CURRENT CONCEPTS

Therapeutic ModalitiesAn Updated Review for the

Hand Surgeon
Tristan L. Hartzell, MD, Roee Rubinstein, MD, Mojca Herman, MA

The number of therapeutic modalities available to the hand surgeon has greatly increased
over the past several decades. A field once predicated only on heat, massage, and cold
therapy now uses electrical stimulators, ultrasound, biofeedback, iontophoresis, phonopho-
resis, mirror therapy, lasers, and a number of other modalities. With this expansion in
choices, there has been a concurrent effort to better define which modalities are truly
effective. In this review, we aim to characterize the commonly used modalities and provide
the evidence available that supports their continued use. (J Hand Surg 2012;37A:597621.
Copyright 2012 by the American Society for Surgery of the Hand. All rights reserved.)
Key words Modalities, rehabilitation, therapy.

upper extremity disorders number of modalities available has greatly increased. A

T
HE MANAGEMENT OF
depends on the collaboration of patient, physi-
cian, and therapist. Frequently, though, it is the
hand therapist who spends the most time with the pa-
tient, controlling edema, pain, and joint contractures
while maximizing tendon gliding, strengthening, and a
return to meaningful functional use. To achieve these
goals, therapists may employ a number of therapeutic
modalities.
The use of therapeutic modalities to help strengthen,
relax, and heal the injured part has been present for
centuries. Since Hippocrates began using hydrotherapy
and massage, natural therapeutic methods such as sun-
light, warm springs, and warm mud have given relief to
millions of people. Only recently has an attempt been
made to better understand therapeutic modalities and
how to use them most effectively.1
As we attempt to create a more exacting science, the
From the Department of Orthopedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles;
and the Advanced Therapy Center, Torrance, CA.
Received for publication April 20, 2011; accepted December 27, 2011.
field initially predicated on massage, heat, and cold now
employs ultrasound, phonophoresis, electrical stimula-
tion, iontophoresis, low-level laser treatment, biofeed-
back, compression pumps, and many others (Table 1)
as part of a multimillion-dollar industry. With this rise
in treatment choices, it is important to remain current on
the science behind the hyperbole.
It is our goal to provide an update on the commonly
used therapeutic modalities in hand surgery, to allow
hand surgeons to decide how best to prescribe them for
their patients.
THERAPEUTIC HEAT
Overview
Heat therapy refers to the application of heat to the body
for pain relief, decreased joint stiffness, muscle spasm
relief, increased collagen extensibility, increased blood
flow, and improved healing, and to aid in the resolution
of inflammatory infiltrates, edema, and exudates.2 4 It
is also called thermotherapy and can take the form of a
heating pad, heat lamp, whirlpool, paraffin bath, ultra-
Current Concepts

No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article. sound, and many others. In humans, the range of ther-
Corresponding author: Tristan L. Hartzell, MD, Department of Orthopedic Surgery, Box apeutic tissue temperatures is 41 to 45 C.2 4
9569902, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-6902; e-mail: Heat is classified by its depth of penetration
tristanhartzell@gmail.com. superficial or deep. Superficial modalities include
0363-5023/12/37A03-0038$36.00/0 moist hot packs, sand bags (Fig. 1), heating pads,
doi:10.1016/j.jhsa.2011.12.042
paraffin baths, heated air with circulating solid

ASSH Published by Elsevier, Inc. All rights reserved. 597

 598 THERAPEUTIC MODALITIES

particles, hydrotherapy, circulated moist air, and Whirlpool tanks work by convection and can si-
infrared radiation. These methods are not able to multaneously debride.
heat beyond a depth of 2 to 3 cm owing to patient
intolerance, tissue resistance to heating, and the Evidence
1 Evidence to support increased stretching and decreased
bodys response to local heating. The 3 deep
modalities of heat are ultrasound, shortwave dia- joint stiffness with heat therapy centers on the fact that
thermy, and microwave diathermy. Ultrasound is the viscoelastic properties of collagen change with ris-
by far the most commonly ing temperature. At human
employed because of its EDUCATIONAL OBJECTIVES body temperatures (37C),
ease of use, safety profile, Discuss the various modes of heat transfer. collagens length-tension
and greater depth of heat- State the evidence behind heat therapy with reference to changes in the curve displays elastic proper-
ing. viscoelastic properties of collagen. ties, but as it is heated to
Heat is also categorized Describe the Huntington response to cold application. therapeutic range tempera-
by its mode of heat trans- Discuss the differences between thermal and nonthermal ultrasound. tures (41 to 45C) it be-
ferconduction (hot packs, comes more viscous.2 As a
Summarize the evidence for the use of transcutaneous electrical nerve result, there is presumed in-
heating pads, and paraffin
stimulation (TENS) for acute and chronic pain in adults.
baths), convection (flu- creased collagen extensibil-
List the various types of biofeedback.
idotherapy, hydrotherapy, ity and improvement in
and circulated moist air Earn up to 2 hours of CME credit per JHS issue when you read the related stretching with therapeutic
heat), or radiation (infrared articles and take the online test. To pay the $20 fee and take this months heating.
radiation, ultrasound, and test, visit http://www.jhandsurg.org/CME/home. However, for superficial
microwave diathermy). heating modalities the hid-
Conduction is the direct exchange of kinetic energy den question is whether they
between objects in contact. Convection is the transfer are actually able to achieve these temperatures for the
of energy from 1 place to another by the movement target tissues collagen to become more viscous. To
of fluids. Moist heat is more effective at warming help answer this, Borrell et al5 measured the tempera-
tissues than dry heat because water transfers heat ture change in healthy male hands at a depth of 0.5 cm
more quickly than air. Finally, radiation is the trans- beneath the skin for joint capsule and muscle heated by
fer of energy by transmission of electromagnetic hydrotherapy, paraffin wax, and heated air with circu-
radiation. It has the advantage of directly targeting lating solid particles. They found that all resulted in a
the areas to be heated (muscle, joints, and nerves) minimum 6.0C and 4.3C temperature increase for
without relying on the transfer of heat through the joint capsule and muscle, respectively. The authors con-
overlying layer of skin. cluded that heating down to 1.2 cm is more effective
Several of the more commonly used heating with superficial modalities than diathermy and ultra-
modalities are moist hot packs, paraffin baths, sound. Other studies, however, have not demonstrated
heating pads, heat lamps, and whirlpool. Moist hot as impressive deep temperature elevations with super-
packs are commonly quilted canvas bags filled ficial heating modalities. Abramson et al6 found that
with sand that absorb hot water. They are wrapped 30-minute paraffin bath dipping treatments only elevated
in towels and can maintain useful temperatures for the subcutaneous tissue 3C and the muscle 1C. With the
20 to 40 minutes. Paraffin baths are a 1:7 mixture immersion methods, they were able to achieve 5C and
of mineral oil and paraffin heated to 53C. Patients 3C elevations, respectively. Similarly, using a hot pack or
can either dip their hands into the bath or use it as infrared heat lamp, Lehmann et al7 were able to increase
Current Concepts

a continuous immersion. Heating pads heat by
conduction and should only be used for 20-minute
intervals. They do not gradually cool like hot
packs and have the potential to burn the patient.
The newer types of pad combine a carbon fiber
heater with a battery and are built into a specific
body wrap (eg, shoulder wrap) for targeted ther-
apy. Heat pads that provide moist heat are also
available. Heat lamps use infrared radiation to heat
and are usually placed 30 to 60 cm from the limb.
the tissue temperature only 1.3C at 2 cm. Hence, it is
unclear whether superficial heating modalities are ef-
fective for increasing collagen viscosity in the digits
and hand. Certainly, for heating the forearm, upper arm,
and shoulder (where needed depths of penetration often
exceed 2 cm), one ought to consider deep heating
modalities if trying to reach the viscous point of colla-
gen.1
The other benefits of heat are vasodilatation, pain
relief, and muscle spasm reduction. It has been clearly

