulcers, gangrene, fevers, or acute inflammation.
  • Contraindications of deep tissue massage: Hypersensitivity to deep pressure and/or pains, DVT, thrombosis, thrombophlebitis, bleeding disorders, aneurysms, malignancy, open wounds, skin atrophy, fractures, ulcers, gangrene, osteoporosis, pregnant, fevers, acute inflammation, gastrointestinal problems (nausea, vomiting), and severe organ conditions (such as failure of heart, lungs, kidneys, or liver).
  • Contraindications of lymphedema drainage: Hypersensitivity to deep pressure and/or pains, malignancy, DVT, thrombosis, thrombophlebitis, bleeding disorders, fevers, acute inflammation, and severe organ conditions (such as failure of heart, lungs, kidneys, or liver).
  • Contraindications of ESWT: Neuropathy, hypersensitivity to deep pressure and/or pains, open wounds, skin infections, seizure, epilepsy, pregnant, and pacemaker.

Light therapy (or Phototherapy)

  • Ultraviolet light (UV) therapy and Low-Level Laser therapy (LLLT) are examples of light therapy.
  • UV therapy uses the electromagnetic wavelength between X-ray and visible to enact a biological response in tissue. Whereas LLLT uses low-powered laser light to produce this response.
  • Transfer Method: While the exact mechanism is still under investigation, there is no known thermal effect. Photons in light temporary make a neural blockade (as an anesthetic) by decreasing mitochondrial membrane potential (MMP) and ATP which decreases the inflammatory neuropeptides.
  • Physiologic effects: Reduces pain. LLLT is proposed to affect fibroblast function, accelerate connective tissue repair,8 and some research suggests LLLT has an anti-inflammatory effect by reducing prostaglandin synthesis.9 UV light may have similar biological effects as LLLT.
  • Indications: It is commonly used to decrease acute and chronic pain and inflammation,10,11 stimulate collagen metabolism and promote wound healing.12 UV light has been used for depression, seasonal affective disorders, vitamin D deficiency, and wound healing.79 UV light (especially blue light) is emerging as a possible therapeutic modality for mild traumatic brain injury (sleep-wake cycle, circadian rhythm, nociception, cognition, mood).80 In addition, UV light has been proposed as an alternate modality for immunomodulation.81
  • Contraindications: UV therapy is contraindicated for treatment over eyes, skin cancer/malignancy, organ disease (heart, lung, kidneys), SLE, fevers, acute inflammation. LLLT also has contraindications for those with irradiation of the neck region in hyperhidrosis, seizure, epilepsy.13

Relevance to Clinical Practice/ Specific Techniques

Hot Packs

  • Provides superficial heat.
  • Most common ones sold in market are pre-packaged.
  • Package inside contains chemicals needed to create thermal energy.
  • Crushing or squeezing the contents in the package activates ingredients (which may be made of magnesium and water or iron, carbon, water, salt mixture).
  • Some hot packs are gel based (and reusable in boiling water for 10-15 minutes) or require addition of hot water (in a bottle).
  • Technique: Wrapping a towel over hot pack and then placed over affected area.
  • Treatment duration is about15 to 20 minutes.
  • Commonly used for soft tissue pains, muscle spasms, strains/sprains, and osteoarthritis.
  • Precautions: Avoid skin atrophy, burns, open wounds, rashes, cardiovascular disease, hypertension, or malignancy.

Heating Pads

  • Provides superficial heat.
  • Most heating pads come in electrical and microwavable forms.
  • Many of the heating pads are wearable with different sizes and shapes (i.e., for shoulder, back, feet, or full body blanket or mattress).
  • Some electrical heating pads include a moist/damp setting with ability to control temperature settings.
  • Others have a weighted fabric component for helping with insomnia and pain.
  • Technique: Place the heating pad over affected area.
  • Treatment duration is about15 to 20 minutes.
  • Commonly used for soft tissue pains, muscle spasms, strains/sprains, osteoarthritis, and menstrual cramps.
  • Precautions: Avoid skin atrophy, burns, open wounds, rashes, cardiovascular disease, hypertension, or malignancy.

