Author(s): Charnette Lercara, MD, Ahmed Elzayat, BA, Lon Yin Chan, MD, Supriya Baskaran, BS, Elver Ho, MD
Originally published: April 4, 2016 Last updated: September 19, 2024
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 that are not temperature related. For other modalities see Therapeutic Modalities – Thermal
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.1
- Other Musical Therapy Types exist: Neurologic Music Therapy (NMT), 2,3 Music Supported Therapy (MST), Melodic Intonation Therapy,4,5 Music glove,6 group music therapy,7 Rhythm- and music-based intervention,30 and Musical sonification.5,9
- Transfer method: Mechanical (vibrations) to acoustic/sound waves (kinetic energy) of differing frequencies. If from radios, television, computers, or radiofrequency machines, energy is transmitted by a wide range of electromagnetic radiation.
- Physiologic effects (many):
- 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.4 This may improve ischemic post stroke recovery and early sensory processing.10,11
- Associative network theory of mood and memory– Memory of events, experiences, or information are associated with certain elements of an event and are stored in neural nodes and are activated by music. Music activates certain experiences or events associated with the specified emotion, environment, or any of our senses.2
- 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.11 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.38
- “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.2
- Enhancement of blood flow – Music can increase blood circulation in acute ischemic stroke post-recovery patients.14
- 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.11
- Indications: Music therapy can improve sub-acute patient motor recovery,15 act as an adjunct in pain management,11 such as in burn patients,16 post-operatively,17 cancer patients,18 alleviate mild and chronic tinnitus.19,20
- Contraindications: Gastrointestinal problems (nausea, vomiting), psychiatric conditions (hallucinosis, psychosis), depression, sensitivity to loud or evocative sounds; music needs to be tailored to personal preference.3
Non Thermal Therapeutic Modalities Table 1 – Music Therapy
Electrotherapy
- This modality uses electricity (electromagnetic radiation) to stimulate nerves 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.29
- 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.22
Non Thermal Therapeutic Modalities Table 2 – Electrotherapy
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.23
- 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 of the skin/body to activate whole body mechanical sensory receptors to prevent swaying of body and falls.25,26,27,28 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 joints, reduce compression and nerve root and disc irritation. Light touch improves cueing to stand and improves balance. Tissue massage can inhibit pain, reduce edema, decrease muscle spasms, improve blood flow, and reduce inflammation. ESWT improves wound healing around soft tissue, bony, and tendinous areas, and decrease pain, releases trigger points, reduces inflammation, and breaks 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 pain.23,24
- 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. 25,26,27,28 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),29,30 burns, fractures, and systemic diseases, comfort for those in palliative care, edema in stroke patients, those with sinusitis or 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 pain, 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 pain, 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, pregnancy, and pacemaker.
Non Thermal Therapeutic Modalities Table 3 – Mechanical Force
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 temporarily 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,30 and some research suggests LLLT has an anti-inflammatory effect by reducing prostaglandin synthesis.33 UV light may have similar biological effects as LLLT.
- Indications: It is commonly used to decrease acute and chronic pain and inflammation,31,32 stimulate collagen metabolism and promote wound healing.34 UV light has been used for depression, seasonal affective disorders, vitamin D deficiency, and wound healing.35 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).36 In addition, UV light has been proposed as an alternate modality for immunomodulation.37
- Contraindications: UV therapy is contraindicated for treatment over eyes, skin cancer/malignancy, organ disease (heart, lung, kidneys), SLE, fevers, and acute inflammation. LLLT also has contraindications for those with irradiation of the neck region in hyperhidrosis, seizure, and epilepsy.38
Non Thermal Therapeutic Modalities Table 4 – Light Therapy
Relevance to Clinical Practice/Specific Techniques
Vibroacoustic therapy (VAT)1,39,40
- Was first developed by Olav Skille and Juliette Alvin in 1968.
- Use of musical sound waves to aid and facilitate 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 changes such as increased 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 hypotension, DVT, bleeding disorder, recent surgery or individuals who have had a recent psychotic episode.
Neurologic music therapy (NMT)2,3,44
- 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 the condition being addressed.
- Commonly used for general neurorehabilitation.