JHS Vol A, March

 THERAPEUTIC MODALITIES
TABLE 1. Modalities Commonly Used in Hand Therapy
Modality Common Clinical Indicationsa
Therapeutic heat Muscle spasms, stiffness, pain, subacute and chronic
inflammatory conditions, edema/infiltrate
resolution, increase local circulation, reduce
muscle guarding
Cryotherapy Inflammation, edema, pain, muscle tone and
spasticity, reduce: nerve conduction velocity,
metabolic rate, intra-articular temperatures,
increase muscle strength, enhance burn healing
Ultrasound Thermal: soft tissue shortening/increase collagen
extensibility, joint stiffness, pain control, scar
tissue, increase blood flow, tissue healing
Non-thermal: surgical skin incisions, wound healing,
tendon injuries (tendonitis), resorption of calcium
deposits, bone fractures, carpal tunnel syndrome,
phonophoresis, herpes zoster infection, stimulation
of tissue regeneration
Electrical stimulation Acute or chronic pain, most postoperative
conditions, fibromyalgia, edema reduction,
osteoarthritis, repetitive strain or cumulative
trauma injuries, strengthening exercises, muscle
re-education, tissue healing, nerve stimulation for
muscle contraction, wound healing, reduction of
muscle spasm, increased blood flow, reduces
muscle guarding
Biofeedback Amputation, arthritis, arthroplasty, burns, crush
injury, Dupuytren release, fracture, focal dystonia,
overuse disorders, pain disorders, peripheral nerve
injury, pollicization, complex regional pain
syndrome, replantation, tendon lacerations with
subsequent repair, tenolysis, tendon transfer, toe-
to-thumb transfer, disuse atrophy, scar adherence,
muscle substitution
C-TRAC Mild to moderate carpal tunnel syndrome
Contrast baths Joint stiffness, pain, edema, inflammatory conditions
such as sprains, strains or tendonitis, subacute
trauma, hyperalgesia or hypersensitivity
Intermittent Ideal for edema during the inflammatory phase of
pneumatic healing, chronic edema requires higher pressure
compression and longer treatment times
pumps
Kinesiotape Pain specific areas, muscle facilitation or inhibition,
edema, ecchymosis
JHS Vol A, March
599
Precautions/Contraindications
Acute trauma, insensate tissue, ischemic
tissue, burns, bleeding disorders
Cold hypersensitivity, cold intolerance
Raynaud disease or phenomenon, over
regenerating peripheral nerves, circulatory
compromise, peripheral vascular disease,
over an open wound, hypertension, poor
sensation, poor mentation, urticaria
Thermal/nonthermal: over a malignant tumor,
thrombophlebitis, repaired tendons before 6
wk, areas of acute inflammation, over
growing epiphyseal plates, over a fracture,
acute infections, over methylmethacrylate
cement or plastic, peripheral nerve lesions,
pacemakers, impaired circulation
Pacemakers, proximity to the carotid sinus or
heart, near catheters (eg, intravenous),
inappropriately grounded machine, areas of
venous or arterial thrombosis or
thrombophlebitis, cardiac disease, impaired
sensation, impaired mentation, malignant
tumor, skin irritation, open wounds
Hypertension, seizures, diabetics, endocrine
disorders, severe psychosis
Osteoporosis, gout, hypothyroidism,
osteoarthritis, septic or rheumatoid arthritis,
renal disease, wrist fracture, pregnancy,
contact allergy to rubber or plastics
Ice or heat sensitivity, or both; loss of
sensation; high blood pressure; circulatory
problems; open wounds; acute injury;
ischemia risk; active infection
Infection, deep vein thrombosis, vascular
compromise, congestive heart failure,
cardiac or renal insufficiency, pulmonary
edema, difficulty with fluid load into
Current Concepts
circulatory system, entrapment
neuropathies, local or proximate
malignancy, anticoagulation
Allergy to adhesive, infection, active cancer, over
radiation burns, congestive heart failure, renal
insufficiency, deep vein thrombosis, metabolic
disease, cellulites, fragile tissue
(Continued)
 600 THERAPEUTIC MODALITIES

TABLE 1. Modalities Commonly Used in Hand Therapy (Continued)

Modality Common Clinical Indicationsa Precautions/Contraindications

Iontophoresis Overuse and chronic tendinopathies, carpal tunnel
syndrome, bursitis, focal hyperhidrosis, edema,
stenosing tenosynovitis (eg, de Quervain),
epicondylitis, nonspecific musculoskeletal pain
Phonophoresis Overuse and chronic tendinopathies, carpal tunnel
syndrome, stenosing tenosynovitis (eg, de
Quervain), epicondylitis, nonspecific
musculoskeletal pain
Mirror therapy Phantom limb pain, paralysis, spatial neglect, chronic
regional pain syndrome and other pain syndromes
Low-level laser Carpal tunnel syndrome, enthesopathies (eg, lateral
therapy epicondylitis), Raynaud disease, rheumatoid
arthritis, and osteoarthritis, and to enhance healing
of soft tissues and bone
a
Supporting data are not necessarily present for each indication.
Open wounds, inadequate vascular supply,
poor sensation, pacemakers, nearby
indwelling catheters, poorly controlled
diabetics, burns, infection, fragile skin,
proximity to the carotid sinus
Open wounds, inadequate vascular supply,
poor sensation, poorly controlled diabetics,
burns, infection, fragile skin
Conflicts with conventional therapy regimens,
psychological barriers such as
posttraumatic stress disorder
None

Experience
As is the case in all rehabilitation facilities, heat therapy
is commonly used in our practice. Rarely does a patient
defer the option of heat treatment. We find it especially
useful before beginning arduous stretching exercises.
Although it is unclear whether superficial heating mo-
dalities provide a clinically relevant increase in collagen
viscosity, we have found that the lessening of pain,
vasodilatation, and reduction in muscle spasms makes
heat a valuable tool in our daily practice.

FIGURE 1: A typical sandbag used for the delivery of
therapeutic heat.
demonstrated that heat vasodilates the tissue, leading to
an increase in blood flow that helps resolve inflamma-
tory infiltrates, exudates, and edema.8,9
Pain relief with heat occurs because of a variety of
reasons. It serves as a cutaneous counterirritant, alters
Current Concepts
CRYOTHERAPY
Overview
Cryotherapy (or cold therapy) refers to the therapeutic
use of cold to induce vasoconstriction, reduce spastic-
ity, decrease the metabolic rate, alter nerve thresholds,
facilitate muscle contraction, and lessen the pain and
edema associated with inflammation.1
Clinical application of cold therapy comes in various
forms including cold or ice packs, ice water immersion,

ice cups, controlled cold compression units, frozen gel

cell membrane permeability, and leads to the release of
endorphins. Also, the vasodilatation associated with
heat decreases ischemia while flushing away pain me-
diators.2 Studies have demonstrated an improvement in
pain tolerance with ultrasound, microwave diathermies,
and infrared radiation in a number of conditions.10
In addition, it has been shown that heat reduces
muscle spasms, although at a basic science level, it is
not fully understood why.11,12
wraps (Fig. 2), frozen towels, vapocoolant sprays, cold
whirlpools, and contrast baths. Cold packs are usually
filled with a gel composed of silica or a mixture of
saline and gelatin, and are for the most part covered
with vinyl. The gel is formulated to be semisolid be-
tween 0 and 5C for the pack to conform to the
contours of the upper extremity. Ice packs are made of
crushed ice placed in plastic bags, through which they
provide more vigorous cooling at the same temperature,