Paraffin bath

  • This is a machine unit which uses paraffin wax (or a combination of wax/oil) covered over the extremity of interest to deliver superficial moisturizing heat.
  • Paraffin wax and mineral oil mix in a 7:1 or 6:1 ratio.
  • Treatment temperature is between 52.5 °C to 54.4 °C.
  • Techniques:
    A. Dipping: Dip body parts into paraffin bath and then quickly remove to build coating of wax, repeat 7-12 times, followed by wrapping in wax paper or plastic bag, then cover with towels.
    B. Immersion: Serial dips is followed by immersion in the paraffin bath for 30 minutes.
    C. Brushing: A brush is used to apply paraffin to large body parts.
  • Treatment duration is about 20- 30 minutes.
  • Commonly used to heat irregular surfaces such as hands and feet, rheumatoid arthritis, osteoarthritis, trauma, contractures, and scleroderma.
  • Paraffin bath with intrinsic muscle exercises has been shown improve precision grip and pain in rheumatoid arthritis,41 provide short term relief of pain, improved function, and improved quality of life for symptomatic hand osteoarthritis,42 and is more effective when combined with mobilization techniques for post-traumatic stiff hand.43 Paraffin baths may have poor efficacy compared to lukewarm water in pretreating hands with scleroderma for hand mobility44 and may offer no additional benefits to home exercises.45
  • Precautions: Avoid poor blood circulation, neuropathy, open wounds, and rashes; catching fire with paraffin wax; monitor temperatures from exceeding the treatment range.

Infrared (Radiant heat)

  • An infrared lamp provides superficial dry heat to the body.
  • Infrared lamps emit light energy which is absorbed through skin and converted to superficial heat with a depth of penetration <1 cm.
  • Technique: Lamp is placed at a distance of about 20 inches away from the skin.
  • Treatment duration is for about 20 minutes.
  • Heating effectiveness decreases dramatically as the distance from body to lamp increases.
  • Commonly used for patients who cannot tolerate the weight of hot packs.
  • Precautions: Avoid burns, light sensitivity, skin drying, and use of photosensitizing medications.


  • This is a type of superficial dry heat which provide the desensitization effect by agitation of particles around the affected extremity.
  • Temperature range is between 115 °F to 120 °F (46.1 °C to 48.9 °C).
  • Technique: Hot air is blown through a container holding fine cellulose particles. Range of motion exercises are allowed during treatment.
  • Treatment duration is about 20 minutes.
  • Commonly used to heat hands, wrists, and arms to decrease pain, edema, and stiffness
  • Fluidotherapy with conventional rehabilitation has been shown to effective for neuropathic pain and reducing edema volume in subacute stage of poststroke CRPS46 and improve activities of daily living.47
  • Precautions: Avoid in infected wounds, those with neuropathy, open wounds, lymphatic obstructions, or vascular diseases (ulcers).

Ultrasound (US)

  • Machine which uses the sound waves via the piezoelectric effect to deliver superficial and/or deep heat.
  • Settings:
    A. Mode: Continuous vs Pulsed. Continuous US provides mainly thermal effects while pulsed US emphasizes nonthermal effect.
    B. Frequency: 0.8-3 MHz. Low frequency US has better heat penetration while high frequency US produce more thermal effect in the superficial area.
    C. Intensity: Determines the strength of the treatment. The upper limit is 3.0 W/cm2.
  • Technique: Stroking with probe on affected areas. Ultrasound gel is needed as a coupling medium. When treating uneven surfaces, the body part can be immersed in degassed water.
  • Treatment duration is 5-10 minutes per site.
  • Commonly used to improve wound healing, range of motion, pain, inflammation, contractures, and a wide variety of soft tissue disorders.
  • Low-intensity pulsed ultrasound (LIPUS) treatment was shown to promote wound healing and can stimulate bone healing in fresh fractures.14 A more recent systemic review, however, of randomized controlled trials of LIPUS in 2017 revealed it has no effect on fresh bone fractures and bone healing and does not improve outcomes but may have applications to other fracture types and after osteotomy.48
  • Precautions: Avoid burns, open or infected skin, malignancy, fractures, children with growth plate not fully developed, near the eyes or the heart, in the pregnant, those with neuropathy, and vascular conditions.