- Precautions: Avoid in patients with mood disorders, psychiatric conditions, gastrointestinal problems, sensitivity to loud/evocative music. There may be a personal music preference.
Music supported therapy (MST)4
- Use of musical sound waves for stroke patients with motor impairments.
- Technique: Training focuses on the patient using hemiparetic limbs on musical instruments (i.e., piano, electric drum).
- Treatment duration varies depending on the condition being addressed.
- Commonly used for stroke motor recovery.
- Precautions: Those with poor motivation. Avoid in patients with mood disorders, psychiatric conditions, gastrointestinal problems, sensitivity to loud/evocative music. There may be a personal music preference.
Melodic intonation therapy6
- 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 glove22,47
- Use of an engineered 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 an engineered 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. The glove was made to promote functional movement with high repetition and afferent inputs to help with post-stroke rehabilitation. Engaging the hands meaningfully and repetitively helped patients improve grasping small items and retain the improvements even one month later.
- Precautions: Avoid use in those with sensitivity to light, visual disturbances, and with seizures/epilepsy.
Group music therapy29
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 can be sung 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 patients with gastrointestinal problems, sensitivity to loud/evocative music, and severe psychiatric or mood disorders.
Rhythm- and Music- based intervention30
- Music activates the dopaminergic pathway in the brain to allow normal movements to be elicited.
- Technique: Music is played, and an activity is performed (e.g., 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 sonification 9,15
- Music can be used to improve gross motor impairments and cognition (spatial awareness).
- Technique: Patient uses hemiparetic limb to move within a 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 if the patient has 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.42
- TENS has been found be effective in treating neuropathic pain for spinal cord injury patients16 and painful diabetic peripheral polyneuropathy.43
- A meta-analysis concluded that strong non-painful TENS near the pain site clinically reduces pain levels during or immediately after treatment.48
- 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)25
- Portable device which delivers low frequency strong physiological stimulation to nerves. The ideal is around 4 kHz along its two currents “true” and “premodulated.”
- 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 for lower back pain, neurological pathologies like carpal tunnel syndrome. Has been studied in treating fecal incontinence and constipation in small studies but may require further research.
- Precautions: Neuropathy, suction discomfort, fevers, seizures, epilepsy, cardiovascular conditions, or anterior chest wall problems.
Neuromuscular electrical stimulation (NMES)22
- 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.
- Therapeutic muscle stimulation: Repetitive simulation is applied to paralyze muscle to minimize atrophy and maintain range of motion.
- FES: Use of electrical stimulation to assist patients in performing a functional task.
- Treatment duration ranges from 20 minutes to an hour depending on the 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, dysphagia and urinary incontinence.
- Precautions: Avoid those who are pregnant, on open wounds, infected areas, Automatic implantable cardioverter-defibrillator (AICD), pacemakers, battery operated implant devices, have seizures, active hemorrhage, malignancy, circulatory impairments, thrombosis, or thrombophlebitis.
Iontophoresis10
- A method that uses low-level current to drive charged substances transdermally
- Technique: Use of electrodes or plates over affected extremities to drive a drug across the skin barrier. There are two types of currents, direct and alternating, but direct is generally preferred. The level of current varies depending on the medication.
- Treatment duration is about 20 to 30 minutes but varies depending on the medication being delivered
- Commonly used medications: NSAIDs, steroids, local anesthetics, opioids, anti-bacterial, anti-viral, anti-fungal, vitamins, and fluoride.
- 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 traction22
- Provides a pulling force to the cervical or lumbar spine by using manual techniques or pulley system or special device.
- Techniques:
- Sustained vs intermittent traction.
- For cervical traction, the neck is flexed between 20-30 degrees while the patient is 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
- 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 patients with spinal instability, infection, compressions, malignancy, or deformity; any bony abnormalities, fractures, or osteoporosis; hypertension or cardiac disorders; acute ligamentous or muscle injuries.
Light touch22
- 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 massage6
- 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 massage46
- Manual manipulation which involves deep, firm pressure and strokes to relax muscles and reduce pains.
- Techniques Trigger point therapy, friction, myofascial release, and stretching.