JHS Vol A, March

 THERAPEUTIC MODALITIES
FIGURE 2: A finger cold wrap.
and require additional insulation when used. Ice water
immersion is an alternative most often used by athletes,
whereby the water temperature ranges between 10 and
15C. Ice cups refer to small paper or Styrofoam cups
of water that are frozen and used to apply a direct and
focal ice massage to the affected area. Controlled cold
compression units alternately pump cold water and air
into a sleeve that is wrapped around the affected area
and are more customarily used directly after surgery.
The temperature of the water is routinely set between
10 and 25C. Frozen gel wraps are an excellent alter-
native for wrapping single digits of the hand. Frozen
wet towels are no longer commonly used because they
are cumbersome and untidy. Vapocoolant sprays are
generally used for rapid cutaneous cooling to allow for
the treatment of trigger points, myofascial pain, and
restricted motion. Cold whirlpool (temperatures range
between 0 and 26C) is not commonly used; however,
its effect and tolerance is similar to ice water immer-
sion.
Evidence
Physiologically, cryotherapy alters hemodynamics,
neuromuscular mechanisms, and metabolic pro-
cesses. Cold causes an immediate constriction of
cutaneous blood vessels by activating cutaneous cold
JHS Vol A, March
601
receptors and stimulating the smooth muscles of
blood vessel walls to contract. Cooling of the tissue
further decreases the production and release of vaso-
dilator mediators, such as histamine and prostaglan-
dins, resulting in a reduction of blood flow.13 This
vasoconstriction continues as long as the duration of
the cold application is limited to less than 15 to 20
minutes.14 If cold is applied for longer periods of
time or when the tissue temperature reaches less than
10C, cold-induced vasodilatation may occur.
This phenomenon is known as the Huntington re-
sponse, whereby a digit exposed to constant cool tem-
peratures will display temperature cycling with
alternating vasoconstriction and vasodilatation. When an
individuals fingers are immersed in an ice bath, the
temperature initially decreases, reflecting vasocon-
striction. However, after 15 minutes the temperature
begins to cyclically increase and decrease, as the
vessels alternate dilating and constricting.15 It is pro-
posed that this vasodilatory response is mediated by
an axon reflex in response to the pain of prolonged
cold or very low temperatures or that it is caused by
inhibition of contraction of the smooth muscles of the
blood vessel walls by extreme cold.16 Maintained
vasodilatation without cycling has also been ob-
served with cooling human forearms at 1C for 15
minutes.17 For these reasons, it is important to be
aware of the temperature being delivered during cold
therapy and the period of time.
Cold therapy also has an effect on muscles. Two
mechanisms are proposed to act sequentially to tempo-
rarily decrease muscle spasticity. First, there is a de-
crease in gamma motor neuron activity. This is fol-
lowed by a decrease in afferent spindle and Golgi
tendon organ activity. Both mechanisms occur as a
reflex reaction to stimulation of cutaneous cold recep-
tors and together work to limit muscle spasm.18,19 As a
result, it is recommended that to reduce spasm and
resistance of muscle to passive stretch, cryotherapy
should be applied before other interventions are em-
ployed.19
Cold therapy decreases the rate of all metabolic
reactions. The activity of cartilage-degrading enzymes,
including collagenase, elastase, hyaluronidase, and pro-
Current Concepts
tease, is inhibited by decreases in joint temperature,
almost stopping at joint temperatures of 30C or
lower.20 It has been speculated that cooling might re-
duce collagen destruction in inflammatory joint dis-
eases such as osteoarthritis and rheumatoid arthritis,13
although this remains to be proven. Furthermore, su-
perficial cooling therapy is unlikely to lower joint tem-
peratures to the necessary threshold.
 602 THERAPEUTIC MODALITIES
The mechanism by which cryotherapy increases the
pain threshold is not fully understood. Many theories
have been proposed including counterirritation via the
gate control mechanism, reduction of muscle spasm,
diminished sensory nerve conduction velocity, and de-
creased post injury edema.21 Nevertheless, evidence
reveals that to achieve an analgesic effect, the skin
temperature must be approximately 10C.22
Cryotherapy both increases and decreases muscle
strength, depending on its duration of application. Iso-
metric muscle strength has been found to increase di-
rectly after the application of ice massage for 5 minutes
or less.23 The proposed mechanisms for this response to
brief cooling include facilitation of motor nerve excit-
ability and an increased psychological motivation to
perform.13 In contrast, after cooling 30 minutes or lon-
ger, isometric muscle strength has been found to de-
crease initially and then to increase an hour later, to
reach greater than pre-cooling strength for the following
3 hours or longer.24 26 It is believed that reduced blood
flow to the muscles, slowed motor nerve conduction,
increased muscle viscosity, and increased joint or soft
tissue stiffness are all contributors to reduced strength
after the 30 minute-prolonged cooling. The mechanism
behind the late increased strength remains to be eluci-
dated.13
For inflammation, it has been found that cryo-
therapy reduces pain and edema, and shortens re-
covery time, if applied within the first 2 days after
an injury. Decreasing tissue temperature slows the
rate of the chemical reactions that occur during the
acute inflammatory response and also reduces the
heat, redness, edema, pain, and loss of function
associated with this phase of tissue healing.27 Two
studies assert that cryotherapy in part prevents
microvascular damage by decreasing the activity
of leukocytes, which damage vessel walls and in-
crease capillary permeability.28,29 This correlates
with clinical evidence demonstrating that the ap-
plication of low-level cryotherapy continuously
for the first postoperative day after surgery reduces
inflammation and pain for up to 3 weeks after
Current Concepts
surgery.30,31
Cryotherapy is effective for controlling the forma-
tion of edema, especially when the edema is associated
with acute inflammation. Researchers have found that
cooling reduces the intravascular fluid pressure and
decreases vascular permeability, thus reducing fluid
flow into interstitial tissue.32
A newer arena that reports successful use of cryo-
therapy is in symptom management of patients with
multiple sclerosis. As demonstrated with improvements
JHS Vol A, March
in electrophysiological measures and in clinical symp-
toms and function, peripheral cooling is recommended
as an adjunct to treatment.3335
Experience
Cold therapy is a universally accepted treatment mo-
dality in the management of upper extremity injuries.
Owing to its ease of application and immediate effects,
cryotherapy is a cornerstone modality in hand therapy.
The positive response noted with its use, particularly in
pain relief, accounts for its frequent use in our therapy
practice.
ULTRASOUND
Overview
Ultrasound refers to a popular physical agent modality
widely used in therapy clinics for the management of
various musculoskeletal injuries. It is used to increase
tissue extensibility; decrease pain; and improve healing
in wounds, tendons, and bone; and for a number of
other miscellaneous purposes.
Ultrasound is based on the use of a high-frequency
sound wave that can be described by its intensity, fre-
quency, duty cycle, effective radiating area, and beam
non-uniformity ratio. The parameters chosen depend on
the presenting condition and the therapists experience
and goals. Generally, therapeutic ultrasound has a fre-
quency between 0.7 and 3.3 MHz to maximize energy
absorption at a depth of 1 to 5 cm of soft tissue.36 It is
generated by applying high-frequency alternating elec-
trical current, at 1 MHz for deeper structures (5 cm) or
3 MHz for superficial tissues (12 cm), to a piezoelec-
tric crystal that is inside an applicator/transducer or
sound head. The crystal responds to the alternating
current by expanding and contracting at the same fre-
quency at which the current changes. Electrical energy
is converted to mechanical energy or sound and pres-
sure waves are emitted from the transducer. This energy
is coupled and transmitted to the patient to effect
changes in tissue.37
Ultrasound can be classified as either thermal (also
known as continuous ultrasound) or nonthermal (also
known as low-intensity or pulsed ultrasound). Thermal
ultrasound specifically refers to the use of ultrasound to
increase the temperature of deep and superficial tissue.
Thermal effects of ultrasound are particularly well
suited for heating tendons, ligaments, joint capsules,
and fascia while not overheating the overlying fat.36 As
a heating agent, it is desirable because it reaches deeper
and heats smaller isolated areas than most superficial
heating modalities. However, it is clinically recom-
mended to use an intensity 3 to 4 times lower when
 THERAPEUTIC MODALITIES
applying 3 MHz ultrasound than when applying 1 MHz
ultrasound.38
Nonthermal ultrasound is not used for heating tis-
sues, but for a variety of biological effects that are
thought to accelerate tissue healing.39 52 Nonthermal
effects can also occur with the use of continuous ultra-
sound.
Evidence
Thermal ultrasound is an effective heating agent for
increasing tissue extensibility of joint capsules, tendons,
and ligaments before being stretched. Several studies
support this notion as long as sufficient intensity and
duration of ultrasound is used.5356 Merrick et al57
cautioned that it is difficult to predict accurate temper-
ature increases that will be produced clinically when
ultrasound is applied owing to a number of unknown
variables, including the thickness of each tissue layer,
the amount of circulation, the distance to reflecting soft
tissue bone interfaces, and variability among ultra-
sound machines.
Thermal ultrasound has also been considered effec-
tive for pain control. As an example, a Cochrane data-
base systematic review of 2 studies on therapeutic ul-
trasound for patients with rheumatoid arthritis found
that ultrasound reduced the number of painful joints,
decreased the number of swollen joints, and decreased
morning stiffness.58
Evidence to support nonthermal ultrasound for ul-
cers and wound healing is mixed.36 A recent system-
atic review of randomized controlled studies on the
treatment of venous ulcers and pressure ulcers with
therapeutic ultrasound concluded that there is no
solid evidence of a benefit of ultrasound ther-
apy.59 61 Conversely, in 2005 the US Food and Drug
Administration (FDA) cleared a non-contact ultra-
sound device for use in wound healing, although this
approval does not necessarily equate with efficacy.
The device applies 40-KHz frequency, 0.1 to 0.5
W/cm2 intensity ultrasound when held 5 to 15 mm
from the wound. To date, 2 small, randomized, con-
trolled trials with favorable outcomes have been re-
ported.62,63 Likewise, the use of ultrasound on the
healing of surgical skin incisions has long been stud-
ied in both animal and human subjects. The studies
indicate that ultrasound may accelerate the healing of
surgical incisions, relieve the pain associated with
surgical procedures, and facilitate development of
stronger repair tissue.64 68
Animal models have been used to study the effect of
nonthermal ultrasound on tendon healing after surgical
repair. The results have been mostly positive, demon-
JHS Vol A, March
603
strating improved tendon healing despite the use of a
wide range of ultrasound parameters.69 73 However, a
lower intensity is recommended to minimize the risk of
any potentially adverse effect from heating acutely in-
flamed tissue postoperatively.36 It is unclear why ten-
dontendon healing would be differentially facilitated
over tendonsheath adhesions with nonthermal ultra-
sound.
Ultrasound may facilitate the resorption of calcium
deposits. Two published case studies, a randomized
controlled trial, and a prospective study, have reported
functional recovery, pain resolution, and elimination of
a calcium deposit in the shoulder after application of
ultrasound; the mechanisms of this effect are un-
known.74 77
The use of nonthermal ultrasound for fracture heal-
ing is gaining renewed interest.36 Recent studies dem-