Phonophoresis (Sonophoresis)

  • Use of ultrasound to drive medications into and through skin by increasing cell permeability for deep heat.
  • Settings:
    A. Mode: Pulsed.
    B. Frequency: 1 MHz.
    C. Intensity: Determines the strength of the treatment. The upper limit is 3.0 W/cm2.
  • Technique: Stroking with probe on affected areas.  Administered with corticosteroids or anesthetics (lidocaine).
  • Treatment duration is for 5 minutes per site.
  • Commonly used for osteoarthritis, bursitis, tendinitis, tenosynovitis, epicondylitis, fasciitis, carpal tunnel syndrome, and rapid skin anesthesia.
  • Phonophoresis has been shown to be effective in symptom and functional improvement of mild-moderate carpal tunnel syndrome but was no different in effectiveness in improving distal sensory and motor findings than non-drug ultrasound therapy.49
  • Precautions: Same as US with the addition of any history of drug allergies.

Shortwave Diathermy (SWD)

  • Machine which converts high frequency alternating electromagnetic current (AC; aka. alternating current; radio waves) to thermal energy (friction) to provide deep heat to large areas of therapeutic interest.
  • Used when therapeutic US is unable to heat deeper tissue structures.
  • SWD units can use either capacitor or inducer cable electrodes.
  • Frequency: Most commonly used is 27.12 MHz.
  • Technique: Capacitor electrodes are placed opposite one another to induce deep heat. If using cable electrodes, these are placed over large area of interest (i.e., wrapped around leg or sitting on back) to induce deep heat.
  • Treatment duration is 20-30 minutes for one body area.
  • Commonly used and effective for short term musculoskeletal pain relief and improving quality of life.50
  • SWD was shown to be effective in knee osteoarthritis in pain reduction and improvement of functionality but there was no difference in whether it was pulsed or continuous setting.51
  • Precautions: Avoid burns, skeletal immaturity (children with long bone growth plates), metal implants, stimulators, or any organs with excess fluid involvement, such as edematous skin, eyes, or uterus (pregnant/gravid).

Microwave Diathermy (MWD)

  • Machine which converts electromagnetic microwaves to thermal energy to provide deep heat.
  • More superficial heat penetration compared to US and SWD: 1-4 cm
  • Frequency: 915 to 2,456 MHz.
  • Technique: Similar to SWD.
  • Treatment duration is 5-15 minutes.
  • Commonly used for superficial muscles and shallow joints.
  • Precautions: same as SWD. Greater caution for those who are pregnant (operator, patient, and those around machine).

Cold Packs

  • Use of commercial cold pack or ice packs to provide cold therapy (lowering temperature) through the Hunting reflex (alternating vasodilation/vasoconstriction).
  • Technique: Cover with towel and do not let skin come in direct contact with cold pack.
  • Treatment duration is 15-20 minutes. Onset of numbness is around 20 minutes.
  • Commonly used for acute musculoskeletal pains, swelling, bruising, inflammation, and strains/sprains.
  • Precautions: Avoid burns, skin hypersensitivity/poor tolerance to cold, those with neuropathy, Raynaud’s phenomenon, peripheral vascular diseases/conditions, open wounds, and cryoglobulinemia.

