Clinical Modalities
When getting care, your treatment can be divided into a few categories. Manual therapy, rehab, and modalities, or things that are applied (technology or topical) are the most common forms of treatment seen in Canada. Over the past few decades, so much research regarding these modalities have come out. As clinicians, we should be focussing on modalities with more robust research backing them up, and throw out old modalities that aren’t just not worth our patient’s time. Let’s go through a few modalities in this blog, and take a deeper dive into what these modalities do, when to add them to a treatment plan and when to avoid.
Cold Laser Therapy or Low-Level Laser Therapy (LLLT)
How it Works:
Cold laser uses specific wavelengths of light (600–1000 nm) that penetrate soft tissue without generating heat. These photons are absorbed by mitochondrial chromophores (e.g., cytochrome c oxidase), which increases ATP production, enhances cellular repair, reduces oxidative stress, and modulates inflammation and pain via reduced prostaglandin and cytokine levels.
Evidence Summary:
LLLT is included in many clinical guidelines including Chronic neck pain, Epicondylitis, Tendinopathys, and short term relief for Osteoarthritis (knee). There is variability in the research based off variants in dosage. Some research supports use for TMJ Disorder. Better for more superficial anatomy/structures.
Contraindications:
Over malignancy, eyes, thyroid, or reproductive organs
During pregnancy (abdomen/pelvis)
Epileptic patients (photosensitivity)
TENS (Transcutaneous Electrical Nerve Stimulation)
How it Works:
TENS devices deliver low-voltage electrical impulses through the skin to stimulate Aβ sensory fibers, which inhibit nociceptive transmission at the dorsal horn via the gate control theory of pain (signals indicating damage/pain). It may also stimulate the release of endogenous opioids and reduce central sensitization over time.
Evidence Summary:
TENS is included in the research surrounding chronic low back pain, Osteoarthritis, fibromyalgia, and post-operative pain. TENS works best as an adjust, especially during movement therapy (training the body to move while stimming so the brain gets used to movement without pain). TENS mainly helps with pain, function and provides an analgesic effect.
Contraindications:
Pacemakers, defibrillators
Over carotid sinus or anterior neck
First trimester of pregnancy
Over infected or broken skin
If the patient has sensory deficits
Should not use as sole therapeutic treatment
Percussion Therapy (Thumper)
How it Works:
Percussive devices deliver rapid, repeated bursts of pressure that stimulate mechanoreceptors, increase local blood flow, and potentially induce a temporary decrease in muscle spindle activity, leading to improved range of motion and reduced perceived muscle soreness (DOMS) (Short-term neurological relaxation via reduced alpha motor neuron firing). This can be used to improve benefits of manual therapy or mobilizations used after percussion.
Evidence Summary:
Percussion may improve short-term range of motion and DOMS. There is insufficient evidence for injury rehab or long-term function gains. This indicates that Percussion should be used with something else, even if it is exercise.
Contraindications:
Fractures, acute injuries, DVT, open wounds, pregnancy (caution)
Over bony prominences or surgical sites
Should not use for deep structures, persistent pain, or in early post-surgical rehab
Therapeutic Ultrasound
How It Works:
Ultrasound therapy uses high-frequency sound waves (typically 1–3 MHz) that pass through tissue and cause molecular vibration, leading to microscopic friction and heat generation (thermal effects). This increases tissue extensibility, promotes circulation, and potentially accelerates healing via non-thermal effects like cavitation and acoustic streaming. These benefits can basically be separated into two categories, thermal and non. Thermal is increasing collagen extensibility and reducing joint stiffness. Non-thermal is promoting fibroblast activity, tissue regeneration, and angiogenesis.
Evidence Summary:
Limited-to-weak evidence for chronic pain and tendinopathy
Effective as adjunct only, not stand alone treatment
Some support for calcific tendinopathy or myofascial trigger points
Contraindications:
Over malignancy, pregnancy (abdomen/spine), growth plates in children
DVT, pacemaker regions, acute fractures
Patients with sensory deficits (risk of burn)
No clinical improvement (should be stopped after 6 to 8 sessions)
Intermittent Pneumatic Compression Boots
How it Works:
These devices use inflatable cuffs that apply sequential compression to the limbs, mimicking the muscle pump. This improves venous return, enhances lymphatic drainage, and may reduce DOMS and post-exercise edema by aiding in the clearance of metabolic waste (e.g., lactate).
Evidence Summary:
There is insufficient evidence to state if boots like these actually help with performance, but there is evidence that it helps with post-exercise recovery (reduced soreness, and subjective fatigue). Boots have been used in vascular medicine for DVGT prevention and chronic venous insufficiency, but this should be done under a medical doctor’s supervision.
Contraindications:
Acute DVT or suspected clotting disorder
Peripheral arterial disease
Open wounds or dermatitis
If patient has cardiac or kidney issues (fluid overload risk)
Should not be used for performance enhancement alone
Red Light Therapy (Over-the Counter Machines)
How it Works:
Uses red (630–700 nm) or near-infrared (800–1000 nm) wavelengths to penetrate skin and interact with mitochondrial photoacceptors (especially cytochrome c oxidase). This boosts ATP production, modulates ROS, and enhances anti-inflammatory and tissue repair responses. Circulation and collagen production are increased, cytokine-mediated inflammation is reduced, and nerve excitability may be decreased (for pain relief).
Evidence Summary:
There is mild to moderate support for post-exercise recovery (very mild pain relief), but more evidence in a dermatology or wound healing. Less potential than clinical grade lasers (class 3b and above). MSK based research is still coming out.
Contraindications:
Photosensitivity, malignancy, pregnancy (unproven safety), epilepsy (flicker sensitivity)
Over tattoos (can heat pigment)
Should not replace active rehab or used without a clear recovery goal
Should avoid eyes
Should not use for deep structures
Regardless of what modalities you or your doctor offers you, in patient-centred care, treatment plans should be tailored around your goals and values. Don’t be afraid to advocate for your health, and to ensure you are getting what you want out of your appointment.
For more information, please visit https://www.ccgi-research.com or email Dr. Gray at hello@madetomove.ca