onstrate that low-dose ultrasound can expedite fracture-
healing time in animals and humans. Malizos et al78
summarized the findings of 4 double-blinded, placebo-
controlled trials. They found that the available data
confirmed acceleration of fracture healing in human
subjects with the application of ultrasound, although 1
study found no effect (with a small sample size). In
addition, a randomized, placebo-controlled trial found
that ultrasound accelerated the healing of scaphoid non-
unions.79 In 1994, the FDA approved a prescription-
only device designed for the application of ultrasound
for fracture healing for home use, and expanded ap-
proval in 2000 for the treatment of nonunions.36 There
is also a transosseous ultrasound that is placed in close
proximity to the fracture via a metal pin or with im-
planted transducers. With it, studies have shown de-
creased fracture healing time, increased bone mineral
density, and improved lateral bending strength in the
healing fracture,80 82 although it is rarely used clini-
cally.
Two randomized, controlled trials suggest that non-
thermal ultrasound is helpful in mild to moderate carpal
tunnel syndrome.83,84 The results indicate greater relief
of symptoms and greater improvements in median
nerve conduction velocity than for patients treated with
sham ultrasound, although larger, multi-institutional
studies are needed to confirm this.
Current Concepts
Experience
Ultrasound is a commonly available therapeutic modal-
ity frequently used in hand rehabilitation settings. In our
practice, ultrasound is carefully selected as an adjunct to
an overall therapy program based on the presenting
pathology, target tissue, stage of healing, and desired
therapeutic effect. Although unified by the term ultra-
 604 THERAPEUTIC MODALITIES
FIGURE 3: Electrodes from a TENS device placed across the
wrist.
sound, thermal ultrasound is an entirely different con-
cept from nonthermal ultrasound. The goals of each are
often vastly different, and require diverse settings and
applications.
ELECTRICAL STIMULATION
Overview
Electrical stimulation is a nonpharmacologic treatment
based on delivering low-voltage electrical currents to
the skin. It can be broadly characterized into 2 catego-
ries: (1) electrical stimulation for pain modulation, and
(2) electrical stimulation for neuromuscular stimulation.
The electrotherapeutic devices now available to deliver
electrical stimulation come in a variety of forms, with a
dizzying array of names. These include transcutaneous
electrical nerve stimulation (TENS), interferential stim-
ulation (IF) or IF current, microcurrent stimulation
(MC) or microcurrent electrical neuromuscular stimu-
lator, high-voltage pulsed galvanic stimulation or high-
voltage pulsed current, and neuromuscular electrical
stimulation (NMES) or functional electrical stimula-
tion. They all share the common feature of delivering
electrical current to the surface of the body to affect the
tissue beneath. Electrical stimulation for transcutaneous
ionic movement (iontophoresis) will be discussed in a
later section.
When electrical stimulation is used for pain modu-
lation, it is called TENS (Fig. 3). It is a relatively safe,
inexpensive modality that is noninvasive and has few
side effects. There is a wide array of stimulators avail-
Current Concepts
able on the market, many of which have the ability to
modify the characteristics of the stimulation (such as
frequency, pulse duration, pulse amplitude, and elec-
trode location) based on clinician and patient prefer-
ence. Generally speaking, TENS can be divided into
high-frequency, low-intensity (conventional TENS [C-
TENS]) and low-frequency, high-intensity (acupunc-
ture-like TENS [AL-TENS]).
Conventional TENS is postulated to work in pain
control by activating non-noxious afferent nerve fibers
JHS Vol A, March
FIGURE 4: High-voltage pulsed galvanic stimulation, with
electrode and battery-powered generator.
in the skin (A beta fibers) that block the transmission of
the pain-carrying fiber input at the level of the dorsal
horn of the spinal cord.85 Acupuncture-like TENS is
intended to generate a muscle twitch that is thought to
increase activity in small-diameter afferent nerve fibers
in muscles, leading to the activation of descending
pain-inhibitory pathways.86 Nevertheless, evidence
supporting the different afferent fibers in TENS is in-
conclusive.86 88
A number of new devices use technology similar to
TENS to modify pain. Infrared stimulation delivers
electrical pulses at typically at 4,000 Hz (compared
with 2 to 150 Hz for traditional TENS devices), with 2
or more currents. One current has a fixed frequency and
the other currents frequency varies by up to 400 Hz.
When the currents intersect, the combined currents pro-
duce an interference frequency, also called a beat. The
intent is that the higher frequency allows the infrared
therapy to penetrate into deeper tissues, while the beat
(which is at a TENS-like frequency of about 100 Hz)
provides the pain modification at this deeper site. Mi-
crocurrent stimulation therapy uses extremely low lev-
els of electrical current (microamperes) to relieve pain
(compared with the milliamperes used in TENS). It is
speculated that the bodys natural electrical current is
disrupted with injury and MC, which works at levels
close to our bodys own current, helps to realign this
natural flow.
High-voltage pulsed galvanic stimulation is also
used to modify pain but applies constant direct current
(Fig. 4). It employs high voltage but low current with
short pulse durations (of constant intensity). In addition
to its pain applications, it is being used to reduce edema,
heal wounds, and stimulate blood flow.
When electrical stimulation is used to cause muscle
contraction, it is called NMES. It can be used for
muscle strengthening, edema control, and muscle reed-
 THERAPEUTIC MODALITIES
ucation. Different parameters of the electrical current
have unique effects on the neuromuscular junction. The
stimulators have thus been classified as low frequency
(1 to 1,000 pulses per s), medium frequency (1,000 to
10,000 pulses per s), and high frequency (greater than
10,000 pulses per s). Smooth titanic muscle contraction
occurs at a frequency of 50 pulses per second.89
Neuromuscular electrical stimulation may strengthen
muscles by activating a greater proportion of type 2
(fast twitch muscle fibers) than occurs with voluntary
contraction.90,91 Nevertheless, much debate remains in
the literature regarding the mechanism by which NMES
affects muscle fiber recruitment for strengthening.92 For
edema reduction, the muscular contraction works by
enhancing blood and lymph flow. Electrical stimulation
used to cause muscle contraction works in muscle re-
education by overcoming the patients conscious or
subconscious attempts not to move the injured limb,
when it would benefit from active movement.1
Evidence
The most thoroughly studied modes of electrical stim-
ulation are TENS and NMES. For sake of brevity, we
will focus on the evidence to support these applications.
Many of the more recent applications of electrical stim-
ulation have been reported only in the form of case
series and much of the evidence is anecdotal.
A Cochrane database review was undertaken to as-
sess the analgesic effectiveness of TENS for acute pain
in adults. It included 12 randomized controlled studies
involving 919 patients. The acute pain conditions in-
cluded procedural and nonprocedural pain.93 Whereas
past studies suggested TENS to be beneficial for pain
control,94 96 the Cochrane review was unable to make
conclusions about the effectiveness of TENS for acute
pain owing to insufficient data.93 Many of the included
studies lacked appropriate controls (it is impossible to
blind a patient to sham TENS), inappropriately assessed
outcomes, and used statistical analysis incorrectly.
Similar Cochrane database reviews have been per-
formed for TENS treatment in chronic pain, rheumatoid
arthritis, and phantom limb pain after amputation.96 98
For chronic pain, 13 of 22 studies included in the
review suggested a positive analgesic effect of TENS,
whereas 9 studies showed no difference. The review
concluded that there was a lack of data to support TENS
use for chronic pain treatment.96 Three randomized
controlled studies were included in the Cochrane re-
view of TENS for the treatment of rheumatoid arthritis
of the hand; the results were conflicting. Acupuncture-
like TENS was found to be beneficial for reducing pain
intensity and improving muscle power scores over pla-
JHS Vol A, March
605
cebo, whereas C-TENS demonstrated no such benefit.
However, on patient assessment of change in disease,
C-TENS reportedly demonstrated a greater clinical ben-
efit than AL-TENS.97 The review was unable to draw a
conclusion about the benefits of TENS for phantom
pain because there are no randomized controlled studies
and those studies that are published have major report-
ing flaws.98
Neuromuscular electrical stimulation has been exten-
sively studied for muscle strengthening and for edema
reduction. With both healthy and impaired muscles, it
has been reported that NMES is an efficient modality
for increasing muscle mass, maximum voluntary
strength, and exercise capacity.99 102 It has been used
to complement voluntary exercise in athletes, as well as
for patients who cannot exercise owing to health con-
ditions such as heart failure or chronic obstructive pul-
monary disease.101,102 Histological studies have also
confirmed this. Eight healthy male subjects underwent
25 sessions of NMES and had needle muscle biopsies
before and after intervention. The researchers found
that muscle fibers showed hypertrophy (both type 1 and
2 fibers), myofibrillar proteins had phenotypic changes
consistent with a strengthening of the cytoskeleton,
energy production systems improved, and antioxidant
defense systems were enhanced.103
In addition, NMES has demonstrated improved
edema reduction in humans104 and animals.105 A sys-
tematic review of 11 studies using electrical stimulation
for edema control in acute injury generally demon-
strated its beneficial effects. The authors also examined
the effects of various parameters on edema control,
such as mode of stimulation, polarity, frequency, dura-
tion of treatment, voltage, intensity, number of treat-
ments, and overall time of treatments. From their re-
view, negative polarity, a pulse frequency of 120
pulses/s, and an intensity of 90% visual motor contrac-
tion seemed to perform best at curbing edema forma-
tion. They suggested that treatment be administered in
either 4 30-minute sessions (30-minute treatment, 30-
minute rest cycle for 4 hours) or a single, continuous
180-minute session.106
Current Concepts
Experience
Electrical stimulation is inexpensive and noninvasive,
and has high patient satisfaction in our practice. Despite
the lack of rigorous scientific data, we often use it in
patients with any painful condition (either related to a
surgical procedure or not), to help reduce edema, and
for muscle reeducation. Stimulator settings are adjusted
based on clinician goals and patient tolerance.
 606 THERAPEUTIC MODALITIES
BIOFEEDBACK
Overview
Biofeedback is a technique that uses electronic equip-
ment to illustrate internal physiological activity in the
form of immediate visual and auditory signals. It en-
ables one to influence otherwise involuntary events by
manipulating the displayed signals and is used for mus-
cle reeducation, muscle facilitation, and relaxation. It
provides a unique opportunity to increase patient moti-
vation during performance by the nature of its imme-
diate feedback. Furthermore, it provides the clinician
with empirical data to objectively measure treatment
effectiveness.
There are 3 types of biofeedback that can be used for
upper extremity injuries: electromyographic (EMG),
thermal, and electrokinesiologic biofeedback. Electro-
myographic biofeedback monitors activity in skeletal
musculature via outputs from the peripheral nerves
across the neuromuscular junction to the motor endplate
in the muscle. The electrical changes from ionic mem-
brane activity are detected through surface electrodes
and relayed to an EMG amplifier. This is then translated
into visual and auditory signals and displayed to give
the patient increased awareness of skeletal muscle func-
tion.107109
Thermal biofeedback monitors vasomotor activity.
Peripheral vasoconstriction signals sympathetic arousal