Ice Massage

  • Combination of ice and massage to provide cold therapy (lowering temperature) through the Hunting reflex (alternating vasodilation/vasoconstriction) and mechanical deformation of forces around the tissues.
  • Technique: use of ice (in a cup) over small areas by using gentle stroking motions.
  • Treatment duration is 7-10 minutes; up to 15 minutes.54
  • Commonly used for acute musculoskeletal pains, swelling, bruising, inflammation, and strains/sprains. May also be used to initiate and facilitate swallowing in stroke patients.53
  • Precautions: Avoid burns, skin hypersensitivity/poor tolerance to cold, those with neuropathy, Raynaud’s phenomenon, peripheral vascular diseases/conditions, open wounds, and cryoglobulinemia.

Vapocoolant Sprays (Freeze or Cold Sprays)

  • Commercially available aerosol spray with liquefied chemical ingredients (chloroethane, tetrafluorane, or dimethyl ether) to provide topical cold anesthetic.
  • Technique: “Spray-and-stretch” is commonly used. Apply the spray in one direction parallel to muscle fibers at a rate of 4 inches/sec while the muscle is passively stretched.
  • Treatment duration is a 30 to 60 seconds.
  • Commonly used before local musculoskeletal injections.
  • Precautions: Avoid skin irritation and local freezing.

Cold Compression Units

  • Machine which uses circulating cold water attached to an intermittent pump unit to provide pneumatic compression to provide cold therapy.
  • Comes in two forms of wearable compressions: static or dynamic.
  • Settings:
    A. Temperature: 45°F (7.2°C).
    B. Pressure: Up to 60 mmHg.
  • Technique: Static compression units are worn on the affected area with simple graded pressure. Dynamic compression units allow the user to have more control over compression pressure (and temperature) over affected area and are used by healthcare professionals and providers.
  • Treatment duration should be 15-20 minutes on and off.
  • Commonly used to treat acute musculoskeletal injury with soft tissue swelling or used after surgical procedures.
  • Precautions: Avoid in those with history of hypercoagulability, deep vein thrombosis, thrombophlebitis, skin hypersensitivity/poor tolerance to cold, those with neuropathy, Raynaud’s phenomenon, peripheral vascular diseases/conditions, open wounds, and cryoglobulinemia.

Vibroacoustic Therapy (VAT)38,39

  • Was first developed by Olav Skille and Juliette Alvin in 1968.
  • Use of musical sound waves to aid and facilitate in the relaxation response.
    • Relaxation response – every object has its own natural frequency. Matching that frequency with VAT will cause the object or tissue to resonate. In resonance, tissues undergo physiology change such as increase blood circulation, metabolism, and reduction in sympathetic activity. Muscular tension is seen to relax due to this resonance response.
  • Technique: Use of sinusoidal, low-frequency (30-120 Hz) sound waves to produce vibrations that are applied directly to the body. Usually on specially designed chair or mattress.
  • Treatment duration is about 30 minutes per session.
  • Commonly used for anxiety/stress, muscular tension, fatigue, pain management and other conditions such as fibromyalgia, tinnitus, and Parkinson’s Disease.
  • Contraindications and Precautions: Avoid pacemakers, seizure disorders, spasticity in Cerebral Palsy,40 hypotension, DVT, bleeding disorder, recent surgery or individuals who have had a recent psychotic episode.

Neurologic Music Therapy (NMT)65

  • Use of musical sound waves for neurorehabilitation.
  • Technique: Under a Neurologic Music Therapist, the patient is trained to use musical instruments and structure (with 20 standardized clinical techniques) to improve neurological recovery.
  • Treatment duration varies depending on condition being addressed.  
  • Commonly used for general neurorehabilitation.
  • Precautions: Avoid in mood disorders, psychiatric conditions, gastrointestinal problems, sensitivity to loud/evocative music. There may be a personal music preference.

Music Supported Therapy (MST)21

  • Use of musical sound waves for stroke patients with motor impairments.
  • Technique: Training focuses on the patient using hemiparetic limb on musical instruments (i.e., piano, electric drum).
  • Treatment duration varies depending on condition being addressed. 
  • Commonly used for stroke motor recovery.
  • Precautions: Those with poor motivation. Avoid in mood disorders, psychiatric conditions, gastrointestinal problems, sensitivity to loud/evocative music. There may be a personal music preference.