- Treatment duration varies and may be between 15 minutes 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)41,35,36
- 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 lymphedema (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)23
- Globally recognized as the lymphatic drainage therapeutic protocol by the International Society of Lymphology.
- Known well in Europe, but now gaining traction in America.
- Composed of four main parts: manual lymphatic drainage (MLD), exercising, self-care, and bandaging.
- Techniques: Same as MLD with the addition of education to patients 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 lymphedema (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) 45,49,50,48
- Device which uses high intensity pulsed mechanical waves to treat musculoskeletal disorders and to promote wound healing, especially for patients with diabetes.
- Does not produce thermal effects.
- US FDA approved for treatment of plantar fasciitis and lateral epicondylitis.
- Technique: Gel is placed over an area of interest. A non-invasive probe is placed over the gel to deliver shock waves to break up calcification and promote microcirculation.
- Treatment duration is approximately 5 minutes.
- Commonly used for chronic recalcitrant tendinopathies, trigger points, pseudoarthrosis (or delayed nonunion bone healing), 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).51
- ESWT can also help induce wound healing by promoting microcirculation and is being studied in patients with diabetic foot ulcers with promising results.52
- Precautions: Pregnant, neuropathy, hypersensitivity to deep pressure and pains, open wounds, skin infections, seizures, pacemaker, or history of coagulopathy.50,53
Gaps in Knowledge/Evidence Base
N/A
Cutting Edge/Unique Concepts/Emerging Issues
Technology-assisted rehabilitation
Modalities that incorporate technological advances are being studied including virtual reality (VR) exergaming (or active video gaming), serious gaming (games produced with the purpose of rehabilitation, wearable technologies, and telerehabilitation.
Wearable technologies with built-in sensors can provide haptic responses in real time, allowing for patients, for example, to recognize and adjust posturally. Wearable technology, when combined with virtual reality, can make exercises and exergaming more immersive and enjoyable. In addition, these modalities can enable telerehabilitation, allowing patients to exercise at home while gathering information for clinicians at another location. The COVID pandemic demonstrated a need for telerehabilitation, but the gap also exists in areas where regular access to physical therapy facilities might be difficult for patients–whether geographically or socially (e.g., frequent car rides). Interestingly, among 45 studies, there was a significance in drop-out rate between experimental vs control groups but not within different experimental groups–though this is likely due to how new the technology is and the current patient populations and may change in the future.54
Soft robotics and functional electrical stimulation 56
Functional electrical stimulation (FES) uses electrodes to activate muscles to stimulate purposeful movements, to help rebuild neuroplasticity in the brain or spinal cord.
Exergaming 57-61
Exergaming is exercise based computer or video games meant to incorporate full body motion to participate in virtual sports or games.57 Playing games is stimulating and thought to help improve adherence to rehabilitation regimens. Additionally, whereas exergaming used to be limited to facilities that had the space (e.g., arcades), technology has advanced to levels that opens up to residential marketing. The advent of Nintendo Wii for instance, a device that can be implemented seamlessly at home has made it possible for similar wearable and portable technology to be applied to physiatry. Mobile phone apps also count as a form of exergaming. This is an exciting new modality that can be customized to patient needs and underutilized as of now.
Artificial intelligence driven rehabilitation
Artificial Intelligence (AI) is a field of mathematical engineering which has the potential to enhance rehabilitation through machine learning, assisted analysis, and making clinical predictions. However, the literature on the use of AI within physical rehabilitation is still currently being developed and further research is required to elicit its total effectiveness. Nevertheless, the field can look forward to continued advancements.55 Examples of how AI has been utilized in rehabilitation include individualized self-management apps, gait analysis, developing individualized therapy recommendations for stroke, and ultrasonography.62,63,64,65
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Original Version of the Topic
Thiru M. Annaswamy, MD, Li Liu, MD. Therapeutic Modalities. 4/4/2016
Previous Revision(s) of the Topic
Benjamin J. Seidel, DO, Lawrence Chang, DO, MPH, Aaron Greenberg, DO. Therapeutic Modalities. 3/11/2021
Author Disclosure
Charnette Lercara, MD
Nothing to Disclose
Ahmed Elzayat, BA
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Lon Yin Chan, MD
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Supriya Baskaran, BS
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Elver Ho, MD
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