and results in lower skin temperature. Conversely, va-
sodilatation indicates sympathetic relaxation and results
in higher skin temperature.110 It is essentially temper-
ature training with a focus on increasing peripheral
temperature, resulting in relaxation of the sympathetic
system.
Electrokinesiologic biofeedback monitors joint an-
gles through the use of feedback goniometers. Through
a simple open-closed circuit system, joint movement is
monitored. The goniometric device is easily adjusted in
postoperative cases and can be attached over a dressing.
Evidence
Biofeedback dates back to the 1920s, when EMG was
established as an accurate diagnostic test for determin-
Current Concepts
ing motor neuron function.111 Smith112 further clarified
EMG signal precision through evidence that there is
little inherent EMG signal in motor units. He concluded
that the signal monitored would be related to either
muscle facilitation or relaxation and not to background
EMG signal noise.
Many studies with small sample sizes support the
use of all 3 types of biofeedback in hand and upper
extremity diagnoses; EMG biofeedback remains the
best studied. Hirasawa et al113 reported success with
JHS Vol A, March
EMG biofeedback in 5 patients who had repairs of
lacerated extensor pollicis longus tendons. Extension
lag of the thumb, functional use, strength, and range of
movement were all improved. Deepak and Behari114
reported considerable success in using EMG biofeed-
back for patients with hand dystonia. Of 10 patients
who completed the program of down-training hyperac-
tive muscle responses, 9 improved their pain rating by
50%. Furthermore, handwriting samples demonstrated
profound improvement. Barthel et al115 reported on 24
patients who were resistant to conventional treatment
for repetitive use syndrome. With EMG biofeedback to
teach muscle use with less effort, the patients were able
to have considerable improvement in pain symptoms
and hand use. Dogan-Aslan et al116 recently studied the
effect of EMG biofeedback on 40 patients with hemi-
plegia after stroke. Their findings indicate a positive
effect of treatment on muscle spasticity, upper extrem-
ity motor function, and ability to perform activities of
daily living.
Dzwierzynski and Sanger117 and Grunert et al118
reported success with thermal biofeedback in treating
patients with complex regional pain syndrome, or reflex
sympathetic dystrophy. By using it as an adjunct to a
comprehensive program (including stellate ganglion
blocks, relaxation training, and range of motion exer-
cises), Grunerts group demonstrated that 20 patients
with longstanding symptoms were able to increase hand
temperature and reduce pain intensity after an average
of 23 treatments. These changes persisted for at least a
1-year follow-up period, with 14 of the 20 patients
returning to work.
Brown et al119 completed a 4-year study to deter-
mine the value of feedback goniometers in hand trauma
both before and after surgery. They concluded that
these electrokinesiologic devices proved to be useful for
increasing range through properly controlled motion.
Unfortunately, biofeedback has not revealed en-
couraging outcomes for all hand-related condi-
tions. Kohlmeyer et al120 were unable to demonstrate
a noteworthy improvement in strength or activities of
daily living among 45 patients with tetraplegia
treated with EMG biofeedback. Thomas et al121 were
equally unsuccessful with the use of biofeedback for
patients with carpal tunnel syndrome. They found
that the feedback group did not show meaningful
changes in the physiological nerve conduction veloc-
ity measure, performance grip strength, or subjective
discomfort levels.
Supporters of biofeedback have suggested that the
variable results are due to improper technique and a
lack of dedication. Furthermore, Middaugh et al,122
 THERAPEUTIC MODALITIES
who performed the Raynauds Treatment Study, con-
cluded that attention to the emotional and cognitive
aspects of biofeedback training and a degree of success
in the initial biofeedback sessions are critically impor-
tant to success.
Experience
Despite some evidence suggesting that biofeedback
helps patients manage certain hand and upper extremity
conditions, its prevalence in hand therapy centers has
diminished over the past several decades. There is a
high learning curve and it is labor intensive. Its setup
can take extended amounts of time as a result of skin
preparation, electrode placement, and multiple adjust-
ments to isolate specific responses. With the insurance
climate changing, there is unpredictable reimbursement
for home biofeedback units.
C-TRAC
Overview
C-TRAC refers to a new hand traction device used for
patients that have failed conservative therapy for carpal
tunnel syndrome. Owing to increasing societal costs of
carpal tunnel syndrome, ranging from lost work time
and medical fees, to legal expenses and postoperative
recurrence,123 C-TRAC was invented in an attempt to
curtail these costs and avoid surgery when possible. It is
designed as a custom pneumatic and dynamic hand
traction device that provides a controlled amount of
stretching force, or traction force, to the transverse
carpal ligament. It is purported to increase the area of
the carpal tunnel through a noninvasive progressive
stretching program.124
C-TRAC consists of a C-shaped semirigid frame
contoured around the dorsum of the wrist and hand
extending from the wrist crease to the metacarpopha-
langeal joint area (Fig. 5). Volarly, 2 plates cover the
thenar and hypothenar eminences. Attached to the in-
side of the frame is an air bladder that inflates into a
tubular shape parallel to the metacarpals. When the
device is inflated, a 3-point force is exerted on the hand:
air bladder on the dorsum of the hand along with the 2
plates on the thenar and hypothenar areas. The resulting
force produces a stretching force along the transverse
carpal ligament.124
Evidence
Measurements on x-ray show that the application of
C-TRAC increases the distance between the trapezium
and the hook of hamate and between the scaphoid and
the pisiform bones approximately 1 to 3 mm.124 This
finding is comparable to a transverse carpal ligament
JHS Vol A, March
607
FIGURE 5: A C-TRAC device, demonstrating placement over
the carpal tunnel and pneumatic pump.
release surgery that results in an increase of 1.5 to 2.7
mm in the diameter of the carpal tunnel postopera-
tively.125,126
Only 1 study to date reports the efficacy and
patient satisfaction of the C-TRAC device. The
inventors of C-TRAC performed the case series
and evaluated its effectiveness in decreasing pain,
tingling, numbness, and number of times woken up
at night in 19 patients who tried and failed at least
4 months of conservative therapy for carpal tunnel
syndrome. The authors reported marked improve-
ment in all symptoms at 4 weeks and results were
maintained at 7 months follow-up.124
Experience
Although the C-TRAC is a newer modality to the field
of hand therapy and there is a lack of established
long-term evidence, we offer the C-TRAC as an adjunct
to our therapy interventions for patients with mild car-
pal tunnel syndrome. It is easy to use, time efficient, and
inexpensive. In our clinical practice we have found that
patients are generally satisfied and report decreased
symptoms of pain, tingling, and numbness after its use.
We do not use the C-TRAC in patients with severe
carpal tunnel syndrome requiring surgery or who re-
spond to other traditional treatments.
Current Concepts
CONTRAST BATHS
Overview
Contrast baths refer to immersion of the hand in hot and
cold water in an alternating manner for a defined length
of time at a predetermined temperature (Fig. 6). It is
believed that contrast baths help decrease edema, in-
crease blood flow, and reduce pain and joint stiffness
via alternating vasoconstriction and vasodilatation of
 608 THERAPEUTIC MODALITIES
FIGURE 6: Contrast baths.
blood vessels.127,128 Essentially, a vascular pumping
effect is created, allowing for edema reduction and
increased mobility.129
Treatment protocols vary tremendously in the rec-
ommended use of contrast baths. These range from a
variety of instructional exercises in the water, starting or
ending in cold versus warm water, the length of time in
each temperature, the suggested ratio of time in hot
relative to cold water, the suggested water temperature
of each, and the overall duration of treatment time. For
example, several authors advocate the immersion of the
hand into hot water initially for 10 minutes, cold for 1
minute, hot water for 4 minutes, and then into cold
water for 1 minute for a maximum of 30 minutes.2,3,130
Other authors recommend a shorter immersion time
such as 3 minutes each, and others suggest even less
time, such as 30 seconds each for a total of 15 minutes.
The most commonly suggested ratio of time in hot
water to cold water is a 4:1 to 3:1 ratio.131133 The
suggested temperature of the hot and cold water is also
variable, ranging from 37 to 45C for hot and from
7.22 to 22C for cold.2,3,128,130 136
Evidence
Contrast baths are commonly used in clinical practice.
However, the evidence to support its use is not well
validated. Breger Stanton et al137 performed a system-
atic review to determine the extent and quality of the
evidence regarding efficacy of contrast baths. They
discovered only a small number of prospective studies
and the diagnoses were limited to subjects with rheu-
Current Concepts
matoid arthritis, diabetes, or foot or ankle sprain. They
concluded that there is insufficient evidence to support
or refute the use of contrast baths for relief of pain and
management of fluid volume, and no study provides
evidence of improved functional outcomes.
There is clear evidence that warm water immersion
alone increases blood flow. However, it remains to be
seen whether contrast baths augment this. Petrofsky et
al138 reported that contrast baths are more effective for
increasing blood flow compared with warm water
JHS Vol A, March
alone, whereas Fiscus et al139 noted the opposite find-
ing. Fiscus and colleagues also concluded that there was
no notable physiological effect on intramuscular tem-
perature after the contrast bath procedure, nor did the
contrast baths affect the lymphatic system. Another
study demonstrated that contrast baths best augmented
blood flow when the subjects were exposed to a warm
room before the procedure.140
There has been 1 published randomized, controlled
study evaluating the effects of specific contrast bath
protocols on hand volume in patients diagnosed with
carpal tunnel syndrome. Their results indicate that the
use of contrast bath treatment had no significant effect
on hand volume in carpal tunnel patients, both preop-
eratively and postoperatively.141
Experience
Although the research data on the efficacy of contrast
baths is weak, its use in hand therapy clinics is wide-
spread. Despite inconsistent protocols, many clinicians
report positive results for managing pain, stiffness, or
edema. Contrast baths are infrequently used in our
setting, but are offered as an option when patients ask
for an alternative treatment modality.
INTERMITTENT PNEUMATIC
COMPRESSION PUMPS
Overview
Intermittent pneumatic compression pumps are devices
that provide alternating extremity compression and re-
laxation. An electric pneumatic pump pushes com-
pressed room air into an inflatable garment or sleeve
that is placed around the involved upper extremity. A
single-chamber pump refers to 1 chamber inflating to
the maximum pressure and then deflating. A multi-
chamber pump refers to sequential compression
whereby the distal segment inflates first to the maxi-
mum pressure and then, as it deflates, the more proxi-
mal segment inflates. Intermittent pneumatic compres-
sion pumps have long been considered an effective tool
for reducing acute and chronic edema, although there
are varying treatment protocols with regard to pressure,
duration, frequency, and type of model.142147 Intermit-
tent compression therapy has also been suggested as an
option for wound healing, pain control, and mobilizing
stiff fingers.
In addition to physically sweeping edema proxi-
mally, intermittent compression is thought to facilitate
the lymphatic systems ability to reabsorb byprod-
ucts.148 The intermittent pressure provided by the pneu-
matic pump increases tissue hydrostatic pressure, driv-
ing lymphatic fluid into lymphatic channels and into the
 THERAPEUTIC MODALITIES 609