Melodic Intonation Therapy66

  • Use of musical sound waves for patients with severe, non-fluent aphasia. 
  • Patients should have good auditory comprehension to participate.
  • Technique: Training focuses on using different musical intonations combined with tapping, rehearsal, and auditory-motor feedback techniques.
  • Treatment duration is about 30 minutes a session. 
  • Commonly used for Broca’s aphasia, apraxia, and left sided brain strokes.
  • Precautions: Avoid in right brain strokes, Wernicke’s aphasia, poor hearing, or auditory comprehension.

Music Glove67

  • Use of glove, music, and virtual reality for improving hand function.
  • US FDA approved for hand therapy for hand rehabilitation.
  • Technique: Use as a home training platform with use of glove on the hemiparetic hand for playing with virtual reality games and songs.
  • Treatment duration varies per session as it is mostly user dependent.
  • Commonly used for stroke survivors with poor fine motor hand control. Can also be used for stroke survivors with poor motivation.
  • Precautions: Avoid in those with sensitivity to light, visual disturbances, and with seizures/epilepsy.

Group Music Therapy68

  • Music in a group setting is used to help patients socialize, improve group cohesiveness, motivation, awareness, mood, and express themselves.
  • Technique: Music is played and even sung vocally among group participants.
  • Treatment duration varies based on individual needs.
  • Commonly used for neurological rehabilitation, mental health needs, and substance abuse.  
  • Precautions: Those with poor motivation and personal music preference. Avoid in gastrointestinal problems, sensitivity to loud/evocative music, and severe psychiatric or mood disorders.

Rhythm- and Music- based intervention69

  • Music activates the dopaminergic pathway in the brain to allow normal movements to be elicited.
  • Technique: Music is played, and an activity is performed (dancing, walking).
  • Treatment duration varies based on individual needs.
  • Commonly used for movement disorders in neurological rehabilitation, most notably for Parkinson’s disease.
  • Precautions: Avoid in gastrointestinal problems, sensitivity to loud/evocative music, and severe psychiatric or mood disorders.

Musical Sonification31,32

  • Music to improve gross motor impairments and cognition (spatial awareness).
  • Technique: Patient uses hemiparetic limb to move in a certain predefined spatial area in sync with music and learns to adapt those movements with sounds heard.
  • Treatment duration varies based on individual needs.
  • Commonly used for stroke motor recovery.
  • Precautions: Avoid in gastrointestinal problems, sensitivity to loud/evocative music, and severe psychiatric or mood disorders. Personal preference.

Transcutaneous Nerve Stimulation (TENS)

  • A TENS unit is a pocket-size programmable device used to apply low frequency electrical stimulation through wires and electrodes attached to the patient’s skin.
  • There are different types of stimulators: conventional, acupuncture, hyperstimulation, pulsed and modulated.
  • Technique: Place electrodes over areas of therapeutic interest. Stimulate nerve fibers and provide symptomatic relief of pain.
  • Treatment duration is normally 30 minutes to 1 hour per session.
  • Commonly used for acute/chronic pain, those who are opioid tolerant (at high frequencies), neuromuscular disease, joint effusion/edema, disuse muscle atrophy, and wound/bone healing.
  • A systematic review found TENS was no more effective than sham or placebo in treating chronic low back pain.15
  • TENS has been found be effective in treating neuropathic pain for spinal cord injury patients16 and painful diabetic peripheral polyneuropathy.17
  • Precautions: Avoid those who are pregnant, on open wounds, infected areas, AICDs, pacemakers, battery operated implant devices, have seizures, active hemorrhage, malignancy, circulatory impairments, thrombosis, or thrombophlebitis.