venous system.149 To be effective, it is purported that

the pump pressure must be greater than the 25-mm Hg
mean capillary pressure and should not exceed the
diastolic blood pressure of the patient.150 For most
upper extremity indications, inflation pressure is gener-
ally advocated to be between 30 and 60 mm Hg.
Anecdotally, intermittent compression therapy has
been suggested as an option for mobilizing stiff inter-
phalangeal joints by alternating finger extension with
finger flexion under pressure. Because the extracellular
fluid is pressed out and the tight capsular ligaments are
stretched into extension and then flexion, it is possible
to mobilize some joints where splinting and other meth-
ods of treatment have failed.151

Evidence FIGURE 7: Kinesiotape applied to an edematous, postoperative

Historically, most research on compression therapy for
upper limb edema is found in the management of
lymphedema after breast cancer treatment. Several con-
trolled studies have documented their usefulness in this
setting.152158 Other studies have mixed results, dem-
onstrating no difference compared with elastic com-
pression159 or showing that it is most effective when a
pump and garment are used in combination.160,161
In addition, the evidence is unclear on optimum pump-
ing pressures, inflationdeflation cycles, the length and
frequency of individual pumping sessions, and the need
for continuation of pumping after initial reduction
has been attained.143,162,163 It appears that pressure
recommendations and treatment protocols are device
dependent.
There is some support for the use of intermittent
compression pumps for nonhealing wounds and pain
control. Montori et al164 performed a retrospective
study on patients with critical limb ischemia and non-
healing wounds. They reported that patients who were
at high risk of amputation were able to achieve wound
healing and limb preservation by using an intermittent
pneumatic compression device. Similarly, Pfizenmaier
et al165 reported an improvement in wound pain, avoid-
ance of digital amputation, and a high rate of healing in
upper extremity ischemic vascular ulcers after intense
intermittent compression pump use. However, they rec-
ognized the limits in their data and stated that a prospec-
hand.
lated. As the pumps continue to squeeze, the fragile
lymphatic vessels in the dermis may be physically
damaged by the pumps or the remaining proteins.169
Experience
Despite a lack of evidence, we occasionally use inter-
mittent compression pumps for edema control. We find
them especially useful in patients with severe,
recalcitrant edema after axillary lymphadenectomy
and radiation for breast cancer treatment. The
downsides are that the machines are often bulky and
expensive, and require diligent use. As a result, we
have found fairly high rates of noncompliance.
KINESIOTAPE
Overview
Kinesiotape refers to a variety of lightweight, econom-
ical elastic tapes that appear to be the latest trend in the
treatment of a myriad of conditions. Kinesiotape is
made of a comfortable fabric that is latex free, air
permeable, water resistant, and heat activated, and
comes in various colors (Fig. 7). Its elastic property
allows it to be stretched to 140% of its original length
before it is applied to the skin.
Kinesiotape differs from traditional taping in its
Current Concepts

tive, randomized, sham-controlled study was needed to
determine whether intermittent pneumatic compression
treatment was truly better than standard medical care.
Some authors have expressed concern that the pumps
may actually injure superficial lymphatics.166 168
The compression removes the fluid component of
lymphedema from the swollen interstitial spaces
while leaving behind the proteins that have accumu-
properties, the method of application, and its goals.170
Its use incorporates a systems approach to the evalua-
tion of soft tissue pathology and directs treatment to-
ward the underlying cause of pathology.171 Its applica-
tion in the clinic is noninvasive and it has a variety of
applications, including muscle facilitation or inhibition,
joint support, pain management, correction of body
mechanics, and assistance of lymphatic drainage.

JHS Vol A, March

 610 THERAPEUTIC MODALITIES
The theoretical rationale for Kinesiotape stems from
observing peripheral somatosensory receptors located
in the superficial skin layers and identifying their rela-
tionship to pain, proprioception, and motor control.
Coopee171 offered a simplified summary for the intel-
lectual rationale behind each major goal of application.
For pain reduction, it is hypothesized that Kinesiotape
may stimulate the mechanoreceptors, thereby activating
the endogenous analgesic system. For lymphatic and
vascular motility, it is speculated that Kinesiotape lifts
the skin and facilitates drainage while decreasing con-
gestion directly under the skin. For muscle function, the
notion is that Kinesiotape facilitates or inhibits contrac-
tion by input through somatosensory stimulation. For
joint function, it is hypothesized that Kinesiotape assists
in adjusting structural alignment by balancing muscle
tone and normalizing fascia involved in the agonist
antagonist relationship.
The positive effects of Kinesiotape (compared with
other tapes) are purported to result from its unique tape
properties combined with the skilled technique of ap-
plication. Improper application can increase pain and
create adverse reactions prompting proper training and
education. It is believed that a clinician should have a
thorough understanding of the conceptual framework
underlying the mechanisms that are intrinsic to its ef-
fectiveness.171 The success of the technique directly
correlates to the clinicians ability to evaluate the patho-
mechanics behind the diagnosis, and then to apply the
tape correctly to affect skin, lymph, muscle, and joint.
Evidence
Various authors have reported improvements in func-
tion, pain, and range of motion through the use of
Kinesiotape.131,172178 Unfortunately, the proclaimed
effects are supported by low levels of scientific evi-
dence.
Thelan et al179 performed a prospective, random-
ized, double-blinded, clinical trial to determine the
short-term clinical efficacy of Kinesiotape on 42 indi-
viduals with shoulder pain, compared with a sham tape
application. They found that the Kinesiotape group had
Current Concepts
immediate improvement in pain-free shoulder abduc-
tion after tape application. However, there were no
differences between the treatment and sham group re-
garding range of motion, pain, and disability scores.179
Yasukawa et al180 investigated the use of Kinesio-
tape for the upper extremity in enhancing functional
motor skills in an acute pediatric rehabilitation setting.
They found the functional improvement from pretaping
to posttaping to be statistically significant, although
they had a small sample size of 15 children. However,
JHS Vol A, March
the authors questioned the lasting effects on motor skills
and functional performance once the tape is removed.
Similarly, Fu et al181 studied the possible immediate
and delayed effects of Kinesiotaping on muscles
strength of healthy young athletes. They surmised that
Kinesiotape does little to improve muscle strength im-
mediately after application or delayed 12 hours later.
Their pilot study results indicate that effects of Kine-
siotape are small and, for the most part, short lived.
Furthermore, Chang et al182 performed a single group
study to determine the immediate effect of forearm
Kinesiotaping on maximal grip strength and force sense
in 21 healthy collegiate athletes. Their results revealed
no significant differences in maximal grip strength, but
reported that Kinesiotape may enhance either related or
absolute force sense.
Finally, Tsai et al183 proposed using Kinesiotape to
decongest lymphedema resulting from breast cancer
treatment. They suggested that short-term Kinesiotape
could be an alternative choice, but long-term data are
lacking.
Experience
Although the current research is still weak in providing
solid scientific evidence to support its use, Kinesiotape
appears widely accepted by patients and physicians as a
treatment modality. In our practice, we occasionally use
Kinesiotape as an adjunct to a well-established rehabil-
itation program. Patients report reduced edema and
resolution of ecchymosis, in addition to some pain
relief, although they have no control to compare with
their personal results.
IONTOPHORESIS
Overview
Iontophoresis (also known as electromotive drug ad-
ministration) refers to the use of a small electrical
charge gradient to propel a medication, bioactive agent,
or other chemical across the skin. It is also sometimes
colloquialized as needleless injection.
An iontophoresis unit consists of a chamber contain-
ing a positively or negatively charged solution of an
active ingredient and its solvent, as well as polarized
electrodes capable of applying a similar charge polarity
to the chamber. The electrodes charge is typically
established using low-voltage, low-amplitude (3- to
5-mA) direct (galvanic) current. This configuration es-
tablishes a repulsive electromotive force that can
achieve noninvasive delivery of a substance transder-
mally. In contrast to transdermal patches that rely on
passive diffusion, this modality uses active transport
 THERAPEUTIC MODALITIES
within an electric field and is thus considered more
efficient and versatile.
Iontophoresis is most commonly used for the deliv-
ery of anti-inflammatory medications to treat conditions
such as epicondylitis, overuse syndrome, carpal tunnel
sydrome, bursitis, and focal hyperhidrosis. It has also
been used for control of edema, stimulation of healing
in chronic skin ulcers, and treatment of herpetic whit-
low, and for various other skin and musculoskeletal
conditions. In addition, it has been used to deliver local
anesthetic solutions subcutaneously in children and in-
tolerant adults without the use of needles. It can be
easily administered at home in carefully selected pa-
tients.
Evidence
In mild and moderate cases, carpal tunnel syndrome is
known to respond transiently to a steroid injection into
(or just proximal to) the carpal canal, but this requires a
blind technique and imposes a risk to the patients
median nerve with each treatment. Several authors have
thus compared the clinical and electrophysiologic effi-
cacy of steroid iontophoresis with steroid injection in
treatment of median nerve entrapment at the carpal
tunnel. In all cases, investigators demonstrated clear
superiority of needle injection, and electrophysiologic
improvement at 2- and 4-month follow-up was unim-
pressive in hands treated with iontophoresis.184,185
Anti-inflammatory medications have been a main-
stay of treatment for epicondylitis for many years, al-
though studies consist mainly of small groups and an-
ecdotal experience. In addition, some controversy has
arisen surrounding the use of anti-inflammatory medi-
cations as the scientific understanding of chronic
degenerative tendinopathies, and the minimal role
of inflammation, has developed. Nevertheless, in 1
randomized, controlled trial, patients treated with
dexamethasone by iontophoresis noted improvement
of symptoms after 2 days compared with placebo, but
this benefit was lost at 1 month.186 Iontophoresis
with topical naproxen showed similar benefits in pain
and function scores in patients with epicondylitis.187
Of note, no studies have compared topical nonsteroi-
dal anti-inflammatory drugs (NSAIDs) with topical
steroids in epicondylitis.
Overuse syndrome is a nonspecific diagnosis related
to generalized tendinopathies from repetitive strain. As
such, anti-inflammatory medications (NSAIDs, acet-
aminophen, etc.) have been used for pain relief, and
there has been some interest in mitigating the adverse
systemic effects of long-term use by favoring local
administration. The results of a small, randomized trial
JHS Vol A, March
611
support the use of NSAID-gel iontophoresis for short-
term pain control. However, systematic reviews have
found no difference in long-term treatment outcomes.
Alternative diagnoses, such as partial tendon tear or
inflammatory arthropathy, should be ruled out.188
In cases of conservatively managed biceps tendi-
nopathy, tendonitis of the flexor hallucis longus, and
mild rotator cuff tendinopathy, some authors have
found anecdotal benefit from iontophoresis of NSAIDs
or glucocorticoids in addition to immobilization and
activity modification,189 but no definitive evidence ex-
ists in the literature to support these applications. As is
the case for many applications of iontophoresis, it is
unclear whether therapeutic drug levels actually reach
the intended target, or if they are swept away by sub-
dermal vasculature.
Palmar and plantar focal hyperhidrosis can be
treated effectively with iontophoresis, and a spe-
cial axillary electrode can be used as well, but
treatments can be time consuming.190,191 The pu-
tative mechanism of action involves the temporary
blockade of sweat glands.192194 Iontophoresis for
hyperhidrosis is typically performed with tap wa-
ter, and equipment is available for home use, but
better results may be obtained using glycopyrro-
nium bromide, a cholinergic inhibitor.195 Data are
sparse from randomized trials; nevertheless, small
studies suggest that iontophoresis is safe and can
alleviate symptoms of palmar or plantar hyperhi-
drosis in approximately 85% of patients.196 199
Side effects include primarily dry, cracked hands
(treated with moisturizers); the primary concern
for patients, however, is the time required to per-
form the treatments. In most studies, the initial
treatment was 20 to 30 minutes per day.199 Non-
responders are commonly referred for local injec-
tion of botulinum toxin. In a study of 20 patients
with palmar hyperhidrosis who had not responded
to iontophoresis therapy, all developed anhidrosis
by 2 weeks after botulinum toxin injection, with
persistent results 12 months after therapy in all
patients.200
Iontophoresis is a novel technique for needleless
administration of lidocaine across the stratum corneum
Current Concepts
barrier to the dermis. It is thus useful for delivering local
anesthesia before minor procedures in children, partic-
ularly in the palms and soles, where the stratum cor-
neum barrier is most impervious to passive diffu-
sion.201,202 Some practitioners have used lidocaine
iontophoresis before venipuncture in both children and
adults. Reports suggest that iontophoresis provides ef-
fective pain relief for venous catheter placement or
 612 THERAPEUTIC MODALITIES
venipuncture within 10 to 20 minutes.201,203206 The
drug is administered in a volume of 0.6 to 1.0 mL of 2%
lidocaine with epinephrine, and should not be used in
patients with sensitivity to amide anesthetics, with pace-
makers, or with lesions near the eye, and over metal
indwelling catheters.206 The demand on provider time
relative to other techniques, major local skin reactions
(including burns), and the emergence of topical lido-
caine creams that have an onset of action similar to
iontophoresis have limited the use of this technique in
clinical practice.207
Experience
Iontophoresis is available in most rehabilitation
facilities and is used in selected patients in our
practice. Despite justified controversy regarding
whether clinically relevant doses of the medication
reach the target tissue, we have experienced posi-
tive outcomes in patients who have undergone
glucocorticoid and NSAID iontophoresis as sec-
ond-line treatments for inflammatory conditions.
We believe that it is a useful addition to the
therapists tool set in carefully selected patients.
PHONOPHORESIS
Overview
Phonophoresis is a form of transdermal (needleless) drug
delivery that requires the therapeutic application of ultra-
sound to enhance the permeability of skin and facilitate the
delivery of topically applied drugs to subcutaneous tis-
sues.208,209 The advantages of transdermal delivery are
well-recognized: easy titration and dose adjustment, lack
of painful injections, and avoidance of hepatic first-pass
metabolism. Electron microscopy and controlled animal
studies have demonstrated the ability of ultrasound energy
to enhance the permeability of the skins stratum corneum
barrier.210215 Commonly used medications include cor-
ticosteroids, NSAIDs, and local anesthetics, and it has
been used for carpal tunnel syndrome, chronic tendinopa-
thy, stenosing tenosynovitis, epicondylitis, overuse syn-
drome, nonspecific musculoskeletal pain, and a number of
other miscellaneous conditions.
Current Concepts
Evidence
Corticosteroid phonophoresis has been investigated as a
safe alternative to injection for mild to moderate carpal
tunnel syndrome, with results disappointingly similar to
those of iontophoresis.184,185
Whereas the initial conservative therapy for rotator cuff
tendinopathy and other chronic tendinopathies consists of
ice, rest, and NSAIDs, ultrasound theoretically stimulates
tendon healing via collagen production, thereby increasing
JHS Vol A, March
tensile strength.44,216218 However, there is little evidence
to support the use of NSAID phonophoresis in these con-
ditions. In fact, the use of NSAIDs for acute tendinopathy
remains controversial, because blocking the inflammatory
response is thought by some to inhibit healing. In the
treatment of chronic tendinopathy, it is unclear what ben-
efit NSAIDs provide without evidence of an inflammatory
process. A review of 32 studies addressing the benefit of
NSAIDs in tendinopathy identified only 9 prospective,
placebo-controlled trials.219 Of these 9 studies, 5 found
some analgesic effect from NSAIDs; none looked at ten-
don healing.
In cases of stenosing tenosynovitis, especially de Quer-
vain and intersection syndrome, hydrocortisone phono-
phoresis over the radial styloid or the point of maximal
tenderness daily has been noted anecdotally to relieve pain
in minor cases. However, there is a lack of clinical evi-
dence to support this modality in these conditions.220
In cases of epicondylitis, studies of phonophoresis
are small and preliminary, but the technique may pro-
vide some short-term benefit. In 1 randomized study of