Interferential Therapy (IFT)70

  • Portable device which delivers low frequency strong physiological stimulation (<250pps) to nerves.
  • Technique: Place electrodes over areas of therapeutic interest. Stimulate nerve fibers under specialized low frequency and provide symptomatic relief of pain.
  • Treatment duration is about 20-30 minutes.
  • Commonly used those uncomfortable or refractory to low frequency TENS.
  • Precautions: Neuropathy, suction discomfort, fevers, seizures, epilepsy, cardiovascular conditions, or anterior chest wall problems.

Neuromuscular Electrical Stimulation (NMES)

  • Device that can electrically stimulate above the motor threshold to cause a muscle contraction.
  • Can be portable.
  • Settings: Therapeutic muscle stimulation or Functional electrical stimulation (FES).
  • Techniques: Place electrodes over muscle areas and then stimulate nerves.
    A. Therapeutic muscle stimulation: Repetitive simulation is applied to paralyze muscle to minimize atrophy and maintain range of motion.
    B. FES: Use of electrical stimulation to assist patient in performing a functional task.
  • Treatment duration ranges from 20 minutes to an hour depending on goal of therapy in conjunction with NMES treatment.
  • Commonly used for muscle strengthening, neuromuscular re-education, cardiovascular conditioning, prevent disuse atrophy, osteoporosis, venous thrombosis, spasticity management, shoulder subluxation in hemiplegic limb, phrenic nerve pacing and urinary incontinence.
  • Precautions: Avoid those who are pregnant, on open wounds, infected areas, AICDs, pacemakers, battery operated implant devices, have seizures, active hemorrhage, malignancy, circulatory impairments, thrombosis, or thrombophlebitis.


  • Gel plate which uses low electrical current to deliver substance bearing a charge through the skin.
  • Technique: Use of electrodes or plates over affected extremities to drive a drug across the skin barrier.
  • Treatment duration is about 20 to 30 minutes.
  • Commonly used medications: anti-inflammatory agents (i.e., corticosteroids).
  • Commonly used for palmar-plantar hyperhidrosis, scar tissues, plantar fasciitis, tendonitis, and bursitis.
  • Precautions: Avoid those who are pregnant, on open wounds, infected areas, AICDs, pacemakers, battery operated implant devices, have seizures, active hemorrhage, malignancy, circulatory impairments, thrombosis, or thrombophlebitis.

Spinal traction

  • Provides a pulling force to the cervical or lumbar spine by using manual techniques or pulley system or special device.
  • Techniques:
    A. Sustained vs intermittent traction.
    B. For cervical traction, the neck is flexed between 20-30 degrees while the patient in a sitting or supine position. More than 20 lbs. is applied intermittently for a minimum of 7 seconds of traction time with subsequent rest time. The traction duration is 20-25 minutes. Up to 50 lbs. is needed to cause intervertebral disc separation.5
    C. For lumbar traction, the most common position is supine with hip and knees flexed to 90 degrees; > 50 lbs. is required for posterior vertebral separation and >100 lbs. is needed for anterior separation.
  • Treatment duration is typically 20 minutes.
  • Commonly used for muscle spasms, joint hypomobility, disc herniation with nerve impingement, spondylolisthesis, narrowed intervertebral foramen, and degenerative facet joints.
  • Precautions: Avoid in spinal instability, infection, compressions, malignancy, or deformity; any bony abnormalities, fractures, or osteoporosis; hypertension or cardiac disorders; acute ligamentous or muscle injuries.

Light Touch

  • Type of mechanical force which involves lightly touching the skin to activate the somatosensory reflex and change in musculoskeletal postural dynamics.
  • Light touch can be used as a compensatory method for other sensory impairments such as blindness or hearing loss.
  • Technique: A part of the body is briefly touched with a finger or object (cane) to cue a patient to modify their body’s biomechanics to prevent falling, swaying, or being imbalanced.
  • Treatment duration is seconds.
  • Commonly used for balance, posture, and gait rehabilitation.
  • Precautions: Hypersensitivity to touch/pain, overstimulation, skin diseases, ulcers, open wounds, and cognitive deficits

Superficial Massage

  • Manual manipulation which involves superficial pressure and strokes to relax muscles and reduce pains.
  • Techniques: Various, with most common being myofascial release.
  • Treatment duration varies and may be from 15 minutes up to an hour.
  • Commonly used for myofascial pains, spasms, and pains.
  • Precautions: Superficial pressure and pain for those who are intolerant to massage, open wounds, hematologic disorders, malignancy, skin atrophy, ulcers, gangrene, or skin infections.