60 patients with lateral epicondylitis, phonophoresis
and iontophoresis with topical 10% naproxen showed
similar benefits in pain and function scores.186,187
In overuse syndromes, rest, ice, stretching, and activity
modification are mainstays of therapy. Although formal
studies are lacking, NSAID phonophoresis has been used
with anecdotal success. There is no empiric evidence to
support the use of this modality, however.221
In patients with nonspecific musculoskeletal pain, hy-
drocortisone phonophoresis has demonstrated symptom-
atic benefit in the literature, although it is unclear whether
there is a publication bias for only positive results. In a
randomized, double-blinded, placebo-controlled trial of
hydrocortisone phonophoresis in such patients, Griffin et
al222 found that 68% improved with treatment versus only
28% after placebo phonophoresis. Other small studies
have demonstrated similar findings in patients with shin
splints and generic inflammatory musculoskeletal condi-
tions.223,224 Several authors have supported the relative
safety of this modality, reporting absence of detectable
systemic levels of agents such as dexamethasone, hydro-
cortisone, and salicylates after phonophoresis.225227
Dexamethasone phonophoresis is believed to reduce
subcutaneous collagen deposition, and is thus avoided
around weakened or unstable joints. It may prove benefi-
cial, therefore, in cases of keloid or exuberant scar forma-
tion,211 but there is no supporting evidence at present.
Experience
Phonophoresis is a commonly available therapeutic mo-
dality frequently used in hand rehabilitation settings de-
 THERAPEUTIC MODALITIES
FIGURE 8: Mirror therapy.
spite the lack of clear evidence demonstrating therapeutic
drug levels at the target tissue. In our practice, phonopho-
resis is carefully selected as an adjunct therapy based on
the presenting pathology, the target tissue, the stage of
healing, and the desired therapeutic effect. We avoid cer-
tain ultrasound parameters that may be more likely to
cause epidermal injury, such as high frequencies and sta-
tionary positioning of the sound head. We often recom-
mend moisturizing with mild lotion to ensure hydrated
skin, and consider leaving the drug on the skin with an
occlusive dressing for several hours after therapy to im-
prove absorption. Hair-bearing areas are often shaven to
limit impedance to drug transmission.
MIRROR THERAPY
Overview
Mirror therapy is used for patients with phantom limb
pain or pain from a paralyzed extremity, or patients
with pain syndromes such as chronic regional pain
syndrome. The patient places the normal limb in 1 side
of a box. The amputated limb is rested into the other
side. A mirror reflects the normal limb so that it appears
to the patient that there is a normal hand in place of the
missing limb (Fig. 8). When the good hand moves, the
artificial visual feedback suggests to the patient that she
is moving the missing or paralyzed limb.
The development of mirror therapy was based on the
observation that patients who had a paralyzed limb, and
then underwent an amputation, were much more likely
to report phantom pain. Ramachandran et al228,229 pro-
posed that when the patient tried to move the paralyzed
limb (before amputation), he received visual and pro-
prioception feedback that the limb did not move. This
feedback then imprinted into the brain when the indi-
JHS Vol A, March
613
viduals arm was present but paralyzed, and remained
even when the limb was no longer present.
Given that individuals report that a phantom limb is
painful because they often feel as if it is stuck in an
uncomfortable position, Ramachandran et al228 further
hypothesized that allowing the patient to see the miss-
ing limb move would break this cycle. By having the
individual look into the mirror on the intact side and
make mirror symmetric movements, it appears to the
subject that the phantom limb is moving. With this
artificial feedback, the brain is retrained and the learned
paralysis eliminated. Patients can then begin to move
the missing or paralyzed limb and unclench it from
painful positions.
Evidence
Chan et al230 performed a randomized, sham-controlled
trial of mirror therapy versus imagery therapy in patients
with phantom limb pain. The authors created 3 groups: (1)
The mirror group viewed a reflected image of their absent
limb and performed mirror therapy; (2) the covered mirror
group performed the same tasks as group 1 but the mirror
was covered with a drape; and (3) the imagery group was
trained in mental visualization to perform tasks with the
absent limb. The researchers found that after 4 weeks of
treatment, 100% of patients in the mirror group reported a
decrease in pain. In the covered-mirror group, only 17%
reported a decrease in pain, whereas 50% reported wors-
ening pain. In the imagery group, 33% reported a decrease
in pain, whereas 67% reported worsening pain. The criti-
cisms of this report have noted the small numbers; there
were only 6 subjects in each group. In addition, there have
been several other reports with mixed results of mirror
therapy in phantom limb pain231233; many of the reports
have small numbers and lack of proper controls.
Mirror therapy has also been used in patients who have
experienced a stroke and have a paretic hand or spatial
neglect. A randomized crossover study of 9 chronic stroke
patients found that mirror therapy improved range of mo-
tion, speed, and accuracy of movement.234 Sathian et al235
also found that 2 weeks of mirror therapy improved
strength and movement in stroke patients with a paretic
arm. Similarly, Stevens and Stoykov236 reported an in-
crease in range of motion, Fugl-Meyer assessment score,
Current Concepts
movement speed, and hand dexterity in paretic arms after
mirror therapy. One of the better studies was a random-
ized, controlled trial of mirror therapy in subacute stroke
patients with limb dysfunction. A total of 40 patients were
enrolled, 20 of whom underwent mirror therapy plus a
conventional stroke rehabilitation program. The control
group consisted of 20 patients who were part of a sham
mirror therapy plus conventional stroke rehabilitation. The
 614 THERAPEUTIC MODALITIES
conventional stroke rehabilitation was intensive: 5 days a
week, 2 to 5 hours a day, for 4 weeks. The mirror therapy
consisted of an additional 30 minutes per day. The re-
searchers found that the mirror therapy group performed
much better in outcome measures that assessed motor
recovery and self-care items. It did not affect spasticity.237
Finally, the successful use of mirror therapy has been
reported in patients with pain syndromes such as com-
plex regional pain syndrome238,239 and in sensory re-
education of severe hyperesthesia after hand injuries.240
Cacchio et al241 performed a randomized, sham-con-
trolled study involving 24 patients with complex re-
gional pain syndrome of a paretic arm. As in the phan-
tom limb study mentioned previously, the patients were
assigned to 1 of 3 groups: (1) the active-mirror group,
who viewed a reflected imaged of their unaffected arm
in a mirror; (2) the covered mirror group; and (3) the
mental imagery group. The authors found that 88% of
patients in the active-mirror group reported reduced
pain, whereas only 12% reported reduced pain in the
covered-mirror group, and 25% in the mental imagery
group. Interestingly, after the randomization period was
completed, 12 patients crossed over to active mirror
therapy. Of the 12 patients who switched to mirror
therapy, 11 then had a significant reduction in pain (P
.002).241
Experience
We have found phantom limb pain, pain associated
with paralysis after stroke, and pain syndromes such as
chronic regional pain syndrome extremely difficult to
treat with traditional therapy modalities. However, we
have been impressed with the results of mirror therapy
and frequently offer this modality to these pain groups.
One downside is that the therapy is intensive, with a
strong commitment required from patient and therapist,
and requires an excellent understanding of the tech-
nique to be effective. In addition, mirror therapy proto-
cols are still in their infancy.
LOW-LEVEL LASER THERAPY
Overview
Current Concepts
Low-level laser therapy (LLLT) refers to the use of low
intensity or low levels of laser light to alter cellular
function. It implies that little heat is transferred when
tissue is irradiated. Other common names include low-
power laser therapy, cold laser, soft laser, biostimula-
tion laser, therapeutic laser, and laser acupuncture. By
setting the laser to the appropriate wavelength, laser
light can penetrate the skin and activate the appropriate
photoreceptor target. Once activated, the stimulated tis-
sue theoretically can induce biological healing.242
JHS Vol A, March
Low-level laser therapy is appealing because it is a
noninvasive, painless, office-based modality. Since
2002, the FDA has allowed several companies to mar-
ket LLLT (as above, it is important to note that FDA
approval does not necessarily indicate effectiveness)
and its indications have expanded over the years. Cur-
rently, it is being used for a variety of soft tissue
ailments.
Evidence
From a basic science perspective, there is some research
that LLLT stimulates the cytochrome c oxidase path-
way and other mitochondrial pathways243 and activates
the tyrosine protein kinase receptors.243,244 The net
result of the complex interplay is the release of growth
factors with the proliferation of cell lines that heal and
regenerate tissue.242246
Nevertheless, the clinical translation of this basic
science evidence remains to be seen. Low-level laser
therapy has been studied for carpal tunnel syndrome,
enthesopathies, de Quervain tenosynovitis, Raynaud
phenomenon, rheumatoid arthritis, and osteoarthritis.242
The results have generally demonstrated that LLLT has
no benefits over a sham laser.
Carpal tunnel syndrome has been the best-studied
pathology. The studies that have demonstrated LLLT to
be an effective therapy have had major limitations;
most notably, they were done without controls.247,248
Fortunately, several randomized, controlled trials of
LLLT versus sham laser have been performed.249 253
Irvine et al249 performed a double-blind, randomized,
controlled trial of LLLT versus sham and found no
significant difference in any of the outcome measures
(Levine Carpal Tunnel Syndrome Questionnaire, elec-
trophysiological data, and the Purdue pegboard test).
Naesar et al250 also published a double-blind, random-
ized, controlled trial on patients with mildly to moder-
ately severe carpal tunnel syndrome. In that study, a
significant treatment effect was only found after those
patients who had demonstrated a response to sham were
excluded. Evcik et al251 reported no difference in the
primary outcomes of pain and function in their random-
ized controlled trial. Similarly, Shooshtari et al252 found
no difference in improvement in clinical symptoms
between LLLT and sham laser, although they did report
an improvement in electrophysiology findings.
Three systematic reviews have been published, with
conflicting results. One group concluded that the evi-
dence to support LLLT in carpal tunnel syndrome is
unsubstantial,253 whereas another summarized the same
studies by suggesting that the negative studies had not
used the appropriate dose of LLLT for carpal tunnel
 THERAPEUTIC MODALITIES
syndrome.254 The last review concluded that the basic
science evidence in support of LLLT is poor, the clin-
ical data are lacking, and overall, the available scientific
data do not support a role for LLLT in the treatment of
carpal tunnel syndrome.242
With regard to other diseases treated by LLLT,
Tumilty et al255 performed a meta-analysis of LLLT for
enthesopathies and de Quervain tenosynovitis. A total
of 12 randomized, controlled trials reported positive
outcomes, whereas 13 had negative outcomes. They
suggested, however, that the studies reporting negative
outcomes had not used the appropriate wavelength. A
Cochrane review of 5 placebo-controlled trials of LLLT
in rheumatoid arthritis concluded that LLLT may have
some benefit for short-term pain relief and morning
stiffness, but that it had little or no effect on functional
outcomes, range of motion, and local joint swelling.256
Similarly, a randomized, controlled trial found no dif-
ference between LLLT and sham laser therapy for
osteoarthritis.257
Experience
There is a lack of data conclusively supporting the use
of LLLT in soft tissue disorders. Nevertheless, we fre-
quently field requests from patients inquiring about the
therapy and look forward to reviewing emerging re-
search on the subject. Currently, we use it when spe-
cifically requested by the referring physician, or when a
patient reports a positive experience in the past and
would like to continue its use.
Over the past several decades, the number of modal-
ities available for treating hand conditions has greatly
increased. With it has come an explosion in research to
better understand which treatments are truly effective.
Although much work remains to be done, the possibil-
ities of noninvasive therapy to better the patient with a
hand injury are limitless. We look forward to the com-
ing years and the next summary of modalities in this
rapidly expanding field.
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JOURNAL CME QUESTIONS

Therapeutic ModalitiesAn Updated Review In patients with rheumatoid arthritis, thermal

for the Hand Surgeon ultrasound has been shown to have what
positive effect?
What factor leads to pain relief with heat therapy?
a. Reduce the number of painful joints
a. Cutaneous counterirritant
b. Decrease the number of swollen joints
b. Changes in cell membrane permeability
c. Decrease morning stiffness
c. Endorphin release
d. All of the above
d. Vasodilatation
e. All of the above

To take the online test and receive CME credit, go to http://www.jhandsurg.org/CME/home.

Current Concepts

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