Deep Tissue Massage71

  • Manual manipulation which involves deep, firm pressure and strokes to relax muscles and reduce pains.
  • Techniques To name a few deep tissue manual techniques, there are trigger point therapy, friction, myofascial release, and stretching.
  • Treatment duration varies and may be from 15 minutes up to an hour.
  • Commonly used for muscle spasms, pains, joint hypomobility, disc herniation with nerve impingement, spondylolisthesis, narrowed intervertebral foramen, and degenerative facet joints.
  • Precautions: Deep pressure and pain for those who are intolerant to massage, open wounds, hematologic disorders, malignancy, fractures, osteoporosis, the pregnant, gastrointestinal issues, and severe organ failure.

Manual Lymphatic Drainage (MLD)

  • Manual manipulation with the goal of removing toxins and waste products within the peripheral lymphatic vessels back into the central lymphatic system.
  • Techniques: Use of manipulation such as compression, vibration/oscillation, effleurage, myofascial release, tapping, or stretching to facilitate transportation of lymph (in head, neck, axilla, arms, or legs) to the lymphatic plexus and then to the central lymphatic system.
  • Treatment duration varies. Usually about 20-30 minutes a session.
  • Commonly used for Breast cancer-related lymphoedema (BCRL), burns, palliative comfort, dependent edema, sinusitis, and post-surgical procedures.
  • Precautions: Hypersensitivity to deep pressure and/or pains, malignancy, DVT, thrombosis, thrombophlebitis, bleeding disorders, illness, inflammation, or severe organ conditions (such as failure of heart, lungs, kidneys, or liver).

Complete Decongestive Therapy (CDT)76

  • Globally recognized as the lymphatic drainage therapeutic protocol by International Society of Lymphology.
  • Known well in Europe, but now gaining traction in America.
  • Comprises of four main parts: manual lymphatic drainage (MLD), exercising, self-care, and bandaging.
  • Techniques: Same as MLD with the addition of education to patient about special types of exercises for lymph removal, self-care (diet modification), and compression garments (sleeves, stockings, compression bras). Includes a rehab program with goals and two phases (intensive, then maintenance phase).
  • Treatment duration varies. Usually about 20-30 minutes a session.
  • Commonly used for Breast cancer-related lymphoedema (BCRL), burns, palliative comfort, dependent edema, sinusitis, and post-surgical procedures.
  • Precautions: Hypersensitivity to deep pressure and/or pains, malignancy, DVT, thrombosis, thrombophlebitis, bleeding disorders, illness, inflammation, or severe organ conditions (such as failure of heart, lungs, kidneys, or liver).

Extracorporeal Shock Wave Therapy (ESWT)

  • Device which uses high intensity pulsed mechanical waves to treat musculoskeletal disorders.
  • Does not produce thermal effect.
  • US FDA approved for treatment of plantar fasciitis and lateral epicondylitis.
  • Technique: Gel is placed over area of interest. Then, a non-invasive probe is placed over gel to deliver shock waves which induces healing and breaks up calcifications.
  • Treatment duration is approximately 5 minutes.
  • Commonly used for chronic recalcitrant tendinopathies, trigger points, pseudoarthrosis, lateral epicondylitis, and plantar fasciitis.
  • ESWT is safe, cost-effective, and helpful for reducing musculoskeletal conditions and can be applied for cancer rehabilitation patients (e.g., erectile dysfunction, lymphedema, and polyneuropathy).52
  • Precautions: Pregnant, neuropathy, hypersensitivity to deep pressure and pains, open wounds, skin infections, seizures, or pacemaker.

Ultraviolet (UV) Therapy

  • UV light is electromagnetic radiation with high energy.
  • There are three types – A, B, C. Type A is safest. The depth of penetration is determined by its wavelength/frequency.
  • Technique: There is no standard treatment protocol. The UV light is directed at a body part to render treatment. Administered in small doses.
  • Treatment duration is variable depending on condition. Ranges from 2 to 20 minutes.
  • Commonly used for stimulating collagen metabolism, wound healing, and localized pain control. Types A and B are used for many skin disorders. Type C is not used as it sterilizes and penetrates and damages the body.
  • Precautions: Burns (UV type B), cataracts/retinal damage (UV type A), skin cancer (melanoma), inflammation, and acceleration of skin aging. Caution with medications (e.g., fluoroquinolones, furosemide, TMP/SMX, diphenhydramine, oral contraceptive pills, tretinoin, isoretinoin) which increases risk for burns with UV.

Low-Level Laser Therapy (LLLT)13

  • LLLT delivers minimal energies (between 1 and 4 Joules).
  • The depth of penetration is determined by its wavelength/frequency.
  • Technique: There is no standard treatment protocol. The laser probe is applied perpendicular to the targeted treatment area.
  • Treatment duration is about 30 to 60 seconds.
  • Commonly used for stimulating collagen metabolism, wound healing, and localized pain control.
  • Precautions: Seizures, epilepsy, malignancy, irradiated neck region in hyperhidrosis, exposed retina, and pregnant exposed abdomen.

Gaps in Knowledge/ Evidence Base

The use of therapeutic modalities in rehabilitation has been present for centuries, but there remains a lack of strong evidence to support its effectiveness and effective use. Well designed and high qualities of studies are needed, including placebo-controlled or sham-controlled trials as well as trials of comparative effectiveness and trials of combination therapies.

Cutting Edge/ Unique Concepts/ Emerging Issues

LLLT is a relatively new therapeutic modality. LLLT received FDA approval in 2002 for the treatment of pain associated with carpal tunnel syndrome and in 2004 for iliotibial band syndrome. Most studies have focused on pain management and wound healing. Recently, the effects of LLLT on nerve tissue have been investigated.18,19 However, the literature on LLLT effectiveness is conflicting. More research is needed to further investigate its effectiveness and to determine optimal treatment parameters.1

Infrared therapy is another novel therapy in regenerative medicine. In one clinical randomized control trial by Sangma et al., infrared heat with routine dressing was more effective in reducing ulcer size and healing for chronic diabetic foot ulcers.55 Newer studies reveal infrared neural stimulation (INS) can help with wound healing and nerve tissue regeneration due to photothermal effects and can be combined with transcranial direct current brain stimulation for inducing neural stimulation and regeneration in traumatic brain injury.56

Music therapy for brain injury recovery is becoming more and more studied on improving mood, motivation, motor function, and cognition.29,31,57,58 The right music can have a profound effect on Parkinson’s Disease and may have further applications in other types of central neurologic diseases. More studies are needed to elucidate the mechanism of music therapy and appropriateness for specifically impaired individuals. Additionally the types of music therapeutic techniques and combined use with other modalities/treatments to improve neurological recovery and the timeframe for using this therapy is still unknown.59 Compared to music, VAT with its focus on low sinusoidal frequency and vibratory sensations may have more individualized future clinical applications in rehabilitation goals, chronic pain, mood, and motivation.60,61 More studies need to be conducted on VAT’s efficacy, timing of implementation, and environment settings (home, hospital, or office).60


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Original Version of the Topic

Thiru M. Annaswamy, MD, Li Liu, MD. Therapeutic Modalities. 4/4/2016

Author Disclosure

Benjamin J. Seidel, DO
Nothing to Disclose

Lawrence Chang, DO, MPH
Nothing to Disclose

Aaron Greenberg, DO
Nothing to Disclose